Is intravenous iron useful for reducing transfusions in surgically treated colorectal cancer patients?

Iron Supplementation Effectively Ameliorates Anemia and Reduces the Need for Blood Transfusion in Patients Undergoing Colorectal Cancer Surgery: A Meta-Analysis

OBJECTIVE

Anemia is common and harmful in patients undergoing colorectal cancer (CRC) surgery. Blood transfusion (BT) is used to treat anemia, but results in a poor oncology prognosis. Iron supplementation may be effective in improving anemia and reducing the need for BT, however, the results remain controversial. This meta-analysis was conducted to evaluate the efficacy of iron supplementation in improving hemoglobin concentrations (Hb) and reducing the need for BT.

METHODS

Up to February 10, 2021, PubMed, Web of Science, Cochrane Library, Embase databases were searched for studies evaluating the effects of iron supplementation on CRC surgery patients. Meta-analysis was conduct using the random-effects model.

RESULTS

Seven trials with 879 participants in total were included in the meta-analysis. The pooled findings suggested that iron supplementation effectively increased Hb (MD 0.41; 95% CI: 0.12, 0.69, P = 0.006) and reduced the risk of BT (RR 0.60, 95% CI 0.45, 0.78, P = 0.0002) compared with the control group. In addition, subgroup analyses showed that these benefits were observed with both oral and intravenous iron supplementation.

CONCLUSION

Iron supplementation is effective in ameliorating anemia and reducing the need for BT in CRC surgery patients.

Iron Deficiency and Anemia in Cancer Patients: The Role of Iron Treatment in Anemic Cancer Patients

Anemia is a prevalent complication in patients with cancer, both at diagnosis and during treatment, with notable negative effects on quality of life and overall prognosis. Iron deficiency is the most common cause of anemia in the patients and can affect almost half of patients with solid and hematologic malignancies. The pathogenesis is complex and multifactorial, including bleeding, malnutrition, medications, and inflammation resulted from cancer and cancer treatment. In fact, either absolute or functional iron deficiency can occur. Most iron deficient cancer patients present with functional iron deficiency, a condition with adequate iron storage but insufficient iron supply for erythroblasts and other iron dependent tissues. Functional iron deficiency is the result of the cancer related cytokine release, but in absolute iron deficiency iron reserves are depleted leading to similar but often more severe symptoms of inadequate iron store. Current therapeutic options in cancer anemia consist of iron administration, erythropoietic stimulating agents, and blood transfusion. The latter should be administered to a minimum, because of problems regarding risks. Here, we present a review on the epidemiology, pathophysiology, clinical outcomes, and therapeutic options of iron deficiency as well as the effect of iron therapy on tumor progression in anemic cancer patients.

Intravenous iron versus oral iron or observation for gastrointestinal malignancies: a systematic review

BACKGROUND

Anemia is a common condition in patients with gastrointestinal cancer. Current evidence for the use of intravenous compared with oral iron in this clinical setting is inconclusive. A systematic review was performed to assess evidence on the efficacy of intravenous iron versus oral/observation in gastrointestinal cancer patients in the preoperative and postoperative setting.

MATERIALS AND METHODS

We searched Medline and Embase from inception until December 2017 with no language restrictions. Outcomes included hemoglobin response, red blood cell transfusion, and adverse events. Screening, data abstraction, and risk of bias appraisal were performed by two independent reviewers. The risk of bias was assessed using the Cochrane tools for randomized and nonrandomized studies.

RESULTS

A total of 10 studies (three randomized-controlled trials and seven nonrandomized studies) were included. Of the six preoperative studies, five reported that hemoglobin was significantly higher in the intravenous group compared with oral iron/observation. Among the four postoperative studies, three studies suggested that hemoglobin was significantly higher in the intravenous group compared with oral iron/observation. The overall risk of bias for all randomized-controlled trials was low. Quality assessments for nonrandomized studies found the risk of bias to be moderate for four studies and critical for three studies.

CONCLUSION

Despite the limitations of the current body of evidence, there is a likely benefit to the use of intravenous iron in this patient population. Further confirmatory research is needed to draw empirical conclusions.

Single dose of intravenous ferric carboxymaltose infusion versus multiple fractionated doses of intravenous iron sucrose in the treatment of postoperative anaemia in colorectal cancer patients: study protocol for a randomised controlled trial

Background

Patients with colorectal cancer (CRC) often present with associated anaemia which is usually present at the time of diagnosis and is aggravated during the postoperative period due to blood loss during the surgery process. Several guidelines advocate for the treatment of postoperative anaemia in these patients in order to prevent complications and allogeneic blood transfusions. However, there are no publications to shed light on the effectiveness of intravenous iron (IVI) administration after CRC surgery and the optimal dose and regimen. We have started a clinical trial with the objective of comparing the effectiveness of 1000 mg of ferric carboxymaltose with fractionated iron sucrose 200 g/48 h for the treatment of postoperative anaemia, by measuring the change of haemoglobin (Hb) levels from postoperative day (POD) 1 to POD 30.

Methods

We designed an open label randomised controlled trial to compare two postoperative IVI treatment regimens. Patients aged > 18 years undergoing CRC surgery, with Hb < 11 g/dL on POD 1 are randomly assigned to receive either 1000 mg of ferric carboxymaltose (single dose) or 200 g/48 h of iron sucrose. The main study endpoint will be the change from POD 1 to POD 30 in Hb levels and the key secondary endpoint the percentage of patients with Hb levels ≥ 13 g/dL at POD 30. Other secondary endpoints include: changes in iron metabolism parameters (Fe, ferritin, transferrin, % saturated trasferrin) at POD 30; total doses of iron received; number of postoperative transfusions; compliance with oral iron treatment; number of medical and surgical complications; adverse reactions reported by the patient; use of health resources after surgery; and changes in quality of life (QoL). It has been estimated that a sample of 48 patients per group will allow detecting a difference of 0.75 g/dL in Hb in the change in Hb levels from POD 1 to POD 30.

Discussion

The results of this study will confirm if the single dose of 1000 mg ferric carboxymaltose should be preferred in front of the fractionated doses and in which type of patients this regimen should be used preferably.

Trial registration

European Union Clinical Trials Register, EudraCT 2015-001005-13. Registered on 6 January 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3125-2) contains supplementary material, which is available to authorized users.

An international consensus statement on the management of postoperative anaemia after major surgical procedures

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

Intravenous iron administration for post-operative anaemia management after colorectal cancer surgery in clinical practice: a single-centre, retrospective study

BACKGROUND

Evidence on the role of intravenous iron (IVI) supplementation after colorectal cancer (CRC) surgery is rather scant. This study was aimed at assessing the benefit of post-operative IVI administration after elective CRC surgery at our institution.

MATERIALS AND METHODS

This was a single-centre, retrospective observational study including all patients who underwent CRC surgery during 2014. Anaemia was defined as a haemoglobin (Hb) <13 g/dL, regardless of gender. Anaemic patients received 200 mg IVI up to three times a week to cover iron deficiency (IVI group). Those who did not receive IVI were placed on standard care (NIVI group). The primary outcome was the proportion of anaemic patients on post-operative day (POD)1 and POD30. Secondary outcomes included Hb changes from POD1 to POD30, transfusion requirements and complication rates.

RESULTS

Of the 159 patients studied, 139 (87%) presented with anaemia: 47 (34%) of these received post-operative IVI and 92 (66%) did not. Patients in the IVI group had lower POD1 Hb levels compared to those in the NIVI group (p=0.001). On POD30, only 103 had their Hb measured (34 IVI, 69 NIVI). Anaemia was more prevalent and more severe among the patients in the IVI group (p=0.027), despite their greater increment in Hb (2.0±1.5 g/dL vs 1.1±1.2 g/dL; p=0.001). Eleven patients needed post-operative transfusions (7 IVI, 4 NIVI; p=0.044). There were no differences in post-operative complication rates between the groups. No IVI-related adverse events were recorded DISCUSSION: Compared with standard care, post-operative IVI administration to anaemic patients improved the recovery of Hb levels at POD30, without increasing post-operative complications.

Intravenous iron therapy for anemic cancer patients: a review of recently published clinical studies

Based on available literature and on the present review, IV iron administration to anemic cancer patients can increase significantly the level of Hb, probably independently from the precise mechanism of anemia itself. However, in future studies, the benefit should be evaluated taking into account whether the anemia is due to absolute or functional iron deficiency; therapeutic modalities might be different for these two conditions. Along the same lines, it appears important to further evaluate the respective roles of PO and IV iron therapies and the modalities of their use in clinical practice. Until the results of such studies are available, it appears reasonable to propose IV iron therapy to anemic cancer patients as the resulting rise of Hb level may increase their quality of life and performance status and reduce the need for erythropoietin-stimulating agents and/or blood transfusions.

[Preoperative management of anemia in oncologic surgery]

Preoperative anemia in patients with cancer is highly prevalent, is associated with increased perioperative morbidity and is a risk factor for transfusion. There is evidence that patients who undergo transfusions have higher morbidity, increased cancer recurrence and poorer survival. The pathophysiology of anemia is multifactorial, with an inflammatory component to which chronic blood loss and nutritional deficiencies can be associated. Therefore, preoperative anemia in patients with cancer should be treated appropriately, given that there is sufficient time in the preoperative period. Of the currently available options, parenteral iron is an effective alternative, especially for those types of cancer that have an associated hemorrhagic component.

The impact of perioperative iron on the use of red blood cell transfusions in gastrointestinal surgery: a systematic review and meta-analysis

Perioperative anemia is common, yet detrimental, in surgical patients. However, red blood cell transfusions (RBCTs) used to treat anemia are associated with significant postoperative risks and worse oncologic outcomes. Perioperative iron has been suggested to mitigate perioperative anemia. This meta-analysis examined the impact of perioperative iron compared to no intervention on the need for RBCT in gastrointestinal surgery. We systematically searched Medline, Embase, Web of Science, Cochrane Central, and Scopus to identify relevant randomized controlled trials (RCTs) and nonrandomized studies (NRSs). We excluded studies investigating autologous RBCT or erythropoietin. Two independent reviewers selected the studies, extracted data, and assessed the risk of bias using the Cochrane tool and Newcastle-Ottawa scale. Primary outcomes were proportion of patients getting allogeneic RBCT and number of transfused patient. Secondary outcomes were hemoglobin change, 30-day postoperative morbidity and mortality, length of stay, and oncologic outcomes. A meta-analysis using random effects models was performed. The review was registered in PROSPERO (CRD42013004805). From 883 citations, we included 2 RCTs and 2 NRSs (n = 325 patients), all pertaining to colorectal cancer surgery. Randomized controlled trials were at high risk for bias and underpowered. One RCT and 1 NRS using preoperative oral iron reported a decreased proportion of patients needing RBCT. One RCT on preoperative intravenous iron and 1 NRS on postoperative PO iron did not observe a difference. Only 1 study revealed a difference in number of transfused patients. One RCT reported significantly increased postintervention hemoglobin. Among 3 studies reporting length of stay, none observed a difference. Other secondary outcomes were not reported. Meta-analysis revealed a trend toward fewer patients requiring RBCT with iron supplementation (risk ratio, 0.66 [0.42, 1.02]), but no benefit on the number of RBCT per patient (weighted mean difference, -0.91 [-1.61, -0.18]). Although preliminary evidence suggests that it may be a promising strategy, there is insufficient evidence to support the routine use of perioperative iron to decrease the need for RBCT in colorectal cancer surgery. Well-designed RCTs focusing on the need for RBCT and including long-term outcomes are warranted.

Perioperative anemia management in colorectal cancer patients: A pragmatic approach

Anemia, usually due to iron deficiency, is highly prevalent among patients with colorectal cancer. Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization. Preoperative anemia predicts for decreased survival. Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes, increased post-operative nosocomial infections, longer hospital stays, increased rates of cancer recurrence and perioperative venous thromboembolism. Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management, minimizes or eliminates allogeneic blood transfusion. This includes restrictive transfusion policy, thromboprophylaxis and anemia management to improve outcomes. Normalization of preoperative hemoglobin levels is a World Health Organization recommendation. Iron repletion should be routinely ordered when indicated. Oral iron is poorly tolerated with low adherence based on published evidence. Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions. Serious adverse events with intravenous iron are extremely rare. Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care. Erythropoiesis stimulating agents may improve response rates. A multidisciplinary, multimodal, individualized strategy, collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.

Is there a role for intravenous iron therapy in patients undergoing colorectal cancer resection?

Worldwide, colorectal cancer (CRC) is one of the most common forms of malignancy and is increasing in incidence in many regions. At diagnosis, approximately 40% of patients with CRC are anemic, a figure that increases over the course of a patient's treatment due to many factors, including ongoing hemorrhage. Preoperative anemia is therefore associated with increased allogenic red blood cell transfusion (ARBT) rates. In the context of CRC, perioperative ARBT has been linked with adverse postoperative outcomes, including higher morbidity, mortality and cancer recurrence rates. Therefore, strategies to potentially reduce the need for ARBT have been the focus of several recent studies. We critically evaluate a recent paper that explores intravenous iron III sucrose as a treatment option for the management of postoperative anemia in CRC patients. This study is a retrospective, observational case-controlled study that was designed to evaluate whether the use of postoperative intravenous iron reduces the incidence of ARBT following CRC resection.