Building Collaborations to Improve the Care and Treatment of Children with Cancer in Mexico

Summary

Each year in Mexico, about 7,000 children under 18 years old are diagnosed with cancer, with Acute Lymphoblastic Leukemia (ALL) being the most common cancer diagnosis. Many children face delays in diagnosis and treatment due to barriers like cost, distance, and inconsistent care. Mexico’s fragmented healthcare system adds to these challenges by dividing care into four groups: government employees, formally employed individuals and those who opt in, those who are unemployed or work in the informal economy, and private healthcare patients. Recent decentralization and changes in the health sector have further disrupted care, causing delays in diagnosis, inconsistent treatment, lack of medications, and early treatment abandonment. Uneven access to specialized tests and inconsistent treatment guidelines further worsen outcomes.

The Mexico in Alliance with St. Jude (MAS) cooperative group was launched to address these issues in 2017. MAS is a collaboration between St. Jude Children’s Research Hospital, Casa de la Amistad para Niños con Cáncer, and pediatric hematology-oncology facilities across Mexico. Its mission is to improve the care and survival rates of children with cancer by enhancing diagnosis, treatment, research, and education. Through a network of over one thousand healthcare professionals and 70 institutions, MAS currently reaches 60% of children with cancer in Mexico.

Key pillars of the alliance include:

1. Collaboration: Connecting through workshops, web-based communications, and strategic alliances with healthcare workers, government agencies, non-governmental organizations (NGOs), academic institutions, and professional organizations. All of these efforts create shared responsibility for improving outcomes.
2. Modernization: Standardizing diagnostic care and treatment approaches, including a nationally adapted treatment schema with the Bridge Project.
3. Quality improvement: Implementing programs like Pediatric Early Warning Systems (PEWS), preventing and controlling infection, and reducing sepsis rates through the “Golden Hour” Collaborative.
4. Evidence-based interventions: Fostering data-driven solutions to enhance care using local and global data, and generating clinical and epidemiological research to inform best practices.

Significance

MAS is the first initiative of its kind in Mexico, bringing together hospitals treating children with cancer to improve outcomes. By fostering trust and communication across previously disconnected institutions and sectors, MAS has created tailored strategies for childhood cancer care that address local, regional, and national needs and encourage open dialogue and consensus-driven strategies.

Starting with just eight hospitals, MAS now collaborates with over 70 institutions and has recently expanded, reaching 100% of the public hospitals in the country, working to analyze and address gaps in childhood cancer care.

MAS has significantly improved pediatric outcomes by ensuring consistent care and reducing disparities. It has helped families overcome financial and logistical barriers while providing medical institutions, foundations, and healthcare providers with better support and training. Through stronger multi-centric, intersectoral partnerships, the group is contributing to building a healthier and more equitable healthcare system for Mexico’s children and adolescents with cancer.

Key achievements since MAS launch include:

• Reducing sepsis rates from 15% to 5% in over 70 participating centers through the “Golden Hour” Collaborative.
• Providing timely and accurate specialized diagnostic studies to over 1,000 patients with suspected leukemia at no additional cost to families.
• Reaching over 1,000 healthcare professionals and 70+ hospitals, with over 140 abstracts presented at international conferences.

MAS’s significance lies in its ability to unite fragmented sectors, fostering collaboration, trust, and the creation of strategies tailored to childhood cancer care. Its growth from 8 to over 70 hospitals demonstrates its expanding impact on providing high-quality, consistent care and addressing disparities. By reducing barriers, MAS is contributing to an equitable and better-quality healthcare system for children with cancer in Mexico.

MAS connects healthcare workers, government agencies, NGOs, and academic institutions through its collaborative approach, ensuring shared responsibility for improving outcomes. The collaboration has implemented clear, measurable interventions and optimized resources to ensure fair quality access to care.

MAS’s long-term goal is to increase childhood cancer survival rates from 50% to over 70% by 2030.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Improved the capacity of hospitals participating in the Bridge Project to streamline access to correct and timely diagnosis by training labs to perform diagnostic tests with fidelity. demonstrated.

Clinical

Capacity building (program-identified benefit)

Increased local research capacity with certification courses on human subject’s research for staff at participating sites and guidance for local research ethics committees. demonstrated.

Clinical

Capacity-building (program-identified benefit)

Improved access to specialized diagnostic laboratory tests at participant sites to support accurate diagnoses and best practices. demonstrated.

Clinical

Clinical innovation access (new TSBM benefit)

Designed and implemented a less toxic treatment schema for pediatric Acute Lymphoblastic Leukemia in the Mexican population, improving local outcomes and reducing early mortality. demonstrated.

Clinical

Clinical innovation access (new TSBM benefit)

Improved early identification of symptoms, reduced inpatient clinical deterioration, and shortened Intensive Care Unit (ICU) stays through the implementation of a Pediatric Early Warning Score (PEWS) scale. demonstrated.

Clinical

Clinical innovation access (new TSBM benefit)

Promoted and provided access to New Generation Sequencing (NGS), a novel approach for Acute Lymphoblastic Leukemia diagnosis. demonstrated.

Clinical

Clinical innovation access (new TSBM benefit)

Enhanced healthcare professionals’ technical skills in diagnostic methods at participating labs by pairing labs for validation. demonstrated.

Clinical

Diagnostic procedures

Developed a technical guideline to improve the treatment of children with fever in emergency rooms by administering antibiotic within 60 minutes of patient’s arrival at the medical institution. demonstrated.

Clinical

Guidelines

Gather reliable data to improve clinical decisions by promoting the role of the Clinical Research Coordinator (Coordinador Investigacion Clinica; CIC). potential.

Clinical

Quality improvement and research support (program-identified benefit)

Increased collaboration and co-created solutions to common healthcare barriers among Mexican medical institutions, partners, and non-profit organizations through in-person and virtual workshops. demonstrated.

Community

Community power & partnerships (new TSBM benefit)

Improved local capacity in infectious diseases, nursing, quality improvement, pathology, and leadership through training local trainers. demonstrated.

Community

Health care delivery

Fostered sustainability for the Golden Hour, Bridge Project, EVAT, and CIC by coaching and supporting local teams, ensuring long-term environmental responsibility and community empowerment. demonstrated.

Community

Health care delivery

Increased local capacity and operational excellence through training healthcare professionals and leaders in quality improvement methods. demonstrated.

Community

Health care quality

Improved quality of care delivered through knowledge-sharing in the development of a healthcare cooperative group (CIC, Golden Hour, Bridge Project, Pathologists Network, and ID Network PRINCIPAL). demonstrated.

Community

Health care quality

Improved quality of care by providing practitioners with access to specialized testing and reports leading to more accurate diagnoses. demonstrated.

Community

Health care quality

Enhanced health care by locally designing and leading improvement strategies through comprehensive, modular, and guided institutional self-assessment with the PrOFILE Tool. demonstrated.

Community

Health care quality

Ensured continuity of treatment for children undergoing cancer treatment during the COVID-19 pandemic with a quality improvement approach. demonstrated.

Community

Health care quality

Increased knowledge and awareness concerning the care of children with cancer through access to newsletters, webinars, and educational portals. demonstrated.

Community

Resource access (new TSBM benefit)

Increase the number of children with cancer cured and decrease the morbidity rate. The cure expectation in Mexico is 50% while it is 84% in developed countries. potential.

Community

Life expectancy & quality of life

Gained access to grant funding and collaborated with local foundations to increase reach and local impact. demonstrated.

Economic

Capacity building (program-identified benefit)

Saved funds by decreasing the patients’ length of stay related to infection or treatment complications by timely interventions and less toxic treatment. demonstrated.

Economic

Cost savings

Improved equity, quality, and impact of healthcare and research by integrating committees and initiatives across a diverse group of healthcare professionals from different fields. demonstrated.

Economic

Diverse healthcare workforce (new TSBM benefit)

Established diverse advisory committees with subject experts to guide the MAS initiatives implementation. demonstrated.

Policy

Committee participation

Promoted Mexico’s official participation in CureAll Framework, a WHO initiative to treat and cure childhood cancer. demonstrated.

Policy

Policies

Fostered local scientific research by publishing papers and abstracts in different academic forums to spread the work the group has been doing in Mexico. demonstrated.

Policy

Scientific research reports

Establish a MAS Steering Committee with continuous presence and participation in forums and workshops oriented to childhood cancer treatment and care. This group comprises three working groups focused on scientific activities, MAS member engagement, and collaboration across MAS pillars and projects. potential.

Policy

Committee participation

Bring pediatric oncology to the national agenda, influencing policy-level change. potential.

Policy

Policies

Influence policy by conducting recurrent advocacy meetings with government national and international agencies. potential.

Policy

Policies

Support childhood cancer advocacy in Mexico using statistics from a hospital-based childhood cancer registry. potential.

Policy

Scientific research reports

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.

Clinical

By joining the MAS group, hospitals have access to working with coaches on improvement science and experts from various government and academic institutions, non-profit institutions, and foundations in the field of childhood cancer in Mexico and internationally.

To decide where to start working to improve childhood cancer outcomes, we reviewed ALL outcomes in eight institution members. Later, we designed and executed a retrospective study called Retro-MAS ALL to systematically identify the factors impacting prognosis, and we documented that infections and treatment-related complications were significant issues. Sixteen hospitals contributed with over 2,000 cases. To do this with high-quality standards and in compliance with best research practices, MAS provided advisory services to the ethics committees at collaborating institutions to obtain the necessary certifications to meet international standards for human subjects studies. We also supported member sites in getting the required certifications to participate in clinical research at an international level. If they lacked an Institutional Review Board, we assured alternate mechanisms to participate in compliance with international regulations. Certification courses on human subjects research and Good Clinical Practice for Clinical Trials with Investigational Drugs were provided to team members at participating sites through the Collaborative Institutional Training Initiatives (CITI) program.

After gathering this information, we developed initiatives to improve patient survival. An obvious need was to reduce treatment-related deaths in ALL patients. With the advice of a panel of experts, MAS designed a treatment schema that included access to lab tests that weren’t available at all the facilities; this effort was named Bridge Project. This required developing and implementing a specialized diagnostic panel for patients with suspected ALL. This panel was designed by experts based on the most current evidence-based recommendations and, considering cost efficiency, included only markers impacting treatment decision-making. Not only was the diagnostic panel created, but funding was also sought from local foundations to ensure patients did not face out-of-pocket expenses. With the addition of this specialized diagnostic panel, a better classification of the disease was possible and more adequate chemotherapy could be prescribed. By adjusting the chemotherapy intensity for each patient without compromising the outcomes, we have decreased early deaths while in treatment. Today, over 1,000 patients from 20 hospitals have benefited. But we didn’t stop there; more recently, we introduced New Generation Sequencing (NGS), a novel approach to diagnostic technology.

Later, we launched a retrospective protocol to assess the solid tumors, and we focused on the neuroblastic tumor, Wilms tumor, and hepatoblastoma diagnosis. Pathology reports and tissue sample processing were reviewed. Similarly to the approach for ALL, the aim was to identify areas of opportunity and design interventions to impact these diseases. A pathologist network is being fostered, and training meetings have been conducted to improve the performance of pathology techniques.

We also launched the Golden Hour to tackle deaths related to infectious diseases. The initiative’s name alludes to the ideal time to administer the first dose of antibiotics in pediatric hematology-oncology patients who present to the Emergency Room with a fever. This quality standard is proven to reduce morbidity and mortality associated with treatment in these patients. The goal was to ensure that patients with fever and a weakened immune system received their first dose of antibiotics within 60 minutes of arriving at the hospital. To achieve this, training personnel in quality improvement was required; coaching was provided during the implementation. This strategy significantly reduced sepsis and infection-related deaths by optimizing patient care in the emergency room and decreasing the need for ICU admissions. Participant hospitals developed local guidelines for managing fever and neutropenia, institutionalizing the process. We also designed an implementation guide through the collaborative group and made it available to any center wishing to implement it.

Additionally, we supported the implementation of PEWS (Pediatric Early Warning System) for the opportune identification of patients deteriorating in hospitalization areas when nurses assess vital signs at the bedside. This intervention has been proven to reduce mortality, shorten stays in the intensive care unit, and reduce costs. The benefits are also seen in improving multidisciplinary team communication and nursing empowerment.

Community

Over the past eight years, MAS has grown into a strong group of 74 hospitals from different health sectors across Mexico. These institutions treat 60% of the country’s children with cancer. The MAS group members possess significant expertise, and we have been looking forward to identifying local champions and empowering them through training; we have developed trainers in different fields to increase local capacity in infectious diseases, nursing, quality improvement, and pathology.

The group has also hosted local in-person and virtual workshops, providing its members a space for sharing knowledge, experiences, and challenges when treating childhood cancer in Mexico. These collaboration spaces have helped the local medical community increase the understanding of the disease and strengthen partnerships among institutions to address common healthcare barriers. Additionally, more than 30 of these institutions have become members, and over 10 are in the process of becoming members of the St. Jude Global Alliance, a global community working to advance care for children with cancer and other catastrophic diseases.

Through its second MAS collaborative, Golden Hour, healthcare workers in more than 85 hospitals in Mexico and Latin America received training on quality improvement, benefiting the treatment of fever in children with cancer. Now that the Collaborative has ended, the group is executing a sustainability strategy through coaching sessions and monthly meetings to help teams continue developing their quality improvement strategies to keep the Golden Hour positive results.

In addition, throughout the recent implementation of the St. Jude Pediatric Oncology Facilitated Integrated Local Evaluation (PrOFILE), a dynamic 360^⸰ evaluation of health services delivery, MAS is developing healthcare improvement strategies based on the results and findings.

Conscious of the effort each implementation takes for the local teams and the importance of sustainability, we have developed a strategy to push forward the institutionalization of all the initiatives so patients’ benefits can endure over time.

Like everyone else, our members struggled with healthcare delivery during the COVID-19 pandemic. With The Cancer Doesn’t Wait initiative, we worked through innovative ideas guided by the quality improvement model to continue childhood cancer treatment and avoid treatment interruptions.

Economic

Improving childhood cancer survival is both costly and complex. The care of childhood cancer requires an enormous collective effort and the participation of various disciplines to improve patient outcomes truly. That is why all our activities integrate multidisciplinary teams—pediatric oncologists, hematologists, nurses, intensivists, infectious disease specialists, emergency physicians, pediatricians, palliative care specialists, social workers, hospital administrators, and other disciplines that contribute in one way or another to patient care.

MAS has involved local foundations supporting childhood cancer from the group’s inception to unite efforts under the belief that together, we are stronger. The group has received four grants from the local foundation Fundación Gonzalo Río Arronte to implement childhood cancer treatment and care projects to accelerate and increase our scope. 

Foundations have a fundamental role in patients’ treatment adherence. The group has worked closely with Casa del Amistad para Niños con Cancer, one of the largest and most well-known national foundations, and the local contributions from the hospitals and their supporting foundations; more children have benefited from being treated in the hospital belonging to MAS, assuring better treatment.

In addition, the American Lebanese Syrian Associated Charities (ALSAC), the fundraising and awareness organization for St. Jude, has contributed by sharing experiences and exploring innovative strategies to increase fundraising with other local foundations.

During the last 7 years, through different initiatives with a focus on improving treatment, decreasing treatment-associated complications, or early identification with opportune interventions, we have been able to reduce the length of stay of patients, saving money for the hospitals, and more efficient use of chemotherapy leading to less waste and the most important, saving lives.

Policy

The participation of some of the members of the MAS Steering Committee in national and international forums has been key in bringing the treatment of childhood cancer to the national agenda. The most recent participation in CONACIA (National Council for the Prevention and Treatment of Cancer in Children and Adolescents) has been instrumental in helping shape policies that support children with cancer.

MAS has also helped raise awareness about the treatment and potential cure of children with cancer and the importance of scientific research and professional development. Through the publication of two scientific papers and over 140 presentations at national and international academic events, members of MAS have been able to share knowledge.

Through regular meetings with government agencies and other national and international contributors, MAS has brought pediatric cancer to the national agenda led by the Ministry of Health. Their advocacy helped Mexico to officially join the World Health Organization’s CureAll initiative, showing a strong commitment to improving care for children with cancer.

Lessons Learned

The success of MAS has been driven by creating and strengthening a collaborative network, facilitating mentorship from St. Jude experts, and establishing a Steering Committee, along with three dedicated working groups focused on collaboration, membership, and scientific initiatives. Currently, the group is developing a sustainability strategy with the centers implementing key quality improvement projects, supported by local coaches and regular meetings to share best practices.

Clinical Research Coordinators have played a crucial role in implementing projects, getting involved in training, protocol approval by the ethics in research local review boards, data collection and analysis, and contributing scientific publications. They have been game changers inside the hospitals.

Furthermore, MAS has collaborated with the Mexican Ministry of Health and nonprofit organizations to advance its objectives and reinforce its impact. The group secures additional funding through local grants, ensuring long-term sustainability and a broader reach. By aligning its efforts with the priorities of local healthcare providers and stakeholders, MAS has fostered trust and commitment.

MAS continues to adapt with resilience, persistence, patience, and positivism. The group has earned credibility by consistently demonstrating results—even among the most skeptical.