Chemoinduction therapy and its response in Jehovah’s Witnesses with acute lymphoblastic leukemia: A systematic review.

Abstract

e18543 Background: The refusal of Jehovah's Witnesses to accept blood and blood product transfusions proves to be a significant clinical challenge in acute leukemia due to chemotherapeutic myelosuppression. There is limited data on the results of chemo-induction in patients with Acute Lymphoblastic Leukemia (ALL). This systematic review intends to assess clinical indicators and prognostic outcomes in ALL patients receiving chemo-induction. Methods: Adhering to PRISMA guidelines, a comprehensive literature search was conducted across four databases (PubMed, Embase, Cochrane, and clinicaltrials.gov) from inception to December 2024 using MeSH and entry terms for ('acute lymphoid leukemia' OR ‘ALL’) AND ('Jehovah's Witness’). Out of 136 search results, after the primary and secondary screening, along with the removal of duplicates, 14 studies were selected. These included 3 case reports, 7 case series, and 4 letter-to-editor studies. Outcomes including remission status, duration of response, and survival after chemo-induction therapy were documented. Results: This systematic review included 14 studies involving 30 ALL patients undergoing chemo-induction with a median age of 39.5 years (IQR: 24.5–44). 50% of the patients were male (n=13/26). 36.3% (n=4/11) were positive for Philadelphia chromosome. The mean Hb at diagnosis was 9 g/dL (95% CI 7.6-10.3), while the mean platelet count at diagnosis was 96.3 x 103/uL (95% CI 55-137.3). During induction therapy, mean Hb and mean platelet count reached a nadir of 4.5 g/dL (95% CI 3.9-5.2) and 23.3 x 103/uL (95% CI 3.6-33) respectively. Supportive agents such as erythropoietin, iron supplementation, folic acid, vit. B12, filgrastim, and romiplostim were administered in an attempt to maintain hematological parameters, in response to chemotherapy-induced myelosuppression. Following induction, complete remission was achieved by 83.3% (n=25). 6.67% (n=2) achieved partial remission, while 10% (n=3) of ALL patients exhibited disease progression. 53.3% (n=16) of ALL patients were alive at the median follow-up duration of 37 months (IQR: 28–44). For chemotherapeutic induction, the majority of the studies utilized vincristine-based combinations with drugs including cyclophosphamide, doxorubicin, methotrexate, prednisolone, rituximab, pegaspargase also being used. Conclusions: Our systematic review shows that it is possible to achieve complete remission in a majority of Jehovah’s Witnesses with ALL using chemotherapeutic induction. The myelosuppressive effects of chemo-induction, in the absence of blood and blood-product transfusions, present a substantial clinical challenge, supportive agents allow us to counteract this to a considerable degree. Careful supportive management enables remission, though long-term survival remains uncertain. Further research is needed to refine transfusion-free treatment strategies.