Abstract
Background Acute myeloid leukemia (AML) is a clinically and biologically complex disease. During the last decade, classification, prognostic scores and treatment have been reviewed. AML with PML::RARA fusion (acute promyelocytic leukemia, APL) has a better prognosis when treatment, based on trans retinoic acid (ATRA), plus arsenic trioxide (ATO) or chemotherapy is not delayed. In Bolivia there is a scarce availability of drugs for the treatment of AML. Very few are commercially available but only daunorubicin, doxorubicin and cytarabine are provided by the public health insurance called, Seguro universal de Salud (SUS). ATRA isn't even imported to the country and most of the support treatments aren't available either. Cochabamba is the third biggest city of the country, with 2.005.373 inhabitants. Hospital Viedma, is the only tertiary public hospital of the city that manages oncologic patients from SUS. It still carries paper-based charts and most of the data from patients who die or loose follow up are destroyed or stored and unavailable for review. Aims. To describe the characteristics of the AML population in our scenery and to know if the basic standards for diagnosis and treatment are met. Methods. We created a record coming from the hospital statistics department and our own bone marrow aspirate (BMA) registry from January 2019 to December 2024 (58 patients). We managed to review, 36 medical records of adult AML patients with a minimal time from diagnosis to analysis of four months. Demographics, baseline disease characteristics, treatment and response were collected. Results. Twenty (55.6%) were from the capital. Five (14%) had APL, all of them diagnosed in 2024. APL patients: Four (80%) were male between ages 19 and 41 years. All of them had hypofibrinogenemia and thrombocytopenia; Four (80%) had bleeding complications; 3 of them, CNS hemorrhages, (2 died, unable to get ATRA). Three (60%) were treated with ATRA (but delayed) with an anthracycline, and achieved complete responses after induction, 2, didn't continue to consolidation, but are alive 11 and 5 months after induction treatment. None of the patients were admitted to the intensive care unit, or received fibrinogen concentrates. The remaining 31 (86%) AML patients had a median of age at diagnosis of 35 years (R 15-79), 13 (42%) were male and 18 (58%) female. None of the patients in our hospital had baseline cytogenetic tests, and four (15%) had a molecular biology test via PCR (PML; RARA, FLT3, NPM1, CEBPA, or BCR/ABL). Four patients were not assessed due to previous diagnosis or treatment in other hospitals. Of 27 newly diagnosed AML patients (non APL), 3 (11%) are alive, and the remaining had abandoned treatment (7, 27%), or died (17, 62%). The main cause of death registered were infections (7, 41%) and relapse/progressive disease (5, 29.4%). Seven (26%) had hyperleukocytosis at diagnosis. Twenty-three (85%) received intensive treatment with 7 plus 3. Sixteen (70%) received daunorubicin and 7 (30%) doxorubicin at 30 mg/m2. Mean time from diagnosis to treatment was 12 days, and median time of hospital stay was 18 days. None of the patients received anti-fungal prophylaxis. Seven (26%) treated patients died within 30 days, 2 of them the first week since diagnosis, and 3 (11%) abandoned follow up after discharge. Out of the 14 (52%) first-month survivors, 8 (57%) achieved morphological complete response (CR) with MRD negative disease by flow cytometry analysis. Four (28.5 %) did not achieve a CR and 2 (14.2%) failed to do the reevaluation. Three (75%) of the patients that didn't attain CR, received the same first line treatment again and none of them survived. Conclusions. This report shows real-word evidence on management of AML in Bolivia. Relevant information was missed due to deficient medical record management. We couldn't classify or stratify risk according to international guidelines due to missing basic diagnostic tests. There is a high rate of treatment abandonment in our population, probably due to socio-economic factors. We have a younger population of AML patients compared to most epidemiological evidence, with a high mortality rate and virtually no access to targeted or second-line treatments. Shortness of ATRA availability is especially challenging. We need extensive report on cases from other hospitals throughout the country to better understand AML in Bolivia in order to improve patient care and insurance coverage in our country.
