We read with interest the recent article by Weiser et al.1 They conducted a trial in patients with acute lymphocytic leukemia who were treated with hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (hyper-CVAD) to delineate the impact of hyperglycemia on patient outcome. Hyperglycemia was found to occur in 37% of the patients. The patients who experienced hyperglycemia were found to have a shorter duration of complete remission compared with those patients without hyperglycemia. Patients with hyperglycemia also were found to have a shorter median overall survival, and they were more likely to develop sepsis and complicated infections. Weiser et al. also found hyperglycemia to be an independent risk factor for early disease recurrence and mortality on Cox regression analysis. However, we have a comment on the study.
Corticosteroids are widely employed in the treatment of patients with cancer, especially those with lymphoid malignancies. Therefore, hyperglycemia is not an uncommon clinical occurrence during chemotherapy, as in the study by Weiser et al.1 In the case of hyperglycemia, the dose of corticosteroid usually is reduced or withdrawn from the treatment. The role of the relative dose intensity of the drugs used in the treatment was not discussed in the study by Weiser et al.1 Is hyperglycemia an independent risk factor based on the relative dose intensity of the drugs used in the treatment? Is there any difference with regard to the relative dose intensity between the patients with hyperglycemia and those without hyperglycemia, although the toxicity was not found to be different in hyperglycemic patients compared with those who were normoglycemic (most likely an indirect indicator of relative dose intensity)? The relative dose intensity should be included in analyses. Therefore, it is difficult to state with certainty that hyperglycemia is an independent risk factor in patients with acute lymphoblastic leukemia without incorporating the relative dose intensity in the analysis.