Background: Acute lymphoblastic leukemia (ALL) requires intensive induction, but implementation of pediatric-inspired regimens in low- and middle-income countries is constrained by diagnostic gaps, procurement instability, and limited supportive-care capacity. We evaluated the feasibility, safety, and affordability of a pragmatically adapted pediatric-inspired induction regimen for adults with Philadelphia chromosome-negative Ph(−) ALL in a Pakistani tertiary hospital. Methods: In this prospective single-center cohort study at the Pakistan Institute of Medical Sciences (December 2024–June 2025), consecutive adults aged 18–50 years with newly diagnosed Ph(−)ALL received an adapted pediatric-inspired induction regimen. The primary outcome was complete remission (CR) after induction, with or without extended induction. Secondary outcomes were early mortality, treatment abandonment, grade 3–4 toxicities, and service delivery feasibility indicators. Affordability was assessed against household income. Results: Among 200 adults (mean age 30.3 ± 8.8 years; 65.5% male), 39.5% presented with WBC ≥ 30 × 109/L and 88.0% with platelets < 50 × 103/µL. CR was achieved in 83.0% of patients. Early mortality was 2.0%, and treatment abandonment was 1.5%. Grade 3–4 toxicities included febrile neutropenia (15.0%) and sepsis (7.5%). The Day-30 evaluability was high (96.5%). Observed out-of-pocket diagnostic costs were USD 119, whereas a guideline-complete diagnostic package would cost USD 929, equivalent to 3–6 months of income for households in the poorest quintile. Conclusions: This adapted pediatric-inspired induction regimen was operationally deliverable in a resource-restricted hospital and produced favorable induction-phase outcomes. Limited diagnostic capacity and a lack of financial protection for testing remain barriers to risk-adapted care. Expanding subsidies for essential diagnostics and stabilizing the procurement of critical agents may yield the greatest implementation gains.
Qazi et al. (Tue,) studied this question.