Supportive care in patients with acute leukaemia: historical perspectives.

Although most treatments for leukaemia were ineffective until the middle of the 20th century, it seemed of interest to review some pertinent examples of the evolution of supportive care from its origin to its current use in this disease. Indeed, patients with leukaemia often have associated life-threatening disorders such as severe anaemia, bleeding or serious infections, and improvements in the management of these complications has totally transformed the outcome of the underlying disease. Modern therapy of acute leukaemia began in the 1960s. The major development in the treatment of acute leukaemia came from St. Jude Children’s Research Hospital in Memphis, with Don Pinkel introducing a four-phase treatment plan for acute lymphoblastic leukaemia, which he called “total therapy”1. The principles that were applied took into account the advantage of combination chemotherapy in overcoming initial drug resistance and inhibiting acquired resistance, as well as the superiority of some drugs for inducing remissions and others for maintaining the remissions. All available antileukaemic agents were incorporated into the plan, including vincristine and prednisone as induction therapy, 6-mercaptopurine and methotrexate for maintenance chemotherapy, and then radiotherapy to the central nervous system to prevent meningeal relapse. This schedule resulted in a tremendous increase in the survival rate of children with acute lymphoblastic leukaemia with more than 50% becoming long-term survivors. Concomitantly to the development of more intensive chemotherapies, the need for supportive care increased. Leukaemia and its treatment can cause a number of complications and side effects. Patients receive supportive care to prevent or control these problems and to improve their comfort and quality of life during the leukaemia treatment. Advances in the control of infections and bleeding have been major factors in the improved outcome of leukaemia therapy. Blood transfusions are an important part of haematological care: transfusions of red blood cells may be used to reduce the symptoms of anaemia and platelet transfusions to reduce the risk of serious bleeding. Transfusions have long been associated with some risk to patients. Blood transfusion technology advanced rapidly during World War II, leading to national systems of blood banks. Prior to 1954, blood transfusions were performed with rubber tubes and glass bottles. Progress in technologies and materials led to significant improvements. The development of plastic phlebotomy equipment has made the procedure of plasmapheresis feasible as an alternate form of blood donation. A platelet replacement programme initiated in children with leukaemia in 1958 demonstrated that platelets had an effect on haemorrhages and mortality. In this brief historical review, we examine the major advances in the history of blood transfusion and the impact of transfusions on the treatment of acute leukaemia. Targeted more specifically at the young haematologist and the general educated reader, this review aims to communicate accounts of scientific and medical discovery and practice in this domain. It relies upon chronology as an organising framework, while stressing the importance of themes.