In India, over the last 25 years the vast majority of leukeamic children in most government institutions have been treated on a uniform treatment protocol called MCP 841. While this protocol has been instrumental in improving the previously dismal outcomes in childhood leukaemia, extensive efforts are required.
An 8-year-old girl from Bengaluru was suffering from high fever. Since the fever was not receding with antibiotics she had to undergo a blood test, which revealed that she had leukaemia. She was referred to a cancer hospital, where she underwent bone marrow examination, which confirmed a diagnosis of Acute Myeloid Leukaemia (AML). The patient received first cycle of chemotherapy and a repeat bone marrow examination showed her to be in remission. Further, she had three courses of chemotherapy to consolidate the response. After completing treatment she continued school and is doing well. But is everyone equally blessed? Today, leukaemia is the most common form of cancer in children. There are two kinds of leukaemia?s depending on type of cell ?affected; lymphoid leukaemia and myeloid leukaemia. It can be acute or chronic. Talking about the prevalence rate, Dr Intezar Mehdi, Consultant, Paediatric Oncologist, HCG, says, ?Leukaemia constitutes almost one-third of all cancers in children varying from 25 to 40 per cent in various areas ofIndia. Acute Lymphoblastic Leukaemia (ALL) is the most common cancer in children. Approximately 75 per cent of leukaemia in children is ALL and rest is AML.? Continuing this line of thought, he says that ALL occurs in 29 children per million children, and AML develops in 5-7 children per million children per year. Elaborating on the prevalence rate, Dr Santanu Sen, Consultant -Paediatrics & Paediatric Oncology, Kokilaben Dhirubhai Ambani Hosptal, avers, ?The incidence rates (number of new cases per year) of all cases of childhood cancers (0- 18 year) are about 150 ? 160 per million children per year. These are the rates, which are available from developed countries such as the UK and USA that have a complete and robust reporting system where every case of childhood cancer is reported and outcomes documented in central cancer registries. Out of all cases of childhood cancers, leukaemia is the commonest accounting for more than 1/3 of all cases with an average incidence of 50-60 per million children.?
Dr Santanu Sen
Status quo of domestic treatment
?Unfortunately, India does not yet have any central cancer registries and even in areas that have a local cancer registry, under-reporting is very common. Talking about the incidence rate in India, Dr Sen continues, ?The reported incidence rates for childhood cancer from various local population-based registries is between 38 -124 per million. It is however widely recognised and acknowledged that this figure probably is a gross underestimation of the true incidence figure.? He emphasises, ?In the US, the incidence of childhood leukaemia is about 50 cases per million. This indicates that approximately 3,000 children are diagnosed with leukaemia each year. In UK, leukaemia account for 30 per cent of all childhood cancers and about 500 new cases are diagnosed each year.? He says, ?Indian rates indicate that with the current population of 1.2 billion, there are between 40,000 to 75,000 new cases of childhood leukaemia per year. We do not know whether this figure is correct, but we do know that only about 1,000 children with leukaemia are correctly treated in India each year.? Seconding the above thought, Dr Raghuram C P, Consultant, Paediatric Oncologist, HCG, explains, ?In India, leukaemia in children seem to be more ???prevalent in urban areas than rural areas. It is thought that this may be due to under diagnosis rather than real difference in incidence, but this needs to be confirmed. The incidence in urban India is comparable to that of developed countries. Indian children tend to get more incidences of T-cell leukaemia; 20-50 per cent in comparison to their Western counterparts where it is only 10-20 per cent.? ?
Symptoms to be aware of ?
Leukaemia can mimic many other conditions. However, according to Dr Sen, there are some classic symptoms that should make every paediatrician think of leukaemia as a probable diagnosis. These are as follows: ?A child having recurrent fever with deep pain in the bones ?A child having unexplained tiredness and fatigue that is persistent ?Presence of sudden development of enlargement of nodes ?Unexplained enlargement of liver and/ or spleen ?Unexplained bleeding or easy bruising ?In most cases no cause can be found for leukaemia in children. Dr Raghuram says, ?In a small number of cases, exposure to radiation or certain chemicals has been implicated. Increased exposure to ionising radiation can cause cancer. Certain chemicals such as benzene, pesticides, alkylating agents have been associated with development of leukaemia. In addition, children with some diseases such as Down Syndrome, Fanconi anaemia, aplastic anaemia, Wiskott-Aldrich syndrome, Ataxia telangiectasia have predisposition to develop leukaemia viruses especially Epstein?Barr virus (EBV) may play a role in the causation of leukaemia/lymphoma cases in a small subset of patients. Viruses especially EBV may play a role in the causation of leukaemia/lymphoma cases in a small subset of patients.? Further, Dr Sen says that it is only in a small minority of cases that we at times suspect a cause, and these are as follows: ?Exposure of a child to radioactivity. (Incidence of leukaemia increased in Hiroshima and Nagasakiand its surrounding areas after the atomic explosion and similar increase in figures have been reported in surrounding areas after the Chernobyl accident) ?Viral infection by HIV and HTLV-1 ?After chemotherapy for some other cancers especially if a group of drugs called alkalyting agents had been used ?Some families have a vastly increased risk of developing cancers, especially in those families which have a genetic mutation called a p53 mutation
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Raghuram C P
Prevention and treatment ?
Unfortunately there is no way to prevent leukaemia as the doctors are still unaware of the cause of it in most cases. Hence, no known lifestyle changes are known to lower the risk of developing leukaemia. However, Dr Sen is of opinion that avoiding tobacco may help prevent a subtype of leukaemia known as AML. Dr Mehdi says early treatment in a dedicated paediatric cancer centre gives good results. However, children who are at high risk of cancer like those with genetic syndromes, or previous history of radiation can be screening for early diagnosis of cancer and treatment initiated early. Chemotherapy is the mainstay of treatment. Chemotherapy is giving drugs by intravenous or oral routes. Usually combination of drugs is required for treating paediatric leukemia. ALL is treated with combination of drugs with intensive chemotherapy for a few months followed by 2-3 years of maintenance chemotherapy. In addition, intrathecal chemotherapy- chemotherapy administration directly into spine by lumbar puncture is also required. Overall cure rates are excellent. Up to 80 per cent of the children are expected to get cured from ALL.
Talking about treatment modalities, Dr Raghuram avers, ?AML is usually treated by combination chemotherapy for 5-6 months of intensive treatment requiring four cycles of chemotherapy. The cure rates are about 50-60 per cent. Supportive care as detailed above including intensive care may be required. Small minority of children with leukaemia might need bone marrow transplantation if the disease has some high risk features or resistant or relapases after treatment.? Dr Sen highlights that leukaemia treatment in most developed countries is undertaken on the basis of clinical trials, which have helped over the last 50 years to improve outcomes and survival figures. These trials have helped answer important questions such as which treatment or what drugs are better and how should certain types of leukaemia be treated. ?In a modern tertiary care hospital setting, however, use of these international protocols such as the UKALL and BFM protocols have lead to vastly improved and similar outcomes and survival figures. In fact, today, the parent of a newly diagnosed leukaemic child, can be assured that their child will be cured of cancer with proper treatment. ?The reported incidence rates for childhood cancer from various local population-based registries is between 38 -124 per million. ?In India, leukaemia in children seem to be more prevalent in urban areas than rural areas. This may be due to under diagnosis rather than real difference, but it needs to be confirmed.???
Chandreyee Bhaumik (chandreyee.bhaumik@network18publishing.com)
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