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Treatment rates of paediatric acute myeloid leukaemia: a view from three tertiary centres in India – response to Gupta et al
We have noted the observations and data presented by Gupta et al regarding the treatment rates of paediatric acute myeloid leukaemia (AML) patients in India. The discussion section of our paper carefully qualified the limitations of extrapolating our data, stressed variations in health care delivery systems and the need for large prospective clinical trials to further address this issue (Philip et al, 2015). Gupta et al have chosen to concentrate on one statement in our paper: ‘In spite of these limitations, it is likely that this data is broadly representative of the experience of many tertiary centres in the country’. We are sure that Gupta et al would agree that there are many more tertiary centres in India (population >12 billion) than the three mentioned in their letter. Our data was obtained from a prospective study that included all age groups: paediatric patients (aged ≤15 years) comprised only 123% of our cohort. The percentage of paediatric patients receiving therapy was significantly higher than in the other two study groups and the complete remission rate in those that took treatment was 82%, with 704 107% overall survival at 1 year. As a policy, we also do not start standard of care therapy in any patient without a careful assessment of the ability of the patient and family to complete the entire protocol. Gupta et al present data that is limited exclusively to the paediatric population and is probably a retrospective analysis undertaken in response to our publication. Further, beyond the post-induction haematological remission rate it is not clear how many of their patients completed the consolidation chemotherapy schedule and what the follow-up survival data was. It follows that this data cannot be directly compared to that presented by us (Philip et al, 2015). The conclusion drawn by Gupta et al is based on the experience from three centres in India (two of which are in the two largest metropolitan cities in the country) that, in summary, states that there is no problem with either access to therapy for AML patients or delivery of standard of care treatment for the majority of patients in India as a whole. Even after limiting the discussion to paediatric patients, this conclusion is flawed at multiple levels. It is important to recognize that the data presented by Gupta et al accounts for a little over 200 paediatric patients/ year. In the absence of reliable and comprehensive data on the incidence of AML in India (there being no reason to suspect that the incidence of AML in India is lower than anywhere else in the world), if one were to extrapolate the SEER
ª 2015 John Wiley & Sons Ltd, British Journal of Haematology
data from the USA (http://seer.cancer.gov/statfacts/html/ amyl.html), India, with a population four times that of the USA, should have 83 320 newly diagnosed cases of AML every year. In USA about 6% of the newly diagnosed AML are below 20 years of age. However, the population pyramid in India is such that individuals aged below 15 years old account for 30% of the population while a similar age group would be about 19% of the population in the USA (https:// en.wikipedia.org/wiki/Demographics_of_India, last accessed 27 October 2015). Taking these factors into account, there should be approximately 7500–10 000 newly diagnosed cases of paediatric AML in India every year. Based on these figures, the numbers presented by the authors represent 2–3% of the paediatric AML cases that should have been diagnosed in the country. It is pertinent to ask the question that is currently socially very relevant: What happened to the remaining 97–98% and where are they? Further, token cytoreductive therapy or therapy limited to induction needs to be actively excluded from these calculations. We are not suggesting that this is the case with the data presented by Gupta et al, but it is not an uncommon practise in India. Worldwide, it is a well-recognized fact that AML is one of the most expensive haematological conditions to treat. If the challenges of access to medical care, low government health expenditure resulting in out of pocket expenses, which at one time was the highest in the world (Balarajan et al, 2011), leading to 39 million people falling below the poverty line, do not apply to this disease as suggested by the utopian model being presented here then we fail to see what other disease process could contribute proportionally to such distressing figures. It is also well recognized that 50–70% of primary health care is provided, depending on location, by the private sector (Yeravdekar et al, 2013). For high-end and complex medical care these figures are likely to be much higher, though they have not been systematically evaluated. In this context one needs to ask why perfectly rational human beings would choose the private sector for such expensive medical care, driving them to destitution, when figures of such quality of care at 90% cost support, as presented by Gupta et al, exists in the country and, in their opinion, is widely available. The only conclusion that can be drawn is that these are token model systems that do not in any way represent the average public health care delivery system. In fact, the lack of facilities for diagnosis, prognostication and treatment outside the major cities is the norm
doi: 10.1111/bjh.13857
Correspondence rather than the exception in India. Why else would families have to travel more than 500 km to receive treatment, as pointed out by us and corroborated by Gupta et al? While we have no doubt about the dedication and commitment of the authors, who all work in fairly challenging conditions, it does not help to believe or reassure the powers that be, that what is achieved within these few centres, both in terms of cost and outcomes, is reflective of what is happening in the country at large. We believe that health care delivery, specifically the treatment of expensive haematological malignancies such as AML, are too important to be left to token model systems of health care delivery or to the whims and limitations of charities, but rather should be the responsibility of the government and concerted efforts at every level are required to ensure that this is delivered.
References Balarajan, Y., Selvaraj, S. & Subramanian, S.V. (2011) Health care and equity in India. Lancet, 377, 505–515. Philip, C., George, B., Ganapule, A., Korula, A., Jain, P., Alex, A.A., Lakshmi, K.M., Sitaram, U.,
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Chepsy Philip Biju George Anu Korula Alok Srivastava Poonkuzhali Balasubramanian Vikram Mathews Department of Haematology, Christian Medical College, Vellore, India. E-mail:
[email protected]
Keywords: acute myeloid leukaemia, real world data, health economics, health care delivery
Abubacker, F.N., Abraham, A., Viswabandya, A., Srivastava, V.M., Srivastava, A., Balasubramanian, P. & Mathews, V. (2015) Acute myeloid leukaemia: challenges and real world data from India. British Journal of Haematology, 170, 110– 117.
Yeravdekar, R., Yeravdekar, V.R., Tutakne, M.A., Bhatia, N.P. & Tambe, M. (2013) Strengthening of primary health care: key to deliver inclusive health care. Indian Journal of Public Health, 57, 59–64.
ª 2015 John Wiley & Sons Ltd, British Journal of Haematology
