Ovarian cancer is the leading cause of death from gynecologic cancer with 14,070 deaths estimated in 2018, according to the National Cancer Institute.
First-line standard treatment for advanced stages consists of debulking surgery followed by systemic platinum-based chemotherapy.
Cytoreductive surgery can be an extensive procedure, and approximately 4.1% to 7.4% of women with advanced ovarian cancer experience excessive bleeding during the intervention, with a red blood cell transfusion rate of 30-40% (Lundin et al. 2014; Vergote et al. 2010). Reported estimated blood loss during ovarian cancer surgery ranges from 200 to 1500 mL (Lee et al. 2011).
Severe anemia has been identified as a predictor of adverse outcome in the peri-operative period, with mortality and morbidity exceeding, respectively, 30% and 55% in patients with hemoglobin level below 5 g/dL (Carson et al. 2002).
There are a number of situations in which a patient may refuse blood transfusions even in life threatening scenarios, with the most well-known involving Jehovah's Witnesses, posing a unique clinical challenge.
The aim of this case-control study is to determine the rate of major complications within 30 days after surgery for ovarian cancer in anemic patients refusing blood transfusion compared with patients who accept blood transfusion.
Facing the refusal of a patient to accept blood transfusion, when absolutely necessary for vital reasons, is probably one of the biggest challenges in health care and one of the most frustrating situations in medical wards.
Understanding the premise behind the beliefs of patients who refuse blood transfusions, especially Jehovah's Witnesses, is crucial to beginning conversations and open dialogues between physicians and patients. Remembering that they can also change their minds over time as life circumstances change is important to the care for these patients. What patients say publicly and what they do privately in the company of their physician may vary, and physicians need to be open and nonjudgmental partners in these decisions.
For this reason, determining the rates of adverse post-operative outcomes in this population of patients will be helpful for adequate patient counseling and pre-operative multidisciplinary planning.
Women with advanced ovarian cancer should be informed that the refusal to accept blood products at the time of surgery may impact their outcomes, final cytoreductive status, time to adjuvant chemotherapy initiation and, therefore, overall prognosis, in order to guide their decision making and to balance refusing blood with the potential consequences of a bloodless surgery.
On the other hand, a worse outcome in anemic patients refusing blood transfusions compared to those undergoing conventional treatment could emphasize the need of standardized written protocols and a multi-disciplinary approach to the management of these patients, aiming to optimize the hemoglobin concentration in clinical situations in which significant blood loss is anticipated.