ASH: 5 Hematology Procedures That Should Stop or Be Limited

Zosia Chustecka

December 04, 2013

The American Society of Hematology (ASH) has issued a list of 5 hematologic tests and/or procedures that should not be continued, or that should be used less than they currently are. Physicians and patients should question these practices, as overuse or misuse of these 5 practices or tests could cause harm, is expensive, and does not improve outcomes, the society says.

The complete list was published online today in Blood. It is part of the Choosing Wisely campaign spearheaded by the American Board of Internal Medicine Foundation that aims to reduce wasteful practices.

The campaign has been running for a couple of years now, and many of the leading professional medical societies in the United States have issued lists of practices that should stop. For example, the American Society of Clinical Oncology (ASCO) has recently issued a second list of 5 cancer practices that should stop, after releasing its first list in April 2012, and the American Society for Radiation Oncology issued its list in September.

This is the first list issued by ASH, and it was developed using "what we think is a unique and rigorous methodology," said Lisa Hicks, MD, from the University of Toronto, who is chair of the ASH Choosing Wisely Task Force and lead author on the recommendations.

"One of our guiding principles was harm...and we zeroed in on tests and procedures that were not only unnecessary or unhelpful in certain circumstances, but also those that had a potential for harm," she explained in an interview with Medscape Medical News. She also commented on each of the recommendations, as listed below.

Red Blood Cell Transfusion: Use Smallest Effective Dose

"Don't transfuse more than the minimum number of red blood cell [RBC] units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, noncardiac inpatients)," the recommendations state.

Transfusion of the smallest effective dose of RBCs is recommended because liberal transfusion strategies do not improve outcomes, compared with restrictive strategies, ASH explains. Unnecessary transfusion generates costs and exposes patients to potential adverse effects without any likelihood of benefit.

Clinicians are urged to avoid the routine administration of 2 units of RBCs if 1 unit is sufficient, and to use appropriate weight-based dosing of RBCs in children.

"Transfusion is a core part of hematology and we think this is a really important principle that we wanted to emphasize," Dr. Hicks said in the interview. "There has been a positive trend recently toward decreasing transfusion, but there are still areas where improvements could still occur."

Limit Use of Thrombophilia Testing

Thrombophilia testing involves a series of blood tests that are carried out on patients who develop venous thromboembolism (VTE) for no apparent reason to check if the patient has protein deficiencies or genetic abnormalities that are involved in blood clotting, Dr. Hicks explained.

The new recommendation from ASH to clinicians is not to use the test in adults with VTE that occurs in the setting of major transient risk factors such as surgery, trauma, and prolonged immobility.

"One of the most common risk factors is surgery," Dr. Hicks commented. If a VTE occurs in a patient who has just undergone surgery, the clot is very likely to be due to the surgery, she commented, and even if this patient had a thrombophilia test, it would not change the way the VTE would be treated.

Thrombophilia testing is costly, ASH notes, and it can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labeled as thrombophilic (which could influence subsequent insurability). In addition, thrombophilia testing does not change the management of VTEs occurring in the setting of major transient VTE risk factors, it adds.

One caveat to the above recommendation in when VTE occurs in the setting of a major risk factor but in patients who also have additional risk factors such as pregnancy, concurrent exposure to hormonal therapy, or when there is a strong positive family history. In these cases, the role of thrombophilia testing is complex and patients and clinicians are advised to seek guidance from an expert in VTE.

Stop Routine Use of Inferior Vena Cava Filters in Acute VTE

Inferior vena cava (IVC) devices are used in some patients with acute VTE in order to prevent a clot from reaching the lungs and causing a pulmonary embolism, which is fatal in about 1 out of 10 cases. The idea with these devices, which look like a small upside down umbrella, is that they sit in the large blood vessel below the heart and catch clots that break off from the long veins in the legs, before they lodge in the lungs, Dr. Hicks explained.

"The idea is very physiologically appealing, it seems to make good common sense," she commented, "but in fact, when you look at the literature, there is very little that supports the use of these filters, and there is growing research suggesting that they cause harm." Among the harms that have been reported are incidents of thrombosis occurring around the filter itself, as well as erosion damage to the vein in which they are placed, she added.

"We really want to make sure that clinicians are thinking about when to place a filter," she said. "There are times when they are appropriate, but we recommend against them being used routinely."

IVC filters are costly, can cause harm and do not have a strong evidentiary basis, ASH points out. The recommendations highlight a recent report of 6373 patients undergoing bariatric surgery who had an IVC filter fitted prophylactically; the results show no reduction in the rate of postoperative VTE, and suggest that there was an increase in the risk for death and/or disability (Ann Surg. 2010;252:313-318).

The main indication for IVC filters is patients with acute VTE who have a contraindication to anticoagulants, for example, because they have active bleeding (for instance from a gastrointestinal ulcer) or they have a high risk of anticoagulant-associated bleeding, ASH notes.

Lesser indications that may be reasonable in some cases include patients experiencing pulmonary embolism (PE), despite appropriate therapeutic anticoagulation, and patients with massive PE and poor cardiopulmonary reserve.

In addition to recommending against routine use of these devices, ASH also says that when the decision to use them has been made, retrievable filters are recommended over permanent filters, and they should be removed when the risk for PE has resolved and/or when anticoagulation can be safely resumed.

In 2010, the US Food and Drug Administration highlighted adverse events that had been reported with IVC filters and expressed concern that retrievable filters intended for short-term placement were not always removed once a patient's risk for PE had subsided.

The recommendations note that recent reports suggest only a minority (between 8% and 34%) of "temporary" IVC filters are ever retrieved. "Thus, clinicians are advised to consider developing a concrete plan for IVC removal at the time of IVC placement," it states.

Limit Use of Plasma/PCCs to Emergencies

This recommendation concerns the use of plasma or prothrombin complex concentrates (PCC) to reverse immediately the anticoagulation effects of vitamin K antagonists such as warfarin.

ASH states that these products should not be used outside of emergency situations, such as patients presenting with major bleeding or intracranial hemorrhage or for whom emergency surgery is anticipated — for example, after a trauma or accident.

These plasma and PCCs can cause serious harm to patients, are costly, and are rarely indicated in the reversal of vitamin K antagonists, the society comments.

In nonemergency situations, ASH recommends administration of the vitamin K antagonist is stopped or the dose is reduced, and/or also recommends administration of small doses of vitamin K, depending on the international normalized ratio and the clinical scenario. Dr. Hicks added that in most nonemergency situations, it is safe to stop the drug and just wait for the anticoagulation effects to wear off, which may take a few days.

"The use of plasma and prothrombin complex concentrations is appropriate only in emergencies," she added.

Limit CT Surveillance of Lymphoma After Curative Therapy

The full recommendation is "limit the use of CT scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma."

"Here, we wanted physicians and patients to question whether every CT scan for surveillance is really necessary," Dr. Hicks explained. "There likely is a role; you'll notice we did not say don't use CT scans, but we do recommend limiting their use," she commented.

A lymphoma patient who has undergone curative-intent treatment and is now in remission typically goes back to the oncology/hematologist every 3 to 6 months for a check-up, she explained. This involves taking a history, a physical examination, and blood tests, and such a patient may also have a routine CT surveillance scan, she said. "What ASH is now suggesting is that, particularly for patients who have been in remission and have been asymptomatic out to 2 years, for most of the time, routine CT scans are not required," she said. In these cases, the potential negative consequences would outweigh any benefit, she added.

CT surveillance in asymptomatic patients in remission from aggressive non-Hodgkin's lymphoma may be harmful through a small but cumulative risk for radiation-induced malignancy, ASH says in its statement. "Physicians are encouraged to carefully weigh the anticipated benefits of post-treatment CT scans against the potential harm of radiation exposure," it adds.

This is particularly important in young patients with good-prognosis lymphoma, the society comments. In some patients groups, such as young women with highly curable lymphoma, the estimated lifetime risk for cancer mortality associated with 10 CT scans approaches the 5-year cumulative probability of lymphoma death, it notes.

In addition, CT surveillance is costly and has not been demonstrated to improve survival, ASH said.

"Due to a decreasing probability of relapse with the passage of time and a lack of proven benefit, CT scans in asymptomatic patients more than 2 years beyond the completion of treatment are rarely advisable," it adds.

The use of routine CT scans in lymphoma was questioned recently by a study conducted by Mayo Clinic researchers and presented at the 2013 ASCO annual meeting.

Basis of Lymphoma Diagnosis

This final shortlist of 5 practices was whittled down from around 20 that were considered in great detail, Dr. Hicks said. One of the practices that nearly made it onto the shortlist, but didn't, concerns procedures used in the diagnosis of lymphoma. The recommendation was that a diagnosis of lymphoma should be based on excisional biopsies, and clinicians should not initiate treatment of lymphoma based of tissue obtained exclusively from fine-needle aspirations.

"Hematology is a specialty with many new and increasingly expensive tests and treatments. While these new diagnostic and treatment strategies represent important advances, there is also potential to pose significant harm and cost to patients if over- or misused," Dr. Hicks said in a statement. "The ASH Choosing Wisely list serves as a reminder to hematologists to take a step back and question whether certain routinely used procedures are really necessary, and to gradually change their practices to maximize the value of care."


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