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Issues in the Management of Cancer-Related Thrombocytopenia

Issues in the Management of Cancer-Related Thrombocytopenia

Drs. Goodnough and DiPersio should be commended for
contributing such a well-written, well-referenced, objective, and authoritative
review of issues in the management of cancer-related thrombocytopenia. Their
article focuses primarily on platelet transfusion risks, rational transfusion
thresholds, and potential novel pharmaceutical triumphs. The general lack of
large-scale, definitive clinical trials in this field is appreciated and
emphasized throughout. Much to my disappointment, the authors seem to have
passed on the opportunity to provide the oncology community with any form of
evidence-based (or evidence-lacking, as the case may be) and practical guideline
for the treatment of thrombocytopenia.

The authors begin by cataloging recognized platelet transfusion-related
complications. They do so in a manner not intended to criticize current platelet
concentrate collection, storage, and infusion methods but rather to provide a
perspective on the risks that must be considered and outweighed by anticipated
benefits before platelet transfusion seems prudent. These principles are
somewhat universal and should be routinely applied to all forms of blood product
transfusion.

Leukoreduction is generally characterized as a methodology to modify platelet
products in order to reduce risk without a clearly demonstrated impact on
clinical outcomes. This comment is based on the fact that despite a
statistically significant reduction in transfusion-related alloimmunization to
platelets from 13% in leukemic patients receiving unprocessed platelets to from
3% to 5% in those receiving leukoreduced products, no difference in other
meaningful outcomes was observed.[1] The authors’ personal
"position" on the use of leukoreduction technologies is unfortunately
summed up by their reference to a more than 10-year-old set of published
guidelines[2] deemed to be still applicable. My guess is that the authors’
true feelings are reflected in what they actually do on a day-to-day basis. Such
insight would have been welcome.

A great difference likely exists between published (recommended) safe
platelet transfusion thresholds and clinically utilized and comfortable
(standard of care) thresholds. Published thresholds often imply or require
uniformity of thrombocytopenia etiology, patient concomitant illness, and
underlying hemorrhagic risk. In the absence of a prudent set of recommendations
and/or guidelines, practicing physicians will continue to transfuse in response
to a higher platelet count threshold, with less regard for long-term
complications and less attention to cost. To the practicing physician, the
perceived needs of an individual patient at a particular moment in her/his care
supersedes concerns about future complications and resource conservation. We can
all agree that, ideally, the patient should be treated, not his/her platelet
count.

Pharmacologic agents for the treatment of cancer-related thrombocytopenia
hold some promise. It seems logical to establish clear thresholds for platelet
transfusion before we can have a working understanding of what threshold to use
for pharmacologic treatment.

I wonder how willing I would be (or any hematology/oncology colleague,
transfusion medicine specialist, or the authors would be) to receive
nonleukoreduced platelets only when the platelet count falls to 10,000/µL in the
setting of leukemia or intensive cytoreductive therapy. I know I would be
uncomfortable with this approach, regardless of the published data.

Conclusions

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