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In Reply: I agree with Dr Ruiz-Argüelles about the importance of socioeconomic factors in influencing outcome of therapy for ALL. In my Editorial, I did consider socioeconomic factors and my assessment of the data focused on studies conducted in industrialized countries, as both of the 2 articles that I addressed involved children within the United States. While access to therapy is clearly an important issue worldwide, race and ethnicity appear to be an independent prognostic feature when children are treated with identical protocols.^1-2 Adherence is an important issue for ALL, as therapy includes a prolonged maintenance phase with orally administered therapy. Currently there is little information to suggest that black or Hispanic patients show lower rates of adherence to therapy. Although data are limited, parental education and income has not been shown to affect outcomes among children enrolled on cooperative group protocols, and the incidence of major protocol deviations is similar between white, black, and Hispanic patients.^1-2 However, as I mentioned in my Editorial, adherence is difficult to measure and could have accounted for the different outcomes. The impact of cultural and socioeconomic factors on adherence is clearly an important area that requires further study.

Ruiz-Argüelles also suggests that nutritional status might explain differences in outcome. The prevalence of malnutrition is substantially lower in industrialized countries and in patients with ALL in particular (in contrast to solid tumors).³ Studies of the effect of malnutrition on outcome, even from developing countries, have yielded conflicting results.^4-5 A study examining more than 1000 children with ALL treated in the United Kingdom did not find a relationship between nutritional status (measured by body mass index) and outcome.⁶ Malnutrition may be associated with increased morbidity and diminished tolerance of chemotherapy, but differences in major protocol violations were not observed among different ethnic/race groups in the study conducted by the Children's Cancer Group.¹ Thus while malnutrition is likely to play a role in survival in developing countries it is unlikely to have accounted for the differences in the 2 studies I discussed.

William L. Carroll, MD
Program in Pediatric Hematology/Oncology
New York University and Mount Sinai Schools of Medicine
New York, NY

1. Bhatia S, Sather HN, Heerema NA, Trigg ME, Gaynon PS, Robison LL. Racial and ethnic differences in survival of children with acute lymphoblastic leukemia. Blood. 2002;100:1957-1964. FREE FULL TEXT 2. Pollock BH, DeBaun MR, Camitta BM, et al. Racial differences in the survival of childhood B-precursor acute lymphoblastic leukemia: a Pediatric Oncology Group Study. J Clin Oncol. 2000;18:813-823. FREE FULL TEXT 3. Sala A, Pencharz P, Barr RD. Children, cancer, and nutrition—a dynamic triangle in review. Cancer. 2004;100:677-687. FULL TEXT | ISI | PUBMED 4. Viana MB, Murao M, Ramos G, et al. Malnutrition as a prognostic factor in lymphoblastic leukaemia: a multivariate analysis. Arch Dis Child. 1994;71:304-310. FREE FULL TEXT 5. Pedrosa F, Bonilla M, Liu A, et al. Effect of malnutrition at the time of diagnosis on the survival of children treated for cancer in El Salvador and Northern Brazil. J Pediatr Hematol Oncol. 2000;22:502-505. FULL TEXT | ISI | PUBMED 6. Weir J, Reilly JJ, McColl JH, Gibson BE. No evidence for an effect of nutritional status at diagnosis on prognosis in children with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 1998;20:534-538. FULL TEXT | ISI | PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2004;291:2541.

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