The Role of Transfusion Oncology in the Care of Cancer Patients

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:05Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer
00:09 --> 00:10Answers with your host
00:10 --> 00:12Doctor Anees Chagpar.
00:12 --> 00:14Yale Cancer Answers features the latest
00:14 --> 00:16information on cancer care by
00:16 --> 00:18welcoming oncologists and specialists
00:18 --> 00:20who are on the forefront of the
00:20 --> 00:22battle to fight cancer. This week
00:22 --> 00:24it's a conversation about transfusion
00:24 --> 00:26oncology with Doctor Edward Snyder.
00:26 --> 00:28Doctor Snyder is a professor of
00:28 --> 00:30laboratory medicine at the Yale School
00:30 --> 00:32of Medicine where Doctor Chagpar is
00:32 --> 00:36a professor of surgical oncology.
00:36 --> 00:38Maybe we can start off by
00:38 --> 00:40you telling us a little bit
00:40 --> 00:44about yourself and what it is you do.
00:44 --> 00:46I'm a professor of laboratory medicine.
00:46 --> 00:48I've been in the field
00:48 --> 00:49for almost four decades,
00:49 --> 00:52and transfusion medicine is basically
00:52 --> 00:55what I do, all aspects of it,
00:55 --> 00:56supplying the blood,
00:56 --> 00:58seeing people who have any reactions
00:58 --> 01:00and providing consultation to
01:00 --> 01:01oncologists whose patients
01:01 --> 01:03may need a blood transfusion.
01:03 --> 01:05And they have some difficulties.
01:07 --> 01:09Talk a bit more about that whole specialty.
01:09 --> 01:11Because for many of us
01:11 --> 01:13we don't really think about
01:13 --> 01:15transfusion medicine or transfusion
01:15 --> 01:18oncology as a specialty in and of itself.
01:21 --> 01:23Tell us a bit more about
01:23 --> 01:25what's the purview of
01:25 --> 01:27people who specialize in that area?
01:27 --> 01:31Transfusion medicine is an area
01:31 --> 01:34that originally started off in
01:34 --> 01:37pathology and what happened was as
01:37 --> 01:40the field grew pretty much stimulated
01:40 --> 01:41by infectious disease concerns,
01:41 --> 01:44it became much more of a consultive
01:44 --> 01:46service involving medicine and surgery,
01:46 --> 01:48so the term blood banking,
01:48 --> 01:51which was really more of the storing
01:51 --> 01:54of blood and so forth which we
01:54 --> 01:56can talk about in a little bit,
01:56 --> 01:59but the consultative aspect of the service
01:59 --> 02:02where we talked to other physicians,
02:02 --> 02:04you had trouble providing blood
02:04 --> 02:06products for patients because of
02:06 --> 02:09a variety of concerns and people from
02:09 --> 02:11a variety of specialties, pathology,
02:11 --> 02:13my backgrounds in internal medicine
02:13 --> 02:14and hematology,
02:14 --> 02:17others are in anesthesiology or surgery.
02:20 --> 02:22And it is more than just storing blood in a refrigerator.
02:22 --> 02:26It really has to do with supplying the
02:26 --> 02:29appropriate blood component for a patient
02:29 --> 02:32in the right amount and at the right time.
02:32 --> 02:34And most physicians, the terminology
02:36 --> 02:38I use or phrase I use,
02:38 --> 02:40if you don't know your jewels,
02:40 --> 02:42know your jeweler, and most physicians don't
02:42 --> 02:45really know much about blood transfusion,
02:45 --> 02:47so they rely very heavily on the blood bank.
02:47 --> 02:49Tell us a little
02:49 --> 02:51bit more about the role of
02:51 --> 02:52transfusion medicine in oncology.
02:52 --> 02:55I mean, many of us think about using
02:55 --> 02:56blood in trauma situations where
02:56 --> 02:59people have lost a lot of blood.
02:59 --> 03:00But for cancer patients,
03:00 --> 03:03things might be a little bit different.
03:03 --> 03:05What are the needs of cancer patients
03:05 --> 03:07when it comes to transfusions?
03:09 --> 03:11Many of the chemotherapeutic
03:11 --> 03:14regimens that are used to treat
03:14 --> 03:16cancer cause what's called a
03:16 --> 03:18hyperproliferative state in the bone marrow.
03:18 --> 03:21That is, the bone marrow is affected
03:21 --> 03:24by the chemotherapy in ways that are
03:24 --> 03:27similar to the effect it has on the tumor.
03:27 --> 03:30And the goal of chemotherapy
03:30 --> 03:32would be to specifically have a
03:32 --> 03:35negative impact on the tumor and
03:35 --> 03:37to leave all healthy tissue alone.
03:39 --> 03:42The chemotherapy also lowers the bone
03:42 --> 03:44marrow's ability to make new blood cells,
03:44 --> 03:46red cells or platelets,
03:46 --> 03:47and when that happens,
03:47 --> 03:49the patient becomes anemic and then
03:49 --> 03:52they need a blood transfusion or if
03:52 --> 03:54their platelet count gets very low,
03:54 --> 03:56they'll need a platelet transfusion.
03:56 --> 03:59The concern is that when you start giving
03:59 --> 04:01blood products to people that they can
04:01 --> 04:04develop an antibody to the component,
04:04 --> 04:07the same way when you get a vaccination,
04:07 --> 04:09you develop an antibody to the material
04:10 --> 00:-01that's injected and some people develop
04:11 --> 04:13antibodies to red blood cells.
04:13 --> 04:16Inside they have hemoglobin,
04:16 --> 04:17which carries oxygen,
04:17 --> 04:18which is important.
04:18 --> 04:21But the surface of the cell is also studded
04:21 --> 04:24with a variety of chemicals called antigens,
04:24 --> 04:26which are foreign to some patients.
04:26 --> 04:29Not everyone has the same blood type.
04:29 --> 04:31Everyone knows about ABO types,
04:31 --> 04:33but there are hundreds of other
04:33 --> 04:36blood types that are on the cell,
04:36 --> 04:39most of which are not clinically significant,
04:39 --> 04:40but some are.
04:40 --> 04:42And when some of those blood
04:42 --> 04:45types of the transfused blood,
04:45 --> 04:47even though they're compatible for the
04:47 --> 04:50ABO system and also the RH system which
04:50 --> 04:53many people know of many of the other
04:53 --> 04:56blood antigens with names that most
04:56 --> 04:58people probably haven't heard of,
05:01 --> 05:04they can develop antibodies to that,
05:04 --> 05:05and when that happens,
05:05 --> 05:07it becomes difficult to find
05:07 --> 05:09blood for that patient,
05:09 --> 05:10especially if they've had
05:10 --> 05:11multiple transfusions.
05:11 --> 05:13And they've developed multiple antibodies,
05:13 --> 05:15so the blood bank director and that
05:15 --> 05:17point the consults with the oncologist
05:17 --> 05:20because the patient has gotten chemotherapy,
05:20 --> 05:22their blood count is dropped and
05:22 --> 05:24they need to get a transfusion most
05:24 --> 05:27of the time it's not a problem
05:27 --> 05:28if things go smoothly,
05:28 --> 05:30but on occasion when there are
05:30 --> 05:33problems they contact the blood bank
05:33 --> 05:35and we work with the physician to
05:35 --> 05:37determine how much blood is needed.
05:37 --> 05:38Also,
05:38 --> 05:40many surgical patients who have cancer
05:40 --> 05:42require blood during operative procedures.
05:42 --> 05:45And we work with the surgeons as
05:45 --> 05:48well to see how much blood is needed
05:48 --> 05:51and whether they need platelets.
05:51 --> 05:52For example,
05:52 --> 05:54platelets are little fragments
05:54 --> 05:56of blood cells.
05:56 --> 05:58Unrelated to red cells,
05:58 --> 05:59although they all derived
05:59 --> 06:01from common lineages,
06:01 --> 06:05going way way back to embryonic cell growth.
06:05 --> 06:07And platelets are also needed and
06:07 --> 06:10for patients and the number of
06:10 --> 06:12platelets may be lower because again,
06:12 --> 06:14the chemotherapy or other illnesses
06:14 --> 06:16that are part of the illness itself
06:16 --> 06:18may cause the platelets to drop.
06:18 --> 06:21So if you were to transfuse a platelet,
06:21 --> 06:23the platelet count may not go
06:23 --> 06:24up to the level
06:24 --> 06:27that's wanted, and you wind up having
06:27 --> 06:29a patient who can't really receive
06:29 --> 06:31platelet transfusions and get
06:31 --> 06:33the response that's needed.
06:33 --> 06:36The platelet count is not
06:36 --> 06:38elevated as expected and that definitely
06:38 --> 06:41requires a consultation from the
06:41 --> 06:43blood bank with the clinician to
06:43 --> 06:45determine what other options there are,
06:45 --> 06:47and there are multiple options
06:47 --> 06:48for finding compatible platelets.
06:48 --> 06:51Then there are other patients who
06:51 --> 06:53have other illnesses where the plasma
06:53 --> 06:56levels of some plasma products may be low,
06:56 --> 06:59and they would need a plasma transfusion,
06:59 --> 07:03so blood banks get involved in a
07:03 --> 07:05variety of issues related to oncology,
07:06 --> 07:08whether it's surgical or
07:08 --> 07:10whether it's chemotherapy, or
07:10 --> 07:12whether it's illness based.
07:12 --> 07:13In some cancers,
07:13 --> 07:16the bone marrow is affected by the growth
07:16 --> 07:19of the tumor and the tumor actually
07:19 --> 07:22replaces some of the bone marrow
07:22 --> 07:26causing platelet counts to become too low
07:26 --> 07:28and for patients who actually have a good
07:28 --> 07:31lifestyle and we consult for those
07:31 --> 07:33issues as well, so
07:33 --> 07:34in addition,
07:34 --> 07:36if someone gets a transfusion and
07:36 --> 07:39they have a reaction of some type,
07:39 --> 07:42whether it's a nallergic reaction or a fever,
07:42 --> 07:44we consult with that as well.
07:44 --> 07:45So we're pretty busy.
07:45 --> 07:47It's a very clinically oriented specialty.
07:47 --> 07:51You make a few really good points,
07:51 --> 07:53and one of which is that some
07:53 --> 07:55cancer patients will need repetitive
07:55 --> 07:57transfusions and can build up
07:57 --> 07:58these antibody responses.
07:58 --> 08:01So just out of curiosity,
08:01 --> 08:03how do you get around that?
08:05 --> 08:08I think this is a question that
08:08 --> 08:10many patients and their families
08:10 --> 08:12may have is should we be donating
08:12 --> 08:14our own blood and banking it,
08:14 --> 08:16knowing that we may,
08:16 --> 08:18with chemotherapy, for example,
08:18 --> 08:21need a transfusion in the future?
08:21 --> 08:23Are there particular banks that
08:23 --> 08:26have rare blood types where
08:26 --> 08:29people who have developed
08:29 --> 08:31many antibodies to various
08:31 --> 08:34antigens can still find blood?
08:34 --> 08:38How do you work around those issues?
08:39 --> 08:41Well, one needs to be creative,
08:41 --> 08:42so let's get some definitions,
08:42 --> 08:44orthologous blood auto logus who
08:44 --> 08:46pronounced autologous is your own
08:46 --> 08:47blood being given back to you,
08:47 --> 08:50and so some of our listeners may say,
08:50 --> 08:53well, why can't I store my own blood?
08:53 --> 08:55Well, if your blood count is high enough,
08:55 --> 08:57you can store your own blood
08:57 --> 08:59someplace and it used to be very popular
08:59 --> 09:02to do that during the AIDS
09:02 --> 09:04epidemic when people were very concerned
09:04 --> 09:06but that when the AIDS,
09:06 --> 09:08a virus and how to treat, it became.
09:08 --> 09:10Part of standard of care
09:10 --> 09:12for for AIDS patients,
09:12 --> 09:14the need to provide it their own
09:14 --> 09:16blood really wasn't important anymore.
09:16 --> 09:18And many blood centers stopped that practice.
09:18 --> 09:20One of the problems with donating
09:20 --> 09:22your own blood is you have to
09:22 --> 09:24have a blood count high enough,
09:24 --> 09:27otherwise you become anemic and you just
09:27 --> 09:29have to give you the blood right back
09:29 --> 09:31or they were actually blood banks that
09:31 --> 09:34were set up where you could freeze blood,
09:34 --> 09:37which was fine as I used to say,
09:37 --> 09:39unless you're on a vacation in Hawaii.
09:39 --> 09:41And something happens and you need
09:41 --> 09:43blood and the blood is frozen in the
09:43 --> 09:45New York or in Washington or New Haven.
09:45 --> 09:48And you can't get to it.
09:48 --> 09:50It became clear that donating
09:50 --> 09:52blood for yourself really wasn't
09:52 --> 09:54going to be very useful,
09:54 --> 09:56and practice is not really
09:56 --> 09:58done much anymore at all.
09:58 --> 10:00Very some places don't even accept some blood
10:00 --> 10:03centers don't even accept autologous blood.
10:03 --> 10:06The second would be a directed donation
10:06 --> 10:09where a family member would donate
10:09 --> 10:12a unit of blood specifically for.
10:12 --> 10:13The patient that requires,
10:13 --> 10:15of course that the blood be compatible,
10:15 --> 10:17which is often is not.
10:17 --> 10:18In addition, come,
10:18 --> 10:19it's not just a relative,
10:19 --> 10:21but some people wanted close
10:21 --> 10:22personal friends,
10:22 --> 10:22or,
10:22 --> 10:24as I used to comment,
10:24 --> 10:25the captain of their bowling
10:25 --> 10:27team was a close friend,
10:27 --> 10:29so they wanted the captain of the
10:29 --> 10:31bowling team to donate blood for
10:31 --> 10:33them because they believe that
10:33 --> 10:34because they were their friend,
10:34 --> 10:36they were biologically safer as
10:36 --> 10:38a donor and they didn't have to
10:38 --> 10:40worry about different diseases.
10:40 --> 10:42Well, quite frankly, you don't know what.
10:42 --> 10:45The captain of your bowling team is,
10:45 --> 10:48it does after they leave the bowling alley.
10:48 --> 10:50So directed donations as a means
10:50 --> 10:52of getting blood from someone
10:52 --> 10:55you're comfortable with doesn't is
10:55 --> 10:57in practice much anymore either.
10:57 --> 11:00So that leaves us with the third category,
11:00 --> 11:03which is what is called allogenic LLOGENEC,
11:03 --> 11:06which is blood from other people.
11:06 --> 11:09And that's what almost all the blood
11:09 --> 11:12that we provide is blood from people
11:12 --> 11:15who are concerned about their fellow.
11:15 --> 11:18Human and they donate blood or they
11:18 --> 11:20donate platelets or they donate red
11:20 --> 11:23cells or plasma to blood centers.
11:23 --> 11:24And that's the blood that's given.
11:24 --> 11:26We have ways of matching the blood
11:26 --> 11:28so that the antigens I talked
11:28 --> 11:30about are not a problem.
11:30 --> 11:32We pick out for someone who was typo.
11:32 --> 11:33We give old blood.
11:33 --> 11:35If someone is type A,
11:35 --> 11:37we can give type A blood or
11:37 --> 11:39type O blood and so forth and
11:39 --> 11:41so on for the various antigens.
11:41 --> 11:43And we have a whole system
11:43 --> 11:45set up in blood banking of.
11:45 --> 11:48Of cells that allow us to determine
11:48 --> 11:50blood that's compatible and we do
11:50 --> 11:52that so that kind of compatibility
11:52 --> 11:54testing is sort of the bread and
11:54 --> 11:56butter of what blood banks do and
11:56 --> 11:58and that's that is taken care of if
11:58 --> 12:00it comes to problems where someone
12:00 --> 12:02with a local blood bank can't
12:02 --> 12:04find anything that's compatible.
12:04 --> 12:06You have systems like the Red Cross
12:06 --> 12:09that have 35 or 40 blood centers
12:09 --> 12:11around the country and they have
12:11 --> 12:13what they call rare donor files
12:13 --> 12:15where they have peoples blood types
12:15 --> 12:18on record and they can ask for
12:18 --> 12:21blood to be sent if they have them
12:21 --> 12:23frozen or they may have liquid
12:23 --> 12:25units that aren't frozen.
12:25 --> 12:27And there are ways of working
12:27 --> 12:29with the larger blood providers
12:29 --> 12:31to work around that issue.
12:31 --> 12:33There are other blood systems
12:33 --> 12:35besides the ABO system.
12:35 --> 12:38One is the HLA system and
12:38 --> 12:41people may have antibodies to HLA or
12:41 --> 12:43they may have antibodies to platelets.
12:43 --> 12:46There are platelet antigens like there
12:46 --> 12:49are red cells and again the Red
12:49 --> 12:51Cross has donor records and we
12:51 --> 12:54can test and find people who are
12:54 --> 12:56compatible for the patient.
12:56 --> 12:57There's a whole series of
12:57 --> 13:00things that we have to do.
13:00 --> 13:02You can't just have a small blood
13:02 --> 13:04bank working on its own.
13:04 --> 13:08You really need to be part of a large system,
13:08 --> 13:10certainly a hospital like Yale,
13:10 --> 13:12with 1600 beds and many,
13:12 --> 13:14many patients who are fortunately
13:14 --> 13:16living longer and longer with malignant
13:16 --> 13:17conditions that are treatable.
13:17 --> 13:20But when they're transfused a lot during
13:20 --> 13:22their therapy when they come back,
13:22 --> 13:25if they have a relapse then the
13:25 --> 13:27possibility of having incompatible blood
13:27 --> 13:29either for red cells or incompatibility
13:29 --> 13:32with platelets becomes a real issue
13:32 --> 13:34and you need a large support structure
13:34 --> 13:36in blood centers to provide blood
13:36 --> 13:39so that the patient can be treated
13:39 --> 13:41and go into remission again.
13:41 --> 13:44So there's a lot we have to do.
13:44 --> 13:46We consult on a lot of different
13:46 --> 13:49issues and it keeps us pretty busy.
13:50 --> 13:53Great, well, we're going to take a
13:53 --> 13:55short break for a medical minute.
13:55 --> 13:58Please stay tuned to learn more
13:58 --> 13:59about transfusion oncology
13:59 --> 14:01with my guest doctor Edward Snyder.
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15:15 --> 15:17Welcome back to Yale Cancer Answers.
15:17 --> 15:20This is doctor Anees Chagpar and I'm
15:20 --> 15:23joined tonight by my guest Doctor Ed Snyder.
15:23 --> 15:25We're talking about transfusion
15:25 --> 15:27oncology and right before the break
15:27 --> 15:29Ed you were talking about the fact
15:29 --> 15:31that some cancer patients require
15:31 --> 15:33multiple transfusions and there's
15:33 --> 15:36really a benefit to being part of a
15:36 --> 15:38large system such as the Red Cross,
15:38 --> 15:41where if you have developed
15:41 --> 15:43antibodies to a particular antigen in blood,
15:43 --> 15:47that there still are rare donors who
15:47 --> 15:49could provide blood for you,
15:49 --> 15:51but I wonder about other modalities
15:51 --> 15:53that might actually reduce our
15:53 --> 15:55need for blood transfusions.
15:55 --> 15:57So what are your thoughts
15:57 --> 15:59on things like that?
15:59 --> 16:02I know that for many of our
16:02 --> 16:04cancer patients there are drugs,
16:04 --> 16:05for example,
16:05 --> 16:09that oncologists use either to increase
16:09 --> 16:12red blood cells or white blood cells.
16:12 --> 16:14How effective are they and do
16:14 --> 16:17you find that that reduces the
16:17 --> 16:18transfusion needs for patients?
16:19 --> 16:22Well, yes, the saying that we have
16:22 --> 16:25in transfusion is the safest unit
16:25 --> 16:28of blood is the one you don't get.
16:28 --> 16:30And even though we do everything
16:30 --> 16:33we can to ensure the blood safety,
16:33 --> 16:35there are still the possibility of concerns
16:35 --> 16:37regarding fever or transmission of illnesses.
16:37 --> 16:40As anytime you do any kind of a
16:40 --> 16:43transplant which really a transplant
16:43 --> 16:46is really what a blood transfusion is.
16:46 --> 16:49Only it's a transplant of red blood cells.
16:49 --> 16:50Platelets.
16:50 --> 16:52There are a variety of reagents which
16:52 --> 16:55are designed to stimulate red cell
16:55 --> 16:58production from some of those have
16:58 --> 17:00shown to cause problems and are
17:00 --> 17:02not used as often as they were.
17:07 --> 17:09There are agents that can be used
17:09 --> 17:11to stimulate platelets as well.
17:18 --> 17:20But those are predicated on the fact
17:20 --> 17:23that your bone marrow can actually make
17:23 --> 17:25more if your bone marrow is damaged
17:25 --> 17:28and you don't have the cells that
17:28 --> 17:30can respond to those chemicals and
17:30 --> 17:33actually make more of those kinds of
17:33 --> 17:35cells that they're not going to be effective.
17:35 --> 17:37Although there are those chemical
17:37 --> 17:39reagents that can be used,
17:39 --> 17:42they may in some patients have
17:42 --> 17:44limited usefulness, so a transfusion
17:44 --> 17:45I think although people try
17:45 --> 17:47to minimize the times,
17:47 --> 17:49blood transfusions are needed,
17:49 --> 17:52they still need to be there.
17:52 --> 17:54One of the things that's important
17:54 --> 17:56about that is a concern about the reactions.
17:58 --> 18:00And there's a variety of types of reactions,
18:00 --> 18:03one of which is a febrile which is a fever,
18:03 --> 18:05and that's because when you're
18:05 --> 18:06giving a foreign protein,
18:06 --> 18:09which blood cells have proteins on them,
18:09 --> 18:10you can get a fever.
18:10 --> 18:12There's that in and of
18:12 --> 18:13itself is not dangerous.
18:13 --> 18:14It's uncomfortable,
18:14 --> 18:16and we like to minimize that from happening.
18:16 --> 18:19But patients do can get a fever.
18:19 --> 18:21They can also get hives,
18:21 --> 18:22or they can get allergic
18:22 --> 18:25reactions they can also have some
18:25 --> 18:26other kinds of complications,
18:26 --> 18:28all of which the transfusion
18:28 --> 18:31service is aware of and we try
18:31 --> 18:34to minimize as much as possible.
18:34 --> 18:36One of the areas that's
18:36 --> 18:38a really big concern is,
18:38 --> 18:39as I mentioned earlier,
18:39 --> 18:41infectious problems and that
18:41 --> 18:44has led to the production of a whole
18:44 --> 18:46new field of transfusion medicine,
18:46 --> 18:48which is pathogen reduction.
18:51 --> 18:5210-15 years ago
18:52 --> 18:56if there was a virus that came out
18:56 --> 18:58like Zika or West Nile,
18:58 --> 19:01we knew there was a virus
19:01 --> 19:04that had entered the blood supply,
19:04 --> 19:06molecular biology was used to
19:06 --> 19:07identify the virus,
19:07 --> 19:10determine where it could be neutralized, and
19:10 --> 19:12tests were made to identify it,
19:12 --> 19:14treatments were developed.
19:14 --> 19:17But then all of that cost money,
19:17 --> 19:20and then the hospitals and the blood
19:20 --> 19:23centers had to spend a lot of money.
19:23 --> 19:23For that,
19:23 --> 19:25the FDA took a long time to approve
19:26 --> 19:28the testing and evaluation of
19:28 --> 19:29donors for that particular illness.
19:29 --> 19:32And while all this was going on,
19:32 --> 19:33Medicare may or may not
19:33 --> 19:34have reimbursed for it.
19:34 --> 19:37So there was a financial what I call
19:37 --> 19:39the banking part of blood banking,
19:39 --> 19:41and then every time you got through
19:41 --> 19:43with one virus, another one came along.
19:43 --> 19:46So the field decided to move to a new type
19:46 --> 19:49of tech that is called a reactive approach.
19:49 --> 19:51That is, you identify a pathogen
19:51 --> 19:53of some sort or something that
19:53 --> 19:55shouldn't be in blood,
19:55 --> 19:58whether it's a virus or bacteria,
19:58 --> 20:00and then you try to mitigate
20:00 --> 20:04it or get rid of it.
20:04 --> 20:05This pathogen reduction technology
20:05 --> 20:07is not reactive, it's proactive.
20:07 --> 20:10There are reagents that are put into
20:10 --> 20:13the blood bag that are designed to
20:13 --> 20:14inactivate pathogens by attacking
20:15 --> 20:17the DNA and RNA of those pathogens,
20:17 --> 20:18blood cells,
20:18 --> 20:20the human red cells and platelets
20:20 --> 20:23do not have DNA or RNA because
20:23 --> 20:25it's not part of what that
20:25 --> 20:26particular cell has,
20:26 --> 20:28they had them when they were growing,
20:28 --> 20:29but when they become mature cells,
20:29 --> 20:31the DNA and RNA isn't there.
20:31 --> 20:33So the only thing that has DNA or
20:33 --> 20:36RNA in a unit of blood is a pathogen.
20:36 --> 20:38So if you can put chemicals in
20:38 --> 20:40that affect the DNA or RNA,
20:40 --> 20:41you're really sparing the good
20:41 --> 20:43cells and you're just trying to
20:43 --> 20:44get rid of any pathogen.
20:44 --> 20:46Well, you can say with all the testing
20:46 --> 20:48why should there be a pathogen there?
20:48 --> 20:49There shouldn't be,
20:49 --> 20:50but sometimes pathogens are in
20:50 --> 20:52very low levels like bacteria,
20:52 --> 20:54but then they can grow.
20:54 --> 20:54Other times,
20:54 --> 20:58new viruses come in like the COVID-19
20:58 --> 21:01virus is not transmitted by blood,
21:01 --> 21:01fortunately,
21:01 --> 21:03as bad as it is,
21:03 --> 21:05and it's a horrific virus,
21:05 --> 21:08but it is not transmissible by blood.
21:08 --> 21:11The HIV virus or AIDS with
21:11 --> 21:12the pathogen reduction technology
21:12 --> 21:15it puts reagents in the blood
21:15 --> 21:17bag that will inactivate pathogens
21:17 --> 21:20and many pathogens share common
21:20 --> 21:23DNA or RNA types so that the
21:23 --> 21:25reagents that are put in
21:25 --> 21:27will be effective against them.
21:27 --> 21:29And indeed the pathogen reduction
21:29 --> 21:31technology that has been studied
21:31 --> 21:33and proven to be successful
21:33 --> 21:35it doesn't
21:35 --> 21:37activate the COVID-19 virus,
21:37 --> 21:39although it's not a bloodborne problem,
21:40 --> 21:42but the next one might be,
21:42 --> 21:45so pathogen reduction has been approved
21:45 --> 21:48for platelets and for plasma they are
21:48 --> 21:50currently doing clinical trials for
21:50 --> 21:53red cells and we are doing several
21:53 --> 21:55of those trials at Yale and at
21:55 --> 21:5715 other sites around the country
21:57 --> 22:00and once we have pathogen
22:00 --> 22:02reduction approved then we will have
22:02 --> 22:04a much safer blood supply because
22:04 --> 22:07not only will we be testing for known
22:07 --> 22:09viruses and pathogens and bacteria,
22:09 --> 22:11but also for unknown ones,
22:11 --> 22:13which is critical for the safety
22:13 --> 22:14of the blood supply.
22:14 --> 22:16These kinds of technologies,
22:16 --> 22:17molecular diagnostics and so forth
22:17 --> 22:20are really the future of transfusion.
22:20 --> 22:20In addition,
22:20 --> 22:23there are other types of approaches,
22:23 --> 22:24immunotherapy to treat patients
22:24 --> 22:25instead of using
22:25 --> 22:27chemotherapy that I mentioned earlier,
22:27 --> 22:28which can have cytotoxic,
22:28 --> 22:31which means it's toxic to cells
22:31 --> 22:33which can lower the amount
22:33 --> 22:34of bone marrow that
22:34 --> 22:36you have. Other types of therapy CAR
22:36 --> 22:38T cell therapy you may have heard
22:38 --> 22:41of or other types of immunotherapy
22:41 --> 22:43where you do not depress the bone
22:43 --> 22:45marrow when those patients may not
22:45 --> 22:47need transfusions because their blood
22:47 --> 22:49counts don't get that become that low.
22:49 --> 22:52There are other aspects of transfusion
22:52 --> 22:54medicine that those patients
22:54 --> 22:56require and we don't have time in this
22:56 --> 22:59discussion to go into all of that,
22:59 --> 23:02but you can be sure that the blood
23:02 --> 23:03transfusion service at the Hospital
23:03 --> 23:06is working closely with the oncologists
23:06 --> 23:08and the surgeons to ensure that the
23:08 --> 23:11best and the safest possible blood for
23:11 --> 23:13their patients and our field grows
23:13 --> 23:15as the field of therapeutics grows.
23:15 --> 23:17So we have the patient's best
23:17 --> 23:18interest at heart.
23:18 --> 23:22There are many sort of tricks in our bag
23:22 --> 23:25if you will, of how we can provide
23:25 --> 23:26safe blood pathogen reduction.
23:26 --> 23:29Again, is a critical advance in the field
23:29 --> 23:32and we just have one more cell type.
23:32 --> 23:34The red cells that the research
23:34 --> 23:36is being done on
23:36 --> 23:39now to have that available in
23:39 --> 23:41a couple of years.
23:41 --> 23:42And the goal,
23:42 --> 23:42of course,
23:42 --> 23:45is to be able to treat patients
23:45 --> 23:47and eventually just do away
23:47 --> 23:48with this field of transfusion,
23:49 --> 23:51because you won't need to give blood.
23:51 --> 23:54But that's not in the foreseeable future,
23:54 --> 23:56so the best we can do is provide
23:56 --> 23:58the safest possible blood,
23:58 --> 24:00the least amount needed,
24:00 --> 24:01and the best quality for
24:01 --> 24:02our patients.
24:02 --> 24:04And you mentioned
24:04 --> 24:06the term pathogen reduction
24:06 --> 24:08it's not pathogen elimination,
24:08 --> 24:11but it still is
24:11 --> 24:13really low odds that people get
24:13 --> 24:15infections with blood these days.
24:15 --> 24:18Can you remind us about those numbers?
24:18 --> 24:21What is the risk of
24:21 --> 24:24getting HIV or hepatitis from a
24:24 --> 24:26bag of blood these days?
24:26 --> 24:29The risk of HIV is in the millions,
24:29 --> 24:33one in a million, one in many millions.
24:33 --> 24:34That's for HIV.
24:34 --> 24:37It's also true for other types of viruses.
24:37 --> 24:40Hepatitis is somewhere in the range
24:40 --> 24:43of about one in 250,000 to 100.
24:43 --> 24:46I'm sorry 1 to 250,000
24:46 --> 24:49to 1 to 500,000 for bacteria.
24:49 --> 24:52The numbers are higher because bacteria
24:52 --> 24:54are much different organisms than viruses
24:54 --> 24:57so the risk of getting a septic
24:57 --> 24:59transfusion reaction is extremely low,
24:59 --> 25:02but the risk of getting some bacteria
25:02 --> 25:05growing in blood is somewhere in
25:05 --> 25:08the range of 1 to the 30,000 in
25:08 --> 25:11that range which are several orders
25:11 --> 25:13of magnitude less than the HIV.
25:13 --> 25:16Part of that problem is you can't
25:16 --> 25:18test for all the different kinds
25:18 --> 25:20of bacteria that there are.
25:20 --> 25:22Some of them grow slowly.
25:22 --> 25:25It depends on where the bacteria came from.
25:25 --> 25:27There shouldn't be any bacteria in blood,
25:27 --> 25:29and most of the time they're not.
25:29 --> 25:31But that's where the pathogen
25:31 --> 25:32reduction comes in,
25:32 --> 25:34because pathogen reduction would
25:34 --> 25:36inactivate any viruses or any bacteria
25:36 --> 25:38that get through the testing that we have.
25:38 --> 25:41So it's not something
25:41 --> 25:43to be concerned about.
25:43 --> 25:45Because the donor
25:45 --> 25:47history is extremely inquisitive.
25:47 --> 25:50We're asking a lot of questions,
25:50 --> 25:53many of which took years
25:53 --> 25:55to get accepted because
25:55 --> 25:57a lot of the questions relate to
25:57 --> 26:00sexual practices and many people were
26:00 --> 26:02offended by those questions when we
26:02 --> 26:04started asking it when we realized
26:04 --> 26:06that HIV was sexually transmitted.
26:06 --> 26:09But it was required to do it
26:09 --> 26:11for the safety of the patients
26:11 --> 26:14who are receiving the blood.
26:14 --> 26:16But now that we know more about
26:16 --> 26:18how to treat these diseases,
26:18 --> 26:21many of those individuals come
26:21 --> 26:23who are negative for these various
26:23 --> 26:25tests are able to donate blood
26:25 --> 26:28and it's a different field.
26:28 --> 26:31We have to grow with the field as the
26:31 --> 26:33knowledge grows and
26:33 --> 26:34that's what transfusion is,
26:34 --> 26:36there's a practical side
26:36 --> 26:37for the patient care.
26:37 --> 26:40There's the collection side and
26:40 --> 26:42there's also the research side
26:42 --> 26:44which is allowing us to advance
26:44 --> 26:46the field in so many different ways.
26:46 --> 26:49One last question is,
26:49 --> 26:50perhaps,
26:50 --> 26:53we had mentioned the fact that
26:53 --> 26:55as therapeutics advance
26:55 --> 26:58we may have less and less need for
26:58 --> 27:01transfusion, but at the moment it
27:01 --> 27:04still is a part of clinical care.
27:05 --> 27:08How do you get around the needs of patients
27:08 --> 27:12who cannot take due to religious reasons
27:12 --> 27:13for example, blood?
27:13 --> 27:16Are there other options for
27:16 --> 27:18them outside of a transfusion?
27:18 --> 27:19That's an excellent
27:19 --> 27:21question. There are individuals who
27:21 --> 27:24do not want a blood transfusion.
27:24 --> 27:27For a variety of religious reasons or
27:27 --> 27:29other reasons, for those individuals,
27:29 --> 27:31consultation with the patients physician
27:31 --> 27:33is required, as well as the family.
27:33 --> 27:36We have a family meeting to discuss options
27:36 --> 27:40and if blood transfusion is not one of them
27:40 --> 27:42you mentioned the various reagents that
27:42 --> 27:45are developed to stimulate the production
27:45 --> 27:48of platelets or red cells in the person.
27:48 --> 27:50Those chemicals can be given that
27:50 --> 27:52may be possible to take some blood
27:52 --> 27:55from the patient prior to treatment
27:55 --> 27:57and store it so that if the
27:57 --> 27:59patient's count does drop,
27:59 --> 28:01they will have stored their own
28:01 --> 28:03blood in advance, which in someone
28:03 --> 28:05who doesn't want to get transfusion,
28:05 --> 28:07of someone else's blood,
28:07 --> 28:09may be willing to accept their own blood.
28:09 --> 28:11Some individuals don't want to
28:11 --> 28:12accept blood from themselves,
28:12 --> 28:15that's been taken out of their body,
28:15 --> 28:17separated, stored, and then given back.
28:17 --> 28:20So it depends on the degree to which the
28:20 --> 28:22individual will be willing to accept blood,
28:22 --> 28:24but those can cause some very
28:24 --> 28:25difficult treatment situations.
28:25 --> 28:28That has to be discussed with the patient,
28:28 --> 28:29the patient's family,
28:29 --> 28:31the physician and the blood bank.
28:31 --> 28:34Doctor Edward Snyder is a
28:34 --> 28:35professor of laboratory medicine
28:35 --> 28:37at the Yale School of Medicine.
28:37 --> 28:39If you have questions,
28:39 --> 28:40the address is canceranswers@yale.edu
28:40 --> 28:43and past editions of the program
28:43 --> 28:45are available in audio and written
28:45 --> 28:46form at yalecancercenter.org.
28:46 --> 28:49We hope you'll join us next week to
28:49 --> 28:51learn more about the fight against
28:51 --> 28:53cancer here on Connecticut Public
28:53 --> 28:55radio funding for Yale Cancer answers.
28:55 --> 28:58Was provided by Smilow Cancer
28:58 --> 29:00Hospital and AstraZeneca.

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August 15, 2021

Yale Cancer Center

visit: http://www.yalecancercenter.org

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