Editorials
Hematologic diseases Social determinants of health General medicine
Volume 216 - Issue 6

Acute leukaemia in Australia: outcomes have improved, but there is still much to do

Authors:  Zhi Han Yeoh and Andrew W Roberts

Med J Aust 2022; 216 (6): 289-290. || doi: 10.5694/mja2.51446
Published online: 4 April 2022

More than ever, we must remain vigilant about ensuring equitable access to new diagnostic tools and therapeutic options

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More than ever, we must remain vigilant about ensuring equitable access to new diagnostic tools and therapeutic options

As we approach the 50th anniversary of President Richard Nixon’s declaration of the “war against cancer”,1 it is appropriate to recognise the improvement in outcomes for people diagnosed with cancer that have been achieved by major global investment in research.2

Acute leukaemias have a devastating effect, even in people who are ultimately cured by intensive therapy. Indeed, one of the early victories in the campaign against cancer was the development of combination chemotherapy regimens that provided hope of cure for one type of acute leukaemia in children, acute lymphoblastic leukaemia (ALL). The most important factors that influence outcomes for people with acute leukaemia are biological: curability is inversely correlated with age and the complexity of the genetic abnormality of the leukaemia.3,4,5

The principles of treatment developed in the 1970s and 1980s have been applied to all acute leukaemias, with varying success. The analysis of South Australian Cancer Registry data reported by Beckmann and colleagues in this edition of the MJA6 indicates that the greatest improvements in survival have been for people under 15 years of age with ALL, consistent with other reports from Australia and overseas.7,8 In Australia, relative 5‐year survival for children diagnosed with ALL now exceeds 90%.6 However, 5‐year relative survival for people with acute myeloid leukaemia (AML), while slowly improving, remains dismal: 12% in 1988–92, and 26% in 2013–17.6

One challenge is clear: we need better therapies, particularly for older people with leukaemia and for everyone with leukaemias of poor genetic prognosis. The improvements in outcomes over time reported by Beckmann and colleagues6 are attributable to refinements of combination chemotherapy regimens, the introduction of allogeneic bone marrow transplantation, and improved supportive care. The impact of precision medicine was only beginning to be felt during the period covered by their analysis, during which patients with certain genetic subgroups of acute leukaemia benefitted from the addition of targeted therapies, such as imatinib for Philadelphia chromosome‐positive ALL and arsenic trioxide and all‐trans retinoic acid for acute promyelocytic leukaemia.9,10

The full impact of precision medicine‐informed treatment paradigms will only become apparent in the next ten years, once broad access to next generation molecular diagnostic technology is achieved and as several newly approved and subsidised targeted therapies (small molecule drugs for AML, immunotherapies for ALL) are fully integrated into routine care. As major health gains initially require increases in expenditure, costs for pathology, hospital care, and pharmaceuticals for first‐line care will increase. This will be offset by longer term reductions in health care expenditure and rewarded by major increases in survival and quality of life for patients. In this way, essential new diagnostic and therapeutic approaches can be cost‐effective for the health care system as a whole.

Another challenge is to ensure that no‐one is left behind by these advances. Paradoxically, the greater the incremental benefit of advanced therapies, the more likely it is that gaps will open between subgroups of patients with the same disease, despite our universal health care system. It is recognised that survival for people with cancer is poorer for those of lower socio‐economic position. This relationship is well established for most malignancies and in many countries, regardless of whether individual‐ or area‐level socio‐economic position is assessed.11,12 Socio‐economic position is a complex construct encompassing social, financial, and occupational features.13 The influence of socio‐economic position on survival differences is moderate: estimates of the risk of death within five years of cancer diagnosis for the most disadvantaged people are generally 1.3–1.5 times greater than those for the least disadvantaged group.11

While confirming differences in survival for younger and older people with acute leukaemias, Beckmann and colleagues3 found no evidence of socio‐economic or regional disparities in leukaemia survival in South Australia,3 for which we congratulate our South Australian colleagues. The authors attributed this parity of outcomes to highly centralised haematology services and critical philanthropic support for patients and their families during extended treatment stays away from home.

These findings by Beckmann and her colleagues indicate that equitable care can be provided, but not that care for people with acute leukaemia is inherently equitable. Their findings contrast with those of another Australian study which found that mortality was higher among leukaemia patients of lower socio‐economic position,14 as well as with those of several overseas studies.11,15 Highly centralised systems have worked well for younger patients receiving intensive therapies, but not necessarily for older Australians. It is for this group of patients that new precision therapies promise to markedly improve outcomes.

More than ever, we must remain vigilant about ensuring equitable access to new diagnostic tools and therapeutic options, as well as clinical trials, as the treatment of acute leukaemias continues to evolve. Partnerships between community‐based specialists and expert centres are needed to provide all Australians access to the same levels of care.

 

Authors

  • Zhi Han Yeoh1,2
  • Andrew W Roberts1,2
  • 1. Peter MacCallum Cancer Centre, Melbourne, VIC
  • 2. The Royal Melbourne Hospital, Melbourne, VIC

Correspondence: roberts@wehi.edu.au

Competing interests

Andrew Roberts chairs the Life Saving Drugs Program Expert Panel of the Australian Department of Health, is a member of the board of directors of the Australasian Leukaemia and Lymphoma Group (National Collaborative Clinical Trials Group) and the national Blood Cancer Taskforce. One of his employers, the Walter and Eliza Hall Institute, receives royalties for Venetoclax, an approved drug for treating some leukaemias; he receives a share of these royalties from the Walter and Eliza Hall Institute. Andrew Roberts is an inventor on a patent related to Venetoclax dosing; his rights are owned by Melbourne Health and were assigned to AbbVie. Neither Andrew Roberts nor Melbourne Health receives royalties related to this patent.

Acknowledgements

We acknowledge the support of the many not‐for‐profit community‐based organisations that support people affected by leukaemias. Andrew Roberts is grateful for research support from the National Health and Medical Research Council (Investigator grant 1174902).

References

Linked content

  • MJA Research: Changes in five‐year survival for people with acute leukaemia in South Australia, 1980–2016

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library