Antineoplastic chemotherapy in Jehovah's Witness patients with acute myelogenous leukemia refusing blood products – a matched pair analysis

Abstract

Background: Acute myelogenous leukemia (AML) may be cured in a substantial number of patients using intensive chemotherapeutic regimens leading to temporary severe myelosuppression. Patients belonging to the denomination of Jehovah's Witnesses (JW), however, are bound by their religious convictions not to accept blood products and are therefore at higher risk for life-threatening events. Reports how to handle this challenge are mainly anecdotal. Material and methods: We here report in much more detail about our experience with nine patients belonging to the denomination of JW who were treated for AML in our department from 1998 to 2007 and who explicitly wished to receive chemotherapy without blood transfusions. Results: Reduced dose induction chemotherapy administered by several treatment cycles to prevent sustained myelosuppression still led to complete remissions in three out of nine of JW patients but was associated with a high rate of relapse. No durable remission was achieved. The overall hazard ratio for death was 12.1 compared to a matched control group treated with full transfusion support. The predominant cause of non-AML mortality was severe anemia (four out of five early deaths) and uncontrollable bleeding (n = 1). Conclusion: Reduced dose chemotherapy without transfusion support in JW suffering from AML is associated with a lower rate of remission, high mortality by severe anemia and very low chances for long-term remissions. Less hematotoxic treatment options including hypomethylating agents or molecular targeted therapies with intensive consolidation after improvement of bone marrow function are promising for these patients but need further investigation.

NCCN Guidelines Insights: Acute Myeloid Leukemia, Version 2.2021

“…Regarding treatment options, the panel recommends considering less myelosuppressive induction, including dose reduction of anthracyclines and use of nonintensive chemotherapy. [52][53][54][55][56] Some of these options may include targeted agents guided by testing for actionable mutations rather than intensive chemotherapy, especially in a noncurative setting. However, the panel notes that chemotherapy dose reductions without transfusion support in patients with AML are associated with a lower rate of remission and a high mortality rate due to severe anemia, and are unlikely to result in durable remissions.…”

“…However, the panel notes that chemotherapy dose reductions without transfusion support in patients with AML are associated with a lower rate of remission and a high mortality rate due to severe anemia, and are unlikely to result in durable remissions. 55 During treatment, measures should be taken to minimize blood loss and decrease the risk of bleeding, including use of pediatric collection tubes, avoiding concomitant medications or procedures that increase the risk of bleeding or myelosuppression, use of oral contraceptive pills or medroxyprogesterone acetate in menstruating women, or administration of proton pump inhibitors, as indicated. 50,57 Vitamin K may be considered as an adjuvant to improve coagulopathy.…”

Tailored therapy and bloodless supportive care measures for a Jehovah’s witness with metastatic Ewing sarcoma

“…1 Unfortunately, suboptimal treatment may result in short term response without durable long-term remission. 9 During instances when a JW patient has chosen a reduced intensity chemotherapy for palliative care, the regimen can be modified to avoid myelosuppression. This can include dose reduction of chemotherapy and/or dose delay until the desired hemoglobin level and platelet count have been achieved prior to proceeding to the next cycle.…”

Çocukluk Çaği Akut Myeloblasti̇k Lösemi̇lerde Kan Ürünü Kullaniminin Kemoterapi̇ Bloklarina Göre Dağilimi

“…Transfusion of blood products is a key component of the supportive management in patients with acute leukemia (20). Indeed, in a past study among AML patients belonging to the denomination of Jehovah's Witnesses (JW), who are bound by their religious convictions not to accept blood products, reduced dose chemotherapy without transfusion support was reported to be associated with a lower rate of remission, high mortality by severe anemia and very low chances for longterm remissions (21). However, due to lack of standardized evidence-based guidelines for blood product transfusions, a wide variation exist in blood product transfusion practices across several clinical scenarios.…”