Despite their refusal of blood products, the vast majority of Jehovah’s Witnesses can complete proposed treatment for haematological and other cancers, research presented at the MOGA ASM here in Melbourne shows.
A systematic review of the literature, comprising four prospective studies, nine retrospective studies and 42 case reports, found all patients completed radiation therapy, 98% competed surgery and 95% completed stem cell transplants.
However only 65% of patients were able to complete proposed chemotherapy.
Medical oncology trainee Dr Rachel Chang, from the Queen Elizabeth Hospital in Adelaide, told the MOGA ASM that there were no guidelines to direct management.
Case reports were included in the review because of the limited evidence base.
While the review found a mortality rate of 1.8% due to patient refusal of blood products, alternative strategies were quite successful. They included bone marrow stimulating agents, autologous blood transfusion, blood product substitutes and blood conservation techniques.
“Clotting factors were deemed to be acceptable by 15% of patients, cell salvage by 84%, erythropoietin by 98% and acute normovolemic haemodilution by 86%,” she said.
The review found erythropoietin, used by 79% of patients, was effective in optimising haemoglobin and helping patients complete surgery (98%) and chemotherapy (85%).
Peg-filgrastim was used in 41% of patients with 98% successful in undergoing a stem cell transplant. Romiplostim was used infrequently (0.6%) but all patients underwent surgery.
Acute normovolemic haemodilution and cell salvage was an effective strategy in all patients when it was used.
Dr Chang said refusal of blood and blood products resulted in suboptimal treatment in 8% of patients.
Some patients were not offered surgery, radiation therapy or chemotherapy because of their decision while others had a limited resection or their chemotherapy dose was modified or discontinued.
Anaemia (4%) was the most common grade 3/4 adverse event, followed by bleeding (2%), thrombocytopenia (1%) and pancytopenia (0.4%).
“There is a mortality risk associated with marrow failure and it is very important to counsel patients and obtain informed consent. However blood conservation techniques can mitigate the risk,” Dr Chang said.
There was also substantial variation among patients in what they would accept before treatment compared to decisions made during treatment.
“In cases of a medical emergency, it is important to re-discuss patients’ advanced care directives as there is evidence they might change their mind.”