{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T08:07:52Z","timestamp":1772611672499,"version":"3.50.1"},"reference-count":26,"publisher":"American Society of Clinical Oncology (ASCO)","issue":"11","content-domain":{"domain":["ascopubs.org"],"crossmark-restriction":true},"short-container-title":["JCO Glob Oncol"],"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:sec>\n                    <jats:title>PURPOSE<\/jats:title>\n                    <jats:p>For children with ALL in low- and middle-income countries (LMICs), treatment regimen adaptation based on local contexts is often necessary. However, the clinical impact of such modifications is poorly understood. The purpose of this study is to examine pediatric ALL treatment regimens used in LMICs, assess for patterns in adaptation to identify common barriers affecting global delivery of ALL care, and describe the breadth of outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>Using the PRISMA guidelines, a systematic review was conducted, across seven databases, of ALL regimens use in LMICs in 2000-2021, documenting the geographic distribution of treatment backbone adoption, regimen modifications, and outcomes. Article characteristics were summarized using descriptive statistics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>\n                      Of 13,900 articles, 125 met abstraction criteria. Data spanned 36 countries (6.4% low-income, 43.2% lower-middle\u2013income, 50.4% upper-middle\u2013income) and 163 regimens, of which 138 (84.6%) referenced a high-income ALL collaborative group regimen as a backbone. Sixty-four percent of regimens (n = 104) were adapted. Individual modifications (n = 390) were consolidated into 73 distinct regimen changes; reduction\/omission of high-dose methotrexate, observed in 30 modified regimens (28.8%), was the most common. Implementation challenges, such as drug access and cost, were cited more frequently than toxicity as the rationale for modification; however, implementation outcomes (eg, feasibility, cost) were only measured in 6.4% of articles. Across all outcomes, 5-year overall survival was higher with modified versus unmodified regimens (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      = .030).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSION<\/jats:title>\n                    <jats:p>Although implementation barriers are primary drivers of ALL regimen adaptations globally, the paucity of reported implementation outcomes represents a methodological gap in the literature. Incorporating implementation science methods and frameworks is critical for the timely and effective delivery of innovative treatment regimens across resource settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1200\/go-25-00286","type":"journal-article","created":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T20:57:17Z","timestamp":1765832237000},"update-policy":"https:\/\/doi.org\/10.1200\/crossmark","source":"Crossref","is-referenced-by-count":1,"title":["Pediatric ALL Treatment Modifications in Low- and Middle-Income Countries: A Systematic Review"],"prefix":"10.1200","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3352-0841","authenticated-orcid":true,"given":"Caitlyn","family":"Duffy","sequence":"first","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Savannah","family":"Allen","sequence":"additional","affiliation":[{"name":"University of South Carolina, Columbia, SC"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0484-1574","authenticated-orcid":true,"given":"Thomas B.","family":"Alexander","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University of North Carolina, Chapel Hill, NC"},{"name":"Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2122-560X","authenticated-orcid":true,"given":"Eden C.","family":"Andrew","sequence":"additional","affiliation":[{"name":"Royal Children's Hospital Melbourne, Parkville, Australia"},{"name":"Hospital for Sick Children, Toronto, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manoo","family":"Bhakta","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6619-5291","authenticated-orcid":true,"given":"Nancy S.","family":"Bolous","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Miguel","family":"Bonilla","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3014-9204","authenticated-orcid":true,"given":"Lisa M.","family":"Force","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Hematology\/Oncology, and Department of Health Metrics Sciences, University of Washington, Seattle, WA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Catherine","family":"Habashy","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University of North Carolina, Chapel Hill, NC"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-4915-3403","authenticated-orcid":true,"given":"Jeremy","family":"Hassan","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cody","family":"McMillan","sequence":"additional","affiliation":[{"name":"Center for Advanced Practice, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael J.","family":"McNeil","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3421-5945","authenticated-orcid":true,"given":"Marta","family":"Salek","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tonya","family":"Ureda","sequence":"additional","affiliation":[{"name":"Department of Epidemiology &amp; Cancer Control (HPV Cancer Prevention Program), St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4586-8933","authenticated-orcid":true,"given":"Ruth","family":"Wang'ondu","sequence":"additional","affiliation":[{"name":"Center for Leukemia Studies, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9835-842X","authenticated-orcid":true,"given":"Becky","family":"Wing-Yan Yuen","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1099-3478","authenticated-orcid":true,"given":"Meenakshi","family":"Devidas","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1066-2879","authenticated-orcid":true,"given":"Heather M.","family":"Brandt","sequence":"additional","affiliation":[{"name":"Department of Epidemiology &amp; Cancer Control (HPV Cancer Prevention Program), St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1790-2679","authenticated-orcid":true,"given":"Michelle L.","family":"Hermiston","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University of California San Francisco, San Francisco, CA"},{"name":"College of Health Sciences, VinUniversity, Hanoi, Vietnam"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5282-7833","authenticated-orcid":true,"given":"Nickhill","family":"Bhakta","sequence":"additional","affiliation":[{"name":"Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"233","reference":[{"key":"e_1_3_10_2_2","unstructured":"Surveillance Research Program NCI: SEER*Explorer: An interactive website for SEER cancer statistics. 2023"},{"key":"e_1_3_10_3_2","doi-asserted-by":"publisher","DOI":"10.3324\/haematol.2020.247031"},{"key":"e_1_3_10_4_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa0900386"},{"key":"e_1_3_10_5_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1400972"},{"key":"e_1_3_10_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(19)30273-6"},{"key":"e_1_3_10_7_2","unstructured":"World Health Organization: CureAll framework: WHO global initiative for childhood cancer: Increasing access advancing quality saving lives. 2021"},{"key":"e_1_3_10_8_2","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-1-1"},{"key":"e_1_3_10_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(18)30909-4"},{"key":"e_1_3_10_10_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10488-010-0319-7"},{"key":"e_1_3_10_11_2","doi-asserted-by":"publisher","DOI":"10.1080\/01621459.1952.10483441"},{"key":"e_1_3_10_12_2","volume-title":"The World by Income and Region Historical Classification by Income in XLS Format","author":"World Bank","year":"2023","unstructured":"World Bank: The World by Income and Region Historical Classification by Income in XLS Format. 2023"},{"key":"e_1_3_10_13_2","unstructured":"World Health Organization: Countries. https:\/\/www.who.int\/countries"},{"key":"e_1_3_10_14_2","doi-asserted-by":"publisher","DOI":"10.1097\/MPH.0b013e31817e4a7d"},{"key":"e_1_3_10_15_2","doi-asserted-by":"publisher","DOI":"10.1002\/pbc.26281"},{"key":"e_1_3_10_16_2","doi-asserted-by":"publisher","DOI":"10.3109\/08880018.2011.629859"},{"key":"e_1_3_10_17_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00277-014-2106-0"},{"key":"e_1_3_10_18_2","doi-asserted-by":"publisher","DOI":"10.1002\/pbc.28667"},{"key":"e_1_3_10_19_2","doi-asserted-by":"publisher","DOI":"10.3389\/frhs.2023.1204138"},{"key":"e_1_3_10_20_2","doi-asserted-by":"publisher","DOI":"10.1097\/00043426-200011000-00004"},{"key":"e_1_3_10_21_2","doi-asserted-by":"publisher","DOI":"10.1186\/s41241-020-00088-9"},{"key":"e_1_3_10_22_2","unstructured":"World Health Organization: WHO Model List of Essential Medicines for Children - 9th List 2023. 2023. https:\/\/www.who.int\/publications\/i\/item\/WHO-MHP-HPS-EML-2023.03"},{"key":"e_1_3_10_23_2","unstructured":"St. Jude Global: Global platform for access to childhood cancer medicines. St. Jude Children's Research Hospital World Health Organization. https:\/\/global.stjude.org\/en-us\/featured\/global-platform-for-access-to-childhood-cancer-medicines.html"},{"key":"e_1_3_10_24_2","unstructured":"ARIA Guide: Pediatric Oncology Guidelines. 2023. https:\/\/aria.stjude.org\/"},{"key":"e_1_3_10_25_2","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-4-50"},{"key":"e_1_3_10_26_2","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-8-139"},{"key":"e_1_3_10_27_2","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-015-0209-1"}],"container-title":["JCO Global Oncology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/ascopubs.org\/doi\/pdfdirect\/10.1200\/GO-25-00286","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T20:57:34Z","timestamp":1765832254000},"score":1,"resource":{"primary":{"URL":"https:\/\/ascopubs.org\/doi\/10.1200\/GO-25-00286"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12]]},"references-count":26,"journal-issue":{"issue":"11","published-print":{"date-parts":[[2025,12]]}},"alternative-id":["10.1200\/GO-25-00286"],"URL":"https:\/\/doi.org\/10.1200\/go-25-00286","relation":{},"ISSN":["2687-8941"],"issn-type":[{"value":"2687-8941","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12]]},"assertion":[{"value":"2025-05-28","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-09-09","order":1,"name":"revised","label":"Revised","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-10","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-12-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e2500286"}}