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Nguyen N, Madarang E, Alencar A, Watts J, Bradley T. The treatment of acute lymphoblastic leukemia in Jehovah's Witnesses and patients who cannot accept blood products. Leuk Res Rep 2022; 18:100355. [PMID: 36338830 PMCID: PMC9630781 DOI: 10.1016/j.lrr.2022.100355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/16/2022] [Accepted: 10/23/2022] [Indexed: 11/07/2022] Open
Abstract
Jehovah's Witnesses and patients who cannot accept blood products diagnosed with acute lymphoblastic leukemia can be a clinical challenge. Chemotherapy can and should be safely used for induction therapy in this population. Blinatumomab and nelarabine are agents with novel mechanisms of action that are minimally myelosuppressive.
Jehovah's Witnesses cannot accept blood products based upon religious beliefs, and when they present with acute leukemia, the ideal treatment strategy can be controversial. We present six cases of Jehovah's Witnesses with acute lymphoblastic leukemia and show that complete remission can be achieved without using anthracycline in 83% (5/6) of patients. We also report, for the first time in this population, that the use of agents with novel mechanisms of action, such as blinatumomab and nelarabine, is associated with minimal myelosuppression and can produce durable responses, with 2 of 6 patients still alive in CR3 at 4.9 and 6.6 years.
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Affiliation(s)
- Nina Nguyen
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center,United States
| | - Ellen Madarang
- University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center,United States
| | - Alvaro Alencar
- Lymphoma Program, Division of Hematology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center,United States
| | - Justin Watts
- Leukemia Program, Division of Hematology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center,United States
| | - Terrence Bradley
- Leukemia Program, Division of Hematology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center,United States
- Corresponding author at: 1121 NW 14th Street, 210C, Miami, FL 33136.
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Bock AM, Pollyea DA. Venetoclax with azacitidine for two younger Jehovah's Witness patients with high risk acute myeloid leukemia. Am J Hematol 2020; 95:E269-E272. [PMID: 32602156 DOI: 10.1002/ajh.25916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/10/2020] [Accepted: 06/23/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Allison M Bock
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel A Pollyea
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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El Chaer F, Ballen KK. Treatment of acute leukaemia in adult Jehovah's Witnesses. Br J Haematol 2019; 190:696-707. [PMID: 31693175 DOI: 10.1111/bjh.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/18/2019] [Indexed: 01/28/2023]
Abstract
Since Jehovah's Witness (JW) patients diagnosed with leukaemia refuse blood transfusions, they are often denied intensive chemotherapy for fear they could not survive myeloablation without blood transfusion support. Treatment of JW patients with acute leukaemia is challenging and carries a higher morbidity and mortality; however, the refusal of blood products should not be an absolute contraindication to offer multiple treatment modalities including haematopoietic stem cell transplantation. In this review we discuss their optimal management and describe alternative modalities to blood transfusions to provide sufficient oxygenation and prevent bleeding.
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Affiliation(s)
- Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen K Ballen
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Conviction in the face of affliction: a case series of Jehovah's Witnesses with myeloid malignancies. Ann Hematol 2018; 97:2245-2248. [PMID: 30088044 DOI: 10.1007/s00277-018-3459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/23/2018] [Indexed: 12/17/2022]
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Wilop S, Osieka R. Antineoplastic chemotherapy in Jehovah's Witness patients with acute myelogenous leukemia refusing blood products - a matched pair analysis. ACTA ACUST UNITED AC 2017; 23:324-329. [PMID: 29212421 DOI: 10.1080/10245332.2017.1411548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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.
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Affiliation(s)
- Stefan Wilop
- a Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty , RWTH Aachen University , Aachen , Germany
| | - Rainhardt Osieka
- a Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty , RWTH Aachen University , Aachen , Germany
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Scharman CD, Burger D, Shatzel JJ, Kim E, DeLoughery TG. Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol 2017; 92:1370-1381. [PMID: 28815690 DOI: 10.1002/ajh.24889] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 01/04/2023]
Abstract
By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.
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Affiliation(s)
- Carlton D. Scharman
- Department of Internal Medicine; Oregon Health and Science University; Portland Oregon
| | - Debora Burger
- Patient Blood Management Program; Oregon Health and Science University; Portland Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Edward Kim
- School of Medicine; Oregon Health and Science University; Portland Oregon
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
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A clinical challenge: Treatment of acute myeloid leukemia in a Jehovah's Witness. Rev Bras Hematol Hemoter 2016; 38:358-360. [PMID: 27863765 PMCID: PMC5119660 DOI: 10.1016/j.bjhh.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/02/2016] [Accepted: 05/12/2016] [Indexed: 01/14/2023] Open
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Chojnowski K, Janus A, Bliźniewska K, Robak M, Treliński J. Long-lasting extreme anemia during the therapy of acute lymphoblastic leukemia in a Jehovah's Witness patient. Transfusion 2016; 56:2438-2442. [PMID: 27385671 DOI: 10.1111/trf.13703] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The treatment of patients with acute leukemia, who due to their religious beliefs refuse to accept blood transfusion, is a great challenge for hematologists. CASE REPORT We present a case of acute pre-T-lymphoblastic leukemia in a Jehovah's Witness who did not accept blood transfusion during chemotherapy. Standard induction and consolidation chemotherapy was used (according to the PALG ALL-6 regiment). RESULTS During consolidation cycles, darbepoietin alfa, intravenous iron, and total parenteral nutrition was administered. Extreme (Hb < 5 g/dL), long-lasting (41 days) anemia was observed with the lowest Hb concentration amounting to 1.3 g/dL (lasting 7 days). CONCLUSION We believe this to be the lowest Hb value observed, particularly one that persisted for such a long period of time and resulted in the patient surviving without consequences. The patient remains in complete remission for more than 2 years after diagnosis.
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Affiliation(s)
| | - Agnieszka Janus
- Department of Hematology, Copernicus Memorial Hospital, Łódź, Poland
| | | | - Marta Robak
- Department of Hemostasis, Medical University of Łódź, and the, Łódź, Poland
| | - Jacek Treliński
- Department of Hemostasis, Medical University of Łódź, and the, Łódź, Poland.
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Emadi A, Bade NA, Stevenson B, Singh Z. Minimally-Myelosuppressive Asparaginase-Containing Induction Regimen for Treatment of a Jehovah's Witness with mutant IDH1/NPM1/NRAS Acute Myeloid Leukemia. Pharmaceuticals (Basel) 2016; 9:ph9010012. [PMID: 27064021 PMCID: PMC4812376 DOI: 10.3390/ph9010012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/19/2016] [Accepted: 03/08/2016] [Indexed: 12/27/2022] Open
Abstract
Treatment of patients with acute myeloid leukemia (AML) who do not wish to accept blood product transfusion, including Jehovah’s Witnesses, is extremely challenging. The use of conventional chemotherapy for induction of complete remission (CR) results in profound anemia and thrombocytopenia requiring frequent transfusions of blood products, without which such treatment will be life-threatening. Finding a well tolerable, minimally myelosuppressive induction regimen for such patients with AML is a clear example of area of unmet medical need. Here, we report a successful treatment of a 52-year-old Jehovah’s Witness with newly diagnosed AML with peg-asparaginase, vincristine and methylprednisolone. The AML was characterized with normal karyotype, and mutations in isocitrate dehydrogenase 1 (IDH1-Arg132Ser), nucleophosmin 1 (NPM1-Trp289Cysfs*12) and neuroblastoma RAS viral oncogene homolog (NRAS-G1y12Va1). After one 28-day cycle of treatment, the patient achieved complete remission with incomplete count recovery (CRi) and after the second cycle, he achieved CR with full blood count recovery. The patient has never received any blood products. Notwithstanding that myeloperoxidase-induced oxidative degradation of vincristine results in its lack of activity as monotherapy in AML, its combination with corticosteroid and asparaginase has resulted in a robust remission in this patient. Diminished steroid clearance by asparaginase activity as well as reduction in serum glutamine level induced by glutaminase enzymatic activity of asparaginase may have contributed to effective killing of the myeloblasts that carry IDH1/NPM1/NRAS mutations. In conclusion, asparaginase-containing regimens, which are approved for treatment of acute lymphoblastic leukemia (ALL) but not AML, can be used to treat patients with AML who do not accept blood transfusion.
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Affiliation(s)
- Ashkan Emadi
- School of Medicine, Marlene & Stewart Greenebaum Cancer Center, University of Maryland, 22 South Greene Street, Room N9E24, Baltimore, MD 21201, USA.
| | - Najeebah A Bade
- School of Medicine, Marlene & Stewart Greenebaum Cancer Center, University of Maryland, 22 South Greene Street, Room N9E24, Baltimore, MD 21201, USA.
| | - Brandi Stevenson
- School of Medicine, Marlene & Stewart Greenebaum Cancer Center, University of Maryland, 22 South Greene Street, Room N9E24, Baltimore, MD 21201, USA.
| | - Zeba Singh
- Department of Pathology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA.
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Garelius H, Grund S, Stockelberg D. Induction with azacytidine followed by allogeneic hematopoietic stem cell transplantation in a Jehovah's Witness with acute monocytic leukemia. Clin Case Rep 2015; 3:287-90. [PMID: 25984306 PMCID: PMC4427369 DOI: 10.1002/ccr3.212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 10/18/2014] [Accepted: 12/07/2014] [Indexed: 11/12/2022] Open
Abstract
We have used a hypomethylating agent instead of conventional chemotherapy to induce remission in a young Jehovah's Witness with acute monocytic leukemia to avoid severe myelosuppression and blood product support. The treatment was consolidated with reduced intensity allogeneic stem cell transplantation. This could be an alternative when transfusions must be avoided.
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Affiliation(s)
- Hege Garelius
- Section for Haematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Sofia Grund
- Section for Haematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Dick Stockelberg
- Section for Haematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital Gothenburg, Sweden
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A Jehovah's Witness with Acute Myeloid Leukemia Successfully Treated with an Epigenetic Drug, Azacitidine: A Clue for Development of Anti-AML Therapy Requiring Minimum Blood Transfusions. Case Rep Hematol 2014; 2014:141260. [PMID: 25371835 PMCID: PMC4202254 DOI: 10.1155/2014/141260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/23/2014] [Indexed: 11/17/2022] Open
Abstract
Therapy for acute leukemia in Jehovah's Witnesses patients is very challenging because of their refusal to accept blood transfusions, a fundamental supportive therapy for this disease. These patients are often denied treatment for fear of treatment-related death. We present the first Jehovah's Witness patient with acute myeloid leukemia (AML) treated successfully with azacitidine. After achieving complete remission (CR) with one course of azacitidine therapy, the patient received conventional postremission chemotherapy and remained in CR. In the case of patients who accept blood transfusions, there are reports indicating the treatment of AML patients with azacitidine. In these reports, azacitidine therapy was less toxic, including hematoxicity, compared with conventional chemotherapy. The CR rate in azacitidine-treated patients was inadequate; however, some characteristics could be useful in predicting azacitidine responders. The present case is useful for treating Jehovah's Witnesses patients with AML and provides a clue for anti-AML therapy requiring minimum blood transfusions.
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Oh SY, Kim SH, Kwon HC, Lee S, Kim KH, Kwon KA, Lee JH, Lee KY, Kim HJ. Bloodless cancer treatment results of patients who do not want blood transfusion: single center experience of 77 cases. Support Care Cancer 2009; 18:1341-6. [DOI: 10.1007/s00520-009-0759-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 10/01/2009] [Indexed: 10/20/2022]
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