The problem of anaemia in patients with colorectal cancer. ISRN Hematol. 2014;2014:547914. [PMID: 24696785 PMCID: PMC3947861 DOI: 10.1155/2014/547914]

Is restrictive transfusion sufficient in colorectal cancer surgery? A retrospective study before and during the COVID-19 pandemic in Korea

PURPOSE

Blood transfusion is one of the most common procedures used to treat anemia in colorectal surgery. Despite controversy regarding the adverse effects of blood products, surgeons have maintained standards for administering blood transfusions. However, this trend was restrictive during the COVID-19 pandemic because of a shortage of blood products. In this study, we conducted an analysis to investigate whether the restriction of blood transfusions affected postoperative surgical outcomes.

METHODS

Medical records of 318 patients who underwent surgery for colon and rectal cancer at Ewha Womans University Mokdong Hospital between June 2018 and March 2022 were reviewed retrospectively. The surgical outcomes between the liberal and restrictive transfusion strategies in pre- and post-COVID-19 groups were analyzed.

RESULTS

In univariate analysis, postoperative transfusion was associated with infectious complications (odds ratio [OR], 1.705; 95% confidence interval [CI], 1.015-2.865; P=0.044). However, postoperative transfusion was not an independent risk factor for the development of infectious complications in multivariate analysis (OR, 1.305; 95% CI, 0.749-2.274; P=0.348). In subgroup analysis, there was no significant association between infectious complications and the hemoglobin threshold level for the administration of a transfusion (OR, 1.249; 95% CI, 0.928-1.682; P=0.142).

CONCLUSION

During colorectal surgery, the decision to perform a blood transfusion is an important step in ensuring favorable surgical outcomes. According to the results of this study, restrictive transfusion is sufficient for favorable surgical outcomes compared with liberal transfusion. Therefore, modification of guidelines is suggested to minimize unnecessary transfusion-related side effects and prevent the overuse of blood products.

Management pattern and medication-related harms and its predictors in colorectal cancer patients: an institutional-based retrospective study

Introduction

Data on colorectal cancer (CRC) patients' thorough management practices and medication-related harms (MRH) are scarce. This study's aim was to investigate the MRHs in patients receiving CRC chemotherapy at the comprehensive specialized hospital of the University of Gondar (UoGCSH).

Methods

A registry-based retrospective cohort study was conducted on CRC patients at the UoGCSH during 2017-2021. From February to May 2022, medical records were reviewed using a pretested data collection tool to collect socio-demographic and disease-related characteristics, MRHs, and medication regimens. MRHs occurrence and adverse drug reactions (ADRs) severity were assessed using standard guidelines and protocols. Version 16/MP of STATA for Windows was used for the analysis. Independent predictors of MRHs were investigated using logistic regression analysis. A p-value ≤0.05 was used to determine an independent variable's statistical significance.

Results

One hundred forty three CRC patients were included, with a mean age of 49.9 ± 14.5 years. About 32.9% and 33.6% had stage II and III cancer, respectively. Significant patients had co-morbidities (15.4%) and complications (13.3%). Fluorouracil (5-FU)-based regimens were given to more than half (56%) of the patients. MRHs were found in 53.1% of the patients, with a mean of 2.45 ± 1.37 MRHs. The most common MRHs were the need for additional drug therapy, sub-therapeutic dose, DDIs, and ADRs. Being on stage IV (AOR = 27.7, 95% CI = 3.85-199.38, p = 0.001), having co-morbidity (AOR = 7.42, 95% CI = 1.80-30.59, p = 0.018) and having complication (AOR = 11.04, 95% CI = 1.72-70.95, p = 0.011) and treated with five or more drugs (AOR = 2.54, 95% CI = 1.07-6.07, p = 0.035) were independent predictors of MRHs.

Conclusion

A fluorouracil-based treatment regimen was most frequently used. MRHs were found in nearly half of CRC patients. Furthermore, MRHs were significantly associated with cancer stage, comorbidity and complication status, and the number of medications used. Because MRHs are common, improving clinical pharmacy services is critical for optimizing drug therapy in CRC patients.

A protocol for a prospective, multicentre observational study to determine if nonanaemic iron deficiency worsens postoperative outcome in patients undergoing elective surgery for resection of colorectal cancer: The NATO study

BACKGROUND

Preoperative absolute and functional iron deficiency anaemia is associated with poor postoperative outcomes in patients undergoing surgery for colorectal cancer. It is biologically plausible that "early", or "nonanaemic" iron deficiency may also be associated with worse postoperative outcomes in similar cohorts, albeit at lesser severity than that seen for anaemia. The evidence supporting this assertion is of low quality.

METHODS

We have designed a prospective, observational study to delineate associations between preoperative non-anaemic iron deficiency and postoperative outcomes after surgery for colorectal cancer. Patients without anaemia, undergoing elective surgery for colorectal cancer will be allocated to an iron replete or an iron deficient group based on preoperative transferrin saturation. The primary outcome is days alive and at home on postoperative day 90. Secondary outcomes include days alive and at home on postoperative day 30, length of hospital stay, readmission to acute care, postoperative complications, health-related quality of life scores, quality of postoperative recovery, and requirement for allogeneic blood transfusion. The planned sample size is 422 patients, which has 80% power to detect a two-day difference in the primary outcome. The study commenced in May 2019.

CONCLUSION

The results of this study will provide patients and clinicians with high-quality evidence concerning associations between nonanaemic iron deficiency and patient-centred outcomes after surgery for colorectal cancer. The study will be conducted in multiple urban and rural centres across Australia and New Zealand. The results will be highly generalisable to contemporary surgical practice and should be rapidly translated.

Clinical pattern and drug-related problems among colorectal cancer patients at oncology center in Ethiopia: A hospital-based study

Objective:

Despite the fact that cancer patients are highly susceptible to drug-related problems due to the effects of cytotoxic agents, data are limited due to a lack of studies on those patients. Hence, we aimed to investigate drug-related problems among patients diagnosed with colorectal cancer.

Method:

A registry-based cross-sectional study was conducted on colorectal cancer patients at the Felege Hiwot Comprehensive Specialized Hospital. Socio-demographic and disease-related characteristics, treatment regimens, and drug-related problems were recorded by reviewing medical records. Standard guidelines, protocols, and databases were used to evaluate the occurrence of drug-related problems and the severity of adverse drug reactions. For the analysis, Stata version 16/MP for Windows was used. Logistic regression analysis was employed to investigate the potential-associated factors of drug-related problems. A p-value ⩽ 0.05 was used to declare the statistical significance of each independent variable.

Results:

A total of 150 colorectal cancer patients were included, with a mean age of 51.4 ± 13.8 years. About 30% and 41.3% had stage II and stage III cancers, respectively. About three-quarters (73.8%) of the patients were given 5-fluorouracil-based combination regimens. The prevalence of drug-related problems was found to be 48.7%, with a mean of 2.12 ± 0.93 drug-related problems. In the Felege Hiwot Comprehensive Specialized Hospital, drug–drug interactions and adverse drug reactions were the most prevalent drug-related problems, which accounted for 50 (32.7%) and 49 (32%) cases, respectively. Being elderly (>50 years old) (p = 0.013), having co-morbidity (p = 0.001), and being on five or more medications (p = 0.002) were independent predictors of drug-related problems.

Conclusion:

Fluorouracil-based chemotherapy was the most frequently used treatment regimen. Almost, half of the colorectal cancer patients had one or more drug-related problems. About one-third of patients had adverse drug reactions and drug–drug interactions. Furthermore, age, co-morbidity status, and the number of medications used were significantly associated with drug-related problems. Clinical pharmacy services should be implemented to optimize drug therapy because the majority of colorectal cancer patients have one or more drug-related problems.

Hematinic and Iron Optimization in Peri-operative Anemia and Iron Deficiency

Purpose of Review

Preoperative anemia is independently associated with worse postoperative outcomes following cardiac and noncardiac surgery. This article explores the current understanding of perioperative anemia and iron deficiency with reference to definition, diagnosis, and treatment.

Recent Findings

Iron deficiency is the most common cause of anemia. It can arise from reduced iron intake, poor absorption, or excess iron loss. Inflammation throughout the preoperative period can drive iron sequestration, leading to a functional deficiency of iron and the development of what was referred to until recently as the “anemia of chronic disease.” Current best practice guidance supports the routine administration of preoperative intravenous iron to treat anemia despite limited evidence. This “one size fits all” approach has been called into question following results from a recent large, randomized trial (the PREVENTT trial) that assessed the use of a single dose of intravenous iron compared to placebo 10–42 days before major abdominal surgery. Although there were no improvements in patient-centered outcomes apparent during the initial hospital stay, secondary endpoints of this trial suggested there may be some late benefit after discharge from the hospital (8 weeks postoperatively). This trial raises questions on (1) the mechanisms of iron deficiency in the perioperative patient; (2) the need to reassess our opinions on generic anemia management; and (3) the need to address patient outcomes after discharge from hospital.

Summary

Despite the known associations between preoperative anemia (particularly iron deficiency anemia) and poor postoperative outcome, recent evidence suggests that administering intravenous iron relatively close to surgery does not yield a tangible short-term benefit. This is made more complex by the interplay between iron and innate immunity. Iron deficiency irrespective of hemoglobin concentration may also impact postoperative outcomes. Therefore, further research into associations between iron deficiency and postoperative outcomes, and between postoperative anemia, delayed outcomes (hospital readmission), and the efficacy of postoperative intravenous iron is required.

Use of Machine Learning and Statistical Algorithms to Predict Hospital Length of Stay Following Colorectal Cancer Resection: A South African Pilot Study

The aim of this pilot study was to develop logistic regression (LR) and support vector machine (SVM) models that differentiate low from high risk for prolonged hospital length of stay (LOS) in a South African cohort of 383 colorectal cancer patients who underwent surgical resection with curative intent. Additionally, the impact of 10-fold cross-validation (CV), Monte Carlo CV, and bootstrap internal validation methods on the performance of the two models was evaluated. The median LOS was 9 days, and prolonged LOS was defined as greater than 9 days post-operation. Preoperative factors associated with prolonged LOS were a prior history of hypertension and an Eastern Cooperative Oncology Group score between 2 and 4. Postoperative factors related to prolonged LOS were the need for a stoma as part of the surgical procedure and the development of post-surgical complications. The risk of prolonged LOS was higher in male patients and in any patient with lower preoperative hemoglobin. The highest area under the receiving operating characteristics (AU-ROC) was achieved using LR of 0.823 (CI = 0.798–0.849) and SVM of 0.821 (CI = 0.776–0.825), with each model using the Monte Carlo CV method for internal validation. However, bootstrapping resulted in models with slightly lower variability. We found no significant difference between the models across the three internal validation methods. The LR and SVM algorithms used in this study required incorporating important features for optimal hospital LOS predictions. The factors identified in this study, especially postoperative complications, can be employed as a simple and quick test clinicians may flag a patient at risk of prolonged LOS.

DPYD c.1905 + 1G>A Promotes Fluoropyrimidine-Induced Anemia, a Prognostic Factor in Disease-Free Survival, in Colorectal Cancer

Background and Aim: In 10-30% of colorectal cancer (CRC) patients, toxic reactions occur after fluoropyrimidine-based chemotherapy. A dihydropyridine dehydrogenase (DPYD) gene variant, c.1905 + 1G>A, leads to intolerance to fluoropyrimidines. Due to the low frequency of this variant in many populations, the prevalence of fluoropyrimidine-induced hematologic side effects in CRC patients with the c.1905 + 1G>A variant is unclear. In this study, we investigated the prevalence of the DPYD c.1905 + 1 variants in a Turkish CRC cohort and the potential effects of these variants on fluoropyrimidine-induced hematologic side effects. Materials and Methods: The DPYD c.1905 + 1 variant was genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis and confirmed by Sanger sequencing in peripheral blood samples of 100 CRC patients who received fluoropyrimidine-based chemotherapy and 60 healthy volunteers. The association of c.1905 + 1 variants with susceptibility to hematologic side effects was evaluated. Results: The DPYD c.1905 + 1G>A variant was more common in the CRC group than in the healthy control group (p = 0.001). The presence of the c.1905 + 1G>A variant was associated with thrombocytopenia (p = 0.039) and anemia (p = 0.035). CRC patients with fluoropyrimidine-induced anemia had shorter disease-free survival than CRC patients without fluoropyrimidine-induced anemia (p = 0.0009). Conclusions: Before administering fluoropyrimidine-based chemotherapy, genetic screening for the DPYD c.1905 + 1G>A variant should be performed with the aim of preventing anemia and anemia-induced complications in CRC patients.

Association of Comorbid Diabetes With Clinical Outcomes and Healthcare Utilization in Colorectal Cancer Survivors

OBJECTIVES

To compare clinical outcomes and healthcare utilization in colorectal cancer (CRC) survivors with and without diabetes.

SAMPLE & SETTING

CRC survivors (N = 3,287) were identified from a statewide electronic health record database using International Classification of Diseases (ICD) codes. Data were extracted on adults aged 21 years or older with an initial diagnosis of stage II or III CRC with diabetes present before CRC diagnosis or no diagnosis of diabetes (control).

METHODS & VARIABLES

ICD codes were used to extract diabetes diagnosis and clinical outcome variables. Healthcare utilization was determined by encounter type. Data were analyzed using descriptive statistics, multivariable logistic, and Cox regression.

RESULTS

CRC survivors with diabetes were more likely to develop anemia and infection than CRC survivors without diabetes. In addition, CRC survivors with diabetes were more likely to utilize emergency resources sooner than CRC survivors without diabetes.

IMPLICATIONS FOR NURSING

Oncology nurses can facilitate the early identification of high-risk survivor groups, reducing negative clinical outcomes and unnecessarily high healthcare resource utilization in CRC survivors with diabetes.

Extricating the Association Between the Prognostic Factors of Colorectal Cancer

PURPOSE

Colorectal cancer (CRC) is one of the recurring and lethal gastrointestinal tract disease rankings as the primary cause of worldwide morbidity and mortality. In general, the tumour node metastasis (TNM) and Dukes classification assist in diagnosis, prognosis and treatments of CRC along with haematological examinations and tumour demographic characterisations in patients.

METHODS

The present investigation is carried out on clinically acknowledged sixty-five CRC patients based on haematological findings and are sorted into stages using TNM and Dukes. The present study is to find the association between haematological findings, demographic characters, differentiation position, lymph node invasion and tumour node metastasis in CRC patients in accordance with their age.

RESULTS

We observed significant (p < 0.05) nexus between lymph node metastasis and tumour node metastasis on the basis of tumour's differentiation demographic positioning and age of the individuals.

CONCLUSION

Earlier location tracing and medicinal treatment or surgery lessen the chance of CRC morbidity and mortality along with prolonging survival rate via prognostic factors and disease position determination.

Associations between non-anaemic iron deficiency and outcomes following surgery for colorectal cancer: An exploratory study of outcomes relevant to prospective observational studies

Iron deficiency is common in colorectal cancer. Despite perioperative guidelines advocating for the correction of non-anaemic iron deficiency prior to major surgery, the impact of this pathology on postoperative outcome is unclear.

We conducted a single-centre, historical cohort study of 141 elective resections for colorectal cancer. We stratified non-anaemic patients into iron deficient and iron replete groups, and collected data on baseline characteristics, preoperative laboratory results, intraoperative events and postoperative outcomes. As this study was an exploratory work for future research, a P-value of 0.25 was considered relevant. Patients in the deficient group demonstrated lower baseline ferritin (median (interquartile range, IQR) 76 (41–141) µg/L versus 207 (140–334) µg/L, P < 0.001) and transferrin saturation (mean (standard deviation, SD) 18% (8%) versus 32% (12%), P < 0.001) than those in the replete group, and lower starting haemoglobin (mean (SD) 138 (10) g/L versus 144 (12) g/L, P = 0.01). The deficient group had increased re-admission (25% (24%) versus 4% (11%), P = 0.15) and all-cause infection (25% (24%) versus 5% (14%), P = 0.24). A decrease of two days in days alive and out of hospital at postoperative day 90 was seen in the deficient group on univariate analysis (median (IQR) 81 (75–84) versus 83 (78–84), P = 0.25). This reduced to 1.24 days in multivariate adjusted quantile regression analysis ( P = 0.22). Days alive and out of hospital at day 90, postoperative re-admission and postoperative infection may be meaningful outcome measures for future prospective observational work examining non-anaemic iron deficiency in patients undergoing major surgery for colorectal cancer.

Iron deficiency in a tertiary gastroenterology center in Romania: prevalence and significancy

Introduction:Iron deficiency has been known to cause significant functional impairment, lower quality of life and higher morbidity and mortality. The aim of this study was to estimate the prevalence and significance of iron deficiency in our patients and medical staff. Material and methods:We performed a prospective cross-sectional study: In July 2016, 383 persons were screened for the presence of iron deficiency (ID): 325 patients and 58 people from the medical staff. Transferrin saturation (TSAT), serum ferritin (SF) and complete blood count were performed. Absolute ID was diagnosed if SF <100 ng/ml and TSAT <20%. Relative ID was defined by SF >100 ng/ml and TSAT <20%. Results:The group of medical staff was younger and had a greater proportion of women. The prevalence of absolute ID was 22.5% in patients and 43.1% in medical staff; relative ID was present in 15% of patients and 1.7% of medical staff. Among patients, the absolute ID was significantly correlated with the female sex (p=0.002) and pre-menopausal status (p=0.01) but did not correlate with diagnosis, age, BMI, nonsteroidal anti-inflammatory drug (NSAID), aspirin or acenocoumarol consumption. The relative ID is associated with advanced age (p=0.03) and diagnosis of cancer and liver cirrhosis (p=0.01). Conclusions:Absolute ID had a high prevalence among patients (22.5%), but there was even a bigger issue among the medical staff (43.1%). Absolute ID was correlated with female sex and pre-menopausal status. Relative ID was related to advanced age, cancer and liver cirrhosis. Abbreviations: serum ferritine- SF, transferrin saturation coefficient- TSAT, iron deficiency- ID, inflammatory bowel diseases- IBD, quality of life- QoL, GI- gastrointestinal.

Comparative analysis of colorectal carcinoma staging using operative, histopathology and computed tomography findings

Background:

The staging of colorectal carcinoma using 3 modalities viz operative, histopathology and CT scan has been subject of interest in accurately defining the extent of disease. This retrospective as well as prospective study was carried out at CMC, Ludhiana, Punjab from November 2011 to May 2014.

Aim:

The objective of this study was to assess the usefulness and accuracy of CT scan findings to state the extent and spread of colorectal malignancy and to correlate these findings with histopathological diagnosis.

Method:

A total of 31 biopsy proven patients showing variable bowel wall thickening involving the colon /rectum on CECT (Contrast Enhanced Computed Tomography) were included in the study. The tumours were staged based on the CT scan findings and were compared with the operative and histopathological findings.

Observations:

Rectum was the most common site of involvement followed by the recto-sigmoid involvement. Metastasis was observed in 5 cases out of the 31 malignant cases. Five of the 7 cases were correctly staged as T1 & T2 lesions on CT having a sensitivity of 83.3%, specificity of 92%, and positive predictive value of 71.4% and a negative predictive value of 95.8% in the diagnosis of T1 and T2 lesions. 15 of the 16 cases were correctly staged as T3 lesions. CT had a sensitivity of 88.2%, specificity of 93.8%, and positive predictive value of 93.8% and a negative predictive value of 86.7% in the diagnosis of T3 lesions. All the 8 cases were correctly staged as T4 lesions. CT had a sensitivity of 100%, specificity of 100%, and positive predictive value of 100% and a negative predictive value of 100% in the diagnosis of T4 lesions.

Conclusion:

We conclude that CT scan is an excellent modality in diagnosing malignant lesions of the colon and rectum.

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia (IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.

Characteristics of colorectal cancer diagnosed with screening abdominal ultrasonography

Patient records were retrospectively analyzed to elucidate the characteristics of patients with colorectal cancer (CRC) diagnosed with screening abdominal ultrasound (US). Patients diagnosed with CRC using abdominal US [localized irregular wall thickening (W) or a hypoechoic mass with a hyperechoic mass (M)] were enrolled. The patients were subjected to colonoscopy and treated surgically between March, 2010 and January, 2015. A total of 5 men (aged 74.0±0.8 years) and 10 women (aged 73.0±12.0 years) were analyzed. Stratification was analyzed with abdominal US. The threshold value of wall thickness to diagnose CRC was investigated with receiver operating characteristic (ROC) curve analysis. The average wall thickness was 2.8±0.4 mm in the surrounding normal tissue and 12.7±5.2 mm in CRC (one-way analysis of variance, P<0.0001). The wall was significantly thicker in CRC compared with the normal colonic wall. The calculated threshold value was 4.3 mm for the diagnosis of CRC. Stratification was preserved in W, while it was lost in M (Chi-squared test, P=0.0196). The hemoglobin concentration was lower, while the C-reactive protein, carcinoembryonic antigen and carbohydrate antigen 19-9 levels were elevated above normal values. The threshold value was 4.3 mm for the diagnosis of CRC with abdominal US.

An evidence-based approach to red blood cell transfusions in asymptomatically anaemic patients

INTRODUCTION

Surgeons and physicians encounter blood transfusions on a daily basis but a robust evidence-based strategy on indications and timing of transfusion in asymptomatic anaemic patients is yet to be determined. For judicious use of blood products, the risks inherent to packed red blood cells, the patient's co-morbidities and haemoglobin (Hb)/haematocrit levels should be considered. This review critiques and summarises the latest available evidence on the indications for transfusions in healthy and cardiac disease patients as well as the timing of transfusions relative to surgery.

METHODS

An electronic literature search of the MEDLINE(®), Google Scholar™ and Trip databases was conducted for articles published in English between January 2006 and January 2015. Studies discussing timing and indications of transfusion in medical and surgical patients were retrieved. Bibliographies of studies were checked for other pertinent articles that were missed by the initial search.

FINDINGS

Six level 1 studies (randomised controlled trials or systematic reviews) and six professional society guidelines were included in this review. In healthy patients without cardiac disease, a restrictive transfusion trigger of Hb 70-80g/l is safe and appropriate whereas in cardiac patients, the trigger is Hb 80-100g/l. The literature on timing of transfusions relative to surgery is limited. For the studies available, preoperative transfusions were associated with a decreased incidence of subsequent transfusions and timing of transfusions did not affect the rates of colorectal cancer recurrence.