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Idiopathic neutropenia: a potential source of ethnic disparity in health care
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Mukaila A Raji, MD; MSc University of Texas Medical Branch
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muraji{at}utmb.edu Mukaila A Raji
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Hsieh and colleagues concluded that benign neutropenia in US blacks (benign ethnic neutropenia) had implications for diagnostic evaluation of neutropenia in blacks (1). Benign neutropenia in US blacks also carries important therapeutic implications, especially as a potential source of ethnic disparity in treatment (and prognosis) for black patients with cancer and mental health conditions. Initiation, optimal dosing and duration of cancer chemotherapy depend, at least in part, on neutrophil count being within the normal range i.e. >1500/mm3 . In the face of benign ethnic neutropenia, there is a high likelihood that blacks with cancer (e.g. breast cancer) may not get optimal adjuvant chemotherapy (2). For example, Hershman and colleagues found that among women (43 blacks and 93 whites) with early stage breast cancer, black women had lower white blood cell count (wbc) cont, lower dose intensity of adjuvant chemotherapy and longer duration of cancer treatment (2). Another implication of benign neutropenia in blacks relates to under-use and increased discontinuation rate of clozapine in blacks with treatment-resistant schizophrenia (3-5). Clozapine has been shown to be effective for treatment-resistant schizophrenia (3-5). The use of clozapine is contraindicated in patients with wbc below 3500/mm3 or absolute neutrophil count <2000/mm3. Such contraindications based on the current wbc range may explain, in part, the lower use and high discontinuation rate of clozapine in blacks with treatment resistant schizophrenia (3). In a study of 1287 Caucasian and 588 African American patients on clozapine for treatment-resistant schizophrenia or schizoaffective disorder, blacks were about 2 times as likely as whites to have their clozapine discontinued as a result of leucopenia (4). In that study, all the patients (n=8) who developed agranulocytosis were white (4). A recent review by Mallinger and Lamberti emphasized the need for a US guideline that recognizes benign ethnic neutropenia and considers alternative normal wbc range for those with this condition, as has been done in Canada and the United Kingdom (3,5). I agree with Hsie et al. that clinicians should consider the possibility of benign ethnic neutropenia in their diagnostic evaluations. Such consideration should also extend to decision-making regarding optimal use of recommended therapies for cancer and schizophrenia. Such consideration may contribute to a reduction of health disparity in blacks. References 1)Hsieh MM, Everhart JE, Byrd-Holt DD, Tisdale JF, Rodgers GP. Prevalence of neutropenia in the U.S. population: age, sex, smoking status, and ethnic differences. Ann Intern Med. 2007;146:486-92. 2)Hershman D, Weinberg M, Rosner Z, Alexis K, Tiersten A, Grann VR, et al. Ethnic neutropenia and treatment delay in African American women undergoing chemotherapy for early-stage breast cancer. J Natl Cancer Inst. 2003;95:1545-8. 3)Mallinger JB, Lamberti JS. Clozapine--should race affect prescribing guidelines? Schizophr Res. 2006 ;83:107-8.. 4)Kelly DL, Kreyenbuhl J, Dixon L, Love RC, Medoff D, Conley RR. Clozapine Underutilization and Discontinuation in African Americans Due to Leucopenia. Schizophr Bull, 2006;doi:10.1093/schbul/sbl068v1. PMID: 17170061 5)Rajagopal S. Clozapine, agranulocytosis, and benign ethnic neutropenia, Postgrad. Med. J. 2005;81:545–46 Conflict of Interest:None declared |
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