January 19, 2007

Sanctions impacted pediatric leukemia survival rates: study

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Haydar Frangoul, M.D.

Sanctions impacted pediatric leukemia survival rates: study

A study by Vanderbilt's Haydar Frangoul, M.D., shows an increase in the death rate among Iraqi children who were treated for leukemia in Baghdad while United Nations sanctions were in place.

Frangoul examined the records of 670 children treated for acute lymphocytic leukemia (ALL) at the Children's Welfare Teaching Hospital in Baghdad between 1990 — when the sanctions went into effect — and 2002. The records documented missed doses of chemotherapy as well as the reasons for missing it.

Patients who refused or discontinued therapy or were lost to follow up before the completion of therapy were excluded from the analysis.

The overall 5-year survival of children who received all of their doses of standard chemotherapy was significantly better — 81 percent — than those who missed doses due to shortage — 58 percent.

This significant difference was observed in children with both high-risk ALL (72 percent survival versus 49 percent survival for those who missed doses) and standard-risk ALL (85 percent survival versus 63 percent).

Frangoul, director of the Pediatric Stem Cell Transplant program at the Monroe Carell Jr. Children's Hospital at Vanderbilt, said the study was a personal one.

It involved the people of his ancestry, and in particular the children who happened to live in Iraq during a time of serious international dispute.

Frangoul, who was born in Baghdad but left in 1975 at the age of 12, has been in touch with co-authors of this study since 1999.

“Dr. Salma Al-Hadad and Dr. Mazin Al-Jadiry are the only two pediatric oncologists at the University of Baghdad Children's Hospital. I have been helping them through the years with treatment plans and other medical questions,” Frangoul said.

“They have been frustrated because there was not enough chemotherapy for children. They had been telling me that medicines were often not getting through and there were limits on other things, like parts for the radiation machinery.”

“The doctors said they often felt like their cancer unit was more like a hospice than a hematology practice,” Frangoul said.

“They reported that if they had 20 or 30 doses of chemotherapy and 80 children who needed it, they would spread it out so all the children would receive some treatment.

“There were also significant limitations in diagnostic and supportive care measures, including a significant shortage in antibiotics.”

Frangoul said this study shows two things.

First, children who do not receive all their prescribed chemotherapy are at higher risk of death, which reinforces the idea that currently prescribed chemotherapy is appropriate and effective.

“But second, and more importantly, is the evidence that those children who were able to receive all their chemotherapy had survival rates comparable to those seen in developed countries despite the lack of sophisticated diagnostic tools and limited supportive care,” Frangoul said.

Frangoul presented the study's results last month at a meeting of the American Society of Hematology.

“It was interesting because some of the people who were there expressed sadness and some outrage, but perhaps as many expressed that there was little that could be done — it's politics.

“I hope this study will add to other studies showing that there are unintended consequences to United Nations sanctions that are underappreciated.”