ROME – When he meets his first patient who refuses blood, Dr. Patrizio Mazzahematologist and Director of the Complex Structure of Hematology and Transplant Section at the Moscati / SS Annunziata of Taranto, he lives that moment with “pathos; the young woman was a girl with autoimmune hemolytic anemia, she had hemoglobin at 4.5, and how Jehovah’s Witness refused blood, was well aware, and me as a doctor I had a duty to do something and cure her. If I were to be a doctor in the desert without a blood donor, what would I do? If I miss the blood what do I do, do I not cure?”.
Asked by Dire for an in-depth study dedicated to bloodless medicine, the haematologist Mazza, a forerunner on the treatment of blood cancers in non-transfused patients and author of over 150 scientific articles published in national and international journals on the results achieved on patients with leukemia and lymphomas and other diseases that refused bloodhas no doubts that, for ethical reasons and respect for self-determination, but also for clinical evidence, “a strategy must be devised from this point of view”.
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MODIFY THE GUIDELINES, BE STRATEGIC
“Hematologists must think”, Mazza reiterates, underlining how this can lead, “being ready also to depart from and modify the guidelines provided”, To results and benefits for the patients themselves, whether they are motivated by religious factors or other reasons. “The message I want to give is that it can be done, hematologists need to think and there is no need to send a 22-year-old girl from Turin to here, or a 36-year-old boy from Milan to Taranto ”.
“To that anemic girl – says the doctor, returning to that first meeting – according to the guidelines it was necessary to give cortisone at 1.5 mg per kilo if she had accepted transfusions, I have devised another way by giving cortisone at 7 mg per kilo and in three days the haemolytic anemia resolved, with a dose five times higher and with the necessary precautions and I discovered that you can cure anemia this way, giving less toxicity to the patient than expected in the guidelines which involve a long period and cortisone is more toxic than not given for three days, and I discovered it in that circumstance ”. A discovery for the benefit of all that Mazza would not have made if he had remained glued to the protocols without thinking about different paths.
THE CASES OF LEUCEMIC PATIENTS
On leukemic patients the same way there are people who without blood are getting a remission of the disease, what matters is the timeliness. “We had the first patient Jehovah’s Witness in ’94, in Taranto We have been treating these patients for 28 years, 2,500 have passed and they have been treated without blood and we have performed 55 autotransplants without any deaths”.
“If patients come here from Milan, Rome, Turin, Arezzo, Naples, Palermo, what does it mean? – asks Mazza – Throughout Italy there is still mistrust, there is a tendency not to want responsibility and to avoid it and I think this is the real problem. If you agree to treat patients who refuse blood, you will have to develop customized strategies, relatives will ask you a lot of questions every day about why the hemoglobin does not rise and you have to stay there to explain that the marrow has its times. If destroyed – the expert points out – it does not produce blood and this happens in two circumstances: for medullary aplasia which is total destruction, or for acute leukemia. In these two situations, on the one hand there is an empty marrow, on the other it is occupied by cancer cells that prevent healthy ones from producing ”, but even in these extreme situations it is possible to operate using bloodless medicine.
“In aplasia – explains Mazza – the discourse is played on time, the marrow must be reactivated in a few weeks and the patient can come out of it if stimulated by drugs; in the case of acute leukemia, action must be taken promptly by destroying the leukemic cells, allowing the healthy ones to regenerate. These are two extreme situations, but in between there are many where there is no complete destruction and where operationally the doctor can juggle and devise strategic systems and the patient who does not want to be transfused, not only Jehovah’s Witnesses, can be cured by safeguarding this desire ”.
THE BLOODLESS TRANSPLANTS
“There is no problem with autotransplantation – explains the Director of Hematology of Taranto – if you start with good hemoglobin there is no problem with red blood cell transfusionif anything, of platelets but the risk of haemorrhage due to platelet deficiency is very low, and lasts four or five days in autotransplantation “.
In the case of donor transplant “we have carried out two successfully – underlines Mazza – a patient twenty years ago with a chronic myeloid leukemia who at the time was not treated with modern drugs and recently a 39-year-old French patient with the same leukemia and in an accelerated phase with resistance to modern drugs. She came out of the transplant brilliantly with one complete remission. Just three months have passed, we cannot say how things will go but the operating result has been there ”.
THE IMPORTANCE OF TIME
“Today we are following five patients with acute leukemia at onset who ask to be treated without blood because Jehovah’s Witnesses and out of the five who are undergoing therapy 2 are in complete remission and three others are on the way. Few patients have been unable to cure by knowingly refusing transfusionsbut it happened not because we couldn’t use the blood, but because the patients started therapy when hemoglobin was already too low at 3 or 4, and he had waited too long to activate the therapy. On their way there had already been a diagnosis when they had hemoglobin at 8 or 9. Had the therapy been started immediately the outcome would have been different. It is therefore essential – Mazza reiterates – to start therapies immediately after diagnosis ”.
So in the “first patient with autotransplant – Dr. Mazza remembers – I also asked myself the problem and instead of beating around the bush with the therapy, a four-day concentrated program was started with the same drugs that are used on seven, we gained three days on the risk of hemorrhage and thus we understood that the problem of red blood cells does not exist in the patient who undergoes autotransplantation and if he starts with a hemoglobin at 10 or 11 he does not arrive below 7 and if he has a healthy heart he does not risk anything, he stays in bed calm. We also understand that the risk of platelet reduction is very limitedin just a few days, they drop below 10 thousand for four or five days and if there are no vascular defects or bleeding predispositions, nothing happens “.
MEDICAL CULTURE AND GUIDELINES
“In Italy, this is the problem – concludes the haematologist Mazza – there is no culture of saying ‘we must devise a system a little different from the guidelines’. In medicine, the guidelines provide general recommendationsbut when we are faced with a patient who does not accept blood these must be adapted, not distorted, the treatment path is the same but with different times. Hematologists should think locally about the individual patient strategydictated by age, type of disease, characteristics, at what point the pathology has reached and the need for reasoning and strategies without the use of blood for that patient who does not accept it must be taken into account for the doctor “.
The field experience of Dr. Patrizio Mazza, who made the SS. Annunziata di Taranto a reference, it is not destined to remain unique. Numerous scientific publications document a legacy of knowledge to be put into a system in scientific societiesamong fellow hematologists, to whom the expert has launched a strong appeal, so that others patients are no longer forced on journeys of hopehowever, at the risk of wasting precious time to find the protection of a right: to be treated with respect for one’s freedom of thought and belief.
BIBLIOGRAPHICAL NOTES, PUBLICATIONS BY PATRIZIO MAZZA
- About 150 papers published in national and international journals with a focus on clinical research on lymphomas: Haematologica Leukaemia and Lymphoma, Bone Marrow Transplantatio, Journal of clinical oncology and Blood;
- Ex multibus: Autologous and allogeneic stem cell transplant in Jehovah’s Witnesses: a single-center experience on 22 patients – PubMed (nih.gov);
- Myeloablative therapy and bone marrow transplantation in Jehovah’s Witnesses with malignancies: single center experience – PubMed (nih.gov).
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