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Dear T, Chiu J, Meirovich H, Malkin A, Amjad R, D'Souza D, Callum J, Leung E, Kelly K, Lazo-Langner A, Solh Z. Are outcomes of locally advanced cervical cancer associated with prebrachytherapy hemoglobin values and transfusion practice? An observational study comparing two large academic centres with divergent clinical guidelines. Brachytherapy 2024:S1538-4721(24)00119-3. [PMID: 39198044 DOI: 10.1016/j.brachy.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/09/2024] [Accepted: 07/31/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND AND PURPOSE Anemia is common in locally advanced cervical cancer. Clinical practice varies greatly for management of anemia during brachytherapy, with some centres providing red cell transfusion to increase hemoglobin levels above 100 g/L. MATERIALS AND METHODS This is a retrospective observational cohort study of adult patients with cervical cancer treated with brachytherapy at two academic hospitals. One hospital (H1) uses a liberal transfusion strategy with hemoglobin threshold of 100 g/L during brachytherapy and the other uses a restrictive target of 70 g/L (H2). RESULTS Overall, 336 patients met inclusion criteria (H1: 150 patients, H2: 186 patients). 11 patients were excluded (2 at H1, 9 at H2). Demographics at both sites were comparable, except for cancer stage and smoking history. External beam radiation and chemotherapy provided was similar. Hemoglobin values were compared at baseline (within 4 weeks of oncology consult), and prior to the first and second brachytherapy treatments. In total, 101red blood cell (RBC) units were transfused to patients at H1 and 19 units to patients at H2. Patients were followed for a median of 37.0 months (0.6-80.5) at H1, and 33.3 months (1.6-82.0) at H2. There was no significant difference in progression-free or overall survival. Multivariable logistic regression analysis showed that FIGO stage was a predictor for both overall survival and cancer progression. Age, tumor size, chemotherapy, and hemoglobin levels were not predictors of disease progression or mortality. CONCLUSIONS The practice of liberal transfusion should be re-evaluated in the absence of robust data to support its use.
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Affiliation(s)
- Taylor Dear
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Jodi Chiu
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | | | - Amie Malkin
- QUEST Research Program, Toronto, Ontario, Canada; Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Razan Amjad
- Department of Radiation Oncology, King Abdulaziz University, Rabigh, Saudi Arabia; Department of Oncology, Division of Radiation Oncology, Western University, London, Ontario, Canada
| | - David D'Souza
- Department of Oncology, Division of Radiation Oncology, Western University, London, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University, Kingston and Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Eric Leung
- Department of Oncology, Division of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kate Kelly
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Division of Hematology, Western University, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Transfusion Medicine, Western University, London, Ontario, Canada.
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Deschner M, Vasanthamohan L, Zayed S, Lazo-Langner A, Palma D, D'Souza D, Omar Gilani S, Gabriel Boldt R, Solh Z. The impact of red blood cell transfusion on mortality and treatment efficacy in patients treated with radiation: A systematic review. Clin Transl Radiat Oncol 2022; 33:23-29. [PMID: 35243018 PMCID: PMC8885402 DOI: 10.1016/j.ctro.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022] Open
Abstract
Higher hemoglobin (Hb) levels may improve outcomes in radiation therapy (RT). There are no standard red blood cell transfusion thresholds for RT patients. We found no differences between standard and higher Hb thresholds during RT. Data is lacking on the effects of transfusion strategies in patients undergoing RT.
Introduction Packed red blood cell (RBC) transfusion is frequently used in patients undergoing radiotherapy (RT) because retrospective data suggest that anemic patients may respond sub-optimally to RT. No high-quality evidence currently exists to guide transfusion practices and establish hemoglobin (Hb) transfusion thresholds for this patient population, and practice varies significantly across centers. This systematic review investigated whether maintaining higher Hb via transfusion in radiation oncology patients leads to improved outcomes. Methods We performed a literature search of studies comparing RBC transfusion thresholds in radiation oncology patients. Included studies assessed patients receiving RT for malignancy of any diagnosis or stage. Excluded studies did not evaluate Hb or transfusion as an intervention or outcome. The primary outcome was overall survival. Secondary outcomes included locoregional control, number of transfusions and adverse events. Results One study met inclusion criteria. The study pooled results from two randomized controlled trials that stratified anemic patients with head and neck squamous cell carcinoma to RBC transfusion versus no transfusion. The study found no significant differences in overall survival or locoregional control after five years, despite increased Hb levels in the transfused group. We conducted a narrative review by extracting data from 10 non-comparative studies involving transfusion in patients receiving RT. Results demonstrated no consistent conclusions regarding whether transfusions improve or worsen outcomes. Conclusions There is a lack of data on the effects of RBC transfusion on outcomes in patients undergoing RT. Well-designed prospective studies are needed in this area.
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Patel S, Vargo JA, Olson A, Mahajan A. Supportive care for toxicities in children undergoing radiation therapy. Pediatr Blood Cancer 2021; 68 Suppl 2:e28597. [PMID: 33818886 DOI: 10.1002/pbc.28597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/16/2020] [Accepted: 07/01/2020] [Indexed: 11/08/2022]
Abstract
Radiation therapy (RT) is an integral part of the management of many pediatric tumors; however, it is associated with both acute and permanent adverse events that can significantly impact a child's quality of life, lead to treatment delays, and potentially affect outcomes of cancer therapy. Prevention, early detection, and optimal management of these adverse effects will help reduce their impact on the patients' quality of life and overall well-being. Unfortunately, there has not been a coordinated effort to study the etiology, evaluate risk factors, and explore novel treatments for these conditions. Studies of supportive care for children undergoing RT are often small and uncontrolled. This review will focus on the impact of irradiation on the different organ systems and their current management. Further studies are required to improve our understanding of the contributing factors and explore novel treatment options for these adverse effects and to enable children and their families to better cope with some of the unavoidable toxicities following multimodality therapy.
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Affiliation(s)
- Samir Patel
- Divisions of Radiation Oncology and Pediatric Hematology, Oncology and Palliative Care, University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - John Austin Vargo
- Department of Radiation Oncology, UPMC Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam Olson
- Department of Radiation Oncology, UPMC Children's Hospital of Pittsburg, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Zayed S, Nguyen TK, Lin C, Boldt G, Beriwal S, Creutzberg CL, Kamrava M, Mendez LC, Velker V, Doll C, Taggar A, Leung E, D’Souza DP. Red Blood Cell Transfusion Practices for Patients With Cervical Cancer Undergoing Radiotherapy. JAMA Netw Open 2021; 4:e213531. [PMID: 33818620 PMCID: PMC8022218 DOI: 10.1001/jamanetworkopen.2021.3531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Packed red blood cell (PRBC) transfusions are used to treat anemia in patients with cervical cancer undergoing radiotherapy (RT) owing to concerns of hypoxia-induced radioresistance. In the absence of high-quality evidence informing transfusion practices for patients receiving external beam RT (EBRT) and brachytherapy, various arbitrary hemoglobin target levels are used worldwide. OBJECTIVE To develop consensus statements to guide PRBC transfusion practices in patients with cervical cancer receiving curative-intent RT with EBRT and brachytherapy. DESIGN, SETTING, AND PARTICIPANTS This international Delphi consensus study was completed between November 1, 2019, and July 31, 2020. A total of 63 international clinical experts in gynecologic radiation oncology were invited; 39 (62%) accepted and consented to participate. Consensus building was achieved using a 3-round anonymous Delphi consensus method. Participants rated their agreement or disagreement with statements using a 5-point Likert scale. An a priori threshold of 75% or more was required for consensus. MAIN OUTCOMES AND MEASURES The preplanned primary outcome of this study was to assess hemoglobin transfusion thresholds and targets for both EBRT and brachytherapy by expert consensus. RESULTS Response rates of 100% (39 of 39), 92% (36 of 39), and 97% (35 of 36) were achieved for the first, second, and third rounds of surveys, respectively. Twenty-three experts (59%) practiced in Canada, 11 (28%) in the United States, 3 (8%) in South America, 1 (3%) in Europe, and 1 (3%) in Asia. Consensus was reached for 44 of 103 statements (43%), which were combined to form the final 27-statement consensus guideline. No specific hemoglobin transfusion threshold was agreed on by consensus for EBRT or brachytherapy. By consensus (89% [31 of 35]), a hemoglobin transfusion target for patients who receive a PRBC transfusion should be 9 g/dL or more and less than 12 g/dL. CONCLUSIONS AND RELEVANCE This study presents the first international expert consensus guideline informing PRBC transfusion practices for patients with cervical cancer undergoing EBRT and brachytherapy. A minimum hemoglobin transfusion target of 9 g/dL was endorsed to balance tumor radiosensitivity with appropriate use of a scarce resource. Randomized clinical trials are required to evaluate the optimal transfusion threshold and target that maximize clinical benefit in this patient population.
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Affiliation(s)
- Sondos Zayed
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Timothy K. Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Cindy Lin
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lucas C. Mendez
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Vikram Velker
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Corinne Doll
- Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eric Leung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David P. D’Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
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5
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Keenan LG, Ibrahim N, Dunne MT, Finn M, Armstrong JG. The effect of anaemia on normal tissue toxicity and survival outcomes in prostate cancer treated with radical radiotherapy and neo-adjuvant androgen deprivation. Br J Radiol 2020; 93:20190577. [PMID: 31944823 DOI: 10.1259/bjr.20190577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE It has been established that survival and toxicity outcomes in some cancer types could be influenced by haemoglobin (Hb) levels. This study aims to determine if pre-treatment Hb is associated with late toxicity or survival outcomes in prostate cancer. METHODS Data from one Phase III randomised controlled trial and one single arm translational trial were analysed. Patients had localized prostate cancer and received ≥70 Gy radiotherapy and neo-adjuvant androgen deprivation between 1997 and 2013. RESULTS 302 males were included. Median follow-up was 6.8 years for toxicity and 10.3 years for survival outcomes. Patients with Hb below the reference range were more likely to experience Grade 2-3 late gastrointestinal toxicity than patients with Hb within the range (p = 0.050). Neither late genitourinary toxicity, erectile function toxicity, prostate-specific antigen relapse free survival nor overall survival of patients were statistically significantly different between groups. CONCLUSION Anaemia in prostate cancer is found in the minority of patients and is usually mild. Prostate cancer patients undergoing radiotherapy with low Hb were more likely to experience Grade 2-3 late gastrointestinal toxicity. ADVANCES IN KNOWLEDGE This study is one of the first in the published literature to investigate the role of Hb in prostate cancer toxicity and survival. We have found an association between Hb below the reference range and late GI toxicity. Consideration should be given to further investigating patients with iron deficiency anaemia to guide management options and outrule underlying GI pathology before proceeding with radiotherapy treatment.
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Affiliation(s)
- Lorna G Keenan
- Cancer Trials Ireland (formally All-Ireland Cooperative Oncology Research Group, ICORG), Dublin, Ireland.,St Lukes Radiation Oncology Network, Oakland Drive, Highfield Road, Rathgar, Dublin, Ireland
| | - Nazir Ibrahim
- St Lukes Radiation Oncology Network, Oakland Drive, Highfield Road, Rathgar, Dublin, Ireland
| | - Mary T Dunne
- Cancer Trials Ireland (formally All-Ireland Cooperative Oncology Research Group, ICORG), Dublin, Ireland.,St Lukes Radiation Oncology Network, Oakland Drive, Highfield Road, Rathgar, Dublin, Ireland
| | - Marie Finn
- St Lukes Radiation Oncology Network, Oakland Drive, Highfield Road, Rathgar, Dublin, Ireland
| | - John G Armstrong
- Cancer Trials Ireland (formally All-Ireland Cooperative Oncology Research Group, ICORG), Dublin, Ireland.,St Lukes Radiation Oncology Network, Oakland Drive, Highfield Road, Rathgar, Dublin, Ireland
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6
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Grover S, MacDuffie EC, Wang Q, Bvochora-Nsingo M, Bhatia RK, Balang D, Chiyapo SP, Luckett R, Ramogola-Masire D, Dryden-Peterson SL, Lin LL, Shin SS, Zetola NM. HIV infection is not associated with the initiation of curative treatment in women with cervical cancer in Botswana. Cancer 2019; 125:1645-1653. [PMID: 30801696 DOI: 10.1002/cncr.31972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/29/2018] [Accepted: 11/09/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer death in Sub-Saharan Africa. The risk of developing cancer is increased for women living with human immunodeficiency virus (HIV) infection. It is unknown which factors predict the initiation of curative chemoradiotherapy (CRT) in resource-limited settings and whether HIV is associated with initiating curative CRT in settings with a high HIV burden. METHODS All women living with and without HIV infection who were initiating curative and noncurative CRT for locally advanced cervical cancer in Botswana were prospectively enrolled in an observational study. The factors associated with receiving CRT were evaluated in all patients and the subgroup of women living with HIV. RESULTS Of 519 enrolled women, 284 (55%) initiated CRT with curative intent. The curative cohort included 200 women (70.4%) who were living with HIV and had a median CD4 count of 484.0 cells/μL (interquartile range, 342.0-611.0 cells/μL). In the noncurative cohort, 157 of 235 women (66.8%) were living with HIV and had a median CD4 count of 476.5 cells/μL (interquartile range, 308.0-649.5 cells/μL). HIV status was not associated with initiating curative CRT (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.58-1.56). The factors associated with receiving curative CRT treatment on multivariable analysis in all patients included baseline hemoglobin levels ≥10 g/dL (OR, 1.80; 95% CI, 1.18-2.74) and stage I or II versus stage III or IV disease (OR, 3.16; 95% CI, 2.10-4.75). Women aged >61 years were less likely to receive curative treatment (OR, 0.43; 95% CI, 0.24-0.75). Among women who were living with HIV, higher CD4 cell counts were associated with higher rates of CRT initiation. CONCLUSIONS The initiation of CRT with curative intent does not depend on HIV status. Significant predictors of CRT initiation include baseline hemoglobin level, disease stage, and age.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Princess Marina Hospital, Gaborone, Botswana.,School of Medicine, University of Botswana, Gaborone, Botswana
| | - Emily C MacDuffie
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Qiao Wang
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, California
| | | | - Rohini K Bhatia
- University of Rochester, School of Medicine and Dentistry, Rochester, New York
| | - Dawn Balang
- Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
| | | | - Rebecca Luckett
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Doreen Ramogola-Masire
- School of Medicine, University of Botswana, Gaborone, Botswana.,Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott L Dryden-Peterson
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sanghyuk S Shin
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, California
| | - Nicola M Zetola
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
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7
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Tu J, Wen L, Huo Z, Wang B, Wang Y, Liao H, Liu W, Zhong X, Kong J, Wang M, Huang G, Yin J, Xie X, Shen J. Predictive value of dynamic change of haemoglobin levels during therapy on treatment outcomes in patients with Enneking stage IIB extremity osteosarcoma. BMC Cancer 2018; 18:428. [PMID: 29661211 PMCID: PMC5902878 DOI: 10.1186/s12885-018-4279-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 03/21/2018] [Indexed: 01/26/2023] Open
Abstract
Background We aimed to investigate the roles of hemoglobin (Hb) concentrations and dynamic change during treatment on outcomes of patients with extremity osteosarcoma. Methods We retrospectively analysed 133 patients with Enneking stage IIB extremity osteosarcoma who underwent standard treatments, including univariate and multivariate analyses of patient charateritics, Hb concentrations and changes during pretreatment, neoadjuvant, adjuvant chemotherapy, and decreased Hb levels (ΔHb) to assess their prognostic value in 5-year overall survival (OS) and lung metastasis-free survival (LMFS). Results Five-year OS or LMFS were similar between patients who were anaemic and non-anaemic during pretreatment, neoadjuvant or adjuvant chemotherapy. Patients with continuously decreasing Hb had lower 5-year OS (52.3%) than those without continuous Hb decrease (68.5%, P = 0.04). Patients with ΔHb > 7.6 g/L had lower 5-year OS (57.5%) than those with ΔHb ≤7.6 g/L (75.8%, P = 0.04). However, continuous Hb decrease had no prognostic effect on 5-year LMFS. Subgroup analyses showed that patients who were anaemic during pretreatment, neoadjuvant, or adjuvant chemotherapy with ΔHb ≤7.6 g/L had better outcomes than those with ΔHb > 7.6 g/L (P < 0.05, for both). Conclusion Dynamic Hb decrease and ΔHb > 7.6 predicted poor5-year OS in patients with Enneking stage IIB extremity osteosarcoma. Attempts to correct anaemia and their effects on outcomes for osteosarcoma patients should be investigated in future trials.
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Affiliation(s)
- Jian Tu
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Lili Wen
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zijun Huo
- Department of Endocrinology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bo Wang
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Yongqian Wang
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Hongyi Liao
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Weihai Liu
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Xian Zhong
- The eight year program, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jianqiu Kong
- The eight year program, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Mengqi Wang
- The eight year program, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Gang Huang
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Junqiang Yin
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Xianbiao Xie
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Jingnan Shen
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
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Jemu M, van Wijk L, Parker M, Jones G. Tumour and treatment factors influencing the outcome of chemo-radiation in stage IIB cervical cancer: a single institution experience. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2018. [DOI: 10.1080/20742835.2018.1441694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Mtabeni Jemu
- Division of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Leon van Wijk
- Division of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- South African Medical Research Council Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - Michelle Parker
- Radiobiology Section, Division of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Glenn Jones
- School of Clinical Medicine and Research, The University of the West Indies, Nassau, Bahamas
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Cybulska P, Goss C, Tew WP, Parameswaran R, Sonoda Y. Indications for and complications of transfusion and the management of gynecologic malignancies. Gynecol Oncol 2017; 146:416-426. [PMID: 28528916 PMCID: PMC5527999 DOI: 10.1016/j.ygyno.2017.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 02/06/2023]
Abstract
Anemia, which is highly prevalent in oncology patients, is one of the most established negative prognostic factors for several gynecologic malignancies. Multiple factors can cause or contribute to the development of anemia in patients with gynecologic cancers; these factors include blood loss (during surgery or directly from the tumor), renal impairment (caused by platinum-based chemotherapy), and marrow dysfunction (from metastases, chemotherapy, and/or radiation therapy). Several peri- and intra-operative strategies can be used to optimize patient management and minimize blood loss related to surgery. Blood transfusions are routinely employed as corrective measures against anemia; however, blood transfusions are one of the most overused healthcare interventions. There are safe and effective evidence-based blood transfusion strategies used in other patient populations that warrant further investigation in the surgical oncology setting. Blood is a valuable healthcare resource, and clinicians can learn to use it more judiciously through knowledge of the potential risks and complications of blood interventions, as well as the ability to properly identify the patients most likely to benefit from such interventions.
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Affiliation(s)
- Paulina Cybulska
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cheryl Goss
- Hematology and Coagulation Laboratory Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rekha Parameswaran
- Transfusion Medicine Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Hematology Service, Department of Medicine, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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10
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The effect of low hemoglobin levels on outcomes of radiotherapy following microscopically complete resection of locally advanced SCCHN: Implications for the future. J Craniomaxillofac Surg 2016; 44:1441-4. [DOI: 10.1016/j.jcms.2016.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/27/2016] [Accepted: 07/01/2016] [Indexed: 12/27/2022] Open
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Hemoglobin level in cervical cancer: a surrogate for an infiltrative phenotype. Int J Gynecol Cancer 2014; 23:724-9. [PMID: 23446376 DOI: 10.1097/igc.0b013e31828a0623] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Hemoglobin (Hb) is a prognostic factor in cervical cancer, but the underlying mechanisms remain unknown. In this study, we hypothesized that low Hb level, either before or during radiotherapy (RT), is a surrogate for a more infiltrative and therefore aggressive disease, with uterine corpus invasion and nodal metastases. METHODS AND MATERIALS Prospectively collected data of patients with locally advanced cervical cancer treated with curative intent using chemoradiation at a tertiary academic center was reviewed. All eligible patients had a positron emission tomographic scan and pelvic magnetic resonance imaging. Hemoglobin levels before RT and Hb nadir during RT were collected from the medical record. RESULTS The median follow-up for 263 eligible patients was 38.7 months. Ninety-six patients (36.5%) had both uterine corpus invasion and positron emission tomography-positive nodal disease (C+N+). Patients with pretreatment Hb level of less than 120 g/L were more likely to have C+N+ disease (47%) compared with patients with a high pretreatment Hb level (32%; P = 0.034). The 3-year disease-free survival and overall survival (OS) were significantly lower in the C+N+ group compared with the remaining patients (40.1% vs 76.1%, P < 0.001, and 59.7% vs 83.1%, P < 0.001, respectively). Patients with low Hb nadir were more likely to have a C+N+ disease (P < 0.001), and low Hb nadir during RT was significantly an indicator of a higher recurrence rate (P = 0.002) and lower OS (P < 0.001). In multifactor analysis, statistically significant prognostic factors for OS included histology, high-echelon nodal involvement, tumor volume on magnetic resonance imaging, C+N+ status, and Hb nadir during treatment. Pretreatment Hb level was not an independent prognostic factor. CONCLUSIONS The combination of corpus invasion and nodal metastases is associated with lower Hb level and inferior prognosis. Because C+N+ state is related to tumor growth from early invasion to the time of presentation, it is unlikely that the correction of Hb level during treatment will have a major impact on outcome.
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Prognostic value of pretreatment hemoglobin level in patients with early cervical cancer. Obstet Gynecol Sci 2014; 57:28-36. [PMID: 24596815 PMCID: PMC3924748 DOI: 10.5468/ogs.2014.57.1.28] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 09/03/2013] [Accepted: 09/16/2013] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The purpose of this study is to investigate the prognostic role of pretreatment anemia in patients with early cervical cancer who underwent radical hysterectomy. METHODS In this study, we retrospectively enrolled patients with early cervical cancer (International Federation of Obstetrics and Gynecology stage IB to IIA) who were treated at Samsung Medical Center, Seoul, Korea, from 1996 to 2007. RESULTS We retrospectively enrolled 805 patients. Median pretreatment hemoglobin (Hb) level was 12.8 g/dL (4.0-16.9) in all patients. Ninety-ninth out of 805 patients had pretreatment anemia (12.3%). Pretreatment anemia was significantly associated with large tumor size, advanced clinical stage, and parametrial invasion. In multivariate analysis, higher pretreatment Hb entailed better prognostic significance in disease free survival (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.078-0.99) but not in overall survival (HR, 0.94; 95% CI, 0.80-1.10). CONCLUSION In conclusion, we found that the negative association between pretreatment Hb level and tumor size and the impact of anemia before treatment on disease free survival adjusted for other factors including clinical stage and pathological findings in early stage cervical cancer.
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Hiniker SM, Roux A, Murphy JD, Harris JP, Tran PT, Kapp DS, Kidd EA. Primary squamous cell carcinoma of the vagina: Prognostic factors, treatment patterns, and outcomes. Gynecol Oncol 2013; 131:380-5. [DOI: 10.1016/j.ygyno.2013.08.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/10/2013] [Indexed: 12/12/2022]
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The Effects of Anemia and Blood Transfusion on Patients With Stage III-IV Ovarian Cancer. Int J Gynecol Cancer 2013; 23:1569-76. [DOI: 10.1097/igc.0b013e3182a57ff6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ObjectivesThe objective of this study was to examine the overall and recurrence-free survival in patients with advanced ovarian cancer based on hemoglobin and blood transfusions.MethodsA retrospective chart review was performed between 2003 and 2007 on patients with pathologically confirmed stage 3–4 ovarian, fallopian, or peritoneal cancers. Data were collected on date of diagnosis, recurrence and death, stage, grade, age, surgery, estimated blood loss, hemoglobin (nadir and average levels), and number of blood transfusions.ResultsTwo hundred sixteen patients were included in the final analysis. In the perichemotherapy, perioperative, and total time frames, 88%, 81%, and 95% of patients were anemic, and 9%, 22%, and 26% of the patients had severe anemia. After adjusting for age, stage, and optimal debulking status, the perichemotherapy hemoglobin level as a continuous variable was weakly associated with recurrence-free survival (adjusted hazard ratio [AHR], 0.98;P= 0.03), and as a categorical variable with both recurrence-free survival (AHR, 2.49;P= 0.003) and overall survival (AHR, 1.91;P= 0.02). The total number of transfusions was also weakly associated with poor recurrence-free survival (AHR, 1.06;P= 0.03).ConclusionsOur study is a retrospective analysis of the effects of anemia and transfusion on ovarian cancer. The rates of anemia in chemotherapy patients are higher than previously reported. Although maintaining average hemoglobin greater than 80 g/L during chemotherapy portends an improved overall survival, blood transfusion does not have any effect. The role of transfusion should therefore be limited to symptomatic patients while giving 1 unit at a time. Further prospective studies will be needed to confirm these results.
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Tuan J, Ha T, Chen W, Hawkins M, Tait D. Effect of Anaemia Prevention on Survival and Local Control in Oesophageal Cancers Treated with Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2012; 24:454-5. [DOI: 10.1016/j.clon.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 03/20/2012] [Indexed: 11/16/2022]
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Hoff CM. Importance of hemoglobin concentration and its modification for the outcome of head and neck cancer patients treated with radiotherapy. Acta Oncol 2012; 51:419-32. [PMID: 22313317 DOI: 10.3109/0284186x.2011.653438] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hypoxia induced radioresistance has been acknowledged for decades. One of the indirect evidences of the influence of hypoxia on radiation response comes from the observations of a correlation between tumor control and hemoglobin level. This review examines the clinical data on the prognostic and predictive role of hemoglobin level and hemoglobin manipulation in radiotherapy of squamous cell carcinomas of the head and neck, a tumor type where hypoxic radioresistance have been previously documented. THE INFLUENCE OF HEMOGLOBIN CONCENTRATION ON TUMOR OXYGENATION AND OUTCOME The aim is to evaluate the existing literature for information of the influence of hemoglobin concentration and hemoglobin modifications on tumor oxygenation and outcome in head and neck squamous cell cancer patients. The data from several randomized trials show that while most studies have confirmed the prognostic value of hemoglobin, increasing the hemoglobin level through transfusion or erythropoietin stimulation did not result in improved outcome for patients with low initial hemoglobin levels. Clinical studies showed that smoking reduced the oxygen carrying capacity of the blood through formation of carboxyhemoglobin, and lead to poorer response to radiotherapy in smokers compared to non-smokers. Smoking also increased the risk of the development of secondary cancers. CONCLUSION AND FUTURE PERSPECTIVES In conclusion, low hemoglobin is a significant negative prognostic factor for radiotherapy of head and neck cancer. Correction of pre-treatment low hemoglobin by blood transfusion and/or erythropoietin stimulating agents does, however, not improve the outcome. Smoking leads to a decrease in effective hemoglobin and poorer treatment outcome. Smoking should be avoided in order to improve the therapeutic efficacy of radiotherapy and development of other smoking-related diseases and/or secondary cancers.
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Affiliation(s)
- Camilla Molich Hoff
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
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Platek ME, Reid ME, Wilding GE, Jaggernauth W, Rigual NR, Hicks WL, Popat SR, Warren GW, Sullivan M, Thorstad WL, Khan MK, Loree TR, Singh AK. Pretreatment nutritional status and locoregional failure of patients with head and neck cancer undergoing definitive concurrent chemoradiation therapy. Head Neck 2010; 33:1561-8. [PMID: 21990220 DOI: 10.1002/hed.21640] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND This study was carried out to determine if markers of nutritional status predict for locoregional failure following intensity-modulated radiation therapy (IMRT) with concurrent chemoradiotherapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN). METHODS We performed a retrospective chart review of 78 patients with SCCHN who received definitive CCRT. We compared patient factors, tumor characteristics, and nutritional status indicators between patients with and without locoregional failure. RESULTS Fifteen of 78 patients (19%) experienced locoregional failure. Median follow-up for live patients was 38 months. On univariate analysis, pretreatment percentage of ideal body weight (%IBW) (p < .01), pretreatment hemoglobin (p = .04), and treatment duration (p < .01) were significant predictors of failure. On multivariate analysis, pretreatment %IBW (p = .04) and treatment time (p < .01) remained statistically significant. CONCLUSIONS Although treatment time is an accepted risk factor for failure, differences in outcome for patients with head and neck cancer undergoing definitive CCRT based on pretreatment %IBW should be examined further.
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Affiliation(s)
- Mary E Platek
- Division of Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Buffalo, New York, USA.
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Hoff CM, Hansen HS, Overgaard M, Grau C, Johansen J, Bentzen J, Overgaard J. The importance of haemoglobin level and effect of transfusion in HNSCC patients treated with radiotherapy--results from the randomized DAHANCA 5 study. Radiother Oncol 2010; 98:28-33. [PMID: 20970213 DOI: 10.1016/j.radonc.2010.09.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 09/23/2010] [Accepted: 09/24/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Patients with head and neck squamous cell carcinoma (HNSCC) and a low level of haemoglobin (Hb) often have a poor response to radiation which may be related to hypoxia induced radioresistance. The aim of the study was to evaluate the prognostic significance of low Hb level and its modification by transfusion in HNSCC patients treated with radiotherapy. The study was performed as a subrandomization in the DAHANCA 5 trial. MATERIAL AND METHODS Patients were randomized to treatment with the hypoxic radiosensitizer nimorazole or placebo, and in addition, patients with "low" pre-irradiation Hb values (females<13 g/dL; males<14.5 g/dL) were subrandomized to plus or minus transfusion. Transfusion was given with packed red blood cells with the aim to achieve a Hb level in the "high" value range. RESULTS A total of 414 patients were included, 243 patients had high Hb levels and 171 patients had low Hb levels. Of the low Hb patients, 82 were randomized to receive transfusion and 89 not to receive transfusion. The treatment arms were well balanced. In the majority of patients, transfusion resulted in increased Hb levels although this tended to decline throughout treatment. Patients with high Hb levels had a significantly better probability of locoregional control, disease-specific survival and overall survival compared to 'low Hb no transfusion' patients. In the low Hb group, transfusion did not improve the outcome in locoregional control, disease-specific survival or overall survival. In multivariate analyses, T and N classifications were significant for all outcome measures, whereas there was no significant influence of transfusion or Hb level on endpoints. CONCLUSION The univariate prognostic significance of high Hb level was demonstrated in patients with HNSCC treated with radiotherapy; however, transfusion prior to and during treatment did not improve the outcome in patients with low Hb values.
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Affiliation(s)
- Camilla Molich Hoff
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
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Bhide SA, Ahmed M, Rengarajan V, Powell C, Miah A, Newbold K, Nutting CM, Harrington KJ. Anemia During Sequential Induction Chemotherapy and Chemoradiation for Head and Neck Cancer: The Impact of Blood Transfusion on Treatment Outcome. Int J Radiat Oncol Biol Phys 2009; 73:391-8. [DOI: 10.1016/j.ijrobp.2008.04.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Revised: 04/07/2008] [Accepted: 04/11/2008] [Indexed: 11/30/2022]
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Tran PT, Su Z, Lee P, Lavori P, Husain A, Teng N, Kapp DS. Prognostic factors for outcomes and complications for primary squamous cell carcinoma of the vagina treated with radiation. Gynecol Oncol 2007; 105:641-9. [PMID: 17363046 DOI: 10.1016/j.ygyno.2007.01.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 01/13/2007] [Accepted: 01/18/2007] [Indexed: 12/27/2022]
Abstract
PURPOSE To analyze the results of treatment and identify prognostic factors for primary squamous cell carcinoma (SCCA) of the vagina managed with radiotherapy at a single institution. MATERIALS AND METHODS Seventy-eight patients were analyzed in this retrospective series. Mean characteristics: follow-up 89 months; age 65 years (range 33-99); tumor size 3.8 cm (0.3-10); treatment hemoglobin 12.4 g/dl (range 8.7-14.4); and tumor dose 72 Gy (range 6-127). In addition, 49% of our cohort had a prior hysterectomy. The FIGO stage distribution: I (42%); II (29%); III (17%); and IVA/B (11%). Sixty-two percent of patients were treated with a combination of external beam radiation (EBRT) and brachytherapy, 22% with EBRT alone and 13% with brachytherapy alone. RESULTS Kaplan-Meier (KM) 5-year pelvic control, distant metastasis free survival and disease specific survival probabilities: stage I, 83%, 100%, and 92%; stage II, 76%, 95%, and 68%; stage III, 62%, 65%, and 44%; and stage IV, 30%, 18%, and 13%. On multivariate analysis: stage; treatment hemoglobin; and prior hysterectomy were prognostic for DSS (p<0.05). The KM 5-year grade 3/4 (G3/4) complication free estimate of our cohort was 84%. G3/4 complications: tumor size and tumor dose were independently predictive (p<0.05). CONCLUSIONS Radiotherapy as a single modality for early stage primary vaginal SCCA produces good results. Advanced stage disease necessitates a combined modality approach and/or new methods. Treatment Hg levels appear to be clinically significant and studies on correction of anemia during treatment are warranted.
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Affiliation(s)
- Phuoc T Tran
- Department of Radiation Oncology, Stanford Cancer Center, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
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Kang SB. Treatment of Cervical Cancer. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2007. [DOI: 10.5124/jkma.2007.50.9.785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Soon-Beom Kang
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Korea.
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Rades D, Tribius S, Yekebas EF, Bahrehmand R, Wildfang I, Kilic E, Muellerleile U, Gross E, Schild SE, Alberti W. Epoetin alfa improves survival after chemoradiation for Stage III esophageal cancer: Final results of a prospective observational study. Int J Radiat Oncol Biol Phys 2006; 65:459-65. [PMID: 16584851 DOI: 10.1016/j.ijrobp.2005.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 12/10/2005] [Accepted: 12/12/2005] [Indexed: 11/26/2022]
Abstract
PURPOSE This prospective, nonrandomized study evaluates the effectiveness of epoetin alfa to maintain the hemoglobin levels at 12 to 14 g/dL (optimal range for tumor oxygenation) during chemoradiation for Stage III esophageal cancer and its impact on overall survival (OS), metastatic-free survival (MFS), and locoregional control (LC). METHODS AND MATERIALS Ninety-six patients were included. Forty-two patients received epoetin alfa (150 IU/kg, 3 times a week) during radiotherapy, which was started at hemoglobin less than 13 g/dL and stopped at 14 g/dL or higher. Hemoglobin levels were measured weekly during RT. RESULTS Both groups were balanced for age, sex, performance status, tumor length/location, histology, grading, T-stage/N-stage, chemotherapy, treatment schedule, and hemoglobin before RT. Median change of hemoglobin was +0.3 g/dL/wk with epoetin alfa and -0.5 g/dL/wk without epoetin alfa. At least 60% of hemoglobin levels were 12 to 14 g/dL in 64% and 17% of the patients, respectively (p < 0.001). Patients who received epoetin alfa had better OS (32% vs. 8% at 2 years, p = 0.009) and LC (67% vs. 15% at 2 years, p = 0.001). MFS was not significantly different (42% vs. 18% at 2 years, p = 0.09). CONCLUSIONS The findings suggest that epoetin alfa when used to maintain the hemoglobin levels at 12 to 14 g/dL can improve OS and LC of Stage III esophageal cancer patients.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University Hospital, Hamburg, Germany
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Kapp KS, Poschauko J, Tauss J, Berghold A, Oechs A, Lahousen M, Petru E, Winter R, Kapp DS. Analysis of the prognostic impact of tumor embolization before definitive radiotherapy for cervical carcinoma. Int J Radiat Oncol Biol Phys 2005; 62:1399-404. [PMID: 16029799 DOI: 10.1016/j.ijrobp.2004.12.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Revised: 12/24/2004] [Accepted: 12/25/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess whether embolization compromises the radiocurability of primary cervical cancer. METHODS AND MATERIALS Two hundred fifty-four patients with primary cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stages IB: 47; II: 91; IIIB: 102; IV: 14) were treated with external beam irradiation and Ir-192 high-dose-rate brachytherapy over a period of 15 years. Of these, 24 patients (9.4%) (FIGO stages IB: 1; II: 8; IIIB: 12; IV: 3) had had bilateral embolization of the internal iliac arteries before referral. The median age of the entire cohort was 66 years (range, 34-85 years). Tumor size was >5 cm and paraortic nodes were enlarged (> or =1 cm) on pretreatment CAT scan in 39.4% and 9.1% of patients, respectively. All patients with hemoglobin levels (hb-l) < or =11 g/dL (28.3%) received packed red cell transfusions (PRCT) before and/or during radiotherapy in an attempt to maintain levels >11 g/dL throughout treatment. Cross-table tests were used to compare the distribution of FIGO stage, tumor size, lymph node status, and pretreatment and treatment hb-l of embolized and nonembolized patients. The impact of embolization, along with the above-listed tumor characteristics, on disease-specific survival (DSS), pelvic control (PC), and distant metastases-free survival (MFS) was determined by univariate and multivariate analyses. RESULTS Embolized patients presented at a statistically significant younger median age (55 vs. 67 years; p = 0.003), with larger tumors (66.7% vs. 36.5%; p = 0.007), and lower pretreatment hb-l (75% vs. 23.5%; p < 0.001) than nonembolized patients. There was no significant difference in stage distribution or lymph node status, and although embolized patients responded better to PRCT (50% vs. 29.6%), this difference was not statistically significant. Univariate analysis showed a trend toward decreased DSS (p = 0.09) and PC (p = 0.07) for embolized patients but no effect on MFS, whereas all other variables tested were significantly correlated with DSS, PC, and MFS (all p < 0.001). In the multivariate model, tumor embolization, FIGO stage, and pretreatment hb-l ceased to impact significantly on outcome. Tumor size remained the most powerful independent predictor for all endpoints tested, followed by treatment hb-l. Paraortic node status was significantly correlated with DSS and MFS. CONCLUSION Although a trend toward poorer DSS and PC was observed in embolized patients, no impact on radiocurability could be demonstrated in multivariate analysis after controlling for the major tumor characteristics and treatment hb-l.
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Affiliation(s)
- Karin S Kapp
- Department of Radiation Oncology, Karl-Franzens University Medical School Graz, Graz, Austria
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Varlotto J, Stevenson MA. Anemia, tumor hypoxemia, and the cancer patient. Int J Radiat Oncol Biol Phys 2005; 63:25-36. [PMID: 16111569 DOI: 10.1016/j.ijrobp.2005.04.049] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 02/16/2005] [Accepted: 04/18/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE To review the impact of anemia/tumor hypoxemia on the quality of life and survival in cancer patients, and to assess the problems associated with the correction of this difficulty. METHODS MEDLINE searches were performed to find relevant literature regarding anemia and/or tumor hypoxia in cancer patients. Articles were evaluated in order to assess the epidemiology, adverse patient effects, anemia correction guidelines, and mechanisms of hypoxia-induced cancer cell growth and/or therapeutic resistance. Past and current clinical studies of radiosensitization via tumor oxygenation/hypoxic cell sensitization were reviewed. All clinical studies using multi-variate analysis were analyzed to show whether or not anemia and/or tumor hypoxemia affected tumor control and patient survival. Articles dealing with the correction of anemia via transfusion and/or erythropoietin were reviewed in order to show the impact of the rectification on the quality of life and survival of cancer patients. RESULTS Approximately 40-64% of patients presenting for cancer therapy are anemic. The rate of anemia rises with the use of chemotherapy, radiotherapy, and hormonal therapy for prostate cancer. Anemia is associated with reductions both in quality of life and survival. Tumor hypoxemia has been hypothesized to lead to tumor growth and resistance to therapy because it leads to angiogenesis, genetic mutations, resistance to apoptosis, and a resistance to free radicals from chemotherapy and radiotherapy. Nineteen clinical studies of anemia and eight clinical studies of tumor hypoxemia were found that used multi-variate analysis to determine the effect of these conditions on the local control and/or survival of cancer patients. Despite differing definitions of anemia and hypoxemia, all studies have shown a correlation between low hemoglobin levels and/or higher amounts of tumor hypoxia with poorer prognosis. Radiosensitization through improvements in tumor oxygenation/hypoxic cell sensitization has met with limited success via the use of hyperbaric oxygen, electron-affinic radiosensitizers, and mitomycin. Improvements in tumor oxygenation via the use of carbogen and nicotinamide, RSR13, and tirapazamine have shown promising clinical results and are all currently being tested in Phase III trials. The National Comprehensive Cancer Network (NCCN) guidelines recommend transfusion or erythropoietin for symptomatic patients with a hemoglobin of 10-11 g/dl and state that erythropoietin should strongly be considered if hemoglobin falls to less than 10 g/dl. These recommendations were based on studies that revealed an improvement in the quality of life of cancer patients, but not patient survival with anemia correction. Phase III studies evaluating the correction of anemia via erythropoietin have shown mixed results with some studies reporting a decrease in patient survival despite an improvement in hemoglobin levels. Diverse functions of erythropoietin are reviewed, including its potential to inhibit apoptosis via the JAK2/STAT5/BCL-X pathway. Correction of anemia by the use of blood transfusions has also shown a decrement in patient survival, possibly through inflammatory and/or immunosuppressive pathways. CONCLUSIONS Anemia is a prevalent condition associated with cancer and its therapies. Proper Phase III trials are necessary to find the best way to correct anemia for specific patients. Future studies of erythropoietin must evaluate the possible anti-apoptotic effects by directly assessing the tumor for erythropoietin receptors or the presence of the JAK2/STAT5/BCL-X pathway. Due to the ability of transfusions to cause immunosuppression, most probably through inflammatory pathways, it may be best to study the effects of transfusion with the prolonged use of anti-inflammatory medications.
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Affiliation(s)
- John Varlotto
- Department of Radiation Oncology, Boston VA Medical Center, Boston, MA 02130, USA.
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Abstract
Chemoradiotherapy with either weekly doses of cisplatin or the combination of 5-fluorouracil and cisplatin has become the standard of therapy for patients with locally advanced cervix cancer. Recently reported studies that are directed at improvements in radiation treatment planning, improved tissue oxygenation, and neoadjuvant chemotherapy are likely to lead to improvements in therapy. Nonsurgical preoperative staging with positron emission tomography and sentinel lymph node evaluation could result in effective surgical staging, or even nonsurgical staging, more accurate radiation treatment planning, and improved local and systemic control with a reduction in short-term and long-term morbidity in the treatment of locally advanced cervix cancer. Well-designed, randomized, prospective clinical trials are needed for a more thorough evaluation of these preliminary findings and to set research directions for the next several years.
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Affiliation(s)
- Harry J Long
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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