The Role of Transfusion Oncology in the Care of Cancer Patients

August 16, 2021

Information

August 15, 2021

Yale Cancer Center

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00:00Funding for Yale Cancer Answers
00:02is provided by Smilow Cancer
00:04Hospital and AstraZeneca.
00:08Welcome to Yale Cancer
00:09Answers with your host
00:11Doctor Anees Chagpar.
00:13Yale Cancer Answers features the latest
00:14information on cancer care by
00:16welcoming oncologists and specialists
00:18who are on the forefront of the
00:20battle to fight cancer. This week
00:22it's a conversation about transfusion
00:24oncology with Doctor Edward Snyder.
00:26Doctor Snyder is a professor of
00:28laboratory medicine at the Yale School
00:30of Medicine where Doctor Chagpar is
00:33a professor of surgical oncology.
00:36Maybe we can start off by
00:38you telling us a little bit
00:41about yourself and what it is you do.
00:44I'm a professor of laboratory medicine.
00:46I've been in the field
00:48for almost four decades,
00:50and transfusion medicine is basically
00:53what I do, all aspects of it,
00:55supplying the blood,
00:57seeing people who have any reactions
00:59and providing consultation to
01:00oncologists whose patients
01:01may need a blood transfusion.
01:04And they have some difficulties.
01:07Talk a bit more about that whole specialty.
01:09Because for many of us
01:11we don't really think about
01:13transfusion medicine or transfusion
01:15oncology as a specialty in and of itself.
01:21Tell us a bit more about
01:24what's the purview of
01:26people who specialize in that area?
01:27Transfusion medicine is an area
01:31that originally started off in
01:35pathology and what happened was as
01:38the field grew pretty much stimulated
01:40by infectious disease concerns,
01:42it became much more of a consultive
01:45service involving medicine and surgery,
01:47so the term blood banking,
01:49which was really more of the storing
01:51of blood and so forth which we
01:54can talk about in a little bit,
01:57but the consultative aspect of the service
02:00where we talked to other physicians,
02:02you had trouble providing blood
02:04products for patients because of
02:07a variety of concerns and people from
02:09a variety of specialties, pathology,
02:12my backgrounds in internal medicine
02:14and hematology,
02:15others are in anesthesiology or surgery.
02:20And it is more than just storing blood in a refrigerator.
02:23It really has to do with supplying the
02:27appropriate blood component for a patient
02:29in the right amount and at the right time.
02:33And most physicians, the terminology
02:37I use or phrase I use,
02:38if you don't know your jewels,
02:41know your jeweler, and most physicians don't
02:43really know much about blood transfusion,
02:45so they rely very heavily on the blood bank.
02:47Tell us a little
02:49bit more about the role of
02:51transfusion medicine in oncology.
02:53I mean, many of us think about using
02:55blood in trauma situations where
02:57people have lost a lot of blood.
03:00But for cancer patients,
03:01things might be a little bit different.
03:04What are the needs of cancer patients
03:06when it comes to transfusions?
03:09Many of the chemotherapeutic
03:12regimens that are used to treat
03:14cancer cause what's called a
03:17hyperproliferative state in the bone marrow.
03:19That is, the bone marrow is affected
03:22by the chemotherapy in ways that are
03:25similar to the effect it has on the tumor.
03:28And the goal of chemotherapy
03:30would be to specifically have a
03:33negative impact on the tumor and
03:35to leave all healthy tissue alone.
03:40The chemotherapy also lowers the bone
03:42marrow's ability to make new blood cells,
03:45red cells or platelets,
03:46and when that happens,
03:48the patient becomes anemic and then
03:50they need a blood transfusion or if
03:52their platelet count gets very low,
03:55they'll need a platelet transfusion.
03:56The concern is that when you start giving
03:59blood products to people that they can
04:02develop an antibody to the component,
04:04the same way when you get a vaccination,
04:07you develop an antibody to the material
04:10that's injected and some people develop
04:12antibodies to red blood cells.
04:14Inside they have hemoglobin,
04:16which carries oxygen,
04:18which is important.
04:19But the surface of the cell is also studded
04:22with a variety of chemicals called antigens,
04:25which are foreign to some patients.
04:27Not everyone has the same blood type.
04:30Everyone knows about ABO types,
04:31but there are hundreds of other
04:34blood types that are on the cell,
04:36most of which are not clinically significant,
04:39but some are.
04:40And when some of those blood
04:43types of the transfused blood,
04:45even though they're compatible for the
04:48ABO system and also the RH system which
04:51many people know of many of the other
04:54blood antigens with names that most
04:56people probably haven't heard of,
05:02they can develop antibodies to that,
05:04and when that happens,
05:06it becomes difficult to find
05:08blood for that patient,
05:09especially if they've had
05:11multiple transfusions.
05:12And they've developed multiple antibodies,
05:14so the blood bank director and that
05:16point the consults with the oncologist
05:18because the patient has gotten chemotherapy,
05:20their blood count is dropped and
05:22they need to get a transfusion most
05:25of the time it's not a problem
05:27if things go smoothly,
05:29but on occasion when there are
05:31problems they contact the blood bank
05:33and we work with the physician to
05:36determine how much blood is needed.
05:38Also,
05:38many surgical patients who have cancer
05:40require blood during operative procedures.
05:42And we work with the surgeons as
05:45well to see how much blood is needed
05:49and whether they need platelets.
05:51For example,
05:52platelets are little fragments
05:55of blood cells.
05:57Unrelated to red cells,
05:58although they all derived
06:00from common lineages,
06:01going way way back to embryonic cell growth.
06:06And platelets are also needed and
06:08for patients and the number of
06:10platelets may be lower because again,
06:12the chemotherapy or other illnesses
06:14that are part of the illness itself
06:17may cause the platelets to drop.
06:19So if you were to transfuse a platelet,
06:22the platelet count may not go
06:23up to the level
06:25that's wanted, and you wind up having
06:27a patient who can't really receive
06:29platelet transfusions and get
06:31the response that's needed.
06:33The platelet count is not
06:37elevated as expected and that definitely
06:39requires a consultation from the
06:41blood bank with the clinician to
06:43determine what other options there are,
06:45and there are multiple options
06:47for finding compatible platelets.
06:49Then there are other patients who
06:51have other illnesses where the plasma
06:54levels of some plasma products may be low,
06:57and they would need a plasma transfusion,
07:00so blood banks get involved in a
07:04variety of issues related to oncology,
07:06whether it's surgical or
07:09whether it's chemotherapy, or
07:11whether it's illness based.
07:13In some cancers,
07:14the bone marrow is affected by the growth
07:17of the tumor and the tumor actually
07:20replaces some of the bone marrow
07:22causing platelet counts to become too low
07:26and for patients who actually have a good
07:29lifestyle and we consult for those
07:31issues as well, so
07:34in addition,
07:34if someone gets a transfusion and
07:37they have a reaction of some type,
07:39whether it's a nallergic reaction or a fever,
07:42we consult with that as well.
07:44So we're pretty busy.
07:46It's a very clinically oriented specialty.
07:48You make a few really good points,
07:51and one of which is that some
07:53cancer patients will need repetitive
07:55transfusions and can build up
07:57these antibody responses.
07:59So just out of curiosity,
08:02how do you get around that?
08:05I think this is a question that
08:08many patients and their families
08:10may have is should we be donating
08:13our own blood and banking it,
08:15knowing that we may,
08:16with chemotherapy, for example,
08:18need a transfusion in the future?
08:21Are there particular banks that
08:24have rare blood types where
08:27people who have developed
08:29many antibodies to various
08:32antigens can still find blood?
08:35How do you work around those issues?
08:39Well, one needs to be creative,
08:41so let's get some definitions,
08:43orthologous blood auto logus who
08:44pronounced autologous is your own
08:46blood being given back to you,
08:48and so some of our listeners may say,
08:50well, why can't I store my own blood?
08:53Well, if your blood count is high enough,
08:56you can store your own blood
08:58someplace and it used to be very popular
09:00to do that during the AIDS
09:03epidemic when people were very concerned
09:05but that when the AIDS,
09:06a virus and how to treat, it became.
09:09Part of standard of care
09:11for for AIDS patients,
09:12the need to provide it their own
09:14blood really wasn't important anymore.
09:16And many blood centers stopped that practice.
09:19One of the problems with donating
09:21your own blood is you have to
09:23have a blood count high enough,
09:25otherwise you become anemic and you just
09:27have to give you the blood right back
09:30or they were actually blood banks that
09:32were set up where you could freeze blood,
09:35which was fine as I used to say,
09:37unless you're on a vacation in Hawaii.
09:40And something happens and you need
09:41blood and the blood is frozen in the
09:44New York or in Washington or New Haven.
09:45And you can't get to it.
09:49It became clear that donating
09:51blood for yourself really wasn't
09:53going to be very useful,
09:54and practice is not really
09:56done much anymore at all.
09:58Very some places don't even accept some blood
10:01centers don't even accept autologous blood.
10:03The second would be a directed donation
10:06where a family member would donate
10:09a unit of blood specifically for.
10:12The patient that requires,
10:13of course that the blood be compatible,
10:16which is often is not.
10:17In addition, come,
10:18it's not just a relative,
10:20but some people wanted close
10:22personal friends,
10:22or,
10:22as I used to comment,
10:24the captain of their bowling
10:26team was a close friend,
10:27so they wanted the captain of the
10:29bowling team to donate blood for
10:31them because they believe that
10:33because they were their friend,
10:35they were biologically safer as
10:36a donor and they didn't have to
10:39worry about different diseases.
10:40Well, quite frankly, you don't know what.
10:43The captain of your bowling team is,
10:45it does after they leave the bowling alley.
10:49So directed donations as a means
10:51of getting blood from someone
10:53you're comfortable with doesn't is
10:55in practice much anymore either.
10:58So that leaves us with the third category,
11:01which is what is called allogenic LLOGENEC,
11:04which is blood from other people.
11:06And that's what almost all the blood
11:09that we provide is blood from people
11:12who are concerned about their fellow.
11:15Human and they donate blood or they
11:18donate platelets or they donate red
11:21cells or plasma to blood centers.
11:23And that's the blood that's given.
11:25We have ways of matching the blood
11:27so that the antigens I talked
11:29about are not a problem.
11:30We pick out for someone who was typo.
11:33We give old blood.
11:34If someone is type A,
11:35we can give type A blood or
11:37type O blood and so forth and
11:39so on for the various antigens.
11:41And we have a whole system
11:43set up in blood banking of.
11:45Of cells that allow us to determine
11:48blood that's compatible and we do
11:50that so that kind of compatibility
11:52testing is sort of the bread and
11:54butter of what blood banks do and
11:56and that's that is taken care of if
11:59it comes to problems where someone
12:01with a local blood bank can't
12:03find anything that's compatible.
12:05You have systems like the Red Cross
12:07that have 35 or 40 blood centers
12:09around the country and they have
12:11what they call rare donor files
12:13where they have peoples blood types
12:15on record and they can ask for
12:18blood to be sent if they have them
12:21frozen or they may have liquid
12:24units that aren't frozen.
12:26And there are ways of working
12:28with the larger blood providers
12:30to work around that issue.
12:32There are other blood systems
12:34besides the ABO system.
12:36One is the HLA system and
12:38people may have antibodies to HLA or
12:41they may have antibodies to platelets.
12:44There are platelet antigens like there
12:46are red cells and again the Red
12:49Cross has donor records and we
12:51can test and find people who are
12:54compatible for the patient.
12:56There's a whole series of
12:58things that we have to do.
13:00You can't just have a small blood
13:02bank working on its own.
13:05You really need to be part of a large system,
13:08certainly a hospital like Yale,
13:10with 1600 beds and many,
13:12many patients who are fortunately
13:14living longer and longer with malignant
13:16conditions that are treatable.
13:18But when they're transfused a lot during
13:20their therapy when they come back,
13:22if they have a relapse then the
13:25possibility of having incompatible blood
13:27either for red cells or incompatibility
13:30with platelets becomes a real issue
13:32and you need a large support structure
13:35in blood centers to provide blood
13:37so that the patient can be treated
13:39and go into remission again.
13:41So there's a lot we have to do.
13:44We consult on a lot of different
13:47issues and it keeps us pretty busy.
13:50Great, well, we're going to take a
13:53short break for a medical minute.
13:56Please stay tuned to learn more
13:58about transfusion oncology
13:59with my guest doctor Edward Snyder.
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15:08More information is available at
15:10yalecancercenter.org. You're listening
15:12to Connecticut Public Radio.
15:16Welcome back to Yale Cancer Answers.
15:18This is doctor Anees Chagpar and I'm
15:21joined tonight by my guest Doctor Ed Snyder.
15:24We're talking about transfusion
15:25oncology and right before the break
15:27Ed you were talking about the fact
15:30that some cancer patients require
15:32multiple transfusions and there's
15:34really a benefit to being part of a
15:37large system such as the Red Cross,
15:39where if you have developed
15:41antibodies to a particular antigen in blood,
15:44that there still are rare donors who
15:47could provide blood for you,
15:49but I wonder about other modalities
15:52that might actually reduce our
15:54need for blood transfusions.
15:56So what are your thoughts
15:58on things like that?
16:00I know that for many of our
16:03cancer patients there are drugs,
16:05for example,
16:06that oncologists use either to increase
16:09red blood cells or white blood cells.
16:13How effective are they and do
16:15you find that that reduces the
16:17transfusion needs for patients?
16:20Well, yes, the saying that we have
16:23in transfusion is the safest unit
16:25of blood is the one you don't get.
16:28And even though we do everything
16:30we can to ensure the blood safety,
16:33there are still the possibility of concerns
16:36regarding fever or transmission of illnesses.
16:38As anytime you do any kind of a
16:41transplant which really a transplant
16:43is really what a blood transfusion is.
16:47Only it's a transplant of red blood cells.
16:50Platelets.
16:50There are a variety of reagents which
16:53are designed to stimulate red cell
16:56production from some of those have
16:58shown to cause problems and are
17:00not used as often as they were.
17:07There are agents that can be used
17:10to stimulate platelets as well.
17:18But those are predicated on the fact
17:20that your bone marrow can actually make
17:23more if your bone marrow is damaged
17:26and you don't have the cells that
17:28can respond to those chemicals and
17:30actually make more of those kinds of
17:33cells that they're not going to be effective.
17:36Although there are those chemical
17:38reagents that can be used,
17:40they may in some patients have
17:42limited usefulness, so a transfusion
17:44I think although people try
17:46to minimize the times,
17:48blood transfusions are needed,
17:50they still need to be there.
17:53One of the things that's important
17:54about that is a concern about the reactions.
17:58And there's a variety of types of reactions,
18:01one of which is a febrile which is a fever,
18:04and that's because when you're
18:06giving a foreign protein,
18:07which blood cells have proteins on them,
18:09you can get a fever.
18:11There's that in and of
18:13itself is not dangerous.
18:14It's uncomfortable,
18:14and we like to minimize that from happening.
18:17But patients do can get a fever.
18:20They can also get hives,
18:21or they can get allergic
18:23reactions they can also have some
18:25other kinds of complications,
18:27all of which the transfusion
18:29service is aware of and we try
18:32to minimize as much as possible.
18:34One of the areas that's
18:36a really big concern is,
18:38as I mentioned earlier,
18:40infectious problems and that
18:42has led to the production of a whole
18:44new field of transfusion medicine,
18:47which is pathogen reduction.
18:5110-15 years ago
18:52if there was a virus that came out
18:56like Zika or West Nile,
18:58we knew there was a virus
19:01that had entered the blood supply,
19:04molecular biology was used to
19:07identify the virus,
19:08determine where it could be neutralized, and
19:10tests were made to identify it,
19:13treatments were developed.
19:14But then all of that cost money,
19:17and then the hospitals and the blood
19:20centers had to spend a lot of money.
19:23For that,
19:24the FDA took a long time to approve
19:26the testing and evaluation of
19:28donors for that particular illness.
19:30And while all this was going on,
19:32Medicare may or may not
19:34have reimbursed for it.
19:35So there was a financial what I call
19:37the banking part of blood banking,
19:39and then every time you got through
19:41with one virus, another one came along.
19:44So the field decided to move to a new type
19:47of tech that is called a reactive approach.
19:49That is, you identify a pathogen
19:51of some sort or something that
19:53shouldn't be in blood,
19:55whether it's a virus or bacteria,
19:58and then you try to mitigate
20:01it or get rid of it.
20:04This pathogen reduction technology
20:06is not reactive, it's proactive.
20:08There are reagents that are put into
20:10the blood bag that are designed to
20:13inactivate pathogens by attacking
20:15the DNA and RNA of those pathogens,
20:17blood cells,
20:18the human red cells and platelets
20:21do not have DNA or RNA because
20:24it's not part of what that
20:25particular cell has,
20:26they had them when they were growing,
20:28but when they become mature cells,
20:30the DNA and RNA isn't there.
20:32So the only thing that has DNA or
20:34RNA in a unit of blood is a pathogen.
20:36So if you can put chemicals in
20:38that affect the DNA or RNA,
20:40you're really sparing the good
20:42cells and you're just trying to
20:43get rid of any pathogen.
20:45Well, you can say with all the testing
20:47why should there be a pathogen there?
20:49There shouldn't be,
20:49but sometimes pathogens are in
20:51very low levels like bacteria,
20:52but then they can grow.
20:54Other times,
20:55new viruses come in like the COVID-19
20:58virus is not transmitted by blood,
21:01fortunately,
21:01as bad as it is,
21:04and it's a horrific virus,
21:06but it is not transmissible by blood.
21:08The HIV virus or AIDS with
21:11the pathogen reduction technology
21:13it puts reagents in the blood
21:15bag that will inactivate pathogens
21:18and many pathogens share common
21:20DNA or RNA types so that the
21:23reagents that are put in
21:25will be effective against them.
21:27And indeed the pathogen reduction
21:29technology that has been studied
21:32and proven to be successful
21:33it doesn't
21:36activate the COVID-19 virus,
21:38although it's not a bloodborne problem,
21:40but the next one might be,
21:42so pathogen reduction has been approved
21:45for platelets and for plasma they are
21:48currently doing clinical trials for
21:50red cells and we are doing several
21:53of those trials at Yale and at
21:5515 other sites around the country
21:58and once we have pathogen
22:00reduction approved then we will have
22:03a much safer blood supply because
22:05not only will we be testing for known
22:07viruses and pathogens and bacteria,
22:09but also for unknown ones,
22:11which is critical for the safety
22:13of the blood supply.
22:15These kinds of technologies,
22:16molecular diagnostics and so forth
22:18are really the future of transfusion.
22:20In addition,
22:21there are other types of approaches,
22:23immunotherapy to treat patients
22:25instead of using
22:26chemotherapy that I mentioned earlier,
22:27which can have cytotoxic,
22:29which means it's toxic to cells
22:31which can lower the amount
22:33of bone marrow that
22:34you have. Other types of therapy CAR
22:37T cell therapy you may have heard
22:39of or other types of immunotherapy
22:41where you do not depress the bone
22:44marrow when those patients may not
22:46need transfusions because their blood
22:47counts don't get that become that low.
22:50There are other aspects of transfusion
22:52medicine that those patients
22:54require and we don't have time in this
22:57discussion to go into all of that,
22:59but you can be sure that the blood
23:02transfusion service at the Hospital
23:04is working closely with the oncologists
23:06and the surgeons to ensure that the
23:09best and the safest possible blood for
23:11their patients and our field grows
23:13as the field of therapeutics grows.
23:16So we have the patient's best
23:18interest at heart.
23:19There are many sort of tricks in our bag
23:22if you will, of how we can provide
23:25safe blood pathogen reduction.
23:27Again, is a critical advance in the field
23:30and we just have one more cell type.
23:32The red cells that the research
23:35is being done on
23:36now to have that available in
23:39a couple of years.
23:41And the goal,
23:42of course,
23:43is to be able to treat patients
23:45and eventually just do away
23:47with this field of transfusion,
23:49because you won't need to give blood.
23:52But that's not in the foreseeable future,
23:54so the best we can do is provide
23:57the safest possible blood,
23:59the least amount needed,
24:00and the best quality for
24:02our patients.
24:03And you mentioned
24:05the term pathogen reduction
24:07it's not pathogen elimination,
24:09but it still is
24:11really low odds that people get
24:14infections with blood these days.
24:16Can you remind us about those numbers?
24:19What is the risk of
24:21getting HIV or hepatitis from a
24:24bag of blood these days?
24:26The risk of HIV is in the millions,
24:30one in a million, one in many millions.
24:33That's for HIV.
24:34It's also true for other types of viruses.
24:38Hepatitis is somewhere in the range
24:41of about one in 250,000 to 100.
24:44I'm sorry 1 to 250,000
24:46to 1 to 500,000 for bacteria.
24:49The numbers are higher because bacteria
24:52are much different organisms than viruses
24:55so the risk of getting a septic
24:57transfusion reaction is extremely low,
25:00but the risk of getting some bacteria
25:03growing in blood is somewhere in
25:05the range of 1 to the 30,000 in
25:08that range which are several orders
25:11of magnitude less than the HIV.
25:14Part of that problem is you can't
25:16test for all the different kinds
25:19of bacteria that there are.
25:21Some of them grow slowly.
25:22It depends on where the bacteria came from.
25:25There shouldn't be any bacteria in blood,
25:27and most of the time they're not.
25:30But that's where the pathogen
25:32reduction comes in,
25:33because pathogen reduction would
25:34inactivate any viruses or any bacteria
25:36that get through the testing that we have.
25:39So it's not something
25:41to be concerned about.
25:43Because the donor
25:45history is extremely inquisitive.
25:47We're asking a lot of questions,
25:50many of which took years
25:53to get accepted because
25:55a lot of the questions relate to
25:58sexual practices and many people were
26:01offended by those questions when we
26:03started asking it when we realized
26:05that HIV was sexually transmitted.
26:07But it was required to do it
26:09for the safety of the patients
26:12who are receiving the blood.
26:14But now that we know more about
26:16how to treat these diseases,
26:19many of those individuals come
26:21who are negative for these various
26:23tests are able to donate blood
26:26and it's a different field.
26:28We have to grow with the field as the
26:31knowledge grows and
26:33that's what transfusion is,
26:35there's a practical side
26:36for the patient care.
26:38There's the collection side and
26:40there's also the research side
26:42which is allowing us to advance
26:44the field in so many different ways.
26:47One last question is,
26:49perhaps,
26:51we had mentioned the fact that
26:54as therapeutics advance
26:55we may have less and less need for
26:59transfusion, but at the moment it
27:01still is a part of clinical care.
27:05How do you get around the needs of patients
27:09who cannot take due to religious reasons
27:12for example, blood?
27:14Are there other options for
27:16them outside of a transfusion?
27:18That's an excellent
27:20question. There are individuals who
27:22do not want a blood transfusion.
27:25For a variety of religious reasons or
27:27other reasons, for those individuals,
27:29consultation with the patients physician
27:31is required, as well as the family.
27:34We have a family meeting to discuss options
27:37and if blood transfusion is not one of them
27:40you mentioned the various reagents that
27:43are developed to stimulate the production
27:45of platelets or red cells in the person.
27:48Those chemicals can be given that
27:50may be possible to take some blood
27:53from the patient prior to treatment
27:55and store it so that if the
27:58patient's count does drop,
27:59they will have stored their own
28:01blood in advance, which in someone
28:03who doesn't want to get transfusion,
28:05of someone else's blood,
28:07may be willing to accept their own blood.
28:10Some individuals don't want to
28:11accept blood from themselves,
28:13that's been taken out of their body,
28:15separated, stored, and then given back.
28:17So it depends on the degree to which the
28:20individual will be willing to accept blood,
28:22but those can cause some very
28:25difficult treatment situations.
28:26That has to be discussed with the patient,
28:29the patient's family,
28:30the physician and the blood bank.
28:32Doctor Edward Snyder is a
28:34professor of laboratory medicine
28:36at the Yale School of Medicine.
28:38If you have questions,
28:39the address is canceranswers@yale.edu
28:41and past editions of the program
28:43are available in audio and written
28:45form at yalecancercenter.org.
28:47We hope you'll join us next week to
28:49learn more about the fight against
28:51cancer here on Connecticut Public
28:53radio funding for Yale Cancer answers.
28:56Was provided by Smilow Cancer
28:58Hospital and AstraZeneca.