Evaluating Risk Factors for Early Mortality in Adult ALL in Brazil

PURPOSE Adult ALL is typically treated with intensive chemotherapy although novel agents like blinatumomab and inotuzumab remain largely inaccessible in low- and middle-income countries (LMICs). Early mortality (EM) during induction is substantially higher in LMICs (10%-25%) than in high-income countries (<5%). This study aimed to identify EM risk factors in patients with adult ALL in LMICs to guide context-specific interventions. METHODS A retrospective cohort study analyzed patients 15 years and older with newly diagnosed ALL between 2009 and 2023, regardless of the phenotype or Philadelphia status. EM was defined as death within 30 days of diagnosis. RESULTS Among 203 patients (median age 36 years), the overall EM was 9.8% and 7.9% was younger than 50 years. Univariate analysis identified positive cerebral spinal fluid, cyclophosphamide during the prephase, low albumin, and obesity as associated with higher EM. In multivariable models, predictors of EM for the full cohort included age, albumin, cyclophosphamide use, and obesity. In patients 50 years and younger, only albumin and cyclophosphamide remained significant. After induction, 51.2% achieved complete response; 17.3% was unevaluable because of complications or death. Infection was common (72.9%). Sociodemographic variables were not associated with EM. CONCLUSION EM was elevated, reflecting LMIC-specific challenges like late diagnosis and limited supportive care. Low albumin and prephase cyclophosphamide use were strongly linked to EM, likely via increased immunosuppression and infection risk. Findings stress the need for locally adapted protocols and simple risk markers to reduce EM in adult ALL.