4.2.1 Supportive therapies

Managing and preventing infection

Treatment-related mortality in AML in CAYA has been shown to be as high as 10 per cent. Time to antibiotics greater than one hour in managing febrile neutropenia in high-risk groups has been

shown to have negative outcomes in paediatric studies. Patients with Down syndrome ALL are also at increased risk of treatment-related mortality and morbidity. Strategies to mitigate infection risk in CAYAs with acute leukaemia are identified below.

  • Mandatory hospitalisation should be considered for all patients with AML and those patients with Down syndrome ALL during induction.
  • Consideration for hospitalisation during induction for non-Down syndrome ALL should be made based on clinical factors.
  • Patients undergoing HSCT or treatment for AML must be treated in facilities appropriate to provide sufficient isolation from airborne pathogens, particularly fungal disease, in facilities such as HEPA filtration and positive pressure rooms.
  • Strategies and policies should be in place for managing infectious patients within the oncology clinical environment and waiting areas.
  • For patients with febrile neutropenia, antibiotics must be administered within an hour of presentation to hospital, or within 30 minutes for inpatients.
  • Patients with AML/ALL during the induction and intensification phases of treatment or those immediately (+ 30 days) post HSCT are at high risk of Pneumocystis jirovecii prophylaxis should be considered in patients where appropriate and anti-fungal prophylaxis administered to all AML and high-risk ALL patients according to national guidelines or those published by cooperative groups (COG 2020).

Adherence and compliance to treatment for acute leukaemia

Frontline treatment for CAYA ALL lasts approximately two years, with much of the treatment (oral chemotherapy) delivered in the home. The rate of medication errors in the home for patients with cancer has been shown to be very high. Suboptimal adherence to oral chemotherapy in ALL increases the risk of relapse (Bhatia 2012). Non-adherence is associated with socioeconomic adversity, highlighting the importance of universal social work referrals in CAYA acute leukaemia.

Clinical pharmacists also play a role in ensuring patients, carers and families have a clear understanding of the medication schedule as well as exploring other potential barriers to adherence that the multidisciplinary team could address. Cancer services must have strategies to support patients, families and carers in adhering to the treatment plan, particularly the role of long-term oral chemotherapy in the home.

The cancer service should have in place a mechanism to measure and record compliance with home-based oral medication administration, including how changes to oral chemotherapy doses are communicated to families in both written and verbal forms.