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Issues in the Management of Cancer-Related Thrombocytopenia

Issues in the Management of Cancer-Related Thrombocytopenia

Cancer-related thrombocytopenia is a clinical problem.
Unfortunately, the qualitative nature and quantitative extent of the problem has
been poorly defined to date. Without knowing these two parameters, the
risk/benefit ratio of any management option for cancer-related thrombocytopenia
is impossible to calculate accurately. Drs. Goodnough and DiPersio have done an
excellent job of delineating many of the potential risks of managing the
problems associated with platelet transfusions.

Although transfusion-related viral infections are high on the list of
potential toxicities, data suggest that, with the exception of cytomegalovirus (CMV),
these occur infrequently. Transfusion-related bacterial infections are not often
considered to be a serious clinical problem. However, if one considers that the
risk of sepsis with apheresis platelets is 1 in 12,000 and the mortality rate
associated with this sepsis is 26% (as the authors suggest), then patients
receiving 10 platelet transfusions over the course of their cancer therapy have
a 1 in 4,800 risk of death from transfusion. That is not a negligible risk,
especially in light of the number of patients who undergo myelosuppressive
treatments for cancer.

Platelet Refractoriness
and Other Limitations

Refractoriness to platelet transfusion due to alloimmunization is listed as a
potential problem with the use of transfusion therapy, but its clinical
significance may be overestimated given the lack of clinical improvement seen in
patients in whom alloimmunization was prevented with the use of leukoreduced
platelets.[1]

The financial expense of platelet transfusion therapy was briefly mentioned,
but deserves more detailed consideration. In calculating its expense, the cost
of all factors associated with the collection of platelets for transfusion
(including, for example, time off from work for the platelet donors) should be
included. These factors are often not accounted for in such analyses.

Another potential downside to platelet transfusions that is not often
mentioned in this type of review is their potential contribution to the
complications that occur after administration of chemotherapy. In blood and
marrow transplant patients, increased use of prophylactic platelet transfusion
is associated with subsequent development of hepatic veno-occlusive disease,
pulmonary dysfunction, and central nervous system (CNS) dysfunction.[2] Although
this association does not confirm a causative role for platelet transfusions in
the generation of CNS, pulmonary, or hepatic complications, data from animal
models and other clinical disorders suggest this possibility.[3-5]

Level of Supportive Evidence

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