By Stanley Schrier, MD
2009-05-01
Dr. Schrier is Active Emeritus Professor in Hematology at
Stanford University School of Medicine and was a past president of ASH.
The story of ASH’s involvement in the study and treatment of anemia
in the elderly (which even when mild can have a profound deleterious
impact on quality of life and cognition) is an example of how being
prepared lets you take advantage of opportunities. Up until 2003, ASH
officers and staff made single, yearly visits to the NIH Institutes
involved in hematologic issues: NCI, NIDDK, and NHLBI. In 2002, I
participated as vice president in the fairly formal courtesy visits,
where we emphasized ASH’s very substantial strengths and mutually
bemoaned the lack of sufficient research money. As an outcome of ASH’s
strategic planning program, there was an increase in ASH’s government
affairs efforts such that staff and officers now make more frequent
visits to these Institutes.
At one of our regular meetings, late in 2003, we were exploring
options for further research. The National Institute on Aging (NIA)
team led by Jack Guralnik, MD, PhD, had just completed and drafted
their National Health And Nutrition Examination Survey (NHANES) 3 study
on anemia in the elderly based on more than 5,000 community-dwelling
elderly. The paper was subsequently published in Blood. The
authors, using WHO criteria, discovered that about 10 percent of men
and women over age 65 were anemic. Some of the findings had been, in
part, previously noted by groups in Italy and elsewhere. The anemia
noted in NHANES 3 was very mild in most cases, and, as a practicing
hematologist, I tended to pay little attention to these patients.
However, the NIA study not only tried to dissect the multiple and
complex causes of the anemia, but showed in fairly dramatic fashion
that even the very mild anemia led to losses in exercise capability and
increased morbidity and mortality after hospitalization and after a
heart attack. Anemia may even lead to loss of a cognitive skill called
executive function. The clinical impact of even mild anemia meant that
it was critical to understand the many underlying causes of the anemia
and to aim for its correction. It was most likely at this moment that
the idea of ASH sponsoring an agenda-setting conference gelled. I had
read the NIA report and knew that ASH members had the requisite skills
and experience to tackle and solve problems of anemia.
Accordingly, in 2004, ASH and the NIA co-sponsored a conference on
anemia in the elderly that was designed to explore the multiple causes
of the anemia, possible means of correction, and the causation of the
associated morbidity. We also decided to propose suggestions for
clinical work-up of affected patients. The conference was funded by
ASH. This agenda-setting conference convened in February of 2004, and
the participants consisted of about 10 gerontologists/ hematologists
from the NIA and 10 ASH experts in disorders of red cells and anemia.
The structure of the meeting was unusual in that the opening
presentation by the NIA group of the NHANES data was the only
PowerPoint presentation allowed. During the conference, we identified
10 key areas for analysis, distributed relevant papers, and assigned
experts to take responsibility for the discussion. Deprived of the
PowerPoint crutch, these experts really interacted. The participants
identified key areas for research, which became the basis for a Request
for Applications (RFA) subsequently sent out by the NIA. There were
about 25 proposals; five R01s were awarded and are now beginning year
three. We reviewed the progress of these grants in Bethesda, MD, this
past fall.
The participants at the agenda-setting conference noted that
hematologists, as well as primary-care physicians, tended to ignore the
usually mild anemia in the elderly, and they recommended that
educational programs were needed to correct this flaw. Accordingly, the
ASH Committee on Practice presented a special education program on this
subject at the 2005 annual meeting. It was well received and needed
three overflow rooms to accommodate the attendees.
About two years ago, NIA convened an ad-hoc advisory group to
consider whether NIA should establish a consortium of centers that
could test treatment strategies for anemia in the elderly. Many ASH
members participated, and we supported the idea, provided that the
consortium would also be able to do basic research to test hypotheses
regarding the causes of the complex anemia. Currently, several
proposals are under review.
The collaboration has now led to a research endeavor that not only
explores new areas of biology but, hopefully, will lead to improved
patient care.
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