Hello!
How frequently a blood test (CBC count) should be done in people with various leukemia (ALL, AML, CLL, CML) at remission "to catch up a relapse"? How early in leukemia's manifestation/relapse the WBC anomalies appear?
Very important practical questions. As to the question of frequency of testing, the answer would be 'depending on the blood counts'. If a patient's blood counts have recovered fully, there is no need to repeat them too frequently. The standard practice is to start repeating weekly and then fortnightly and then gradually reducing the frequency (two monthly, three monthly... and so on). The important thing is the stability of the counts- ie if there is a change in any of the cellular parameters, the frequency of testing should be increased.
The answer to your second question is 'extremely variable and unpredictable and will depend on several factors that are unique to each disease category( and any associated prognostic factor(s). Just to give you one example, a young patient with common ALL with no adverse prognostic markers may enjoy a long period of remission. On the other hand, an elderly patient with Philadelphia chromosome positive ALL, the situation will be different. So the bottom line is 'one cannot have a uniform policy for all disease categories in all the patients. Should be patient specific. Hope that makes sense. Best wishes.
Many thanks for your answer, Dr. Sivakumaran! Could you give any references of publications on this matter, please?
In pediatric acute leukemia several studies show that routine blood testing for CBC is of little or no value both regarding earlier detection of relapse and the potential benefit. See eg pmid 22378688 (AML) or 15390274 (ALL)
Things might be entirely different if you monitor minimal residual disease
in the blood eg by PCR of fusion transcripts. Early detection of relapse by
these methods can surely detect relapses earlier and allow
for early intervention. This is eg employed in CML.
Thank you very much, Dr. Abrahamsson. However, there are other several studies that demonstrate a value of CBC testing as an independent prognostic factor (particularly, WBC count) in children with leukemia.
Blood. 2014 Jan 2;123(1):70-7.
Ann Hematol. 2014 Oct;93(10):1677-84
Oncol Lett.2014 Apr;7(4):1169-1174.
Maybe I misunderstood? WBC at diagnosis is a traditional prognostic indicator in pediatric ALL and AML as the articles show. However introduction of other prognostic tools such as minimal residual disease assesment of early treatment response along with more intensive treatment has reduced the influence of WBC at diagnosis.
I was referring to the value of doing routine evaluations of WBC after end of therapy which I consider to be very low once they are normalised.
The best way to predict a relapse is by minimal residual disease which can detect a malignant cell in millions depending on the technique and the tools used. PCR detects fusion transcripts whilst flow cytometry detects a leukaemia-associated immunophenotype (LAIP).
Considering ALL, the difference in management of ALL relapse occurs between an early vs a late relapse. So once the child is in remission after initial treatment, it doesn't matter if relapse is diagnosed at 1 month follow up or at 3 months of follow up. Always a good symptom evaluation and clinical examination will aid in help you to plan your investigation.
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