Impact of healthcare setting on survival in adults with acute lymphoblastic leukemia in Latin America: insights from a large multinational cohort.
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BACKGROUND: Outcomes of adults with acute lymphoblastic leukemia (ALL) in Latin America remain poorly characterized, particularly across public and private healthcare systems. In this study, we evaluated overall survival (OS) and relapse rates in a multinational cohort, aiming to identify key factors associated with these outcomes. METHODS: We retrospectively analyzed patients aged ≥15 years with newly diagnosed ALL treated at 45 centers in Brazil, Argentina, and Chile between 2015 and 2023. Overall survival (OS) and event-free survival (EFS) were estimated using Kaplan-Meier methods. Cox models incorporating country as a shared frailty term evaluated factors associated with mortality. FINDINGS: Among 1121 patients, median age was 34 years, 56.1% were male, 81.4% had B-lineage ALL, and 24.7% had Philadelphia chromosome-positive (Ph-positive) ALL. Overall, 53% were treated in public centers. Induction mortality was higher in public than private settings (10.0% vs. 1.2%; p < 0.0001), whereas hematopoietic stem cell transplantation was less frequent (18.1% vs. 46.6%; p < 0.0001). At a median follow-up of 36.2 months, 3-year OS and EFS were 49.9% and 41.1%, respectively. Three-year OS was 42.9% in public and 57.6% in private centers (p < 0.0001). Private healthcare remained independently associated with lower mortality overall (HR 0.53, 95% CI 0.42-0.68) and across major subgroups. Three-year relapse incidence was 43.9%. Among Ph-negative adolescents and young adults, male sex and leukocytosis were independently associated with increased mortality. In Ph-positive ALL, upfront dasatinib was associated with improved OS, primarily through lower non-relapse mortality rather than reduced relapse incidence. INTERPRETATION: Survival of adults with ALL in Latin America has improved compared with historical reports, but substantial disparities persist between public and private settings. Our findings support prioritizing investment in public-sector supportive care, diagnostic and treatment infrastructure, timely access to transplantation, and equitable availability of effective therapies as key strategies to improve survival across the region. FUNDING: None.