Blood transfusion has no effect on colorectal cancer survival. A population-based study

Perioperative Blood Transfusions Are Associated With Worse Overall Survival But Not Disease-Free Survival After Curative Rectal Cancer Resection: A Propensity Score-Matched Analysis

BACKGROUND

The effects of blood transfusions on oncologic outcomes after surgery remain inconclusive. Thus, we examined the association between receiving a perioperative blood transfusion and oncologic outcomes in patients undergoing curative rectal cancer resection.

OBJECTIVE

The purpose of this study was to assess the association between receiving a perioperative blood transfusion with disease-free and overall survival in patients undergoing curative resection of clinical stage I to III rectal cancer. We hypothesized that blood transfusion is associated with worse disease-free and overall survival in this patient cohort.

DESIGN

This was a retrospective cohort study using a propensity score-matched analysis.

SETTINGS

The study involved 6 tertiary academic medical centers in the United States contributing to the United States Rectal Cancer Consortium.

PATIENTS

Patients who underwent curative resection for rectal cancer from 2010 to 2018 were included.

MAIN OUTCOME MEASURES

The primary outcome was disease-free survival. The secondary outcomes were overall survival, intensive care unit length of stay, hospital length of stay, surgical site infection, and readmission.

RESULTS

Of the 924 patients eligible for matching, 312 patients were matched, including 100 patients who received a transfusion and 212 who did not. In a propensity score-matched analysis, receiving a perioperative blood transfusion was not associated with worse 5-year disease-free survival (transfused, 78%; not transfused, 83%; p = 0.32) but was associated with worse 5-year overall survival (transfused 65% vs not transfused 86%; p < 0.001) and increased hospital length of stay (transfused, 9.9 d; not transfused, 7.6 d; p = 0.001).

LIMITATIONS

Despite propensity matching, confounding may remain. Propensity matching may limit the power to detect a difference in disease-free survival.

CONCLUSIONS

Receiving a perioperative blood transfusion is not associated with worse disease-free survival but is associated with worse overall survival. Such findings are important for clinicians and patients to understand when considering perioperative blood transfusions. See Video Abstract at http://links.lww.com/DCR/B531.

LAS TRANSFUSIONES DE SANGRE PERIOPERATORIAS SE ASOCIAN CON UNA PEOR SOBREVIDA GLOBAL, PERO NO CON LA SOBREVIDA LIBRE DE ENFERMEDAD POSTERIOR A LA RESECCIN CURATIVA DEL CNCER DE RECTO UN PUNTAJE DE PROPENSIN POR ANLISIS DE CONCORDANCIA

ANTECEDENTES:El impacto de las transfusiones de sangre en los resultados oncológicos posteriores a la cirugía no son concluyentes. Por lo anterior, estudiamos la asociación entre recibir una transfusión de sangre perioperatoria y los resultados oncológicos en pacientes llevados a resección curativa de cáncer de recto.OBJETIVO:El propósito de este estudio fue evaluar la asociación entre recibir una transfusión de sangre perioperatoria con la sobrevida libre de enfermedad y la sobrevida general en pacientes llevados a resección curativa de cáncer de recto en estadio clínico I-III. Nuestra hipótesis es que la transfusión de sangre se asocia con una peor sobrevida global y libre de enfermedad en esta cohorte de pacientes.DISEÑO:Es un estudio de cohorte retrospectivo que utilizó un puntaje de propensión por análisis de concordancia.AMBITO:El estudio se realizó en seis centros médicos académicos de tercer nivel en los Estados Unidos que contribuían al Consorcio de Cáncer de Recto de los Estados Unidos.PACIENTES:Se incluyeron pacientes que fueron llevados a resección curativa por cáncer de recto entre 2010 y 2018.PRINCIPALES VARIABLES EVALUADAS:El objeitvo principal fue la sobrevida libre de enfermedad. Los objetivos secundarios fueron la sobrevida global, el tiempo de estancia en la unidad de cuidados intensivos, el tiempo de la estancia hospitalaria, la infección del sitio quirúrgico y el reingreso.RESULTADOS:De los 924 pacientes elegibles para el emparejamiento, se emparejaron 312 pacientes, incluidos 100 pacientes que recibieron una transfusión y 212 que no. En el puntaje de propensión por análisis de concordancia, recibir una transfusión de sangre perioperatoria no se asoció con una peor sobrevida libre de enfermedad a 5 años (TRANSFUSIÓN 78%; NO TRANSFUSIÓN 83%; p = 0,32), pero se asoció con una peor sobrevida global a 5 años (TRANSFUSION 65% vs NO TRANSFUSION 86%; p <0,001) y aumento de la estancia hospitalaria (TRANSFUSIÓN 9,9 días; NO TRANSFUSION 7,6 días; p = 0,001).LIMITACIONES:A pesar de la concordancia de propensión, pueden existir desviaciones. El emparejamiento de propensión puede limitar el poder para detectar una diferencia en la sobrevida libre de enfermedad.CONCLUSIONES:Recibir una transfusión de sangre perioperatoria no se asocia con una peor sobrevida libre de enfermedad, pero sí con una peor sobrevida global. Es importante que los médicos y los pacientes comprendan estos hallazgos al considerar las transfusiones de sangre perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B531. (Traducción-Dr Lisbeth Alarcon-Bernes).

Perioperative transfusion and the prognosis of colorectal cancer surgery: a systematic review and meta-analysis

Background

Perioperative transfusion can reduce the survival rate in colorectal cancer patients. The effects of transfusion on the short- and long-term prognoses are becoming intriguing.

Objective

This systematic review and meta-analysis aimed to define the effects of perioperative transfusion on the short- and long-term prognoses of colorectal cancer surgery.

Results

Thirty-six clinical observational studies, with a total of 174,036 patients, were included. Perioperative transfusion decreased overall survival (OS) (hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.24 to 0.41; P < 0.0001) and cancer-specific survival (CSS) (HR, 0.34; 95% CI, 0.21 to 0.47; P < 0.0001), but had no effect on disease-free survival (DFS) (HR, 0.17; 95% CI, − 0.12 to 0.47; P = 0.248). Transfusion could increase postoperative infectious complications (RR, 1.89, 95% CI, 1.56 to 2.28; P < 0.0001), pulmonary complications (RR, 2.01; 95% CI, 1.54 to 2.63; P < 0.0001), cardiac complications (RR, 2.20; 95% CI, 1.75 to 2.76; P < 0.0001), anastomotic complications (RR, 1.51; 95% CI, 1.29 to 1.79; P < 0.0001), reoperation(RR, 2.88; 95% CI, 2.05 to 4.05; P < 0.0001), and general complications (RR, 1.86; 95% CI, 1.66 to 2.07; P < 0.0001).

Conclusion

Perioperative transfusion causes a dramatically negative effect on long-term prognosis and increases short-term complications after colorectal cancer surgery.

Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis

OBJECTIVE

To assess the putative impact of perioperative blood transfusions on overall and disease-free survival in patients undergoing curative resection of stage I-III rectal cancer by applying propensity-scoring methods.

BACKGROUND

Whether perioperative blood transfusions negatively impact survival remains a matter of great debate.

METHODS

In a single-center study, 401 patients undergoing open curative resection of stage I-III rectal cancer between 1996 and 2008 were assessed. The median follow-up was 34.2 months. Patients who did and did not receive perioperative blood transfusions were compared using Cox regression and propensity score analyses.

RESULTS

Overall, 217 patients (54.1%) received blood transfusions. Patients' characteristics were highly biased concerning transfusions (propensity score 0.77±0.23 vs. 0.28±0.25; P<0.001). In unadjusted analysis, blood transfusions were associated with a 119% increased risk of mortality [hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.34-3.57, P=0.001]. In propensity score-adjusted Cox regression (HR: 1.02, 95% CI: 0.65-1.58, P=0.970), blood transfusions did not increase the risk of overall survival. Similarly, in propensity score-adjusted Cox regression (HR: 0.86, 95% CI: 0.60-1.23, P=0.672), blood transfusions were not associated with an increased risk of recurrence.

CONCLUSIONS

This is the first propensity score-based analysis providing compelling evidence that worse oncological outcomes after curative rectal cancer resection in patients receiving perioperative blood transfusions are caused by the clinical circumstances requiring transfusions, not due to the blood transfusions themselves. Therefore, concerns about overall and disease-free survival should be no issue in the decision-making regarding perioperative blood transfusions in patients undergoing curative rectal cancer resection.

Impact of intraoperative blood loss on long-term survival after lung cancer resection

PURPOSE

The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.

METHODS

We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.

RESULTS

Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.

CONCLUSION

Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Long-term survival in the intensive care unit after erythrocyte blood transfusion

BACKGROUND

Erythrocyte blood transfusions are commonly used in intensive care units, yet little is known about their effects on long-term survival.

OBJECTIVE

To determine the effect of erythrocyte blood transfusion in intensive care units on long-term survival.

METHODS

Retrospective analysis of a prospectively collected database of 2213 patients admitted January 27, 2001, to April 30, 2002, to the cardiac, burn, neurological-neurosurgical, and combined medical-surgical intensive care units in a tertiary care, university-affiliated, urban medical center. Further analysis was done on a case-control subgroup (n=556) formed by matching scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II and propensity scores.

RESULTS

Although transfusion was univariably associated with increased risk of death at all 3 times (0-30, 31-180, and >180 days after admission to the unit), multivariable adjustment with Cox modeling showed that transfusion had no association with mortality for the first 2 intervals (0-30 and 31-180 days), but was associated with a 25% lower risk of death (hazard ratio, 0.75; 95% confidence interval, 0.57-0.99; P=.04) in patients who survived at least 180 days after admission to the unit. In the case-control patients, after correction for APACHE II risk of death and propensity to receive a transfusion, transfusion had no association with mortality for the first 2 intervals, but was associated with 29% lowered risk of death (hazard ratio, 0.71; 95% confidence interval, 0.50-0.99; P=.046).

CONCLUSION

Blood transfusion was associated with a decreased risk of late (>180 days) death in intensive care patients.

Tumour location is a prognostic factor for survival in colonic cancer patients

OBJECTIVE

To evaluate survival and prognostic factors in a consecutive series of colon cancer patients from a defined city population in Norway.

METHOD

All patients with adenocarcinoma of the colon diagnosed between 1993 and 2000 were registered prospectively. Five-year actuarial survival and 5-year relative survival rates were calculated. Cox regression analyses were used to study the effect of prognostic factors on survival.

RESULTS

In the study period 627 patients were admitted. Overall 5-year relative survival was 50% in females and 52% in males. Five-year relative survival in 410 (65%) patients operated with curative intent, was 74% for females and 79% for males. Tumour location in the transverse colon, splenic flexure and descending colon (OR = 1.8), emergency operation (OR = 1.7), TNM stage (OR = 1.8-2.9), blood transfusion of more than two units (OR = 1.8) and age (OR = 4.0-7.1) were independent negative prognostic factors.

CONCLUSION

Colon cancer located in the transverse and descending colon is associated with poor prognosis. Comparison of results from different centres is difficult due to selection and classification differences, and different methods used for calculation of survival.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer.

OBJECTIVES

The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004.

SEARCH STRATEGY

Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses.

SELECTION CRITERIA

Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data.

DATA COLLECTION AND ANALYSIS

A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence.

MAIN RESULTS

The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis.

AUTHORS' CONCLUSIONS

This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.

[Perioperative transfusion in colorectal surgery]

Several studies have evaluated the role and effect of blood transfusion in colorectal surgery. To date, no recommendation concerning its use in colorectal surgery has been yet published. However, blood transfusion is often required in colorectal surgery, especially in anaemic patients who suffer from malignant disease. The aim of this review is to define the effect of blood transfusion on oncologic and operative results, and to evaluate the clinical potential of alternative to allogeneic blood transfusion in order to promote the development of transfusion policy in colorectal surgery.

Comparison of multivisceral resection and standard operation for locally advanced colorectal cancer: analysis of prognostic factors for short-term and long-term outcome

PURPOSE

The aim of the present study is to clarify the characteristics of multivisceral resection and to discuss strategies for improving the overall outcome of multivisceral resection for locally advanced colorectal cancer.

METHODS

The study included 323 patients who electively underwent curative surgery for pT3-pT4 colorectal carcinoma without distant metastasis. We evaluated the short-term and long-term outcome of multivisceral resection relative to that of the standard operation by means of multivariate analysis of the prognostic factors.

RESULTS

Of 323 patients, 53 (16.4 percent) received multivisceral resection because of adhesion to other organs. Multivisceral resection was significantly associated with tumor size, depth of invasion, operative blood loss, operation time, and blood transfusion (all: P < 0.0001). Overall morbidity rates were 49.1 percent after multivisceral resection vs. 17.8 percent after the standard operation (P < 0.0001), and postoperative mortality rate was 0 percent in both groups (not significant). Only multivisceral resection (odds ratio, 2.725; 95 percent confidence interval, 1.125-6.623; P = 0.0264) was an independent factor for overall postoperative complications. The survival rate of patients after multivisceral resection was similar to that after the standard operation (5-year rate, 76.6 percent vs. 79.5 percent, P = 0.9347). Lymph node metastasis (hazard ratio, 2.510; 95 percent confidence interval, 1.460-4.315; P = 0.0009) and blood transfusion (hazard ratio, 2.353; 95 percent confidence interval, 1.185-4.651; P = 0.0145) were independently associated with patient survival.

CONCLUSIONS

For locally advanced colorectal cancer, the long-term outcome after multivisceral resection is comparable to that after the standard operation. However, it should be recognized that multivisceral resection is associated with higher postoperative morbidity. In addition, a reduction in the incidence of blood transfusion may contribute to improving patient survival.

Effect of blood transfusion on long-term survival after cardiac operation

BACKGROUND

Blood transfusions have been linked to increased morbidity and mortality. Bleeding during and after cardiac operations and the hemodilution effects of cardiopulmonary bypass commonly result in blood transfusions. Because we could not find any studies evaluating the effects of transfusion on long-term survival after cardiac operation, we sought to determine these effects.

METHODS

We studied 1,915 patients who underwent first-time isolated coronary artery bypass operations between July 6, 1994 and December 31, 1997 at our institution. Patients with transfusions were compared with those who had not been transfused. Long-term survival data were obtained from the United States Social Security Death Index. Groups were compared by Cox proportional hazard models, Kaplan-Meier survival plots, and hazard functions.

RESULTS

Six hundred forty-nine of 1,915 study patients (34%) received a transfusion during their hospitalization. Transfused patients were older, smaller, and more likely to be female, and had more comorbidity. Transfused patients also had twice the 5-year mortality (15% vs 7%) of nontransfused patients. After correction for comorbidities and other factors, transfusion was still associated with a 70% increase in mortality (risk ratio = 1.7; 95% confidence interval = 1.4 to 2.0; p = 0.001). By multivariate analysis, transfusion, peripheral vascular disease, chronic obstructive pulmonary disease, New York Heart Association functional class IV, and age were significant predictors of long-term mortality.

CONCLUSIONS

We found that blood transfusions during or after coronary artery bypass operations were associated with increased long-term mortality.

Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies

BACKGROUND

There is controversy over whether perioperative allogeneic red blood cell transfusions are associated with an increased risk of cancer recurrence, postoperative infection or death in patients with cancer undergoing surgery.

METHODS

A systematic meta-analysis was performed to answer this question. Studies were identified from electronic databases (Medline 1966-1997, Cancerlit 1983-1997, Current Contents, Cinahl 1982-1996, Healthstar 1990-1997, Bioabstracts 1990-1996 and Embase), by hand search of the bibliographies of identified studies and relevant journals, and by contact with experts in the field. All randomized controlled trials or prospective cohort studies with active comparator controls (autologous or leucocyte-depleted allogeneic blood) were eligible for inclusion if they reported on mortality, infection or recurrence rate in patients with cancer undergoing potentially curative surgical resection. The validity of the identified studies was assessed by means of a standardized scale, and data abstraction was carried out by two investigators independently. A random effects model was used for data synthesis.

RESULTS

Of the 2172 references identified, only 17 studies fulfilled the inclusion criteria. After exclusion of duplicate publications, six randomized controlled trials and two prospective cohort studies with appropriate concurrent controls were included in the analysis. The summary risk ratios were 0.95 (95 per cent confidence interval (c.i.) 0.79-1.15) for all-cause mortality and 1.06 (95 per cent c.i. 0.88-1.28) for cancer recurrence, the two endpoints that were appropriate to combine statistically. There was significant heterogeneity (explainable by differences in study design and patient characteristics) in the postoperative infection data and the summary risk ratio was 1.00 (95 per cent c.i. 0.76-1.32) for the four studies that were appropriate to subject to meta-analysis. Given the sample sizes of these eight studies, this meta-analysis had insufficient power to detect a relative difference of less than 20 per cent in the frequency of death, cancer recurrence or infection between the allogeneic and control transfusion arms.

CONCLUSION

Although more studies are required before a definitive statement can be made, at this time there is no evidence that allogeneic blood transfusion increases the risk of clinically important adverse sequelae in patients with cancer undergoing surgery.