The Role of a Multi-Center Tumor Board Discussion in Managing Acute Leukemia in Under-Resourced Settings

Background: Most of the global population lives in under-resourced settings (URS), wherein management of acute leukemia (AL) is particularly challenging amid reduced access to standard of care treatments and inadequate infrastructure. While infrastructure development in URS will take time, we proposed a bidirectional exchange of knowledge through participation in acute leukemia tumor boards (ALTB) as an achievable short-term goal. We created this initial step toward delivering high-quality AL care in URS to foster awareness about the unique challenges faced across different settings and provide a platform to enhance learning and collaboration. This project aimed to assess the feasibility of initiating a multi-center ALTB discussion for managing adult patients with AL at the Academic Model for Providing Access to Health (AMPATH) in Western Kenya.

Methodology: An ALTB was established by approaching AL clinicians and staff at institutions interested in global oncology. A proposal was made highlighting the need, objectives, structure, and expected impact of the ALTB. Thirty-one clinicians (21 physicians, 1 physician assistant, 4 residents, 3 fellows, and 2 administrative personnel) from AMPATH and eight institutions across the US participated over one year via a virtual video platform. Clinicians from western Kenya presented AL cases, outlined the available management plan, and highlighted any challenges to implementation. This was followed by a didactic presentation related to the evidence-based standard of care, potential modifications to the treatment plans, gaps in care identified, and all clinicians reflecting on ways to improve AL care in Kenya and the US. At the end of the first year of ALTB, we collected data on the new AL cases identified and received feedback from participants on how ALTB impacted patient care.

Results and discussion Six ALTB sessions were planned, four occurred, and 6 out of 60 new AL cases were discussed between July 2021 and June 2022. Conflicting schedules and patient care activities at AMPATH postponed two sessions. The rate of active participation was 45% (n=14). Knowledge and experience managing different types of AL were shared through discussions surrounding the cases presented. Gaps identified included limited diagnostics with the absence of cytogenetics, infection control, and lack of AL clinical trials in Kenya and surrounding countries. To enhance awareness across settings, the ALTB reviewed the currently available diagnostic and treatment options for AL patients in Kenya, which is constituted almost entirely of traditional, non-targeted chemotherapy. Suggestions on improving AL care during the ALTB were implemented and directly impacted care. These included adding flow cytometry to cytology when confirming remission, improvement in care coordination, and protocol revisions to reduce treatment toxicity while maintaining effectiveness. Of note, the median overall survival of patients with AML at AMPATH was 45 days in 2020 and 150 days in 2022. Participants acknowledged the importance of learning how AL care is delivered in URS and well-resourced settings (WRS). However, participants in URS felt case presentations from WRS would also be essential for learning. Future directions for our team include expanding to more institutions in URS and WRS and strengthening the bidirectionality of cases shared. We also plan to add e-consults to allow for collective in-the-moment input on patient care and to account for when synchronous ALTB sessions are postponed. This broad understanding of existing gaps in care and increase in partnerships will help advocate for future interventions, including infrastructure development and clinical trials, to provide feasible and effective treatment options for people living with AL worldwide. This initial year-long effort shows that gathering and engaging a multi-center ALTB is feasible.

Conclusion We have demonstrated the feasibility of a virtual multicenter ALTB in fostering collaborative AL care. We also met our initial goal of creating awareness about the unique challenges of providing AL care in different settings. ALTB impacted patient care as cases were discussed and plans were adjusted in real-time. Our next steps include further exploration of these sessions’ utility and long-term impact on patient care.

LeBlanc:AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; AstraZeneca: Consultancy, Research Funding; Agios/Servier: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astellas: Consultancy; BMS/Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; BlueNote: Consultancy; Flatiron: Consultancy; Genentech: Consultancy; GSK: Consultancy; Pfizer: Consultancy; BeiGene: Honoraria; Seagen Inc: Research Funding; Novartis: Consultancy. Cornetta:Indiana University: Other, Research Funding; Charles River Laboratory: Other; Genezen Inc: Other.