Transfusion practice review for oncology patients

A physician in California (who is chair of a small rural hospital's internal medicine department and a member of the hospital transfusion committee) reports that his institution is updating its local transfusion guidelines, focusing initially on the use of RBCs for oncology patients. They are also trying to develop a monitoring strategy using either prospective or retrospective Audit Criteria to address the issue of inappropriate transfusions, which was prompted by a 3 month long review that showed many oncology patients received RBC transfusions with pre-transfusion hemoglobin levels above 10 g/dL. He adds that the oncologists argue that oncology patients are 'different' and that significantly looser transfusion criteria should apply to their patients than general medical patients.

At the inquiring physician's hospital, the oncologists have advocated the following transfusion criteria for their patients:

He has posed the following questions and requests input from colleagues of the e-Network Forum:

1. Should an oncology patient who is receiving chemotherapy and/or radiation be maintained at or above a certain pre-determined hemoglobin level, even if there is a lack of symptoms attributable to anemia, including a lack of non-specific symptoms such as fatigue or dyspnea? If so, what should the level be?
2. How does the presence of non-specific symptoms in an oncology patient such as fatigue or dyspnea influence the decision to transfuse? A related question is: how do colleagues define 'symptom' in 'symptomatic anemia?' If RBCs are transfused, how liberally should they be used to treat non-specific symptoms?
3. Should target hemoglobin levels for epoetin alfa (EPO) therapy be different from those for RBC transfusion? If EPO 'does not work,' should RBCs then be used to achieve the same target? How does the literature supporting liberal use of EPO to improve quality of life measures affect criteria for transfusion of RBCs?
4. What if an oncology patient has an active co-morbid disease state, such as active cardiac or lung disease? If the patient just has a 'history of' or risk factors for these conditions, without active evidence of increased need for oxygen carrying capacity, at what threshold Hgb level should RBC transfusion be used?

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Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator