Viana M B, Fernandes R A, de Carvalho R I, Murao M
Department of Pediatrics, Federal University of Minas Gerais, Belo Horizonte, Brazil.
Int J Cancer Suppl. 1998;11:56-61.
The results of the treatment of acute lymphoblastic leukemia (ALL) in children depend not only on the biologic diversity of the leukemia cell, the multi-drug treatment schedule and the individual variability of drug metabolism, but also on the socioeconomic and cultural background of the leukemic child. Social and cultural disparity is very marked in underdeveloped countries and has been increasing in industrialized nations. The prognostic influences of these factors are poorly documented and sometimes mistakenly attributed to differences in ethnic origin. We have investigated in Brazil the relative impact of malnutrition and socioeconomic status on the outcome of ALL, adjusting for the known influence of biologic factors. Children with ALL (n = 167) treated with a Berlin-Frankfurt-Munster-based protocol were studied prospectively. At a median follow-up of 1623 days, the estimated probability of disease-free survival was 43 +/- 4%. The main cause for interruption of remission was bone-marrow relapse. Socioeconomic indicators of poverty (poor housing conditions, low per capita income and energy consumption) were significantly associated with a greater risk of relapse in univariate analysis. They were consolidated in a single index, socioeconomic status (SES), defined by the product of monthly per capita income times mean familial daily energy consumption. Other unfavorable findings included age, z score for the height for age at diagnosis (HAZ) below-1.28 and the z score for weight for age below-1.28. After adjustment in Cox's multivariate model, only HAZ and poor SES remained as predictive factors for relapse. Poor prognosis for leukemic children of low SES is just another indicator of social inequality.
儿童急性淋巴细胞白血病（ALL）的治疗结果不仅取决于白血病细胞的生物学多样性、多药治疗方案以及药物代谢的个体差异，还取决于白血病患儿的社会经济和文化背景。社会和文化差异在欠发达国家非常显著，在工业化国家也呈上升趋势。这些因素对预后的影响记录不足，有时还错误地归因于种族差异。我们在巴西研究了营养不良和社会经济地位对ALL预后的相对影响，并对已知的生物学因素影响进行了校正。对采用基于柏林-法兰克福-明斯特方案治疗的ALL患儿（n = 167）进行了前瞻性研究。在中位随访1623天时，无病生存的估计概率为43±4%。缓解期中断的主要原因是骨髓复发。在单因素分析中，贫困的社会经济指标（住房条件差、人均收入低和能源消耗低）与更高的复发风险显著相关。这些指标合并为一个单一指数，即社会经济地位（SES），由人均月收入乘以家庭每日平均能源消耗得出。其他不利因素包括年龄、诊断时年龄别身高z评分（HAZ）低于 -1.28以及年龄别体重z评分低于 -1.28。在Cox多变量模型校正后，只有HAZ和低SES仍然是复发的预测因素。社会经济地位低的白血病患儿预后不良只是社会不平等的另一个指标。
