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Quality of Life in Transfusion-Dependent MDS

Panelists: Vinod Pullarkat, MD, City of Hope Medical Center; Jamile Shammo, MD, Rush University Medical Center; Rami S. Komrokji, MD, Moffitt Cancer Center; Thomas Prebet, MD, PhD, Yale Cancer Center; Ellen K. Ritchie, MD, New York Presbyterian Hospital
Published: Monday, Jan 16, 2017


Transcript:

Vinod Pullarkat, MD:
Thomas, can you comment on your use of transfusions?

Thomas Prebet, MD, PhD: I think it’s important to acknowledge that transfusion is the most common treatment of MDS worldwide and that getting transfusions will be a big change in the lives of the patients. When they become transfusion-dependent, it’s a huge change in their lifestyle and their quality of life. So, objectively, what we should have to do for these patients is to try to maintain, as long as possible, their quality of life. And that will basically drive a way to consider transfusion based on hemoglobin levels, but also the comorbidities of the patients. Is the patient having any preliminary comorbidities, any cardiac comorbidities? We know from prior studies that one of the potential consequences of anemia in these patients is increased risk of cardiovascular events, and that may be something driving the prognosis and potentially risk of death for these patients. So, that will be the way we need to assess a patient. What’s the quality of life of the patient? What’s the daily activities they have? What are the comorbidities? To try to have an idea or the exact needs for transfusion, what should be the threshold of transfusion we’ll be using for this patient?

Ellen K. Ritchie, MD: It’s not a one-size-fits-all.

Thomas Prebet, MD, PhD: Correct.

Ellen K. Ritchie, MD: Our blood bank is always trying to tell us it’s one-size-fits-all, that there is an absolute level, but actually it varies per patient depending upon what their comorbid illness is and what they’re required to do in their life. If they actually are trying to maintain a full-time job or to maintain work, it’s very different than if they’re sedentary all day long at home. So, taking those factors into consideration really changes that range quite a bit.

Rami S. Komrokji, MD: Finally, I think we are getting into more objective tools to assess quality of life. There are now quality-of-life tools that are specific for MDS that are starting to be incorporated. The tools clearly show there’s basically correlation between cytopenias and patient quality of life, and that improving their cytopenia, even with transfusions alone, will improve the quality of life in terms of how they feel. But, obviously, it also affects the quality of life because now they are dependent to come to the center every 2 weeks.

Ellen K. Ritchie, MD: That’s a full-time job for some patients. Actually, when you come in in the morning for your transfusion, by the time your type and hold is done, by the time the units are identified for you, by the time those units are transfused for you, it can be a longer than an 8-hour business day. So, it’s a real commitment for patients to be treated with transfusion, and that actual burden of coming in constantly for blood counts and transfusion can really be a driver for treatment.

Vinod Pullarkat, MD: So, there are two things I see. One is there is a general underestimation, particularly of transfusion dependence, in many of these patients, particularly the lower-risk patients. Second is, for me, it’s very difficult to know how many transfusions a patient has had. Can you share your experiences?

Ellen K. Ritchie, MD: It’s not easy to find in the electronic medical record. When you’re trying to figure out actually how many transfusions a patient has had, it can take a very long time, hours actually, to quantify that. And, if they’re being seen in more than 1 place—they have a summer home in 1 place or they’re wintering in Florida—or you’re sharing with their primary MD, you have really no idea what the total number is. I think that that’s a real problem for us, especially when we consider patients for iron chelation or things like that where they’ve had 50 units or 15 units. It makes a difference.

Vinod Pullarkat, MD: In all the studies, the number of transfusions correlates well with the ferritin and other measures of iron overload, and their outcome. So, I think that’s an important measure.

Transcript Edited for Clarity
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Transcript:

Vinod Pullarkat, MD:
Thomas, can you comment on your use of transfusions?

Thomas Prebet, MD, PhD: I think it’s important to acknowledge that transfusion is the most common treatment of MDS worldwide and that getting transfusions will be a big change in the lives of the patients. When they become transfusion-dependent, it’s a huge change in their lifestyle and their quality of life. So, objectively, what we should have to do for these patients is to try to maintain, as long as possible, their quality of life. And that will basically drive a way to consider transfusion based on hemoglobin levels, but also the comorbidities of the patients. Is the patient having any preliminary comorbidities, any cardiac comorbidities? We know from prior studies that one of the potential consequences of anemia in these patients is increased risk of cardiovascular events, and that may be something driving the prognosis and potentially risk of death for these patients. So, that will be the way we need to assess a patient. What’s the quality of life of the patient? What’s the daily activities they have? What are the comorbidities? To try to have an idea or the exact needs for transfusion, what should be the threshold of transfusion we’ll be using for this patient?

Ellen K. Ritchie, MD: It’s not a one-size-fits-all.

Thomas Prebet, MD, PhD: Correct.

Ellen K. Ritchie, MD: Our blood bank is always trying to tell us it’s one-size-fits-all, that there is an absolute level, but actually it varies per patient depending upon what their comorbid illness is and what they’re required to do in their life. If they actually are trying to maintain a full-time job or to maintain work, it’s very different than if they’re sedentary all day long at home. So, taking those factors into consideration really changes that range quite a bit.

Rami S. Komrokji, MD: Finally, I think we are getting into more objective tools to assess quality of life. There are now quality-of-life tools that are specific for MDS that are starting to be incorporated. The tools clearly show there’s basically correlation between cytopenias and patient quality of life, and that improving their cytopenia, even with transfusions alone, will improve the quality of life in terms of how they feel. But, obviously, it also affects the quality of life because now they are dependent to come to the center every 2 weeks.

Ellen K. Ritchie, MD: That’s a full-time job for some patients. Actually, when you come in in the morning for your transfusion, by the time your type and hold is done, by the time the units are identified for you, by the time those units are transfused for you, it can be a longer than an 8-hour business day. So, it’s a real commitment for patients to be treated with transfusion, and that actual burden of coming in constantly for blood counts and transfusion can really be a driver for treatment.

Vinod Pullarkat, MD: So, there are two things I see. One is there is a general underestimation, particularly of transfusion dependence, in many of these patients, particularly the lower-risk patients. Second is, for me, it’s very difficult to know how many transfusions a patient has had. Can you share your experiences?

Ellen K. Ritchie, MD: It’s not easy to find in the electronic medical record. When you’re trying to figure out actually how many transfusions a patient has had, it can take a very long time, hours actually, to quantify that. And, if they’re being seen in more than 1 place—they have a summer home in 1 place or they’re wintering in Florida—or you’re sharing with their primary MD, you have really no idea what the total number is. I think that that’s a real problem for us, especially when we consider patients for iron chelation or things like that where they’ve had 50 units or 15 units. It makes a difference.

Vinod Pullarkat, MD: In all the studies, the number of transfusions correlates well with the ferritin and other measures of iron overload, and their outcome. So, I think that’s an important measure.

Transcript Edited for Clarity
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