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When Less is Just Right

Philadelphia is chock full of historical firsts, including in the field of medicine. Just last month, two of Penn Medicine’s big “firsts” celebrated their birthdays:  the Perelman School of Medicine at the University of Pennsylvania – the nation’s first medical school – turned 250 and Pennsylvania Hospital, the nation’s first hospital, turned 264. For over two and a half centuries, both institutions have been home to individuals on the cutting edge of clinical care. (Visit the online home of our recently published book detailing that rich history for some examples!)

Ford-labcoat

One area of ongoing innovation is overseen by Patricia A. Ford, MDthe founder and director of the Center for Bloodless Medicine & Surgery (CBMS) at Pennsylvania Hospital, director of the Peripheral Stem Cell Transplant Program, and clinical professor of Medicine.

Almost 20 years ago, Ford performed the world’s first bloodless autologous stem cell transplantation in a non-Hodgkin’s lymphoma patient. A stem cell transplant was the only chance of a cure for this patient, yet a typical autologous stem cell transplant was out of the question, since this patient was one of Jehovah’s Witnesses. He, as do all Witnesses, firmly believes that blood “stands for life…has special significance…and should not be misused” or removed from the body and stored as it would via a transfusion.

These beliefs call Witnesses to seek bloodless medicine and surgery, which refers to a variety of techniques that allow a patient to be treated without blood or blood product transfusions.

Ford, who established the CBMS in 1996, making it one of the oldest and largest bloodless centers in the U.S., has been at the forefront of treatment for patients without using whole blood or blood products such as red cells, white cells, platelets and plasma.

But let’s get back to that first patient in 1995. An autologous stem cell transplant – a type of transplant in which the person's own stem cells are used – was the recommended course of treatment. In such a transplant, the cells are collected in advance and returned to the body to replace stem cells damaged by high dose chemotherapy used to treat certain types of cancers.

However, at that time, it wasn’t thought possible to successfully treat a patient with an autologous stem cell transplant without a blood transfusion or other blood product support. It was thought to be unsafe – and unsurvivable - since blood products are customarily used to prevent and treat infections that may arise due to depleted white and red blood cell supplies during the period before the transplanted cells “engraft” and begin producing new blood cells in the patient’s body. Yet this patient did survive and lives today, disease free.

After the success of the first patient, Ford and colleagues wondered, can another individual survive a stem cell transplant without blood products?  Sadly, two weeks post-transplant, the second patient didn’t make it.

“After the second patient’s case study, we had to stop and ask the really tough questions,” Ford said. “Is it ethical to continue this work? What mortality rate and chance of cure is acceptable? While I and the team were emotionally devastated from the loss of this patient, family members met with me to tell me how much they appreciated what I had attempted to do as no one else had given them any hope. And they asked me to continue to treat others in the same situation.”

Determined to honor her patient and the family’s wishes, Ford continued to treat others, refining and perfecting the procedure and teaching the protocol to other clinicians around the world. Ford has performed 138 bloodless autologous stem cell transplants at PAH.

This spring in the Journal of Clinical Oncology, Ford and her colleagues reported that autologous stem cell transplantation can be safely performed without blood product support in patients with hematologic malignancies, or blood cancers.

The study included 125 Jehovah’s Witnesses with lymphoma, multiple myeloma, or amyloidosis who were treated with high-dose chemotherapy and autologous stem cell transplantation between 1996 and March 2014.

The team reported they were able to manage all bleeding complications without the need for blood transfusions. There were few complications and no patient deaths during the study. Adopting such practices are proving both clinically and cost effective since they reduce transfusion-associated risks and complications including:  human error; platelet refractoriness (the failure to achieve desired platelet levels, post-transplant); acute transfusion reactions such as fever, chills, and hives; transfusion-transmitted infections; and transfusion-related lung injury.

“We’ve shown that patients can survive with blood levels never before thought possible all without receiving transfusions,” said Ford. “By applying very specific medical strategies – such as priming patients with intravenous iron and erythropoietin to increase their hemoglobin levels prior to transplantation – we can effectively and safely care for these Witness patients. This type of ‘pre-procedure management’ also applies to treating bloodless surgery patients as well.”

The CBMS receives an average of 1,000 referrals annually for various medical and surgical conditions and treats over 700 bloodless patients a year at PAH. While blood management and conservation strategies were originally developed for Jehovah’s Witnesses who reject transfusions because of their beliefs, they are now becoming standard practice throughout Pennsylvania Hospital.

 

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Views expressed are those of the author or other attributed individual and do not necessarily represent the official opinion of the related Department(s), University of Pennsylvania Health System (Penn Medicine), or the University of Pennsylvania, unless explicitly stated with the authority to do so.

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