NEWS-Line for Lab Professionals

Improving Tests, Improving Lives

FEATURE STORY	06/15/2008
Author: Kristine Brennan
"I was mesmerized by the lab," recalls Steven Marionneaux, Laboratory Manager of the clinical oncology laboratory at St. Vincent's Comprehensive Cancer Center (SVCCC). As a kid, he would sometimes accompany his aunt to her lab tech job and watch her identify bacteria in microbiology. That fascination has not faded for Marionneaux, who uses his passion for discovery to help improve treatment-and quality of life-for seriously ill patients. An interest that began with a chemistry set and a microscope culminated in a BS in medical technology from Louisiana State University. "I considered going to medical school, but for some reason I just gravitated toward the lab, as I had more of an interest in the diagnostic, technical, behind the scenes side of the profession. In the end, I really wanted to do this," says Marionneaux, who has held his current position for more than five years. This is not his first work experience at SVCCC, a large cancer center in St. Vincent's Hospital Manhattan, part of Saint Vincent Catholic Medical Centers. "I was one of the original staff who participated in the development and construction of SVCCC in 1997," Marionneaux says. "In 2002, I left the laboratory for a short time and worked as a project manager for a medical education company. We worked with experts in migraine and inflammatory bowel disease and wrote journal articles, newsletters, slide kits, and symposia. After about a year-and-a-half of this I realized that I missed the lab and went back to work as the hematology manager at Beth Israel Medical Center, also in New York City. After a year of this, I got a call from SVCCC with an offer to come back." St. Vincent's Comprehensive Cancer Center is an outpatient clinic dedicated to cancer research and treatment. It is a hematology-oncology Center of Excellence in the treatment of multiple myeloma and myelodysplastic syndrome. It is one of the largest multiple myeloma treatment centers in the US. Multiple myeloma is an incurable blood cancer in which malignant plasma cells over proliferate in the bone marrow, crowding the space making it difficult to produce normal blood cells. This can result in anemia, bleeding and susceptibility to infection. The plasma cells produce large amounts of monoclonal protein, which causes problems like hyperviscocity and kidney damage. Normal immunoglobulin production is suppressed, which also increases susceptibility to infection. The malignant plasma cells secrete osteoclast activating factor, which induces bone resorption, elevated blood calcium, osteolytic lesions and fracture. "The disease is a difficult one: the goal is life extension and quality of life by trying to maintain remission," says Marionneaux, who adds that new treatments are in development. SVCCC has a very active research department with numerous patients enrolled in clinical trials. Myelodysplastic syndrome is characterized by defects in blood-forming cells in the bone marrow. The body's immune system destroys many of these abnormal blood cells as they develop in the bone marrow and as a result there are not enough cells in circulation. In about one-third of cases, myelodysplastic syndrome is a precursor to leukemia. "These patients and their physicians are heavily dependent on laboratory tests to monitor the disease," explains Marionneaux. Promoting patients' well-being and quality of life is at the heart of everything he does at SVCCC. In the lab, he has the final word on regulatory compliance and QA/QC. His staff of 10 has ample opportunity for professional growth, because he is both a mentor and a delegator—a necessity, given his long list of responsibilities. "The techs are self-motivated. They have a high level of concern for their work and want to make sure it's done correctly. They have a really good attitude," he enthuses. He makes a point of including them in research projects, and crediting them as co-authors whenever the clinical oncology lab publishes findings. Marionneaux has an inside track on helping future laboratory professionals grow personally and professionally, since he is an instructor at the St. Vincent School of Medical Laboratory Technology. He is responsible for teaching the entire hematology/coagulation section to senior students. He also gives weekly lectures to physicians in St. Vincent's hematology/oncology fellowship program. "I teach them various aspects of hematology, particularly peripheral blood and bone marrow review," he explains. Marionneaux's boundless energy keeps him motivated to pursue better tests to aid in the fight against life-threatening illnesses. "One thing that is really great is working with the clinicians, and through working with them, determining their needs for laboratory testing. From there, we develop appropriate tests in the lab to support clinical programs," he says. He can cite numerous successes, thanks to his tenacious efforts to serve the multiple myeloma population that requires specialized blood and urine tests. "Up until about a year ago, we were sending a lot of the tests out. These tests are labor intensive and require considerable expertise. The tests are: serum and urine protein electrophoresis, serum and urine immunofixation, urine total protein, quantitative immunoglobulins, kappa and lambda free light chains, beta2-microglobulin, and C-reactive protein. These tests mostly serve as tumor markers for disease. They contain important information for the clinicians about disease status and prognosis." One drawback of outsourcing the tests was longer turnaround times. Marionneaux's goal was to expedite test results so that oncologists could fine-tune treatment regimens immediately. He realized that the best way to achieve this was to bring these tests into his clinical oncology laboratory. Doing that required the right instrumentation as well as techs with the know-how to use it. "What I did was research to find the best methods and technology. We needed state-of-the-art equipment to improve quality and turnaround times." Electrophoresis and immunofixation are semi-automated procedures and require an interpretation of the results. "We had a lot to learn about interpreting the complex protein patterns often seen in multiple myeloma. Probably 90 percent of our samples contain one or more monoclonal protein. The techs have all done an amazing job at getting up to speed." In another case, online research by Marionneaux led the way to developing a more specific test. While there are a number of ways to do a urine protein test, he sought the best test to quantify the malignant proteins of multiple myeloma patients. "I searched through textbooks and PubMed and found that one method—pyrogallol red—captures more of the myeloma proteins when present in samples than our current method. But the pyrogallol red was not something that was readily installed on the chemistry instrument. "What we had to do to incorporate the test was program the specific reaction parameters onto analyzer. We were one of the first in the country to do this. Because it was such a novel idea, we did an abstract and poster and presented them at a national laboratory meeting." Marionneaux's lab was also the first in the US to use a new method for quantitation of kappa and lambda free light chains in serum. "We wrote an abstract about our experience which was just accepted for presentation at this year's AACC meeting in Washington D.C. The poster is in process." When he was done making all of these changes and improvements, Marionneaux and colleagues had essentially created a multiple myeloma lab within the oncology lab. "It took about two years to do all of this transition and bring these tests in," he says. "The myeloma team and their patients are very happy with the results. They're pleased with how fast we're able to carry these tests out, and they're happy with the quality of the results. We've reduced the total time from four to seven days to about one to two days. It's really been a wonderful thing here." His interactions with SVCCC's clinicians give him vital information about what kinds of tests oncology patients need in order to get customized treatment plans. "I go to a number of meetings," he says. "One of them is where the fellows in the hematology/oncology program present challenging cases to all of the physicians at the cancer center, and a number of doctors from the hospital and other clinical staff, including the lab and research staff. So it's a crowded presentation, and during these meetings a lot is learned about how to manage difficult cases. But we also learn about the laboratory needs of the clinical staff. "They needed a way to monitor aspirin therapy," Marionneaux recalls of a particular meeting. Cancer patients are more prone to thrombosis than the general population, so they often take low-dose aspirin or other anti-platelet medications daily to prevent blood clot formation. Although this is a simple, effective measure for many patients, a small percentage of them don't respond, meaning their platelets are not inhibited. If this goes undiscovered, they may miss out on needed dose adjustments or alternative medications to inhibit clotting. "So, we wanted to find a way to determine whether or not people are sensitive to aspirin," he explains. "Historically, the way to monitor that was to do a platelet aggregation study which requires instrumentation and a specialized staff to perform the test and to interpret the results. It's a difficult thing to do." Marionneaux realized that doing conventional platelet aggregation studies in his lab wasn't feasible, and that the aggregation studies done in the larger hospital lab would not accurately check for response to aspirin therapy because they did not use arachidonic acid as an agonist. With the needs of St. Vincent's physicians—and, most importantly, their patients—in mind, he began to research a more practical way of monitoring aspirin therapy. At the time of this interview, Marionneaux was starting to reap the rewards of his search. "This week, we are validating a new test that allows us to monitor anti-platelet therapy using platelet agonists and platelet aggregation performed on the hematology instrument that we already have in place. The test utilizes blood collection tubes coated with various platelet agonists. The arachidonic acid component, necessary for measuring aspirin sensitivity, was only recently FDA approved. We're going to have it up live soon! Then the physicians will be able to monitor their patients on anti-platelet medications. We'll be one of the first in the country to actually use it for this purpose." Marionneaux and his colleagues are not just in the business of making discoveries; they share their contributions with fellow scientists through published studies and posters. A seasoned speaker and presenter, he looks forward to enhancing his credentials very soon. An MS in Clinical Laboratory Science from the University of Medicine and Dentistry of New Jersey will be completed this year. "After I finish my master's, I'm considering continuing on and pursuing a PhD," he says. "I think it's important to have an advanced degree for a lot of reasons. But in general, a bachelor's degree allows you to do good work in the clinical lab. I also highly encourage my students to obtain the ASCP certification immediately upon graduating." Since Marionneaux teaches at St. Vincent School of Medical Laboratory Technology, he has access to a talent pool from which to hire qualified, motivated techs. "I am grateful to have a group of technologists who are all very ambitious. I hired most of them when they were right out of school, and they have great attitudes and love to learn." He cites the nationwide shortage of lab techs, but feels fortunate that it has not caused him to compromise on the qualities he seeks when hiring. Two key requirements to work in the SVCCC lab, according to Marionneaux, are "a well-rounded background" with at least a bachelor's degree in clinical laboratory science, and a willingness to take on diverse tasks. "We have a lot of interaction with physicians and nurses and patients," he explains. The technologists and phlebotomists are getting a good understanding of how the whole process of clinical medicine works." Marionneaux would like to see more curious, intelligent people in the lab. He feels that the profession's relatively low visibility and pay scale, compared to other allied health careers, discourage young people from entering the profession. "There's not a lot of recognition and understanding of what lab professionals do," he observes. "Hospital staff—even physicians and administrators—do not understand. I also think salaries have lagged behind nursing and physical therapy and other allied health fields. "What I believe and hope is going to happen," he concludes, "because there's a shortage now, is that the law of supply and demand will ultimately drive salaries up." Steven Marionneaux is the Laboratory Manager of St. Vincent's Comprehensive Cancer Center, New York, New York. He has 23 years of experience in all areas of laboratory work, with a special emphasis on hematology. He holds a BS in Medical Technology from Louisiana State University, and will complete an MS in Clinical Laboratory Science from the University of Medicine and Dentistry of New Jersey in fall 2008. Marionneaux is ASCP certified, and also works as an instructor at the St. Vincent's School of Medical Laboratory Technology, and St. Vincent's Fellowship program in hematology/oncology, both in New York, New York. Kristine Brennan is a freelance writer on the editorial staff of NEWS-Line for Laboratory Professionals.
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