Challenges in Leukemia Diagnosis and Treatment in Mexico: A Survey By the Alliance for Leukemias in Mexico on Resource Availability, Infrastructure, and Access to Advanced Therapies for Leukemia Patients

Introduction
Leukemias have seen significant advancements in recent years due to improved understanding of the disease, risk stratification, supportive care, and novel therapies. In Mexico, as in other low—and middle-income countries, outcomes are generally inferior, largely due to limited access in an environment of great disparity. The objective of this study was to identify the factors associated with differences in access to resources and infrastructure for diagnosis, risk stratification, follow-up, and advanced therapies.

Methods
A survey was conducted among onco-hematologists (pediatric and adult) treating leukemia patients across the country using the RedCAP platform. Questions were asked about available resources as well as the most significant barriers to leukemia treatment and how they would prioritize a project to improve patient care. In this abstract, we will not report the data related to drug-access.

Results
We analyzed data from 175 physicians practicing in 30 Mexican states. Among respondents, 42% were located in major cities like Mexico City, State of Mexico, and Nuevo León (CDMX/EDOMEX/NL). Public practice constituted 72% of respondents (equally divided between secondary and tertiary care), while private practice made up the remaining 28%. A majority (61.7%) treated adult patients, with 28.6% treating children and 9.7% managing both. The median experience was 11 years (range 0-45). Notably, only 29.5% reported having a dedicated leukemia clinic.

Nearly all respondents (93.1%) had access to an intensive care unit (ICU) and a blood bank (91.4%). However, institutional programs for hematology-oncology residents varied significantly: 33.3% in public institutions vs. 6.1% in private (p<0.001), 60.9% in tertiary care vs. 4.7% in secondary (p<0.001), and 46.6% in CDMEX/EDOMEX/NL vs. 10.9% elsewhere (p<0001). Similarly, access was higher in the Central region (36.6%) compared to the North (13.3%) and South (7.1%) (p=0.001).

Flow cytometry (FC) was the most accessible diagnostic tool (99.4%). However, only 33.7% had local access (within the institution), while 44% relied on an external lab agreement, and 17.1% depended solely on out-of-pocket payments for external labs without reimbursement. Local access to FC was significantly higher in CDMEX/EDOMEX/NL (OR 12.64, 95% CI: 5.87-27.22) and tertiary care (OR 25.00, 95% CI: 8.06-77.51). Conversely, out-of-pocket payment reliance was more common outside CDMEX/EDOMEX/NL (OR 8.54, 95% CI: 2.47-29.54) and in secondary care (OR 3.26, 95% CI: 1.09-9.81).

Access to karyotyping followed a similar pattern: 84.5% overall, with 23.3% having local access, 39.4% relying on external labs, and 18.9% dependent on out-of-pocket payments. Similar to FC, local access was higher in CDMEX/EDOMEX/NL (OR 3.75, 95% CI: 1.76-7.96) and tertiary care (OR 10.26, 95% CI: 3.32-31.72). Out-of-pocket payment reliance was more likely outside CDMEX/EDOMEX/NL (OR 5.42, 95% CI: 1.97-14.96) and in secondary care (OR 5.94, 95% CI: 1.83-19.31).

Next-Generation Sequencing (NGS) access was significantly lower at 43.4%. Only 16.1% had access through external labs, while 15.5% relied solely on out-of-pocket payments. Access was more likely in private practice compared to public (OR 9.14, 95% CI: 4.13-20.24) and in tertiary care (OR 10.26, 95% CI: 3.32-31.72). Out-of-pocket payment reliance was again more common outside CDMEX/EDOMEX/NL (OR 3.96, 95% CI: 1.44-10.88).

Physicians identified access to diagnostic and risk stratification tests as the primary barrier to managing leukemia patients (64.2% ranked it as priority 1 or 2 out of 7). This was followed by access to drugs (47.7%). Similarly, improving access to diagnostic/stratification tests was ranked as the top priority for a leukemia care improvement program (73.0%)

Conclusions
This project establishes a strong foundation for an implementation project focused on overcoming existing disparities in leukemia care across Mexico. The identified heterogeneity in access, with a significant portion of patients treated outside major centers, necessitates novel, decentralized approaches to ensure universal access to essential diagnostic, risk stratification, and follow-up tests. Future efforts should prioritize the development and evaluation of such decentralized strategies to improve patient outcomes nationwide.