Coagulation studies are still a benchmark in clinical and research testing facilities, especially when it comes to more complicated cases. Despite taking great strides in genetic and molecular diagnostic modalities and treatments, more visual-based testing methods continue to be relied on under tricky circumstances. In a recent interview, Cheryl Hirsch-Ginsberg, MD, professor and deputy department chair in the department of laboratory medicine at MD Anderson Cancer Center, discussed the role of coagulation and hematology in her facility and how it's adapting to the changing industry.
In the department of laboratory medicine at the MD Anderson Cancer Center, Hirsch-Ginsberg, along with two fellow colleagues, Xin Han, MD, and Xiaoping Sun, MD, PhD, acts as a consultant, running a variety of tests ranging from basic to complicated procedures, particularly with thromboelastography. She also works within the chemistry department, under the direction of Beverly Handy MD and Qing H. Meng, PhD, and assists in administrative matters. The coagulation tests mainly range from basic to more complicated tests, such as protein C, antithrombin and Dilute Russell's viper venom time (DRVVT) lupus anti-coagulant tests, but the coagulation and hematology team also looks at peripheral blood and body fluid slides.
"The technologists use the instruments, and review the results and perform any manual reflex test required to assure accurate results," said Hirsch-Ginsberg. "And once the accuracy of the analyzed results are verified, the pathologists confirm the results and add the interpretation, which is based on a combination of the raw results and the patient's history."
As cancer patients are often already predisposed to coagulation disorders (bleeding and clotting disorders), the coagulation reports tell the attending physicians and scientists if there is anything going on that might affect further treatments. Some determining factors come down to characteristics that might cause hyper-coagulability, such as protein mutations like the factor V leiden mutation. The coagulation specialists at MD Anderson try to keep an eye out on any patients presenting with thrombosis to help understand and treat, as well as to make sure there are no adverse reactions with their current state during treatment.
"It's very important for their treatment to know if they have some factor deficiencies, which are going to predispose them to bleeding," continued Hirsch-Ginsberg. "Or if there are actually prothrombotic conditions -- In which case, you have to worry more about DVT [deep vein thrombosis] prophylactics."
Physicians and clinicians are never going to find all the causes or indicators for complications. Tests like the protein C and antithrombin assessments work for very specific causes. On the other hand, the thromboelastrography works to give medical professionals an overall idea of a patient's clotting data. Because this allows for a general picture of a patient's coagulation readings, the cause becomes less important as the test tells clinicians if a patient is in a prothrombotic state and how well it's being managed.
"The problem with specific tests is that not all the causes of bleeding or prothrombotic states are known, and therefore, you certainly can't test for them - so, just not finding a decreased antithrombin or a decreased protein-C level doesn't mean that the patient is still not at risk for thrombosis," explained Hirsch-Ginsberg. "So, you can only rule out what you test for, but there's a whole host of other causes that are completely unknown."
While coagulation remains reliant on time-tested modalities, the industry continues to press forward, bringing new testing options to the field. The addition of genomic testing and molecular diagnostics provides a different perspective and new methods of understanding cancer, and in some cases of predicting response to therapy. Automation and new technologies is also speeding up turnaround times on relatively older testing options, allowing for faster results at all levels. These new additions and technical developments are helping medical professionals to manage and improve treatments as they gain a broader understanding of the unknown causes behind certain problems and complications a patient might experience.
"So, in that sense technology is affecting things - certain automation, getting flow through the lab in a more expedited fashion," said Hirsch-Ginsberg. "So, those things help you get the answers faster and help you manage your samples better -- and then things like genomics can add information that will enhance our understanding and management of the patients.
The coagulation team at MD Anderson is looking into the future. Hirsch- Ginsberg cited thromboelastography as a testing modality with a lot of potential in particular. The current standards rely on finding deficiencies in clotting that could lead to bleeding, which is important in the analysis and treatment of cancers, but remains limited as an option. The implementation of methods that look at the thrombotic state in general -- such as the thromboelastography (clot initiation through clot dissolution) - has led to a better understanding of the disorders as a whole. As the industry moves towards personalized medicine, the understanding of an individual patient's coagulation profile can be applied elsewhere for improved results.
Michael Jones is on staff at ADVANCE.