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The treatment of childhood Acute Lymphoblastic Leukaemia (A.L.L.) is a long and complicated regime. The duration of treatment is over 100 weeks and a child would have similar number visits to hospital for treatment or monitoring.
The treatment protocol comprises of an induction, several intensifications. and a prolonged maintenance phase. This final phase consists of regular oral chemotherapy together with pulse intravenous chemotherapy. The potential importance,, in relation to cure rates, of good compliance throughout this phase is highlighted in the new MRC UKALL 97 trial.
During the maintenance phase, a child's oral chemotherapy is adjusted according to their full blood count on a weekly basis. A higher count would result in an incremental increase in their dosage and vice-versa. The child attends a weekly haematology out-patient clinic for a blood count. After waiting for the result, the clinician prescribes the appropriate dose. The child would then have to wait further for a 7 day prescription to be dispensed.
This prolonged process is repeated each week taking at least two hours. The inconvenience of traveling and visiting the hospital also needs considering. The paediatric haematology team decided it was only necessary for children to visit the hospital once, a month, for their intravenous chemotherapy, provided they were fully monitored and well. The paediatric clinical pharmacist and Macmillan nurse subsequently devised a new scheme called "Telephone Maintenance".
This new scheme allows the child to visit hospital every four weeks, while on the intervening weeks their blood sample is collected at a more convenient location (e.g. GP practice or at home by the parents). Their blood is sent to the hospital for analysis and the result, reported to the paediatric haematology team.
The scheme is discussed with the children and families prior to starting the, maintenance phase. The pharmacist counsels the family about the medication and how the dispensing will be different. They will now receive a four week supply of medicine, sufficient to allow for any doseage changes. The chemotherapy is labelled in a less conventional manner with doses printed on the label (e.g. Full dose = 50mg (5ml), Half dose = 25mg (2.5ml)). The volume of medicine will depend on which formulation is dispensed. These changes are re-inforced with written patient information.
Once, the blood result is known, a member of the team telephones the family to inform them of the following weeks dose (i.e. full dose, half dose or withhold). The parents should refer to their medicines labels to determine the volume of medicine needed. This can be clarified since full details of the dispensing are recorded in the medical notes. This process is repeated each week until the child returns to hospital.
The families are told to record the doses given and to bring all their medicines to each four weekly visit. This allows a crude assessment of compliance and rationalises the quantity of drugs they keep at home. The pharmacist organises the prescribing and dispensing of the medication prior to the visit which further reduces the wait for the family. Currently, a questionnaire asking the children and their family's opinion of the scheme is being undertaken.
In conclusion, the main advantages of this system are:-
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