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The Future Role of Blood Transfusions in MDS

Panelists:James M. Foran, MD, FRCPC, Mayo Clinic Cancer Center; Azra Raza, MD, Columbia University Medical Center; David P. Steensma, MD, Dana-Farber Cancer Institute
Published: Monday, Jun 27, 2016


Transcript:

James M. Foran, MD, FRCPC:
There’s been a change, nationally, in the philosophy of transfusion. ASH, for instance, last year issued their Choosing Wisely guidelines, and their first guideline was transfuse only as little as you need to maintain an acceptable hemoglobin, 7 to 9 g, to help to minimize symptoms or overcome symptoms of anemia. And I perceived that there has been pushback about transfusion patients nationally. In some ways, that’s an application of intensive care or critical surgery randomized studies on how to run a hemoglobin and when to transfuse to an outpatient ambulatory population that hasn’t been validated. That’s my opinion, not a fact. But I wondered what you thought about that, about the evolving role of transfusion and about the national trend in transfusion, and how that influences your practice.

Azra Raza, MD: Yes. So, two points here. One is the European guideline, actually, that individuals over the age of 70, with lower-risk MDS, must have a hemoglobin of 10 g to maintain their quality of life. Their guidelines are far more relaxed than ours, and that’s something to be followed. Second, is that for me, there’s only one indication for transfusion, which is the level that patient tolerates. If they become symptomatic at 9 g, then I am going to transfuse them at 9 g. Another patient can tolerate down to 7 g quite well without a disturbance in their daily function. And we have the function that, look, maybe bringing it to 9 g will help. We bring it to 9 g, makes no difference, then I know. So, I think, once again, it is very, very individual-dependent, and you need to work with the patient to develop a wise attitude toward transfusion. And I like this guideline, that you try to maintain it in a reasonable level: don’t let it fall below 7 grams, but you don’t have to push everybody to have over 10 g.

James M. Foran, MD, FRCPC: No, it’s more restrictive than it needs to be. It’s somewhat arbitrary, at times over the last few years—and I understand the impetus for that—but I think it needs to be applied to the person. And I think that can be incorporated into something where the practices are set up to monitor the frequency or burden of transfusions over time—the ferritin over time—and also the response to transfusion, the symptom burden over time, to determine where that person should run. That is something we all do intuitively as we treat patients. But maybe I’ll be doing more systematically to help monitor this issue, because it is the greatest cytopenia or the most important cytopenia of the disease.

Azra Raza, MD: One thing I want to say, educationally what happens is, I’ll have a patient who’s very nervous, because he says, “Dr. Raza, every time I’ve gotten a transfusion, my hemoglobin has gone up by 2 g. This time I got a transfusion, it only went up by a gram, and within a week I’m back for another transfusion. Am I dying? Is my disease progressing?” And many times I have to calm them down by saying, “No, it’s not your disease. It’s the donor whose blood you received. It isn’t that every single time you’re going to get a transfusion, it will be from a donor, who is equally compatible with your blood. Occasionally, we will have a donor whose cells will die more rapidly in your body.” So, many times, these kinds of changes are not at all related to the disease but related to the donor. Of course, we have to be vigilant about it. There is a consistent fall or increase in transfusion that’s not going away with multiple transfusions. Then we need to restage their disease at that point. But I just wanted to say it, because don’t get excited about one or two transfusions looking very odd and suggesting disease progression.

James M. Foran, MD, FRCPC: I’m glad you said that. That happens in our practice also, where somebody—they track their numbers so closely—if it doesn’t fit exactly into how it’s been, they start to panic. Any time I see a change in the anemia, a change in the transfusion burden, it seems obvious, but we stop and say, is somebody bleeding? Did their platelet count drop? Is there some other contributing cause? Because it’s not always the disease.

Transcript Edited for Clarity
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Transcript:

James M. Foran, MD, FRCPC:
There’s been a change, nationally, in the philosophy of transfusion. ASH, for instance, last year issued their Choosing Wisely guidelines, and their first guideline was transfuse only as little as you need to maintain an acceptable hemoglobin, 7 to 9 g, to help to minimize symptoms or overcome symptoms of anemia. And I perceived that there has been pushback about transfusion patients nationally. In some ways, that’s an application of intensive care or critical surgery randomized studies on how to run a hemoglobin and when to transfuse to an outpatient ambulatory population that hasn’t been validated. That’s my opinion, not a fact. But I wondered what you thought about that, about the evolving role of transfusion and about the national trend in transfusion, and how that influences your practice.

Azra Raza, MD: Yes. So, two points here. One is the European guideline, actually, that individuals over the age of 70, with lower-risk MDS, must have a hemoglobin of 10 g to maintain their quality of life. Their guidelines are far more relaxed than ours, and that’s something to be followed. Second, is that for me, there’s only one indication for transfusion, which is the level that patient tolerates. If they become symptomatic at 9 g, then I am going to transfuse them at 9 g. Another patient can tolerate down to 7 g quite well without a disturbance in their daily function. And we have the function that, look, maybe bringing it to 9 g will help. We bring it to 9 g, makes no difference, then I know. So, I think, once again, it is very, very individual-dependent, and you need to work with the patient to develop a wise attitude toward transfusion. And I like this guideline, that you try to maintain it in a reasonable level: don’t let it fall below 7 grams, but you don’t have to push everybody to have over 10 g.

James M. Foran, MD, FRCPC: No, it’s more restrictive than it needs to be. It’s somewhat arbitrary, at times over the last few years—and I understand the impetus for that—but I think it needs to be applied to the person. And I think that can be incorporated into something where the practices are set up to monitor the frequency or burden of transfusions over time—the ferritin over time—and also the response to transfusion, the symptom burden over time, to determine where that person should run. That is something we all do intuitively as we treat patients. But maybe I’ll be doing more systematically to help monitor this issue, because it is the greatest cytopenia or the most important cytopenia of the disease.

Azra Raza, MD: One thing I want to say, educationally what happens is, I’ll have a patient who’s very nervous, because he says, “Dr. Raza, every time I’ve gotten a transfusion, my hemoglobin has gone up by 2 g. This time I got a transfusion, it only went up by a gram, and within a week I’m back for another transfusion. Am I dying? Is my disease progressing?” And many times I have to calm them down by saying, “No, it’s not your disease. It’s the donor whose blood you received. It isn’t that every single time you’re going to get a transfusion, it will be from a donor, who is equally compatible with your blood. Occasionally, we will have a donor whose cells will die more rapidly in your body.” So, many times, these kinds of changes are not at all related to the disease but related to the donor. Of course, we have to be vigilant about it. There is a consistent fall or increase in transfusion that’s not going away with multiple transfusions. Then we need to restage their disease at that point. But I just wanted to say it, because don’t get excited about one or two transfusions looking very odd and suggesting disease progression.

James M. Foran, MD, FRCPC: I’m glad you said that. That happens in our practice also, where somebody—they track their numbers so closely—if it doesn’t fit exactly into how it’s been, they start to panic. Any time I see a change in the anemia, a change in the transfusion burden, it seems obvious, but we stop and say, is somebody bleeding? Did their platelet count drop? Is there some other contributing cause? Because it’s not always the disease.

Transcript Edited for Clarity
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