The use of pediatric-based protocols in the management of adult acute lymphoblastic leukemia (ALL) appears to result in improved survival, particularly in young adults. However, significant treatment-related toxicities have been identified with these regimens, including osteonecrosis and peripheral neuropathy. These are potentially disabling and can adversely affect quality of life (QoL); however, the long-term impact of such treatment regimens on health-related QoL in this adult population has not previously been reported. We therefore aimed to assess various dimensions of QoL in long-term survivors of adult ALL following treatment with a modified Dana Farber Cancer Institute 91-01 pediatric protocol, which is used as standard frontline therapy in our institution.
QoL was self-reported using 5 psychometrically validated instruments: the EORTC QLQ-C30, the Functional Assessment of Cancer Therapy fatigue subscale (FACT-F), the Brief Pain Inventory, the Subjective Peripheral Neuropathy Screen (SPSS), and the 9-item Patient-Health Questionnaire (PHQ-9). Standard analyses of each instrument were conducted. Where available, results were compared to published population normative data.
29 patients (median age 41 years, range 21–64, 90% male), in continuous complete remission at a median of 28 months following completion of the two-year treatment protocol, were enrolled between March 2010 - April 2012. In comparison to reference data from a general population, the mean global health score on the EORTC QLQ-C30 was similar (p=0.68), but leukemia survivors had lower cognitive (p<0.001) and social (p<0.001) function scores, as well as more marked financial difficulty (p<0.001). The most prevalent and severe of the symptom items assessed by the EORTC QLQ-C30 were fatigue and pain, both of which showed significant inverse correlation with global health status and all functional scales (physical, role, emotional, cognitive, and social). Some degree of fatigue was reported by 83% of patients. Evaluation by FACT-F revealed worse fatigue scores for leukemia survivors compared with the general population (p=0.03). Mean pain intensity was higher in those more than 24 months from completion of treatment, vs. < 24 months (p=0.04). In the 9 patients (31%) experiencing moderate-severe pain, the most common sites were joints and neck/back. Of the 10 patients reporting regular use of analgesics, 4 were using opioids. The SPSS identified 12 patients (43%) with moderate or severe symptoms associated with peripheral neuropathy (burning, paraesthesias and/or numbness), mostly affecting the lower extremities. Neuropathy was more severe in patients over age 40 (p<0.01). The PHQ-9 identified 4 patients (14%) with significant depressive symptoms.
Long-term adult ALL survivors who were treated with a pediatric-based regimen generally do well in terms of global QoL. However, fatigue, joint-related pain and neuropathy symptoms are common and can negatively affect QoL. Impairments in the domains of cognitive function and social function, as well as the prominence of financial hardship in this population, are findings that warrant further exploration.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.