Acute Myeloid Leukemia in Western Kenya: Exploring Outcome Disparities through Cases

Introduction: For young adults with acute myeloid leukemia (AML) in the United States, 60-80% can achieve complete remission and 33% can be cured with intensive treatment; in India that figure drops to overall 1-year survival of 55.6%; in Western Kenya overall 1-year survival is less than 10%. In the United States, achievement of complete remission is an appropriate goal. As described in Wanjiku 2021, in western Kenya, patients are typically not treated with standard induction therapy due to lack of supportive care. Three cases of children and young adults in Eldoret, Kenya with AML in the month of April 2022 are discussed to elucidate barriers to successful treatment in resource-limited settings.

Cases: Case 1 (WK) is a 19 year old man with symptoms of dizziness, fatigue, abdominal pain, and wasting for one year, referred from Kericho District Hospital with bone marrow aspirate suspicious for acute myeloid leukemia, referred for flow cytometry, cytogenic/molecular studies, chemotherapy and management of acute myeloid leukemia. Family paid in advance for flow cytometry. Prior to referral he received hydroxyurea, allopurinol, and 6 units of blood. Hemoglobin on arrival was 4.0 g/dL, white blood cells 64.5, platelets 16. Four units of blood were ordered, only one was available. His condition deteriorated and he died of respiratory failure. Case 2 (WC) is a 16 year old man with puffy face, severe pallor, nosebleeds, and exercise intolerance, referred from Kericho District Hospital with bone marrow aspirate suspicious for acute myeloid leukemia. Hemoglobin was 5.5 g/dL, white blood cells 15, platelets 52. Five units of blood were ordered, no blood was available. Family paid in advance for chemotherapy, and he was started on "prephase 1" etoposide 50mg/m2 IV infusion over 1 hour for 6 days, then discharged to follow up in oncology clinic in two weeks. Case 3 (MK) is a 25 year old woman local to Eldoret, with one week of generalized body pain, abdominal pain, and weakness. Peripheral blood smear demonstrated 90% blasts and reduced platelets, and she presented to the hospital for bone marrow aspiration and blood transfusion. Initial hemoglobin 2as 5.2 g/dL, WBC 28.9, platelets 71. Five units of blood were ordered, and she received four. Bone marrow aspirate reported nonspecific features of acute leukemia, flow cytometry reported 93% blasts, AML-M0.

Discussion: Significant disparities and barriers exist in the treatment of acute myeloid leukemia in resource-limited settings. The first step is diagnosis, including awareness and access to early treatment and diagnostic capabilities. Anecdotally, the rate of AML in the Kericho region is attributed to environmental exposures related to tea farming. In the setting of Western Kenya, some patients especially in Eldoret and Kericho had access to bone marrow aspirate and referral capability to flow cytometry. The next major barrier identified was supportive care, including scarcity of blood products. In April, the blood shortage was reported to be related to federal holiday, meaning that classes of school students and military recruits were not coming to donate blood on a regular basis. The next major barrier was induction of chemotherapy, including the practice of low-dose chemotherapy (low-dose cytarabine or etoposide alone) without intent to cure, due to concerns of managing the complications of induction chemotherapy. On the far end of the treatment spectrum, bone marrow transplant was not an option in the country of Kenya, and patients seeking this treatment option were obligated to travel abroad.

Conclusion: Key barriers exist to treatment of AML in western Kenya, which contribute to disparities in outcomes of young adults with AML in western Kenya compared to the United States. Barriers identified from examining cases included access to bone marrow aspiration and flow cytometry, availability of blood products, choice of chemotherapy approach (low-dose versus standard induction), supportive care environment, and availability of treatment options including bone marrow transplant. More research is needed to identify the causes of death for patients in this local population, and create a system that can reduce the international disparities and move towards equitable goals of remission and cure.

References: Wanjiku CM, Melly B, Kilach C, et al. Acute Myeloid Leukemia in Western Kenya: A Snapshot [ASH abstract 1223]. Blood. 2021;138(Supplement 1):1223.

No relevant conflicts of interest to declare.