Acute leukaemia in Jehovah's
witnesses
Javier Bueno, Javier Zuazu, Teresa Villalba, Antoni
Julià
Servicio de Hematología Clínica. Hospital Vall
d'Hebron. Barcelona. Spain.
Correspondence: Javier Bueno, Servicio de Hematología
Clínica. Hospital Vall d'Hebron. Barcelona. Spain.
E-mail: jabueno@hg.vhebron.es
The letter by Mazza
et al.1 in
the November issue of Haematologica prompted us to comment again
on some ethical and practical issues concerning to the treatment
of acute leukaemias in Jehovah's Witnesses (JW). Here, we resume
our experience, previously reported.2 Case #1 was a
27-year-old male, with ALL (L3), treated with vincristine,
daunorubicin, prednisolone, L-asparaginase, cyclophosfamide,
methotrexate and CNS prophylaxis. He achieved a partial remission
in eight weeks without the need of transfusions. The patient
decided not to have more aggressive treatments and received
6-mercaptopurine and methotrexate. One month later his leukaemia
recurred and he was again treated intensively with high-dose
methotrexate followed by one cycle of POMP. Since these treatments
were not effective, we decided to use again two cycles of
daunorubicin, vincristine, cyclophosfamide, and prednisolone. It
was during this period that the patient reached the nadir of
haematological counts: haemoglobin 23 g/L, platelets
7x109/L and white blood cells (WBC)
0.1x109/L. Nevertheless, he was not transfused or
treated with erythropoietin. Later on, his performance status and
haematological counts improved and he was discharged. A few days
later however, he again worsened and died because of anaemia and
progressive disease, 11 months after diagnosis. Case #2 was a
23-year-old female with a B immature ALL. Previously, she had been
admitted into another hospital, but she did not receive treatment
because she warned the medical staff about her religious beliefs
and her doctors recommended a transfer to another hospital. In our
Centre she was treated with vincristine and prednisolone,
achieving a complete remission in four weeks. The nadir of her
haematological counts was haemoglobin 46 g/L, WBC
2.3x109/L and platelets 116x109/L. She
continued maintenance treatment with methotrexate and
6-mercaptopurine. The disease recurred 26 six months later and the
patient was treated again with vincristine and prednisolone and
again she achieved complete remission. The maintenance treatment
is methotrexate and 6-mercaptopurine and the disease continues in
complete remission 27 monts later. The conclusion of Mazza et al.
is that acute leukaemia in JW can be treated with the same
protocols employed in transfused patients. Even though we agree
essentially with this conclusion, we think that is very important
to remark several points. First, we feel that this conclusion does
not apply to treating acute leukaemia in JW with protocols that
include blood or marrow transplantation (BMT). These procedures
are sufficiently hazardous per se, to be performed without the
support of transfusions, most notably in the case of allogeneic
transplantation. Moreover, a great part of JW do not accept to be
transplanted. Secondly, it is very important to differentiate the
diverse types of leukaemia: Acute lymphoblastic leukaemia is an
entity very different that acute myeloblastic leukaemia. Likewise
M3 FAB's type has a very good posibility of entering complete
remission with ATRA as a single treatment. As Mazza pointed out,
there are in the literature very few cases of treatment of AL in
Jehovah's Witnesses without transfusions: In addition to the five
cases from Mazza,1 Cullis et al.3 collected
several published cases and Kerridge et al.4 reported
an additional one. The great majority of these cases refer to
acute lymphoblastic leukaemia and we can suppose that results in
AML are so bad that they aren't worthy of being published. Third,
we think that acute leukaemia in JW must be treated, because the
first cause of death in the majority of cases is not anaemia but
other complications of AL, namely infections. Our case #1 received
aggressive treatment in two occasions and although his counts were
extremely low he recovered and was discharged until the disease
progressed. Other case reports support this opinion.5-8
But we also should consider the economic and social impact that
this decision represents. These patients expend more time in the
hospital, they need erythropoietin and other growth factors and,
as Cullis3 points out, cause an important psychological
stress on doctors and nurses caring for them, aware of the fact
that a timely transfusion could relieve their suffering and delay
death. Fourth, if we accept that one ought to treat all these
patients, what could possibly be the better way? In ALL it is
clear, a moderately myelotoxic scheme, like vincristine plus
prednisone (perhaps with the addition of daunorubicin and
L-asparaginase) can achieve a complete remission. The use of
all-trans-retinoic acid in acute promyelocytic leukaemia may
achieve complete remissions without bone marrow aplasia. More
difficult is to treat an acute myeloblastic leukaemia (AML). The
usual treatments are excessively toxic and, even though there are
sporadic remissions without transfusions, the general rule is the
death of these patients caused by anaemia or haemorrhage. Perhaps
one should use other treatment strategies such as the treatments
used in the elderly (low dose cytosine arabinoside or oral
idarubicin).
In conclusion, our opinion is that acute leukaemia in Jehovah's Witnesses has to be treated depending on the patient's wishes, the type of leukaemia and the current hospital's rules. Probably the best way is to use a moderately myelotoxic treatment, started as soon as possible. Conventional AML schemes and autotransplantation are high dose therapies that almost always require transfusional support. We consider them relatively contraindicated, while the possibility of an allogeneic transplant should not be currently considered.
