Effect of Malnutrition at the Time of Diagnosis on the Survival of Children Treated for Cancer in El Salvador and Northern Brazil Francisco Pedrosa, M.D., Miguel Bonilla, M.D., Aiyi Liu, Ph.D., Karen Smith, R.D., C.N.S.D., M.S., Diana Davis, B.S., Raul C. Ribeiro, M.D., and Judith A. Wilimas, M.D. Purpose: To investigate the relationship between survival and malnutrition at the time of diagnosis among children treated for cancer in two developing countries. Patients and Methods: We studied 443 children treated for cancer between 1995 and 1998 at two centers in San Salvador, El Salvador, and Recife, Brazil. Median age at diagnosis was 4.9 years; 283 children had leukemia and 160 had solid tumors. Z-scores were calculated for weight for age (WAZ), height for age (HAZ), and weight for height (WHZ) at diagnosis. Z scores <-2 indicated malnutrition. Patients were also stratified by low-risk disease (solid tumors: stage I, stage II, or localized; acute lymphocytic leukemia: white blood cell count <25,000/ L, no central nervous system involvement, no mediastinal mass and age >1 and <10 yrs) and high-risk disease (all other patients, including those with acute or chronic myelocytic leu- kemia). Results: Z-scores indicated malnutrition in 23.5% (WAZ), 22.8% (HAZ), and 15.7% (WHZ) of patients. Z-score was not significantly related to overall survival rates, to survival rates analyzed by type of malignancy or risk status, or to survival rates at the end of the first month of treatment. Conclusions: We found no relationship between nutritional status and survival in these patients. This implies that future protocols for use in developing countries can be designed to provide optimal treatment intensity despite the high incidence of malnutrition. Key Words: Nutrition—Childhood malignancy—Prognostic factors. Malnutrition is a significant pediatric health problem in developing countries. The reported incidence ranges from 8% to 75%, depending on the country, the assess- ment methods used, and the definition of malnutrition (1). Children with malnutrition and cancer may experi- ence delayed treatment, predisposition to infection, and altered drug metabolism (2). Poor nutritional status is generally assumed to adversely affect the prognoses of children treated for malignancies. However, support for this hypothesis is limited by the small size of studies reported to date and by their inconsistent definitions of malnutrition. We analyzed the relationship between mal- nutrition and survival among patients treated for solid tumors and leukemia at two pediatric institutions in Recife, Brazil, and San Salvador, El Salvador. The two centers are affiliated with St. Jude Children’s Research Hospital through its International Outreach Program. PATIENTS AND METHODS Patients were treated between 1995 and 1998 at Hos- pital de Niños Benjamin Bloom, San Salvador, El Sal- vador, and at the Instituto Materno-Infantil de Pernam- buco, Recife, Brazil. The pediatric cancer program in Recife, directed by one of the authors (F.P.), presently provides modern protocol-based care to approximately 100 patients yearly. Its ongoing relationship with St. Jude Children’s Research Hospital was formalized in 1997. The pediatric cancer program in El Salvador, also directed by one of the authors (M.B.), was begun in 1993 with the introduction of a protocol for treating acute lymphocytic leukemia (ALL) that was based on St. Jude’s Total Therapy XIII ALL protocol. After its early modification to reduce the risk for death from infection, this protocol improved the overall survival rate of chil- dren in El Salvador with ALL from approximately 10% to between 50% and 60% (3). Both centers provide care Submitted for publication October 8, 1999; accepted January 4, 2000. From the Departments of Hematology-Oncology (R.C.R., J.A.W.), and Biostatistics and Epidemiolgy (A.L.), the International Outreach Program (R.C.R., J.A.W.), and Clinical Nutrition Services (K.S.), St. Jude Children’s Research Hospital, Memphis, Tennessee, U.S.A.; the Department of Pediatrics (D.D., R.C.R., J.A.W.), University of Ten- nessee College of Medicine, Memphis, Tennessee, U.S.A.; Hospital de Niños Benjamin Bloom (M.B.), San Salvador, El Salvador; and Insti- tuto Materno-Infantil de Pernambuco (F.P.), Recife, Brazil. Supported in part by grant RR00211 from the U.S. Public Health Service General Clinical Research Center and by the American Leba- nese Syrian Associated Charities (ALSAC). Address correspondence and reprint requests to Dr. Judith A. Wilimas, Saint Jude Children’s Research Hospital, Division of Hema- tology/Oncology, 332 North Lauderdale Street, Memphis, TN 38101. E-mail: judith.wilimas@stjude.org Journal of Pediatric Hematology/Oncology 22(6): 502–505, November/December 2000 © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia 502