Rethinking preoperative anemia: Challenging WHO guidelines and targeting hemoglobin levels in major elective surgery

An estimated 23%-45% of patients undergoing major surgery have anemia, with the most common causes being iron deficiency anemia and anemia of inflammation or chronic disease.

In this episode, Drs. Mojola Omole and Blair Bigham speak with Dr. Clarissa Skorupski and Dr. Yulia Lin, two authors of the practice paper in CMAJ, "Five things to know about preoperative anemia in major elective surgery." Dr. Skorupski is a third-year internal medicine resident at the University of Toronto, and Dr. Yulia Lin is the division head of transfusion medicine and tissue bank at Sunnybrook Health Sciences in Toronto. They highlight the high prevalence of preoperative anemia, its adverse outcomes, and the importance of targeting a preoperative hemoglobin level of 130 g/L for both sexes.

Next, Drs. Bigham and Omole take a critical look at the WHO guideline which sets a lower hemoglobin threshold of 120 g/L for female bodies. They speak with Dr. Michelle Sholzberg, the head of hematology-oncology and the director of the Hematology Oncology Clinical Research Group at St. Michael's Hospital in Toronto. Dr. Sholzberg argues that the WHO's sex-based hemoglobin thresholds for diagnosing anemia perpetuate structural discrimination in medicine, as they normalize anemia in females and are based on outdated data with a high risk of bias. Dr. Sholzberg describes how the policies and clinical practices following the biased thresholds may impact health-related quality of life, cognitive function, and the health of pregnant individuals and their babies.

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Transcript

Dr. Mojola Omole:

Hi, I'm Mojola Omole.

Dr. Blair Bigham:

I'm Blair Bigham. This is the CMAJ Podcast. Jola, today we're talking about a Five Things You Need To Know paper on pre-operative anemia in major elective surgery, and I found the top line of this to be super interesting, I want to get your take as a surgeon. But the authors have suggested that a pre-operative hemoglobin less than 130, or 13 for my Stanford friends, would be predictive of poor outcomes. And so they're recommending that for elective surgery people get their hemoglobin driven up to 130, not with blood transfusions, but by treating things like iron deficiency. What's your take on that? Do you wait for everyone's hemoglobin to hit 130 before you take them to the OR?

Dr. Mojola Omole:

Nope.

Dr. Blair Bigham:

Nope.

Dr. Mojola Omole:

Not at all. I'm just like, hemoglobin? It's fine, I'm not going to lose any blood. Obviously, with certain patients I would consent for blood, but when they describe the complications you can have, it really was, for me at least, practice changing to want to be treating this and not just saying, it's not 60, it's fine.

Dr. Blair Bigham:

Well, I'm super curious what the authors have to say because I'm always taught, for at least ICU and emergency medicine, we try not to transfuse people. We tolerate anemia, we tolerate pretty profound anemia sometimes. And so to hear that even a hemoglobin of 120 can be predictive of a poor outcome after an elective surgery, I just find that so fascinating. So, I'm really excited to get into it with the authors here, and then afterwards we're going to talk to one of our dear friends, a hematologist who's been on this show before, who's going to help us understand a little bit more about how we should be achieving optimum hemoglobin levels before elective surgery.

Dr. Mojola Omole:

And also talking about in particular just the difference in target levels between male and females. I'm really looking forward to this.

Dr. Blair Bigham:

Let's get into it. Dr. Clarissa Skorupski and Dr. Yulia Lin are two authors of the practice paper in CMAJ entitled, “Five Things to Know About Pre-Operative Anemia in Major Elective Surgery”. Dr. Skorupski is a third year internal medicine resident in the University of Toronto, and Dr. Yulia Lin is division head of Transfusion Medicine and Tissue Bank at Sunnybrook Health Sciences in Toronto. Thanks so much for joining us.

Dr. Clarissa Skorupski:

Thank you so much for having us today.

Dr. Blair Bigham:

I want to start off by something I was surprised by in the Five Things You Need To Know article, and that was the number 130. I feel like I'm always being told that lower hemoglobins are fine, you can tolerate them, you don't need to transfuse. We go as low as 70, 65 in the ICU where I work. Tell me where does that number come from and that top line recommendation?

Dr. Clarissa Skorupski:

I think at its core the number 130, it stems from how anemia has been historically defined. I think one of the things we mentioned in our five things is that traditionally a hemoglobin of 130 in men and a hemoglobin of 120 in women is what's been used to define the value of normal, the kind of threshold between anemic versus non-anemic. So, when it comes to the surgical population and the preoperative population, there's been a lot of large retrospective studies that have been done in the US, in Europe, all over the world, that had looked at this number of 130 is actually the cutoff where we start to see impacts of preoperative anemia on surgical outcomes and important outcomes, including things like mortality, morbidity, how long we stay in hospital, complications we can experience.

Dr. Blair Bigham:

Hang on. You're saying that if your hemoglobin is less than 130, let's say it's 118 and you go for surgery, you actually have worse outcomes even if your hemoglobin is that high? To me that's, I mean, that's through the roof for an ICU doctor. So, how do we get people to 130 then? Are you delaying their surgery and treating them for anemia and working up their anemia beforehand?

Dr. Clarissa Skorupski:

I think there's a lot of good questions to tease apart there. So, it's true-

Dr. Blair Bigham:

Yeah, I'm excited about this. This is really surprising to me.

Dr. Clarissa Skorupski:

It's good. And I think anemia is, as you say, it's so common, especially when we're dealing with inpatients a lot of the time, again, as an internal medicine resident on the ward, every day we see 90s, 80s, 100s, and we don't really blink an eye or think about it. So, why this is so different is we're really focusing on an elective population, and a lot of times an ambulatory patient population where there should be or there could be an opportunity to intervene if found early enough to try and bring that hemoglobin level up. And the number 130, that's what's so interesting about a lot of the retrospective data that's been done in this area, they found that even mild anemia, when you're looking at numbers 110 to 120, 120 to 130, it still has an impact on outcomes. It does worsen with the severity of anemia, but we know even small changes in the preoperative hemoglobin number between changes by 10 can impact outcomes.

Dr. Blair Bigham:

So, tell me more about those outcomes, what happens to patients when they are operated on without a hemoglobin of 130?

Dr. Clarissa Skorupski:

There's a spectrum. Preoperative anemia has been shown to be independently associated with an increased risk of 30 and 90 day postoperative mortality, and then other things as well, postoperative morbidity, things that they've looked at are increased rates of postoperative complications like stroke, myocardial infarction, infection, the degree for how long patients stay in hospital, and also readmission rates. So, how often are patients being readmitted at the 30-day mark or the 90-day mark? It's a lot of things, but they're all things that have been seen, and caveat is this is a lot of observational data, but these are all things that preoperative anemia has been associated with observationally.

Dr. Mojola Omole:

When we're talking about operations, you talk about major elective surgeries. So, what's classified under major elective surgeries?

Dr. Clarissa Skorupski:

There's been a lot of studies in this area that do use variable definitions, but some of the common things that we talk about are orthopedic surgeries. So, whether it's lower limb orthoplasty, total knees. Cardiac surgery is a big patient population where preoperative anemia has been studied, so your CABG patients, valve replacements, and also in the cancer surgery populations, so those undergoing colorectal cancer resections, hepatectomies, gynecologic surgeries, patients undergoing hysterectomy, these all fall within that definition.

Dr. Blair Bigham:

Anemia I think often sort of doesn't get much attention, a lot of people come and go from the emergency department with the hemoglobin at 95 and people are like, whatever, not my problem. Tell me, why do you think that anemia doesn't get that appreciation? And how do you hope that this most recent Five Things You Need To Know is going to change everyone's practice?

Dr. Yulia Lin:

Yeah, it's a great question and it's funny when we talk about the operating room and anemia, often anemia is sort of in the background, just as you said, people just see it and they're like, oh, it's fine. But we don't know whether it's just a reflection of that patient's underlying illness and that is what's leading to the anemia, or maybe there's actually something that's treatable and correctable. And I guess that's what we're really trying to advocate for is that in some of these cases a good proportion of these cases are things like iron deficiency anemia, which are completely treatable and preventable. And so we think, why would that not be something that we would try to optimize just as we would try to optimize a whole host of different factors before going to the operating room for these patients to do better? We can't often change the blood loss that occurs, so we're trying to decrease that [inaudible 00:07:57] hemoglobin.

Dr. Mojola Omole:

There is no blood loss in surgery.

Dr. Blair Bigham:

There is never blood loss in the op note

Dr. Mojola Omole:

Blood loss is less than five mils. Thank you.

Dr. Yulia Lin:

Absolutely. I think I totally would want to be in your OR for sure, Jola. But unfortunately working in the blood bank, sometimes bleeding happens, and so we're trying to do everything that we can to try to optimize that patient before they get to the OR.

Dr. Mojola Omole:

What's the lead time in terms of optimization? So, I'm thinking for example you have someone who presented with iron deficient anemia, they were scoped and it ends up showing that they have sickle cancer, and their hemoglobin is 99. What should the next steps be and how long would it take?

Dr. Yulia Lin:

In a lot of these cases, for example here in Ontario, we have a patient blood management program called ONTraC, so there are nurses at 23 different hospitals that can help with optimizing patients for surgery. So, for example, in that case, our institution, we have the diagnostic assessment nurses, and so even before they see the surgeon, when that first consult or referral goes to the nurse, she can actually detect, oh, there's iron deficiency, we're going to refer her to the blood conservation team and we can get her in to start on some type of iron supplementation. I would say that, typically we say that the hemoglobin will increase by 10 points per week, especially in that type of setting. So, for that type of setting, if we had three weeks, we probably could very much optimize that patient to a normal hemoglobin. And that would make you excited, I think for the OR.

Dr. Mojola Omole:

I know, because honestly, I just kind of ignore the hemoglobin if it's not below a 100, and just say, oh, we'll deal with them when we get there. But knowing that it only literally takes three weeks, which is around the same time to get into the operating room, it makes sense.

Dr. Blair Bigham:

Other than iron deficiency, what other common causes would there be for anemia that you could fix within a week or two?

Dr. Yulia Lin:

There's iron deficiency, there's anemia of inflammation which may have a component of iron deficiency, and those are a couple of the two most common. But there would for example also be anemia of kidney disease, and in those cases we can supplement for example with epoetin alpha or erythropoiesis stimulating agents. So, we can increase the hemoglobin in short times. Ideally we would have six to eight weeks, you don't always have that, but ideally we would have more time. So, there are ways to optimize. And remember that in some of these studies even a 10 point increase or decrease in the hemoglobin made a difference. So, that may mean the difference between having two units versus one unit. And again, with every unit that's transfused, we see worse outcomes.

Dr. Blair Bigham:

So, here's where I'm getting a little bit mixed up. On one end your paper makes a strong argument that if your hemoglobin is less than 130, you're going to have potentially a worse outcome. And yet there's also this literature around transfusions causing potentially worse outcomes in this very conservative approach to transfusions. Help me reconcile those two things, is it the transfusion itself because it's like a graft from somebody else that's causing outcomes to be worse? Is it the volume? I'm just kind of mixed up on that.

Dr. Yulia Lin:

Actually it's a great question and it's a hard one to sort of reconcile. I think when you look at it, for transfusions postoperatively we don't know whether the worst outcomes that we see in observational studies are due to the fact that the patient got to the point where they needed a transfusion. So, all these bad things happen, like you have myocardial ischemia, you have a stroke, you have all these other things that happen because you're so anemic, and then you get the transfusion. So, is the transfusion just a confounder and a sign that the patient dropped to that level in the first place? Versus transfusion adding an additional poor prognostic factor. I will say that if you look at randomized control trials of transfusion at different thresholds, 70 versus 90, there's no difference in outcomes, different differences in the amount of blood that people receive. And there's differences I think in transfusion reactions, but that hasn't been definitively shown. So, I think the transfusions post, I do wonder if some of that is just the fact that you got to that level and had some bad outcomes that required the transfusion, which then again speaks to trying to optimize them as much as you can beforehand so that they don't even drop to that hemoglobin and you don't even have to make a decision about transfusion.

Dr. Blair Bigham:

Right. Okay, that makes a lot more sense.

Dr. Mojola Omole:

So, recommended preoperative hemoglobin of 130 for both female and male patients. So, we normally see different targets for males and females. Why do you advise for a single target for hemoglobin?

Dr. Clarissa Skorupski:

That came from the initial WHO definitions that are sex-based, like biological sex-based definitions of what we consider to be anemia. But observational data has shown that women are, and this is referring to sex, women are at a higher risk of losing a greater proportional red blood cell mass given for the same amount of estimated blood loss. So, if a woman loses 500 ccs of blood versus if a man were to lose 500 ccs of blood during an operation, the women actually lose a greater proportion of their circulating red blood cell mass. So, that-

Dr. Mojola Omole:

Really?

Dr. Clarissa Skorupski:

Yeah. And-

Dr. Mojola Omole:

Why is that?

Dr. Clarissa Skorupski:

I think it's-

Dr. Mojola Omole:

Is that just physiological?

Dr. Clarissa Skorupski:

I think it's physiologic, I think related to things we look about are women have lower red blood cell masses than men for a smaller body surface area on average. Yulia, I don't know if there were other things related to that you could comment on.

Dr. Yulia Lin:

Yeah. I mean, I think it's really interesting because using that hemoglobin, if you look at data over time, women are more often transfused after the same surgery as men. So, I wonder if because we've been using these differential hemoglobins that we're kind of disadvantaging women. So, in fact I feel like we need to be more aggressive with women so that they actually have a good hemoglobin as they're going in undergoing the same surgery. In the US data, when they look at it, there's no difference between males and females in terms of their outcomes or what level things happen at which is 130. So, there's definitely been a real move within preoperative anemia management and other areas outside of preoperative anemia management to treat males and females with the same hemoglobin.

Dr. Blair Bigham:

So, I feel like we've been so excited talking to you here that our queue line's been a little all over the map. I want to give our listeners a real chunk of information that they can take away to participate in screening for preoperative anemia. So, I'm going to try a couple of things here and then feel free to add on. Number one, whether you're male or female, a hemoglobin of 130 or greater is preferred before any major elective surgery. Number two, most commonly any anemia under 130 will be iron deficiency, which within a couple of weeks you might actually be able to get their hemoglobin up if you treat it. And third, if it's a more acute situation, transfusions of blood products are not your way to reduce mortality, either pre-op or post-op. How's that for some other-

Dr. Yulia Lin:

It's amazing.. I'm so happy right now.

Dr. Blair Bigham:

But I must admit something, Yulia, you live and breathe this. What else do you want everyone listening to know?

Dr. Yulia Lin:

Well, I think that when we think about patient blood management, especially thinking about the audience, who I hope is of course lots of different physicians, but also primary care providers, that primary care providers, as soon as they make a referral for a surgical consult, really they can at that point check the patient's CBC, check their iron stores and see if they can get them started on iron supplementation early so that there's even more time to sort of improve that hemoglobin if it is, for example, something as simple as iron deficiency before they get to the operating room, or even before they get to the consults.

Dr. Mojola Omole:

Awesome. Thank you so much. I find this fascinating. I'm going to start caring more about anemia.

Dr. Yulia Lin:

Yay.

Dr. Blair Bigham:

Dr. Skorupski is a third year internal medicine resident at the University of Toronto, and Dr. Yulia Lin is division head of Transfusion Medicine and the Tissue Bank at Sunnybrook Health Sciences in Toronto. Coming up after the break, we're going to take a closer look at the rationale behind the different anemia guidelines for men and women. Are they grounded in evidence or something else?

Speaker 5:

Insert commercial here.

Dr. Mojola Omole:

Dr. Michelle Sholzberg is the head of hematology oncology and the director of the Hematology Oncology Clinical Research Group at St Michael's Hospital in Toronto. As we mentioned before, the CMAJ practice paper recommends a single standard for preoperative anemia for both men and women. That's a shift from the current WHO guidelines. We're going to take a critical look at those guidelines with Michelle. Thank you so much for joining us again, Michelle. How are you?

Dr. Michelle Sholzberg:

Thank you, Jola. It's wonderful being here. Thank you for putting up with me again.

Dr. Mojola Omole:

No, you're one of our favorite guests. So, currently the WHO guidelines, what are they for diagnosing anemia in I guess biological men and women?

Dr. Michelle Sholzberg:

Great question. So, currently the WHO suggests sex-based thresholds for anemia. So, in biological males the threshold to define anemia is a hemoglobin under 130 grams per liter and for females under 120.

Dr. Mojola Omole:

So, I guess my first question is why?

Dr. Michelle Sholzberg:

That's another really great question and a really loaded question, and I'm about to give you a loaded answer. So, this is an example of structural discrimination in medicine. The WHO first put forth these recommendations in 1968, and this was on the basis of four published reports and one set of unpublished observations, of only which two in fact looked at sex-based differences in hemoglobin thresholds to define anemia. So, as a clinical epidemiologist, we would define that as data that is at very high risk of bias and certainly outdated. And why that's particularly problematic is it normalizes possible anemia amongst females. Where did this come from? Why do we think that females have a different hemoglobin threshold? Largely we are learning that this is due to untreated iron deficiency amongst women or individuals with the capacity to menstruate of reproductive age.

And that is because people who menstruate lose at least 15 to 20 milligrams of elemental iron per cycle, and they may or may not get pregnant. And with each pregnancy it takes about a gram of iron to make a baby, to make the extra maternal blood volume, to account for the low PO losses, to account for the placenta to be produced. And I know a gram doesn't sound like a lot of iron, but that's equivalent to 177 large steaks. So, it's really easy to be iron deficient when you're regularly menstruating, and because iron rich foods are expensive, and also it's really easy, and in fact impossible to eat your way out of iron deficiency in pregnancy. So, it just becomes very problematic throughout all of those years.

Dr. Mojola Omole:

So, just going back, what do you think the impact of having this, and I think you've touched on it a bit, having this differences in guidelines like in the terms of the quality of health, quality of life and health for women who menstruate, what is the impact of this?

Dr. Michelle Sholzberg:

The impact is huge and multifaceted, because essentially laboratory-based thresholds are what defines our concept of normal as clinicians. And as clinicians when a result comes from the lab, and if it's flagged or not flagged, that really shapes our view of the patient and their experience. So, the impact of iron deficiency even in the absence of anemia is substantial and it's associated with a decreased health related quality of life. In the presence of anemia, it's even worse, and there are clear associations with various morbidities and also mortality. But we know in individuals with iron deficiency in the absence of anemia that health related quality of life is lower on the basis of fatigue, lower IQ on the basis of diminished attention, memory and speed, lower exercise tolerance, diminished cardiovascular reserve. So, of course, as a hematologist I'm totally biased about the importance of iron for erythropoiesis production of red blood cells, but iron is important for many cells in our body ranging from myocytes, to neurons, to cytochromes in our liver and other metabolic enzymes, and it's even directly involved in the generation of ATP. So, it's really important and the impacts are huge, and there are also additional impacts for pregnant individuals, for the person who's carrying the fetus, and also there's evolving literature indicating that there are impacts for the baby as well that can be enduring.

Dr. Mojola Omole:

It's astounding just to think about it. I guess it's also nerve-wracking to think about how many more systemic inequalities do we have, not just in delivery of healthcare, but in something that's supposed to be either high or low, not knowing that it's actually built on discrimination and some, or all sorts of inequities.

Dr. Michelle Sholzberg:

Exactly. I would say my clinical and research interest in this area began over a decade ago, and the more that I learn, the more appalled that I've become. And what's even more frustrating is that there's resistance to changing perceptions and really reevaluating the literature using proper methodology. I have had multiple experiences in the very recent past where I've presented this work and presented our data where I was met with a lot of anger and frustration from some individuals in the audience, physicians, indicating that we are going too far with the idea of social determinants of health, and that there are biological differences that we are not even considering. Now, I don't mean to imply as a hematologist who's become an expert in bleeding disorders and anemia that I am not considering biological differences that exist between males and females. Of course androgens and growth hormones impact erythropoiesis.

Of course estrogen has some inhibitory effect on erythropoiesis as well, I'm not denying that, absolutely not. But there is evidence in the literature indicating that when you treat patients with iron deficiency, males versus females, that there's an increment in the hemoglobin in the females, and less so in the males, suggesting that the discrepancy really relates to untreated iron deficiency. And there is now evidence that comes from large data sets showing that the proximity in the hemoglobin thresholds for males and females, it's really tight, it's really close before menarche. It separates during the reproductive years, during menstruation, pregnancy and lactation, all of which are high iron demand states. And then guess what happens after menopause? They come back together. It goes even deeper, so there are trimester-based pregnancy anemia thresholds that change over the course of pregnancy, that is largely due to untreated iron deficiency. And the whole concept of dilution is overblown. If it was all on the basis of dilution, I would not be able to correct anemia every single time that I do when I treat a pregnant patient with intravenous iron.

Dr. Mojola Omole:

I guess I'm a bit confused and just perplexed about why such strong reactions? And would it be the end of the world if we had the same threshold? Would the difference of 10 make such a, I guess I just don't understand why it's so polarized. Hasn't the World Health Organization revisited this?

Dr. Michelle Sholzberg:

There have been meetings in the recent past to discuss revisions. This was another really important, but I must say, distressing learning for me. I've come to realize that anemia is very political.

Dr. Blair Bigham:

What?

Dr. Michelle Sholzberg:

I know.

Dr. Blair Bigham:

How is anemia political?

Dr. Mojola Omole:

Why?

Dr. Michelle Sholzberg:

I know, right? Well, because we are privileged. We live in Canada, and we live in a place where people can have access to healthcare services universally, we don't have universal PharmaCare of course. Anyways, in general we're doing pretty well, right? So, we know that globally 30% of the population has anemia, and the majority of that anemia is due to iron deficiency. There are some parts of the world, and this is on the basis of WHO data, where 65% of the population has anemia. So, if we were to reframe what's normal versus abnormal, then that means that we're redefining the proportion of the population or the prevalence of a disease state in a given country.

Dr. Mojola Omole:

Would that not mean we need to do more about it? I don't understand.

Dr. Blair Bigham:

No, it would make it look like someplace suddenly had way more anemia than it did the year before. Is it like a KPI? Countries are like, we're going to reduce anemia. I don't know, remember that West Wing episode where they wanted to redefine something and then they couldn't because it would look like there were more Americans without jobs just by redefining it?

Dr. Mojola Omole:

I guess from you, but what I feel like I'm seeing is that by not redefining it, you get to ignore a problem, and not actually come up with solutions to treat it. Instead of saying, okay, well, we know that many countries have iron deficiency in its population, let's make this a target. But it's like, well, let's just pretend it's not there. It's like how I do with my bills, I don't open them, so there's no bills.

Dr. Blair Bigham:

And it sounds like it's not just the lab threshold. I can think of a thousand times when I've heard a colleague say to a pregnant woman, "Oh, don't worry. Your hemoglobin's 97. That's pretty good for someone who's pregnant," and just moved right on, "Next." Not even checking iron. I do that too, "Oh, your hemoglobin's 97? Eh, you're pregnant." There's this threshold in our own minds that anemia just doesn't matter.

Dr. Michelle Sholzberg:

Yeah, right. Because it's been normalized. Exactly. And also,

Dr. Blair Bigham:

Right. By the guidelines, by the threshold…

Dr. Michelle Sholzberg:

But I don't want to imply that this isn't really tough to address, and it's not that it's so tough to address with that one individual patient who's in front of you. But the three of us are busy clinicians, right? Lots of patients over the course of the day, you're reviewing lots and lots of lab tests. The sheer prevalence of this problem is enormous. And because it's so common, it requires not just, oh, the treatment and et cetera, it requires access to treatment, access to education, because it just isn't as easy as saying here, take your iron pills.

See you later. Well, there're estimates up to 70% of patients on iron supplements, oral iron supplements have GI side effects. So, it's not so easy, it's not so easy. And access to intravenous iron, not so easy. Access to medications to control heavy menstrual bleeding, not so easy. There are lots of barriers to care from a women's health lens. Of course, when I'm using the word woman and women I'm using it honestly deliberately to highlight some pretty important knowledge and care gaps for women, but of course I don't mean they're exclusive. It refers to all patients who have the capacity mentioned.

Dr. Blair Bigham:

I don't want to move on from this global and systemic chat, but I do want to get into the individual patient challenges, and you mentioned getting IV iron for someone, which for family doctors can be nearly impossible. And I have people sent to the ER for iron transfusions just because the family doc's like, that's the only way you're going to get iron, just go to the ER. Or patients who come to the ER frequently and say, "I'm just here for iron." And for me, I'm like, "Cool. I can do that for you." But how silly that you had to wait four and a half hours just to see me so I could write for some IV iron. What are some of the sort of lower hanging fruit that we can work on so that clinicians in Canada can get people iron when they think they need it?

Dr. Michelle Sholzberg:

That is the point, Blair. That is the point.

Dr. Blair Bigham:

I feel like you're going to have an aneurysm, Michelle. No one else can see you on camera but Jola and I, and you're literally losing it.

Dr. Michelle Sholzberg:

The problem there is also systemic. So, access to infusion centers is a challenge. Private infusion centers require private insurance or ability to pay out of pocket. Which demographic of individuals is most commonly affected by iron deficiency? Those of lower socioeconomic status, and also those of minority race and ethnicity. So, with one foul swoop right there, we've just ensured that more rich white people are going to get treated. What about public infusion centers? What about at hospitals? Okay. Very few hospitals have the resources to dedicate infusion centers for non-chemo therapeutics. And culturally, we are positioned for good reason to prioritize cancer care. And currently, non-malignant hematology is underfunded, and many cancer centers are refusing referrals for patients with iron deficiency because they cannot accommodate the volumes.

Dr. Mojola Omole:

What I was thinking as we're talking is that by not addressing these inequalities, by resisting against it, we're actually holding ourselves back from innovation. This is something that is rich, whether you're doing it for lower income settings to figure out a way of delivering iron in an affordable, compact way, and then also here of actually creating programs that actually address this. This is something that when we talk about improving women's health, this is something that is actually low hanging fruit if we just want to address it.

Dr. Michelle Sholzberg:

Correct. If it's prioritized. If it's prioritized, and that requires resources.

Dr. Mojola Omole:

Awesome. Thank you so very much, Michelle. We've covered a lot. Dr. Michelle Sholzberg is the head of hematology and oncology, and the director of the Hematology Oncology Clinical Research Group at St Michael’s Hospital in Toronto.

Dr. Blair Bigham:

Thank you. Michelle. Jola, it sounds like being anemic is an emergency.

Dr. Mojola Omole:

Well, I think part of it is that, and I think anyone that works in women's health will say that when you're dealing with the female sex, that it is not prioritized. Patients are anemic. First of all, the guidelines for their anemia are different, so we're tolerating a higher degree of anemia, but then that's not even being dealt with properly. For me-

Dr. Blair Bigham:

And even if they're not anemic, they could still be iron deficient.

Dr. Mojola Omole:

Exactly. 

Dr. Blair Bigham:

So, are you going to be ordering iron for people in clinic and delaying surgeries until you get that hemoglobin up? How does this change your day-to-day work?

Dr. Mojola Omole:

Well, I think for me anyone, well, first of all, for anyone that's having major surgery, I now know that there's someone I can connect with at Scarborough Health that can help me increase their iron within weeks, right? And so that I can do it. For patients who are having non-emergency surgeries, like their gallbladders, those types of things, I am comfortable in starting someone on iron. And so it would be I order iron studies on them, make sure I cc the family doctor, start them on some iron, and then check it again. I do think you weigh it together. If we're already waiting three months for your surgery, that's a great time to try and improve that. So, I think oftentimes as specialists we kind of defer things to family physicians and say, well, somebody else can take care of that, but this actually directly impacts the work that I do. And so this affects their morbidity or also mortality. And even a simple gallbladder can become something more complicated. So, definitely for me, this is practice changing.

Dr. Blair Bigham:

Right. For me in the ER I'm just going to pay closer attention to the actual hemoglobin and sort of reset the numbers where I sort of say, ah, that's fine. Look at the MCV, make a more concerted effort. Maybe start adding iron studies, which is something we tend not to do very often in the emergency department. Maybe it's clinically appropriate in those circumstances to go ahead and just add it on, because I can do something about it, and I have a captive audience, they're there. Maybe I can offer them an iron infusion and just get things moving for that patient's symptoms.

Dr. Mojola Omole:

Yeah. For sure. And I think we really have to strongly advocate for benign hematology, especially anemia, of having the ability for you not to be waiting years or months to get an iron infusion and having to go to the emergency instead to get an iron infusion.

Dr. Blair Bigham:

The hematologists at my hospital are so busy with referrals, they just can't handle everything because they, I mean they work so hard. I hear all the emergency doctors and hematologists groaning right now because we're like, ah, we need to investigate anemia more. But we do. It sounds like the evidence is pretty clear on that. How we do that and who does that, that's up for the system to imagine.

Dr. Mojola Omole:

For sure. Thank you for joining us on today's episode, I'm Mojola Omole.

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

Until next time, be well.