Access to acute promyelocytic leukemia treatment in New York City

Abstract

Abstract Introduction Acute promyelocytic leukemia (APL) is a medical emergency that requires urgent administration of all trans retinoic acid (ATRA). Disseminated intravascular coagulopathy secondary to APL is common, and urgent transfusions of blood, platelet, cryoprecipitate and plasma are often needed. Prior to diagnosis, patients typically seek medical attention at their local emergency department for non-specific symptoms, including fevers, chills, night sweats, unintended weight loss, life threatening bleeding or bruising. However, appropriate treatment may not be readily available at all hospitals should an APL diagnosis be suspected. To understand whether APL treatment is accessible throughout our home city, we conducted an exploratory study to determine whether ATRA and transfusion support are readily available in all hospitals in New York City connected to an emergency department. Methods All 50 hospitals with emergency departments (ED) listed by the NYC Department of Health and Mental Hygiene were initially identified. Veterans Affairs hospitals and specialty hospitals without an open ED were not included in this study. One hospital was excluded because it closed in April 2025. One hospital was excluded because it is a psychiatric facility and transfers out all patients with active medical issues. In total, 48 hospitals with open emergency departments were included in this study. Hematology/oncology and/or oncology pharmacy leadership in each hospital were sent surveys to answer the following questions: 1) Is oral tretinoin or ATRA available on formulary at your hospital for treatment of APL? 2) Does your hospital treat acute leukemias? If not, where do you refer patients for APL treatment? 3) Is there a hematology/oncology consultation service at your hospital? If a hospital had not responded despite 3 attempts, the inpatient pharmacy for the non-responding hospital was called by phone and asked about availability of ATRA. Transfusion medicine or blood bank staff were also surveyed at each hospital regarding availability of red blood cell, platelet, cryoprecipitate, and plasma. Differences in availability of APL treatment among NYC boroughs or by hospital type was analyzed by Chi-square test. Differences in mean distance to the nearest or designated tertiary leukemia center were analyzed by one-way ANOVA test. Results 22 of 48 (46%) hospitals in NYC with publicly accessible EDs had ATRA available on formulary. 11 of 44 (25%) hospitals who provided responses treat leukemia. 38 of 42 responders (90%) have hematology/oncology consultation services. Availability of ATRA varied widely among the 5 boroughs in NYC: The Bronx (33%), Brooklyn (43%), Manhattan (62%), Queens (44%), and Staten Island (33%). 5 of 11 (45%) hospitals that treat acute leukemias in NYC are in Manhattan. Academic hospitals (88%) were more likely to carry ATRA than community (38%) or public (36%) hospitals, p=0.035. Academic hospitals (71%) were more likely to treat acute leukemias than community (19%) or public (9%) hospitals, p=0.026. Hospitals in the outer boroughs were farther away from the nearest or designated affiliated tertiary leukemia center than hospitals in Manhattan: The Bronx (4.6 mi), Brooklyn (8.7 mi), Manhattan (3.8 mi), Queens (10.9 mi), Staten Island (15.1 mi), p<0.001. 46 of 48 (96%) hospitals had an on-site blood bank and provided RBC transfusion support. 45 of 48 (94%) had platelets and fresh frozen plasma. 43 of 48 (90%) had cryoprecipitate. Conclusion ATRA was available in fewer than half of NYC hospitals with emergency departments. Patients in the outer boroughs must travel longer distances to receive leukemia specialty care than patients in Manhattan. Nearly all hospitals can readily provide RBC, platelet, and plasma transfusion support, but cryoprecipitate may not always be available. This is the first and only comprehensive study known to date that has determined the availability and accessibility of APL treatment in all hospitals of a city or region, including New York. Our findings illustrate that access to APL treatment varies widely between Manhattan and the outer boroughs. Leukemia care is largely concentrated in Manhattan. This discrepancy underscores the need to improve availability of ATRA and standardize initial APL treatment across all hospitals regardless of where patients initially seek medical care.