Anaemia is associated with poor overall survival but not with inferior local control in patients with muscle invasive bladder carcinoma treated by radical external beam radiotherapy. A retrospective study

Impact of anemia on the survival of patients undergoing radical cystectomy for bladder cancer

OBJECTIVE

To evaluate the prevalence of preoperative anemia and its effect on oncological outcomes in patients undergoing radical cystectomy (RC) due to bladder cancer.

MATERIAL AND METHODS

Retrospective single-center study with 176 RCs between May 2008 and July 2018. Anemia was defined according to the WHO classification (male<130mg/dL, female<120mg/dL). Kaplan-Meier test was used to estimate recurrence-free, cancer-specific and overall survival rates. Multivariate logistic regression was used to identify factors associated with overall mortality rates.

RESULTS

Overall, 89 (50.6%) patients had preoperative anemia, and 44 of them (49.4%) received neoadjuvant chemotherapy. Anemic patients resulted in higher rates of ASA (ASA>2: 54.6 vs. 27.5%; P=.003), ectasia rate previous to RC (41.6 vs. 19.5%; P=.002), treatment with neoadjuvant chemotherapy (49.4 vs. 19.5%; P<.001), blood transfusion rate (25.8 vs. 11.5%; P=.015) and pathological stage (pT>2: 49.4 vs. 33.3%; P=.03) compared to non-anemic patients. Median follow-up was 27.2 months (IQR 11.12-72.28). Median overall survival (105 vs. 34 months, log-rank; P=.001), cancer-specific survival (89 vs. 61 months; P=.004) and recurrence-free survival (85 vs. 57 months; P=.002) were significantly lower in anemic patients compared to the non-anemic group. In multivariable Cox analysis, preoperative anemia, pT>2 and N≥1 were independently associated with overall mortality.

CONCLUSION

Preoperative anemia was common in patients undergoing RC for bladder cancer, and it is related with a worse cancer prognosis. Anemia is a preoperative modifiable factor; we believe that the implementation of Patient Blood Management programs during prehabilitation may have a relevant role in improving the oncological outcomes in these patients.

Prognostic implications of preoperative anemia in urothelial carcinoma: A meta-analysis

The prognostic significance of preoperative anemia (PA) has been identified in various malignancies. However, its predictive role in urothelial carcinoma (UC) remains controversial. The aim of this study was to investigate the prognostic value of PA in UC patients. We performed a meta-analysis of the association between PA and survival outcome in UC patients. Electronic databases were searched up to June 30, 2016. Study characteristics and prognostic data were extracted from each included study. Cancer-specific survival (CSS), recurrence-free survival (RFS), and overall survival (OS) were pooled using hazard ratio (HR) with corresponding 95% confidence intervals (CI). Herein, 12 studies comprising 3815 patients were included in the meta-analysis. There were 1593 (41.76%) patients in the PA group and 2222 (58.24%) in the control group. The overall pooled HRs of PA for CSS, RFS, and OS were significant at 2.21, (95% CI: 1.83-2.65, Pheterogeneity = 0.49, I2 = 0%), 1.87 (95% CI: 1.59-2.20, Pheterogeneity = 0.22, I2 = 28%), and 2.04(95% CI: 1.76-2.37, Pheterogeneity = 0.36, I2 = 9%) respectively. Stratified analyses indicated that PA was a predictor of poor prognosis based on ethnicity, sample size, tumor T stage, G grade, lymphovascular invasion (LVI), concomitant carcinoma in situ (CIS), and follow-up values. Our findings show that PA has negative prognostic effects on the survival outcome (CSS, RFS, and OS) in UC patients and can serve as a useful and cost-effective marker to aid prognosis prediction.

Preoperative Anemia and Low Hemoglobin Level Are Associated With Worse Clinical Outcomes in Patients With Bladder Cancer Undergoing Radical Cystectomy: A Meta-Analysis

PURPOSE

The aim of this study was to determine the effect of preoperative anemia status and hemoglobin level on clinical outcomes in patients with bladder cancer undergoing radical cystectomy.

MATERIALS AND METHODS

A systematic review of literature with meta-analyses of predefined outcomes based on a search of PubMed and EMBASE was performed. Hazard ratios (HRs) measuring the association between preoperative anemia/hemoglobin and all-cause mortality, cancer-specific mortality, and disease recurrence were calculated with random effects model. Study heterogeneities were quantified by I² tests. Publication bias was assessed with funnel plots.

RESULTS

A total of 17 studies evaluating the impact of preoperative anemia status (categorical, 11 studies) and hemoglobin level (continuous, 7 studies) on clinical outcomes were included. The cutoff value of anemia varied among studies (10.5-13.5 g/dL for male, 10.5-13.4 g/dL for female). Meta-analyses showed that compared with non-anemia, anemia was associated with increased all-cause mortality (HR, 1.75; 95% confidence interval [CI], 1.48-2.05; P < .00001; I² = 30%), cancer-specific mortality (HR, 1.80; 95% CI, 1.45-2.25; P < .00001; I² = 26%), and disease recurrence (HR, 1.37; 95% CI, 1.16-1.62; P = .0002; I² = 9%). Meta-analyses showed that higher level of hemoglobin was associated with decreased all-cause mortality (HR, 0.90; 95% CI, 0.87-0.92; P < .00001; I² = 13%), cancer-specific mortality (HR, 0.90; 95% CI, 0.85-0.95; P = .0003; I² = 61%), and disease recurrence (HR, 0.95; 95% CI, 0.91-0.99; P = .01; I² = 53%). No obvious publication bias was observed.

CONCLUSIONS

Preoperative anemia and low hemoglobin level are associated with earlier recurrence and shorter survival of patients with bladder cancer undergoing radical cystectomy. However, well-designed prospective studies with large sample size and limited confounding factors are needed to confirm and update our findings.

Chronic anemia due to mitomycin C is drug dose-dependent, normocytic, progressive, related to erythropoietin levels and quantitatively predictable: implications for radiochemotherapy

Mitomycin C (MC) is used as therapy against solid tumors, also combined with other chemotherapeutic agents or radiotherapy. It may cause acute, subacute, or chronic anemia capable of modifying the results of chemo- and radiotherapy. Erythropoietin may be lowered by cancer itself or because of chemoradiotherapy. There are few studies investigating the relationship between erythropoietin and chronic anemia.We prospectively analyzed the chronic anemia and erythropoietin in 38 patients with solid cancer. Patients were 40 to 82 years of age. MC was randomly given every 3 weeks as a single drug at 10 or 20 mg/m². When myelotoxicity occurred the next therapy cycle was delayed until recovery. RBC indices, hemolysis, erythropoietin, liver and kidney function were studied. MC cycles were 136 (3.6 ± 1.4 per pt), 32 being delayed because of myelotoxicity.Hematocrit, hemoglobin and RBC were inversely related to the cumulative dose (r = 0.70 to 0.86; p 0.03 to 0.01) of MC. Other tests remained stable. Anemia occurred almost twofold earlier in the 20 mg/m² group (p=0.049). basal erythropoietin, already lower than in age and sex watched 81 non cancerous subjects (p<0.001), decreased during MC therapy (p<0.01). For each given MC mg/m² a 0.0372 Hb mg/dl reduction occurred. Chronic anemia due to MC is accompanied by erythropoietin reduction. These results can help in designing chemoradiotherapy.

The prognostic value of hemoglobin in patients with anal cancer treated with chemoradiotherapy

PURPOSE

This study aimed to evaluate the impact of hemoglobin level on clinical outcome (local response, progression-free survival, and overall survival) in patients with carcinoma of the anal canal treated with definitive chemoradiotherapy.

METHODS

This is a retrospective study of patients with anal cancer treated between 1992 and 2005 with definitive chemoradiotherapy at Tom Baker Cancer Centre. Patient treatment, laboratory, and outcome data were extracted from the chart.

RESULTS

Seventy-two patients treated with definitive chemoradiotherapy were identified. The median age was 56 years, the male-to-female ratio was 1:2, and the median tumor size was 3.5 cm. At 6 weeks after the completion of chemoradiotherapy, 62% of patients (38/61) had complete clinical response, and 34% (21/61) had achieved a partial clinical response. At 3 months after treatment, complete clinical response was observed in 78% (49/63) and a partial response in 16% (10/63). The median pretreatment hemoglobin level was 138.5 g/L, and the median on-treatment hemoglobin level was 129 g/L. Distant relapse was associated with hemoglobin levels in the lowest quartiles, pretreatment and on-treatment (P = .007 and P = .008, respectively). Hemoglobin levels were not associated with response at 6 weeks or 3 months. A pretreatment hemoglobin level of <130 g/L was associated with worse progression-free and overall survival (P < .0001, both). A hemoglobin on-treatment level of <121 g/L was associated with progression-free and overall survival (P < .0001 and P = .019, respectively), when stratified by gender.

CONCLUSIONS

Hemoglobin status was correlated with progression-free and overall survival, and distant relapse, but not clinical response, in patients with carcinoma of the anal canal treated with chemoradiotherapy. The clinically relevant cut point, and the value of correcting hemoglobin levels before or during treatment, remains to be elucidated.