David J. Kuter, MD, PhD, Professor of Medicine, Harvard Medical School, and Director of the Center for Hematology at Massachusetts General Hospital, Boston, commented on the findings for The ASCO Post.

“TOPPS is a good attempt to address whether transfusions are helpful as prophylaxis in patients having intensive induction chemotherapy and stem cell transplant,” he said, noting that it has been difficult to conduct studies of transfusion practices.

He pointed out that the study did show that prophylaxis was beneficial in preventing minor bleeding, although it was not powered to show a difference in the occurrence of the more concerning life-threatening bleeding. “These are very rare events, and studies cannot be powered to show a difference in these,” he explained.

Four Important Points

He said TOPPS should be interpreted in the context of four important points. “First, minor bleeding events are important in terms of quality of life,” he said. “For a patient, being covered in bruises is a cosmetic issue, like having to wear a wig for chemotherapy. We often dismiss lower-grade events as irrelevant, but they are not to the patient.”

Second, the elimination of prophylactic transfusions would obviously save money for the health-care system. However, transfusions are no more expensive than prophylactic antibiotics, “which are given like water to these patients,” he pointed out. It would, however, be reasonable to lower the dose of platelets transfused, he said. The Prophylactic Platelet Dose Trial (PLADO) evaluated the effect of varied platelet dosing on clinical bleeding among hospitalized hematology/oncology patients and found no differences among 3, 6, or 12 units.¹ “We learned that in prophylactic transfusion, dose is irrelevant. Most centers use 6 units but you could use 3, and you get a 50% cost savings,” he emphasized.

Third, it may become possible to select subgroups who will benefit most from transfusions, he said. In TOPPS, prophylactic transfusion prevented not only minor bleeding but major bleeding as well in the subgroup of patients who were not undergoing autologous stem cell transplant. This finding needs further study, he said.

Finally, he proposed that the threshold for initiating platelet transfusions be reconsidered. “It used to be 20,000/µL, now it’s 10,000/µL (as was done in this study), and some advocate for 5,000/µL as the trigger point,” he said. His own policy is to “transfuse sparingly, and only if platelets fall to below 10,000/µL.”

Dr. Kuter concluded that since transfusion-related risks are generally minor, the TOPPS findings are unlikely to change clinical practice. “People like me think that to not transfuse anyone runs the risk for rare events,” he said, “and we do other things prophylactically to prevent rare events.” ■

Disclosure: Dr. Kuter reported no potential conflicts of interest.

Reference

1. Slichter SJ, Kaufman RM, Assmann SF, et al: Dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med 362: 600-613, 2010.