Bloodless stem cell transplantation, performed without the transfusion of allogeneic blood or blood products, has numerous clinical advantages, especially among populations of patients who prefer, for religious or other reasons, no blood methods of medical and surgical treatment. Patricia A. Ford, MD, is widely considered the pioneer of bloodless surgery and medicine. The ASCO Post recently spoke with Dr. Ford about her groundbreaking work in this challenging field.
Please tell our readers a bit about your background and how you became interested in bloodless transplantation.
It started about 25 years ago, when I was a brand new attending at Graduate Hospital and some representatives from the Jehovah Witness community in the Philadelphia area approached the hospital asking if we’d be willing to provide care for their members in the tristate area, which numbered about 70,000. The hospital agreed but noted they would need a hematologist-oncologist to run the program, so the administration reached out to me. At the time, I did not know a lot about Jehovah Witnesses, but I was certainly willing to treat them and respect their autonomous beliefs.
It just so happened that at that time, I was setting up an autologous stem cell lab. Over the next couple of years, I met with leaders in the Jehovah Witness community and actually trained for a while in Europe, where they’d already been providing bloodless surgery. I subsequently became proficient in treating patients with profound anemia and a low platelet counts in different clinical situations. And that was the beginning of my path into bloodless transplantation.
First Bloodless Transfusion
When did you have your first encounter with a Jehovah Witness patient requiring an autologous transplant?
About 3 years into this process, a Jehovah Witness who needed an autologous transplant was admitted into the hospital. He was in his mid-30s and had non-Hodgkin lymphoma that had relapsed and had failed to respond to multiple lines of standard-dose chemotherapy. Our standard treatment for him would be high-dose chemotherapy with autologous stem cell transplant, but as a Jehovah Witness, under his religious convictions, he could not undergo therapy that needed red blood cell, plasma, or platelet transfusion support.
“I believe bloodless autologous transplantation should become standard of care in all transplant centers for patients who decline transfusion.”— Patricia A. Ford, MD
Tweet this quote
So I explained that without a transplant, he’d probably would have just a couple of months to live. I also told him that with a transplant, he had a 50% chance of survival and that I’d developed enough expertise that I would be willing to perform a bloodless transplant. After an extensive search of the literature, I discovered he’d be the first person ever to undergo this procedure. After meeting with members of the Watchtower, the hospital’s internal review board, and the patient’s family, he fairly rapidly decided to have the transplant.
How were your interactions with the Jehovah Witness leaders at that point?
They were very open and supportive of my program. In fact, they brought up Dr. Denton Cooley— who conducted the first successful heart transplant in the United States and the first on a Jehovah Witness—as an example of someone who has led the way. They knew it was the young man’s only hope for survival and wanted him to undergo the treatment.
At that point, I went through our institutional review board and the ethics committee, plus all the medical staff who would be caring for him. Everyone was on board, so we moved forward, and he did wonderfully. He was in and out of the hospital within 20 days, and his blood cell counts never dropped to a problematic level. A normal hemoglobin for a man is 12 g/dL or above, and his was 14 g/dL, which was very unusual. It never dropped below 8 or 9 g/dL. Not only did he come through the procedure with few side effects, he was indeed cured. He went on to marry and have a family, so it was truly a great success story.
The Most Bloodless Autologous Transplants in the World
That success must have accelerated the program.
Well, my second patient, also young and in a desperate clinical situation, died of profound anemia during her transplant. So at that point, I had a 50% mortality rate and thought about closing the program. However, the patient’s parents heard the news and flew back from California and pleaded with me to continue the program, because I was the only one who’d given their daughter a chance and they wanted more Jehovah Witnesses to have that opportunity. I kept the program open and not only did we do the first bloodless autologous treatment, but we’ve done 180 autologous stem cell transplants, the most in the world.
Hemoglobin: Clinical Need, Not Number
Please elaborate on your bloodless stem cell transplant program.
Our mortality rate with bloodless autologous stem cell transplants is zero, and the national rate using blood products is also under 1%. Moreover, my transplant mortality rate is the same, with or without transfusion. In my non–Jehovah Witness transplant patients, I use about 90% fewer transfusions than the national norm, just because of the techniques I’ve learned in bloodless transplant.
“My dream would be for hematologists and oncologists to take the lead in developing better guidelines and pathways for the use of blood products.”— Patricia A. Ford, MD
Tweet this quote
This is important for oncologists worldwide because blood transfusion is still standard of care in autologous transplantation, and I would argue that transfusions should not be based solely on a hemoglobin number but more so on a clinical need. Many centers still have residents automatically transfusing when a patient’s hemoglobin drops below 8 g/ dL. Moreover, they transfuse platelets when the count drops below 10,000/mL, which is actually in the ASCO guidelines. I would challenge that number because of my 180 Jehovah Witness transplants, I’ve only had one serious bleeding issue, and I’ve given no platelets.
Future Standard of Care?
Given your success in managing blood-related issues during transplantation, what would you like to see happen in the community at large?
First, I would like to see Jehovah Witnesses have the ability to be treated near their home towns rather than have to travel long distances to large transplant centers such as mine. Right now I receive Jehovah Witness patients from across the country because their centers are unwilling to
treat them. I believe bloodless autologous transplantation should become standard of care in all transplant centers for patients who decline transfusion. Although about 95% of these patients are Jehovah Witnesses, 5% decline transfusion for other reasons.
Are you getting any pushback from entities that don’t support the widespread use of bloodless transplant?
Not anymore. In fact, we’re partnering with the American Association of Blood Banks (AABB). We’re all on the same page in terms of better transfusion policy procedures and what we term PBM: patient blood management. The Society for the Advancement of Blood Management (SABM) first used that term, which has since become widely adopted by organizations throughout the United States and globally. In fact, the National Summit on Overuse organized by the Joint Commission and American Medical Association in 2012, identified that although blood transfusions can be life-saving, there are also risks associated with unnecessary transfusions that can contribute to worse patient outcomes and even death, highlighting the need for better education, metrics, and transfusion avoidance.
Society for the Advancement of Blood Management
Please bring the readers up to speed on SABM.
The idea for the Society arose in 2001, in which I am proud to have been one of the founding members. These dedicated volunteers recognized the need for patient blood management to be a standard of care, with blood tranfusions being viewed as an alternative. We had a lot of support from different entities, and we’ve grown into a robust international organization.
Our initial focus was to treat people who had declined transfusion; however, we rapidly recognized there were too many unnecessary blood transfusions, and the strategies we employed should be used broadly. As an aside, I remember being in a room with a Jehovah Witness patient and explaining what a bloodless surgery entailed, and his roommate called from behind the curtain and said, ‘I want a bloodless surgery, too.’ That stuck with me because the things we’re doing with blood management resonate with patients. And if you visit the SABM website, you’ll see our mission is to establish patient blood management as a worldwide standard of care resulting in improved health for everyone through education and training.
Please share any closing thoughts on this vital issue.
I would like to see a better awareness in ASCO of the realization that oncologists are among the biggest overusers of blood products. We should be the leaders in this field, ensuring that our patients are not exposed to unnecessary risks without clinical benefit. We should lead in educating our patients while developing standards and guidance on appropriate blood use. I would like to see patients not have to travel to a bloodless transplant center but instead receive their transplant at their local hospital with the use of very simple blood management strategies. My dream would be for hematologists and oncologists to take the lead in developing better guidelines and pathways for the use of blood products.
DISCLOSURE: Dr. Ford reported no conflicts of interest.