The Application of Guideline Adherence Around MPNs

Ruben Mesa, MD, and Jamile M. Shammo, MD, discuss treatment guidelines, pathways, and pharmacologic treatment options that play a role in the standard of care for MPNs.

Bruce Feinberg, DO: We have already been talking about quality programs, and we are going to go deeper into that. I want to begin with this: from a clinician’s standpoint, the classical approach to a quality care program would first involve something like an NCCN [National Comprehensive Cancer Network] guideline adherence program. You then might move into something more formalized like a clinical pathway that could be institutional.

Ruben, you talked about the variance in the heterogeneity that you were seeing. Are you seeing more application of guideline adherence? When you think of guideline adherence, it usually means a carrot or a stick: you have to have some way to generate that adherence. At a minimum, you have to have tracking to know that. Are you seeing results from your observations that more of that is being done, specifically around MPNs [myeloproliferative neoplasms]?

Ruben Mesa, MD: There is much more referencing of the NCCN guidelines in terms of management decisions that are made. I would say it is still probably a minority of practices that have already put MPNs into a more formal pathway. To be candid, as we have more options that are expensive, I suspect there will be greater adherence as it relates to their utilization. Many of these treatments, other than ruxolitinib, are quite inexpensive interventions, so there is probably less of a push in that regard. What I do see is that how these are implemented lends itself well to these pathways.

For example, let’s take the issue of hematocrit level. The hematocrit goal is being under 45%. Part of the challenge in our field is that there are a lot of individuals who come in, and their hematocrit is 46%. Do they get a phlebotomy? What if it is 48%? Historically, that was quite variable, but our colleagues in Italy did a study asking this question, did it matter if you were 45% to 50% vs under 45%? What they found surprised them: there was a 4-fold higher risk of thrombosis if you let the hematocrit be above 45%. This is in part because, if you think about the chronicity, they were probably spending most of their time above the target range, which exposes the patient to greater risk. There is an example of something that is fairly easy to track. When the CBC [complete blood count] test was done, how often was the hematocrit above 45.0%? Did it result in a reflexive phlebotomy? It is well aligned with that.

Bruce Feinberg, DO: I am curious. As you talk about the concern of variability in terms of the level hematocrit and whether to phlebotomize, do you see any extreme the other way: phlebotomizing to iron deficiency with the hope that they will require fewer phlebotomies or that you will not miss that hematocrit over 45%?

Ruben Mesa, MD: It is probably much more toward to under-phlebotomizing than over-phlebotomizing. I would also say there is certainly a more frequent delay in the initiation of cytoreductive therapy where it might be beneficial. I mean that if they are getting tons of phlebotomies, and they do not tolerate them, they should probably be receiving cytoreduction. Or if they have difficult symptoms that are not being addressed, they might benefit from cytoreduction. Or if they have strong cardiovascular risk factors, they are 58 years old, and they have a BMI [body mass index] of 35, and they are not receiving cytoreduction. I would say that, if people are erring, they probably err on the side of undertreatment vs overtreatment.

Bruce Feinberg, DO: Jamile, that same question, institutionally: is there any kind of a clinical pathway in the institution? Is there anything more than just CME [continuing medical education] and grand rounds once a year on the subject? What is done to try to make sure there is that level of knowledge in primary care for recognition and for referral and to decrease that variance at the level of the practitioner?

Jamile M. Shammo, MD: This is pretty much it: simply educating primary care physicians that you must have a good explanation for abnormally elevated blood parameters for which you do not have a good explanation. Chronically elevated blood cell counts that do not have a good answer should be triggering your referral to hematology, but that sometimes triggers referrals a little too soon for reactive purposes. Nevertheless, I suppose that is always a byproduct of what could happen in these conditions. There is a tremendous amount of overlap with reactive conditions that you simply cannot figure out unless you do the work-up.

With phlebotomy, it is unfortunately something that we have to deal with when it comes to PV [polycythemia vera], and it is sometimes difficult to identify a laboratory test that would do this. From a logistical perspective, do you go with the hematocrit, or do you go with the hemoglobin? It is difficult to identify the particular parameter that you go after. It is my understanding that it could be a logistical issue in trying to identify that and go with it. There are many difficulties along the way, but it somehow works. We try to optimize the blood counts in all those patients moving forward. It is not easy, but that is the clinical pathway at my hospital [Rush University Medical Center].

Transcript edited for clarity.

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