Acute Promyelocytic Leukemia, Are US Doctors and Hospitals Prepared? Tools and Know How, Yes; But, What about Readiness?

Acute Promyelocytic Leukemia (APL) is a hematologic emergency or urgency. It is a potential disaster that is also potentially curable. My research attempts to ascertain the readiness to care for patients who present with this (suspected) diagnosis and require urgent therapy.

I polled a sample of approximately 140 (United States) hematologist-oncologists as to the availability of Tretinoin/all-trans retinoid acid (ATRA) on a stat basis at the hospitals at which they practice and 18 responded. In other words, is the medicine on the shelf and can be given when ordered.

Available on the shelf and ready to give ATRA at all hospitals in which practiced: 2/18

Do not know: 3/18

Not available at all hospitals practiced: 13/18

Amazingly, one of the physicians stated that the family is given a prescription to get ATRA filled, and another responded that he had to "beg" to get the hospital to obtain it.

I posted two questions on a social media site in the Emergency Medicine category; This social media web site states that the total physician membership is 343,000 (verified). The responses are as follows:

Is ATRA on the shelf and available at the hospital they practice (17 responses to this question)

13/17 Do not know

2/17 On the shelf and available

2/17 Not on the shelf and would need to be ordered

Is APL a possible question for board exam in Emergency Medicine? (16 responses to this question)

9/16 No

4/16 Not sure

3/16 Yes

The price for ATRA according to www.uptodate.com is (Tretinoin Oral) 10 mg (100): $2988.16. Issues related to this topic include the cost, the supply (sold in quantities of 100), shelf life/expiration date, the agggregate cost to maintain it at every hospital based ER , and consideration that the patients are not all acutely ill and sometimes can wait a day before starting therapy. Even if this approach of not having ATRA in stock is not optimal, this approach is occurring.

Whether or not Joint Commission or the more voluntary Commission on Cancer should require that ATRA be on the shelf at a hospital, or available within a certain amount of time may merit further discussion.

Finding out how prepared we are to treat APL is not an easy undertaking and my effort seems to indicate that we probably do not have the wherewithal in many cases. Obtaining more data on the scope of the problem and perhaps devising a "Practice Guideline" by experts in the APL area dealing with the timeliness of availability of ATRA would seem to be in order. The lifesaving nature of the intervention would seem to justify the consideration of having hospitals maintaining a supply at all times. If the manufacturer would be willing to sell a supply of #30 (currently available in bottles of 100 per Facts and Comparison 2015 edition), this might be useful in implementing wider availability.