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Unique Challenges in MPNs

Unique Challenges in MPNs. 2012 Bay Area MPN Patient Symposium Laura C. Michaelis, MD Loyola University Medical Center. Topics to Discuss. Overview: Gender and Cancer Gender and MPNs Special issues facing females with MPNs Clotting Pregnancy Bleeding

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Unique Challenges in MPNs

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  1. Unique Challenges in MPNs 2012 Bay Area MPN Patient Symposium Laura C. Michaelis, MD Loyola University Medical Center

  2. Topics to Discuss • Overview: Gender and Cancer • Gender and MPNs • Special issues facing females with MPNs • Clotting • Pregnancy • Bleeding • Modifiable risk factors – both genders • Conclusions

  3. Cancer: Sex-based differences Breast Ovarian Cervical Testicular Prostate

  4. Cancer: Gender-based differences

  5. Gender and Cancer • Does the disease occur more frequently in one sex vs. the other? • Diagnostic bias? • Due to exposure? • Due to genetic predisposition? • Does the disease behave differently in one sex vs the other? • Modulated hormones? Gender-based lifestyle differences? • Interactions that we don’t understand? • Are there different consequences to the disease or treatment that depend on gender?

  6. Sex RatioHematologic diseases

  7. More women diagnosed than men More men diagnosed than women Cartwright et al. British Journal of Hematology 2002, 118 1071-1077

  8. Clinical Trial Inclusion

  9. Topics to Discuss • Overview: Gender and Cancer • Gender and MPNs • Special issues facing females with MPNs • Clotting • Pregnancy • Bleeding • Modifiable risk factors – both genders • Conclusions

  10. Challenges: Clotting • ET – most common MPN in fertile women • Hormonal contraception + ET = hypercoaguable state • Pregnancy + ET = hypercoaguablestate • Thrombosis -- #1 cause of maternal death

  11. Challenges: Fertility • Contraception • Combination hormones >progesterone only OCPs • General population have a 3–6-fold increased risk of venous thrombosis with OCPs • One retrospective study of >300 patients. Subset on OCPs • ET + OCPs = 23% VTE • ET no OCPs = 7% VTE

  12. Challenges: Pregnancy • Pregnancy outcomes likely impacted • Live birth rate 50-70% • First trimester loss 10-20% • Late pregnancy loss 10% • Increased rates of placental abruption, intrauterine growth restriction • Can we change those outcomes?

  13. Preconception Counseling • Risk Assessment • Prior VTE or arterial clot • Prior hemorrhage • Prior pregnancy complication • Diabetes or Hypertension requiring treatment • Platelet count of >1500 X 109 before or during pregnancy

  14. Preconception Counseling • Multidisciplinary approach • Discussion of teratogenic drugs • Therapeutic options • Aspirin • LMWH • Cytoreductive therapy • Delivery and post-partum plan • Breastfeeding information

  15. Pregnancy: Low-Risk Patients Antiplatelet agents  reduce risk of VTE in ET patients • Generally • Continue low-dose aspirin • Monitor platelet or Hct • Keep HCT under 45% • Consider venesection if necessary • Increased plasma volume of pregnancy means no set targets Pregnancy is thrombotic Aspirin is likely safe in pregnancy (APLA pts)

  16. Pregnancy: High-risk patients • Remove possible teratogeneic drugs • Taper off hydrea or anagrilide 3-6 months prior to conception • Hydrea likely contraindicated, men and women • Anagrilide crosses the placenta • Cytoreduction • Interferon-alpha-- Case reports indicating likely safe • Prevent Clotting • LMWH • Prophylactic or, in some cases, therapeutic doses

  17. Challenges: Bleeding • More common when platelets are elevated • 1,000-1,500 X 109 • Often related to acquired Von WillebrandsDisease • Occurs in both men And women

  18. Topics to Discuss • Overview: Gender and Cancer • Gender and MPNs • Special issues facing females with MPNs • Pregnancy • Clotting • Bleeding • Modifiable risk factors – both genders • Conclusions

  19. Outcomes: Venous, Arterial Events like stroke, heart attack, VTE, bleeding Exercise Healthy Weight HTN control Smoking DM MPN lipids

  20. Conclusions • Get involved in your care • Ask questions • Participate in clinical trials • Control what you can • Any questions?

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