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Waheed A, Shammo J, Dingli D. Paroxysmal nocturnal hemoglobinuria: Review of the patient experience and treatment landscape. Blood Rev 2024; 64:101158. [PMID: 38071133 DOI: 10.1016/j.blre.2023.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 03/12/2024]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by complement-mediated hemolysis and thrombosis through the alternative pathway. The most common symptom of PNH is fatigue due to chronic anemia, which can negatively impact quality of life (QoL) and affect overall well-being. The currently approved therapies for PNH significantly limit intravascular hemolysis (IVH) and reduce the risk of thrombosis; however, they are associated with an infusion schedule that can become burdensome, and not all patients experience complete disease control. Several new complement inhibitors are in development that address the need for convenient routes of administration and aim to provide better disease control. With the variety of new treatment options on the horizon, hematologic markers as well as QoL concerns, patient opinion, and lifestyle factors should be considered to choose the optimal PNH treatment for each specific patient.
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Affiliation(s)
- Anem Waheed
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Jamile Shammo
- Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
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Vijenthira A, Starkman R, Lin Y, Stanworth SJ, Bowen D, Harrison L, Wintrich S, Callum J, Buckstein R. Multi-national survey of transfusion experiences and preferences of patients with myelodysplastic syndrome. Transfusion 2022; 62:1355-1364. [PMID: 35686926 DOI: 10.1111/trf.16946] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfusion dependence on red blood cells (RBCs) is common for patients with myelodysplastic syndromes (MDS) but transfusion practice and experience for outpatients with MDS are largely unknown. METHODS We conducted a web-based cross-sectional multi-national survey to audit real-world transfusion practices and understand the experiences and preferences of patients with MDS requiring RBC transfusion. The survey comprised 57 questions and was distributed to patients in the United States of America, Canada, and the United Kingdom. RESULTS 447 respondents (45% female) with a median age of 72 years (IQR 66-77) were eligible on the basis of receiving an RBC transfusion in the last 8 weeks. There was wide variability in the hemoglobin thresholds for transfusion with the most common being <80 g/L. 40% of patients were transfused at a lower threshold (<70-75 g/L), with the largest proportion of these patients from the United States. Patients experienced significant symptoms prior to receiving a transfusion with fatigue and dyspnea having the most negative impacts on quality of life. Finally, patients endorsed two potential alterations to transfusion care that could improve their quality of life, including self-administered point of care testing of hemoglobin and higher hemoglobin transfusion thresholds. Of these patients, 62% preferred a threshold of at least 85 g/L, and 20% preferred a threshold of at least 100 g/L. DISCUSSION In summary, this multi-national survey of patients with MDS requiring RBC transfusions demonstrated substantial variation in patients' experiences and preferences that differed also by country, supporting the need for further comparative clinical trials of transfusion practice interventions.
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Affiliation(s)
- Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - David Bowen
- Department of Hematology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | | | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Rena Buckstein
- MDS Research Program, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
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Anemia requiring transfusion in breast cancer patients on dose-dense chemotherapy: Prevalence, risk factors, cost and effect on disease outcome. Support Care Cancer 2022; 30:5519-5526. [PMID: 35314996 PMCID: PMC8937495 DOI: 10.1007/s00520-022-06970-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Dose-dense chemotherapy improves survival but with increased toxicity and treatment-related cost. We report the prevalence of anemia and the possible risk factors associated with chemotherapy-related anemia and determine the cost and time-delay associated with transfusion requirement in Indian patients with non-metastatic breast cancer on dose-dense preoperative chemotherapy. METHODS In this study, triple-negative breast cancer (TNBC) patients were treated preoperatively with docetaxel and cyclophosphamide alternating with epirubicin and cisplatin every 2 weeks. Patients were evaluated for anemia pre- and post-chemotherapy. We examined trends in the red cell indices, transfusion requirement, time to transfusion, as well as risk factors associated with transfusion during treatment, along with delay in treatment due to anemia and the additional cost incurred. RESULTS A total of 116 consecutive women with nonmetastatic TNBC were treated with preoperative chemotherapy. The median age was 44.5 years. 56.1% of patients had stage III disease. Anemia was detected at baseline in 54 (46.5%) patients with mild anemia (10-12 g/dl) in 42 (36.2%) patients and moderate anemia (8-10 g/dl) in 12 (10.3%) patients. During the course of treatment, all patients developed anemia. A total of 44 patients (37.9%) required transfusion during chemotherapy, with 55(47.4%) patients developing grade 1-2 anemia and 40 (34.5%) patients developing grade 3 anemia. The factors associated with anemia requiring transfusion were a steeper decline in hemoglobin after two cycles (OR 1.65, p = 0.02), low-grade tumor (OR 2.48, p = 0.03), and thrombocytopenia grade 3 or 4 (OR 4.35, p = 0.034), of which tumor grade and thrombocytopenia remained significant in multivariate analysis. Nearly one-fourth of the study population had a delay between two cycles of chemotherapy due to anemia. A median additional cost of INR 7000 was incurred among those requiring blood transfusion. CONCLUSION Anemia is a common toxicity associated with dose-dense chemotherapy during curative breast cancer treatment leading to delay in treatment and increased cost. Low-grade tumor, grade 3 or 4 thrombocytopenia, and grade 2 or higher anemia after two cycles of chemotherapy are risk factors for blood transfusions during treatment.
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Bektas M, Copley-Merriman C, Khan S, Sarda SP, Shammo JM. Paroxysmal nocturnal hemoglobinuria: patient journey and burden of disease. J Manag Care Spec Pharm 2020; 26:S8-S14. [PMID: 33356781 PMCID: PMC10408416 DOI: 10.18553/jmcp.2020.26.12-b.s8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients with paroxysmal nocturnal hemoglobinuria (PNH) often experience a lengthy path to diagnosis. Fewer than 40% of patients with PNH receive a diagnosis within 12 months of symptom onset, and 24% of all PNH diagnoses can take 5 years or longer. Diagnostic delay is a source of distress and can affect emotional well-being for patients with PNH. In PNH disease management, patients and care providers focus on risk of organ failure and mortality related to disease progression; nonetheless, patients' health-related quality of life (HRQOL) is largely affected by extensive treatment requirements and nonfatal complications of disease, such as fatigue. In particular, thrombosis is associated with significant impairments in physical and social functioning and global health status and significant fatigue. Among patients with anemia who are transfusion dependent, the burden of transfusion is considerable. Transfusion dependence has a negative effect on HRQOL; is associated with risks and complications, including iron overload; and results in lost productivity due to travel times to and time spent at infusion centers. DISCLOSURES: This research was developed under a research contract between RTI Health Solutions and Apellis Pharmaceuticals and was funded by Apellis Pharmaceuticals. Bektas, Copley-Merriman, and Khan are employees of RTI Health Solutions. Sarda is an employee of Apellis Pharmaceuticals. Shammo consults for Apellis Pharmaceuticals.
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Affiliation(s)
- Meryem Bektas
- Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle, NC
| | | | - Shahnaz Khan
- Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle, NC
| | - Sujata P Sarda
- Global Health Economics and Outcomes Research, Apellis Pharmaceuticals, Waltham, MA
| | - Jamile M Shammo
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
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Patient Burden and Real-World Management of Chemotherapy-Induced Myelosuppression: Results from an Online Survey of Patients with Solid Tumors. Adv Ther 2020; 37:3606-3618. [PMID: 32642965 PMCID: PMC7340862 DOI: 10.1007/s12325-020-01419-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 12/31/2022]
Abstract
Introduction Chemotherapy-induced myelosuppression (CIM) is one of the most common dose-limiting complications of cancer treatment, and is associated with a range of debilitating symptoms that can significantly impact patients’ quality of life. The purpose of this study was to understand patients’ perspectives on how the side effects of CIM are managed in routine clinical practice. Methods An online survey was conducted of participants with breast, lung, or colorectal cancer who had received chemotherapy treatment within the past 12 months, and had experienced at least one episode of myelosuppression in the past year. The survey was administered with predominantly close-ended questions, and lay definitions of key terms were provided to aid response selection. Results Of 301 participants who completed the online survey, 153 (51%) had breast cancer, 100 (33%) had lung cancer, and 48 (16%) had colorectal cancer. Anemia, neutropenia, lymphopenia, and thrombocytopenia were reported by 61%, 59%, 37%, and 34% of participants, respectively. Most participants (79%) reported having received treatment for CIM, and 64% of participants recalled chemotherapy dose modifications as a result of CIM. Although most participants believed their oncologist was aware of the side effects of CIM, and treated them quickly, 30% of participants felt their oncologists did not understand how uncomfortable they were due to the side effects of CIM. Overall, 88% of participants considered CIM to have a moderate or major impact on their lives. Conclusion The data highlight that despite the various methods used to address CIM, and the patient-focused approach of oncologists, the real-world impact of CIM on patients is substantial. Improving communication between patients and health care providers may help improve patients’ understanding of CIM, and foster shared decision-making in terms of treatment. Additional insights from patients should be obtained to further elucidate the totality of life burden associated with CIM.
This study looked at people with cancer who received chemotherapy and developed a condition where their bone marrow activity was reduced, called myelosuppression. This meant they had fewer red blood cells that carry oxygen around the body, white blood cells that help fight infections, and platelets that help the blood to clot. The researchers wanted to understand how chemotherapy-induced myelosuppression affects peoples’ lives and their cancer treatment, and people’s experiences of treatment for myelosuppression. Overall, 301 people in the USA with breast, lung, or large bowel (colorectal) cancer completed an online survey. They had all received chemotherapy in the last year, and had myelosuppression at least once during their treatment. The survey showed that around 8 in 10 people (79%) had to be treated for myelosuppression, and around 7 in 10 people (73%) felt they received treatment for myelosuppression quickly. Chemotherapy was delayed, reduced, or stopped because of myelosuppression in around 6 in 10 people (64%). Around 3 in 10 people (30%) felt their oncologist did not understand the discomfort that myelosuppression caused them, and around 9 in 10 people (88%) felt that myelosuppression made their quality of life worse. The researchers concluded that because myelosuppression impacts peoples’ lives and their ability to keep receiving chemotherapy to treat their cancer, effective prevention and treatment for this condition are important. Better communication between people and their health care teams could help them to understand how people experience myelosuppression and make plans for treatment together.
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Early and sustained improvement in fatigue-related quality of life following red blood cell transfusion in outpatients. Qual Life Res 2020; 29:2737-2744. [PMID: 32382935 DOI: 10.1007/s11136-020-02517-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Outpatients with hematologic disease often receive red cell transfusion to treat anemia and fatigue. The effect of transfusion on fatigue-related quality of life and how well this effect is sustained has not been quantified. The study aim was to describe the early and sustained impact over 4 weeks of red cells on patient-reported fatigue in outpatients age ≥ 50 receiving transfusion as routine clinical care. METHODS FACIT-Fatigue scale scores were measured pre-transfusion and at visits targeting 3, 7, and 28 days post-transfusion. Group-based trajectory modeling of patient fatigue scores by study day was used to identify the number of distinct trajectories (Groups), then longitudinal mixed effects modeling of fatigue scores was used to estimate group-specific mean improvements early after transfusion and between days 3 and 28 post-transfusion. RESULTS Four distinct fatigue score trajectory groups were identified and were found to be correlated with baseline fatigue scores (means 12, 26, 34, and 47 points). In the three groups with the lowest fatigue trajectories (indicating greater fatigue), improvements in fatigue early after transfusion achieved the established minimum clinically important difference (≥ 3 points, Group p = 0.0039). In all trajectory groups, mean fatigue levels did not change significantly between 3 and 28 days (± 1 point, Group p = 0.60). CONCLUSION Patient-reported fatigue varies widely among older adult outpatients with hematologic disorders. Nonetheless, trajectory modeling suggests that most anemic patients can expect a noticeable improvement in fatigue in the first few days after transfusion that generally is sustained up to 4 weeks.
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Lin Y, Buckstein R. Outpatient transfusions: time to study what matters to patients. Transfusion 2019; 59:1887-1890. [DOI: 10.1111/trf.15382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics; Sunnybrook Health Sciences Centre; Toronto Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Canada
- University of Toronto Quality in Utilization, Efficacy, & Safety in Transfusion (QUEST) Research Program; Toronto Canada
| | - Rena Buckstein
- Division of Hematology; Odette Cancer Centre, Sunnybrook Health Sciences Centre; Toronto Canada
- Department of Medicine; University of Toronto; Toronto Canada
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Stephens JM, Li X, Reiner M, Tzivelekis S. Annual patient and caregiver burden of oncology clinic visits for granulocyte-colony stimulating factor therapy in the US. J Med Econ 2016; 19:537-47. [PMID: 26745764 DOI: 10.3111/13696998.2016.1140052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs) is indicated for chemotherapy patients with a significant risk of febrile neutropenia. This study estimates the annual economic burden on patients and caregivers of clinic visits for prophylactic G-CSF injections in the US. METHODS Annual clinic visits for prophylactic G-CSF injections (all cancers) were estimated from national cancer incidence, chemotherapy treatment and G-CSF utilization data, and G-CSF sales and pricing information. Patient travel times, plus time spent in the clinic, were estimated from patient survey responses collected during a large prospective cohort study (the Prospective Study of the Relationship between Chemotherapy Dose Intensity and Mortality in Early-Stage (I-III) Breast Cancer Patients). Economic models were created to estimate travel costs, patient co-pays and the economic value of time spent by patients and caregivers in G-CSF clinic visits. RESULTS Estimated total clinic visits for prophylactic G-CSF injections in the US were 1.713 million for 2015. Mean (SD) travel time per visit was 62 (50) min; mean (SD) time in the clinic was 41 (68) min. Total annual time for travel to and from the clinic, plus time at the clinic, is estimated at 4.9 million hours, with patient and caregiver time valued at $91.8 million ($228 per patient). The estimated cumulative annual travel distance for G-CSF visits is 60.2 million miles, with a total transportation cost of $28.9 million ($72 per patient). Estimated patient co-pays were $61.1 million, ∼$36 per visit, $152 per patient. The total yearly economic impact on patients and caregivers is $182 million, ∼$450 per patient. LIMITATIONS Data to support model parameters were limited. Study estimates are sensitive to the assumptions used. CONCLUSIONS The burden of clinic visits for G-CSF therapy is a significant addition to the total economic burden borne by cancer patients and their families.
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Affiliation(s)
- J Mark Stephens
- a a Prima Health Analytics, Health Economics , Weymouth, MA , USA
| | - Xiaoyan Li
- b b Global Health Economics, Amgen Inc. , Thousand Oaks, CA , USA
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DeYoung Sullivan K, Vu T, Richardson G, Castillo E, Martinez F. Evaluating the Frequency of Vital Sign Monitoring During Blood Transfusion: An Evidence-Based Practice Initiative. Clin J Oncol Nurs 2015; 19:516-20. [DOI: 10.1188/15.cjon.516-520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sumpio C, Knobf MT, Jeon S. Treatment complexity: a description of chemotherapy and supportive care treatment visits in patients with advanced-stage cancer diagnoses. Support Care Cancer 2015; 24:285-293. [PMID: 26026977 DOI: 10.1007/s00520-015-2775-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/12/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE Modern chemotherapy regimens are growing increasingly complex, involving lengthy outpatient infusions, and additional visits for supportive care. The treatment of advanced-stage patients is uniquely one of unremitting therapy and varying complexity. The study's purpose was to describe and quantify the dimensions of treatment complexity in terms of chemotherapy (CT) and supportive care (SC) visits. METHODS Electronic medical records for 121 subjects with stages III and IV cancer were reviewed. Visits were classified as SC and CT types, and actual hours and visit numbers were calculated for a 3-month treatment period. Analysis included descriptive and generalized linear modeling statistics. RESULTS Subjects ≥65 years spent fewer total hours (M = 18.17 h, SD = 10.17 h, p = 0.04), but experienced more total visits (M = 10.96 visits, SD = 4.65 visits, p = 0.02) than younger subjects. More than 71% of younger patients spent two or more hours per chemotherapy visit, compared to 41.7% of older patients (p = 0.001). Older subjects were more likely to have a SC visit (p = 0.03), but did not differ from younger subjects in SC visit numbers (p = 0.3) or hours (p = 0.6). Females averaged 3.81 more total hours (M = 22. 61 h, SD = 11.06 h, p = 0.055) and had more total visits (M = 10.80 visits, SD = 3.71, p = 0.02) than males. By visit type, women spent twice the hours undergoing SC than males (M = 3.3 vs. 1.5 h, p = 0.051), but genders did not differ in CT visit hours or average length. By diagnosis, colon/esophageal subjects spent more hours in CT visits (M = 21.90 h, SD = 8.60 h, p < 0.01), and lung subjects trended toward spending more hours in SC visits (M = 4.80 h, SD = 8.23 h, p < 0.06). CONCLUSIONS Advanced-stage cancer patients differed in visit types, hours, and treatment length undergoing CT and SC visits. Age, gender, and diagnosis explained the differences, and this study adds new understanding to the phenomenon of treatment complexity.
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Affiliation(s)
- Catherine Sumpio
- School of Nursing, Fairfield University, 1073 North Benson Road, Fairfield, CT, 06824, USA.
| | - M Tish Knobf
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, USA
| | - Sangchoon Jeon
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, USA
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Corey-Lisle PK, Desrosiers MP, Collins H, De La Orden M, Payne KA, Levaché CB, Dumont P. Transfusions and patient burden in chemotherapy-induced anaemia in France. Ther Adv Med Oncol 2014; 6:146-53. [PMID: 25057301 DOI: 10.1177/1758834014534515] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To estimate the patient burden in terms of the time spent on outpatient red blood cell (RBC) transfusions indicated for chemotherapy induced-anaemia (CIA) in patients with cancer in France. METHODS A retrospective chart review of patients with cancer receiving an outpatient RBC transfusion was conducted at seven treatment centres in France. Total treatment time for one transfusion visit per patient was measured as the elapsed time between pre- and post-transfusion vital sign assessment, including time from transfusion start to stop. Elapsed time from haemoglobin (Hb) level testing to transfusion start and from blood draw for compatibility testing to transfusion start were recorded. In addition, estimated travel time and distance to the transfusion centre, and clinical and demographic information were collected. RESULTS A total of 103 patients [63.1% men; mean age 66.2 years, standard deviation (SD) 11.9] were enrolled in the study (1 August 2010-31 October 2010). The four most frequent diagnoses were lung cancer (31.1%), urological cancer (15.5%), gynecological cancer (14.6%) and gastrointestinal/colorectal cancer (14.6%). Mean elapsed time between prevital and postvital sign assessment was 4.0 h [95% confidence interval (CI) 1.9-6.1], including a mean of 3.4 h (95% CI 2.5-4.2) for the transfusion itself. Hb level testing (mean pre-transfusion Hb level 8.0 g/dl, SD 0.8) and blood draw for compatibility testing were completed in a mean of 28.8 h (95% CI 1.3-56.2) and 9.4 h (95% CI 0-21.4) prior to transfusion respectively. Patients' one-way mean travel time to the transfusion centre was 32.9 min (95% CI 28.5-37.4) and mean distance travelled was 25.4 km (95% CI 11.6-39.3). CONCLUSION In France, CIA treatment with RBC transfusion is a time-consuming activity for patients that includes multiple trips to a medical facility, blood testing and the transfusion procedure itself. This burden is important to consider in the context of optimizing proactive monitoring and planning for supportive oncology care.
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Affiliation(s)
| | | | | | | | | | | | - Patrick Dumont
- Department of Pulmonology, Centre Hospitalier Chauny, Chauny, France
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