VIEWPOINTS it is often overlooked or ignored by health-care providers . To provide comprehensive care for TGNB patients , hospitals should include hematologists on multidisciplinary teams to assess thrombotic risk associated with gender-affirming therapies or planned surgical interventions , and to advise on the compounding effect of underlying hematologic disorders . Proper risk assessment of erythrocytosis and knowledge of the expected complete blood count parameters , and of the relative risks of VTE associated with the different formulations and delivery systems of hormone therapies , are vital .
Hematologists have a commitment to provide unbiased , culturally sensitive , comprehensive care .
Education about culturally sensitive care is also essential , and something that 70.4 % of oncologists expressed a desire for in a survey . 6 In the clinic , providers can practice culturally sensitive care by asking about and using patients ’ pronouns and avoiding assumptions that are based on traditional gender norms , such as inferring relationship roles during medical evaluations . Adding gender identification to our email signature and Zoom calls are other examples of steps we can all take . Institutions should also adopt interventions to create welcoming , inclusive clinical and hospital environments .
That includes training for each person who interacts with the patient – from the hospital staff cleaning the rooms to the physician making treatment decisions .
Hematologists have a commitment to provide unbiased , culturally sensitive , comprehensive care and engage in shared decision-making with all our patients . We need to check our biases at the door and engage in dialogue with our TGNB patients to establish a trusting and mutually respectful therapeutic alliance .
Alexandra Wolanskyj-Spinner , MD Associate Editor
* Name has been changed to protect confidentiality .
References 1 . UCLA School of Law Williams Institute . How Many Adults Identify as Transgender in the United States ? June 2016 . Accessed
September 8 , 2021 . https :// williamsinstitute . law . ucla . edu / publications / trans-adults-united-states /. 2 . GLAAD . Accelerating Acceptance 2017 . Accessed September 8 , 2021 . https :// www . glaad . org / publications / acceleratingacceptance-2017 . 3 . Connors JM , Middeldorp S . Transgender health and haematology – a matter of respect . Lancet Haematol . 2020 ; 7 ( 5 ): e367 . 4 . Center for American Progress . Protecting and Advancing Health Care for Transgender Adult Communities . August 18 , 2021 . Accessed September 8 , 2021 . https :// www . americanprogress . org / issues / lgbtq-rights / reports / 2021 / 08 / 18 / 502181 / protecting-advancinghealth-care-transgender-adult-communities /.
5 . National Center for Transgender Equality . National Transgender Discrimination Survey : Full Report . September 11 , 2012 . Accessed September 8 , 2021 . https :// transequality . org / issues / resources / national-transgender-discrimination-survey-full-report .
6 . Schabath MB , Blackburn CA , Sutter ME , et al . National survey of oncologists at National Cancer Institute-designated Comprehensive
Cancer Centers : attitudes , knowledge , and practice behaviors about LGBTQ patients with cancer . J Clin Oncol . 2019 ; 37 ( 7 ): 547-558 . 7 . Hana T , Butler K , Young LT , Zamora G , Lam JSH . Transgender health in medical education . Bull World Health Organ . 2021 ; 99:296-303 . 8 . Dimant OE , Cook TE , Greene RE , Radix AE . Experiences of transgender and gender nonbinary medical students and physicians .
Transgend Health . 2019 ; 4 ( 1 ): 209-216 .
You Make the Call : Readers ’ Response
We asked , and you answered ! Here are a few responses from this month ’ s “ You Make the Call .”
To see how the expert responded , turn to page 13 .
CLINICAL DILEMMA :
I am treating a 61-year-old female diagnosed with Philadelphia chromosome-positive ( Ph +) acute lymphocytic leukemia ( ALL ) who has multiple comorbidities , including severe diabetes and obesity ( body mass index of 43 ), who is not a candidate for allogeneic hematopoietic cell transplantation . She was initially treated with a single cycle of rituximab , hyper-CVAD ( hyperfractionated cyclophosphamide , vincristine sulfate , doxorubicin hydrochloride , and dexamethasone ), and dasatinib . She achieved a complete remission , but had a difficult induction course and was then switched to dasatinib , prednisone , and vincristine . A bone marrow biopsy continues to show morphologic and immunologic remission , but is still positive for BCR-ABL transcripts at a low level . Should I continue maintenance as before , switch to a different tyrosine kinase inhibitor , or try other immune treatments such as blinatumomab ?
I would suggest continuing “ POMP ” -style maintenance chemotherapy with prednisolone , vincristine , 6- mercaptopurine ( and rituximab if CD20 positive , as was suggested in the clinical information ). The patient should also receive intrathecal chemotherapy .
In addition to this , the patient should continue on a TKI with monthly quantitative polymerase chain reaction testing . If the BCR-ABL transcripts remain at a low level and continue to decline , dasatinib could continue , but we would have a very low threshold for switching to ponatinib . With the BCR-ABL transcripts at a very low level , commencing at just 15 mg per day and continuing would be reasonable ( rather than the 45 mg daily dose ), given the high incidence of thrombosis and noting this patient ’ s comorbidities .
Also , it may be worthwhile to highlight the high risk of morbidity and mortality with initial hyper- CVAD – type therapy . The Germans have presented on this and recommend starting at lower dose chemotherapy with a TKI , which has been found to provide better short-term results with the same long-term disease control .
Julian Cooney , FRACP , FRCPA , MBBS Murdoch , Australia
I would recommend checking a BCR-ABL mutational analysis to guide a change in the TKI . If no mutations are detected , I would switch to ponatinib 30 mg daily ( a dose associated with less toxicity ).
Reshma Ramlal , MD Lexington , KY
I would recommend treatment with blinatumomab and a TKI .
Sabine Gerull , MD Basel , Switzerland
Based on the results of the GIMEMA study by Robin Foà , et al ., a combination of blinatumomab and a TKI would be a less toxic option . Testing of the primary Ph + ALL clone towards different TKIs or defining the point mutation might support a change to another TKI .
Revisiting the bone marrow sample at diagnosis , including cell sorting to identify an underlying CML , would support an allogeneic hematopoietic cell transplantation . However , the patient ’ s condition doesn ’ t allow this .
I would not start with CAR T-cell therapy in this case because of the complete remission . That might be an option at relapse .
Friso Calkoen , MD Utrecht , Netherlands
I would consider two options . The first is ponatinib plus dexamethasone , given the higher potency of ponatinib . This extrapolates from the CALGB 10701 study of TKI plus dexamethasone , which might have similar response rates compared to cytotoxic chemotherapy . While on ponatinib , I would give antiplatelet therapy to prevent thrombosis . The second option is blinatumomab , which has a U . S . Food and Drug Administration approval for measurable residual disease positivity in this setting .
Shyam A . Patel , MD , PhD Worcester , MA
See more reader responses at ashclinicalnews . org / you-make-the-call .
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