1
|
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.
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Gennigens C, De Cuypere M, Seidel L, Hermesse J, Barbeaux A, Forget F, Albert A, Jerusalem G, Kridelka F. Correlation between hematological parameters and outcome in patients with locally advanced cervical cancer treated by concomitant chemoradiotherapy. Cancer Med 2020; 9:8432-8443. [PMID: 32954675 PMCID: PMC7666723 DOI: 10.1002/cam4.3465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 01/28/2023] Open
Abstract
Background Hemoglobin (Hb), white blood cell (WBC), and polymorphonuclear neutrophil (PMN) blood counts may be correlated with outcomes in patients with locally advanced cervical cancer. Methods Hb, WBC, and PMN counts were measured at diagnosis and during concomitant cisplatin‐based chemoradiotherapy (CCRT) in a retrospective sample of 103 patients between 2010 and 2017. Red blood cell (RBC) transfusions were also recorded. The associations between hematological variables and patient overall survival (OS) and recurrence‐free survival (RFS) were assessed by Cox regression models. Results The 3‐year OS and RFS rates were 81.4% and 76.8%, respectively. In addition to tumor size and smoking, OS and RFS were found to be significantly associated with changes in WBC and PMN counts from the first to the last cisplatin cycle. Hb count throughout the treatment and RBC transfusions were not predictive of outcome. Conclusions This study found no association between Hb count or RBC transfusions and outcome. The daily practice of maintaining the Hb count above 12 g/dL during CCRT should be weighed against the potential risks of transfusions. Drops in WBC and PMN counts during treatment positively impacted OS and RFS and could, therefore, serve as biomarkers during CCRT to adapt the follow‐up and consider the need for adjuvant systemic treatments.
Collapse
Affiliation(s)
| | | | - Laurence Seidel
- Department of Biostatistics, CHU Liège and Liège University, Liège, Belgium
| | | | | | - Frédéric Forget
- Department of Medical Oncology, Libramont Hospital, Libramont, Belgium
| | - Adelin Albert
- Department of Biostatistics, CHU Liège and Liège University, Liège, Belgium
| | - Guy Jerusalem
- Department of Medical Oncology, CHU Liège and Liège University, Liège, Belgium
| | - Frédéric Kridelka
- Department of Obstetrics and Gynaecology, CHU Liège and Liège University, Liège, Belgium
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
Park SY, Seo KS, Karm MH. Perioperative red blood cell transfusion in orofacial surgery. J Dent Anesth Pain Med 2017; 17:163-181. [PMID: 29090247 PMCID: PMC5647818 DOI: 10.17245/jdapm.2017.17.3.163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 08/24/2017] [Accepted: 09/03/2017] [Indexed: 01/28/2023] Open
Abstract
In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.
Collapse
Affiliation(s)
- So-Young Park
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| |
Collapse
|
7
|
|
8
|
Bishop AJ, Allen PK, Klopp AH, Meyer LA, Eifel PJ. Relationship between low hemoglobin levels and outcomes after treatment with radiation or chemoradiation in patients with cervical cancer: has the impact of anemia been overstated? Int J Radiat Oncol Biol Phys 2015; 91:196-205. [PMID: 25446609 DOI: 10.1016/j.ijrobp.2014.09.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/09/2014] [Accepted: 09/15/2014] [Indexed: 02/03/2023]
Abstract
PURPOSE Previous reports have suggested that anemia increases rates of recurrence after radiation therapy for cervical cancer. However, these studies may not have fully corrected for confounding risk factors. Using a well-characterized cohort of cervical cancer patients, we examined the association between anemia and outcomes before and after the introduction of chemoradiation as standard of care. METHODS AND MATERIALS We reviewed the records of 2454 patients who underwent definitive radiation therapy from 1980 through 2011. Minimum hemoglobin level (Hgbmin) was recorded for 2359 patients (96%). Endpoints included freedom from central recurrence (FFCR), freedom from distant metastasis (FFDM), and disease-specific survival (DSS). RESULTS For the entire cohort, hemoglobin concentrations of 9, 10, and 12 g/dL before and during radiation were all significantly associated with FFCR, FFDM, and DSS (all P<.001) on univariate analysis. However, on multivariate analysis, only Hgbmin less than 10 g/dL during RT (RT-Hgb<10) remained significant, and it was correlated with lower DSS (P=.02, hazard ratio [HR] = 1.28) and FFDM (P=.03, HR = 1.33) but not with FFCR. In a subset analysis of patients receiving chemoradiation (n=678), RT-Hgb<10 was associated only with DSS (P=.008, HR = 1.49), not with FFCR or FFDM. In this subgroup, despite an association between RT-Hgb<10 and DSS, the use of transfusion was not correlated with benefit. CONCLUSIONS No evidence was found supporting anemia as an independent predictor of central recurrence in patients treated with definitive radiation therapy with or without chemotherapy. Less emphasis on correcting anemia in cervical cancer patients may be warranted.
Collapse
Affiliation(s)
- Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|
9
|
Gangopadhyay A, Das J, Nath P, Biswas J. Haemoglobin levels may predict toxicities in patients on pelvic chemoradiation for carcinoma of the cervix-experience of a regional cancer centre. Ecancermedicalscience 2014; 8:431. [PMID: 24963348 PMCID: PMC4027891 DOI: 10.3332/ecancer.2014.431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Haemoglobin levels and tissue oxygenation influence tumour outcome in carcinoma cervix radiotherapy. The clinical impact of haemoglobin levels on acute normal tissue toxicity during radiation and interaction with chemotherapy in carcinoma of the cervix is underexplored. This paper aims to explore this issue. METHODS Treatment toxicity among 227 patients with squamous cell carcinoma of the cervix stages II B-IV A, receiving pelvic radiotherapy or chemoradiation at our institute, were studied prospectively. The baseline and weekly haemoglobin levels during treatment were recorded. Acute toxicities were recorded using Radiation Therapy Oncology Group (RTOG) acute toxicity and Common Terminology Criteria for Adverse Events (CTCAE) criteria, version 4. For the analysis, patients were divided into two groups, depending on nadir haemoglobin levels. A cut-off value for anaemia was selected at 12 gm/dL. Toxicity was compared between anaemic and non-anaemic groups. RESULTS Patients on chemoradiation and having haemoglobin levels >12 gm/dL suffered significantly higher dermatitis (two-tailed p value = 0.0288) and vaginal mucositis (two-tailed p value = 0.0187) of at least RTOG acute toxicity grade 2, compared with the anaemic group. In contrast patients receiving radiotherapy alone did not experience any significantly greater mucocutaneous toxicity if haemoglobin was >12 gm/dL. Anaemia had significantly greater impact on malaise and neutropenia (two-tailed p value <0.0001) of CTCAE grade 1 and above among chemoradiation patients, as opposed to those receiving radiotherapy alone (two-tailed p values = 0.0012 for neutropenia and 0.0422 for malaise). CONCLUSION Haemoglobin values >12 gm/dL significantly worsen acute mucocutaneous toxicity in locally advanced cervical cancer patients receiving chemoradiation. Similar effects are not observed in the absence of chemotherapy.
Collapse
Affiliation(s)
- Aparna Gangopadhyay
- Department of Radiation Oncology Chittaranjan National Cancer Institute, 37 SP Mukherjee Road, Kolkata 700026, India
| | - Joydeep Das
- Department of Radiation Oncology Chittaranjan National Cancer Institute, 37 SP Mukherjee Road, Kolkata 700026, India
| | - Partha Nath
- Department of Medical Oncology, Chittaranjan National Cancer Institute, 37 SP Mukherjee Road, Kolkata 700026, India
| | - Jaydip Biswas
- Department of Medical Oncology, Chittaranjan National Cancer Institute, 37 SP Mukherjee Road, Kolkata 700026, India
| |
Collapse
|
10
|
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.
Collapse
|
11
|
Abdel-Razeq H, Abbasi S, Saadi I, Jaber R, Abdelelah H. Intravenous iron monotherapy for the treatment of non-iron-deficiency anemia in cancer patients undergoing chemotherapy: a pilot study. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:939-44. [PMID: 24039403 PMCID: PMC3770628 DOI: 10.2147/dddt.s45674] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Anemia in patients with cancer who are undergoing active therapy is commonly encountered and may worsen quality of life in these patients. The effect of blood transfusion is often temporary and may be associated with serious adverse events. Erythropoiesis-stimulating agents are not effective in 30%–50% of patients and may have a negative effect on overall survival. Aims To assess the efficacy and feasibility of intravenous iron therapy in patients with cancer who have non-iron-deficiency anemia and who are undergoing treatment with chemotherapy without the use of erythropoiesis-stimulating agents. Methods Adult patients with solid cancers and non-iron-deficiency anemia were included. Ferric sucrose at a dose of 200 mg was given in short intravenous infusions weekly for a total of 12 weeks. Hemoglobin level was measured at baseline, every 3 weeks, and 2 weeks after the last iron infusion (week 14). Adverse events related to intravenous iron were prospectively reported. Results Of 25 patients included, 19 (76.0%) completed at least three iron infusions and 14 (56.0%) finished the planned 12 weeks of therapy. The mean hemoglobin level of the 25 patients at baseline was 9.6 g/dL (median, 9.9 g/dL; range, 6.9 g/dL 10.9 g/dL). The mean change in hemoglobin level for the 15 patients who completed at least 9 treatments was 1.7 g/dL (median, 1.1 g/dL; range, −1.9 g/dL to 3.2 g/dL); it reached 2.1 g/dL (median, 1.3 g/dL; range, −0.2 g/dL to 4.6 g/dL; P = 0.0007) for the 14 patients who completed all 12 weekly treatments. Five (20.0%) patients were transfused and considered as treatment failures. No treatment-related adverse events were reported. Conclusion Intravenous iron treatment alone is safe and may reduce blood transfusion requirements and improve hemoglobin level in patients with cancer who are undergoing anticancer therapy. Further randomized studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan.
| | | | | | | | | |
Collapse
|
12
|
|
13
|
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.
Collapse
Affiliation(s)
- Mary E Platek
- Division of Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Buffalo, New York, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Duh MS, L Mark T. Cost-effectiveness of epoetin alfa and darbepoetin alfa in patients with chemotherapy-related anemia. Expert Rev Pharmacoecon Outcomes Res 2010; 5:383-94. [PMID: 19807257 DOI: 10.1586/14737167.5.4.383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anemia frequently develops during cancer chemotherapy and contributes to a variety of adverse clinical outcomes. Correction of anemia has been shown to improve patient outcomes; however, the cost considerations of supportive-care interventions have also become increasingly important to payors. Chemotherapy-related anemia can be managed via red blood cell transfusion; however, inherent transfusion-associated risks (e.g., infectious transmission and immunosuppression) can be particularly problematic in patients with cancer. Epoetin alfa and darbepoetin alfa, alternatives to blood transfusion in patients with chemotherapy-related anemia, are both effective at improving hemoglobin levels and transfusion requirements in patients actively receiving chemotherapy. Determining the relative cost-effectiveness of these erythropoietic therapies is an active research area.
Collapse
|
15
|
Serkies K, Badzio A, Jassem J. Clinical relevance of hemoglobin level in cervical cancer patients administered definitive radiotherapy. Acta Oncol 2009; 45:695-701. [PMID: 16938812 DOI: 10.1080/02841860600833160] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The prognostic impact of pretreatment hemoglobin (Hb) level and its changes during definitive radiotherapy was evaluated by univariate and multivariate analysis in the group of 453 FIGO IB-IIIB cervical cancer patients. Pretreatment anemia (Hb < 12 g/dl) was present in 148 patients (33%), and anemia at the end of irradiation in 48%; in 64% Hb level declined during therapy. Median overall survival in patients with initial Hb >or=12 g/dl was 66 months compared to 22 months in those with lower baseline Hb levels (p = 0.0001). This difference was mainly due to increased risk of distant spread in anemic patients (40% compared to 25% in subjects with pretreatment Hb >or=12 g/dl; p = 0.001). Baseline Hb >or=12 g/dl was also associated with longer disease-free survival and improved local control. Declining Hb level during radiotherapy predicted for impaired 5-year disease-free survival and local control probability. In multivariate analysis, low pretreatment Hb level remained associated with worse overall and disease-free survival, whereas adverse impact of declining Hb level on outcome was not observed. With regard to other clinical factors, stage and tumor extension (uni- or bilateral parametrium involvement for Stage III) were the only independent determinants of prognosis.
Collapse
Affiliation(s)
- Krystyna Serkies
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Poland.
| | | | | |
Collapse
|
16
|
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]
|
17
|
Weber RS, Jabbour N, Martin RCG. Anemia and transfusions in patients undergoing surgery for cancer. Ann Surg Oncol 2007; 15:34-45. [PMID: 17943390 PMCID: PMC7101818 DOI: 10.1245/s10434-007-9502-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 06/03/2007] [Accepted: 06/05/2007] [Indexed: 12/13/2022]
Abstract
Preoperative, operative, and postoperative factors may all contribute to high rates of anemia in patients undergoing surgery for cancer. Allogeneic blood transfusion is associated with both infectious risks and noninfectious risks such as human errors, hemolytic reactions, transfusion-related acute lung injury, transfusion-associated graft-versus-host disease, and transfusion-related immune modulation. Blood transfusion may also be associated with increased risk of cancer recurrence. Blood-conservation measures such as preoperative autologous donation, acute normovolemic hemodilution, perioperative blood salvage, recombinant human erythropoietin (epoetin alfa), electrosurgical dissection, and minimally invasive surgical procedures may reduce the need for allogeneic blood transfusion in elective surgery. This review summarizes published evidence of the consequences of anemia and blood transfusion, the effects of blood storage, the infectious and noninfectious risks of blood transfusion, and the role of blood-conservation strategies for cancer patients who undergo surgery. The optimal blood-management strategy remains to be defined by additional clinical studies. Until that evidence becomes available, the clinical utility of blood conservation should be assessed for each patient individually as a component of preoperative planning in surgical oncology.
Collapse
Affiliation(s)
- Randal S Weber
- University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.
| | | | | |
Collapse
|
18
|
Papatheofanis FJ. Comparative costs of treatment with epoetin alfa and darbepoetin alfa for anemia in the oncology and nephrology settings. Expert Rev Pharmacoecon Outcomes Res 2007; 7:59-73. [DOI: 10.1586/14737167.7.1.59] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
19
|
Le T, Alshaikh G, Hopkins L, Faught W, Fung MFK. Prognostic Significance of Postoperative Morbidities in Patients With Advanced Epithelial Ovarian Cancer Treated With Neoadjuvant Chemotherapy and Delayed Primary Surgical Debulking. Ann Surg Oncol 2006; 13:1711-6. [PMID: 17009146 DOI: 10.1245/s10434-006-9125-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 05/22/2006] [Accepted: 06/07/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND To examine the prognostic significance of postoperative morbidities in patients with ovarian cancer treated with neoadjuvant chemotherapy and interval surgical debulking. METHODS Retrospective chart reviews of all patients treated with neoadjuvant chemotherapy and interval debulking were performed from 1999 to 2002. Descriptive statistics were used to summarize the distributions of important clinical variables. Logistic regression was used to identify statistically significant predictors of postoperative morbidities. Cox regression was used to model time to first clinical progression. Survivals were estimated by the Kaplan-Meier method and compared with the log rank test. P < .05 was considered to be statistically significant. RESULTS Fifty-eight patients were treated with neoadjuvant platinum-taxane combination chemotherapy. Major surgical complications were observed in four patients (6.8%). There were no perioperative deaths. The presence of concurrent medical comorbidities was associated with the development of significant postoperative morbidities (P = .038). Cox regression showed any macroscopic residual disease (P = .04) and the presence of significant postoperative morbidities (odds ratio, 4.7, 95% confidence interval, 1.8-12.7, P = .002) to be predictive of a shorter progression-free interval. CONCLUSIONS Neoadjuvant chemotherapy followed by interval surgical debulking carried a low risk for postoperative morbidity. The adverse influence of marked postoperative morbidity on progression-free survival needs further study.
Collapse
MESH Headings
- Adenocarcinoma, Clear Cell/drug therapy
- Adenocarcinoma, Clear Cell/surgery
- Adenocarcinoma, Clear Cell/therapy
- Adenocarcinoma, Mucinous/drug therapy
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Mucinous/therapy
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma/drug therapy
- Carcinoma/surgery
- Carcinoma/therapy
- Carcinoma, Endometrioid/drug therapy
- Carcinoma, Endometrioid/surgery
- Carcinoma, Endometrioid/therapy
- Combined Modality Therapy
- Cystadenocarcinoma, Serous/drug therapy
- Cystadenocarcinoma, Serous/surgery
- Cystadenocarcinoma, Serous/therapy
- Female
- Gynecologic Surgical Procedures
- Humans
- Middle Aged
- Neoadjuvant Therapy
- Neoplasm Staging
- Neoplasms, Glandular and Epithelial/drug therapy
- Neoplasms, Glandular and Epithelial/surgery
- Neoplasms, Glandular and Epithelial/therapy
- Ovarian Neoplasms/drug therapy
- Ovarian Neoplasms/surgery
- Ovarian Neoplasms/therapy
- Postoperative Complications
- Prognosis
- Retrospective Studies
- Survival Rate
Collapse
Affiliation(s)
- Tien Le
- Division of Gynecologic Oncology, Ottawa General Hospital, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6.
| | | | | | | | | |
Collapse
|
20
|
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.
Collapse
Affiliation(s)
- John Varlotto
- Department of Radiation Oncology, Boston VA Medical Center, Boston, MA 02130, USA.
| | | |
Collapse
|
21
|
Silliman CC. Immunomodulatory Effects of Stored Packed Red Blood Cells in the Injured Patient. ACTA ACUST UNITED AC 2005. [DOI: 10.1111/j.1778-428x.2005.tb00129.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
22
|
Abstract
Anemia is extremely common in patients with cancer. Low hemoglobin levels are associated with diminished quality of life and possibly decreased overall survival. Successful treatment of anemia has undeniable benefits for patients, often yielding dramatic symptomatic improvement that can be very satisfying for clinicians to observe. This review focuses on evolving issues in the management of anemia in patients suffering from cancer. Topics addressed include new evidence-based guidelines concerning the use of epoetin alfa, the evolving role of darbepoetin alfa in cancer-associated anemia, the potential for concomitant iron supplementation to maximize response to erythropoietic agents, the unresolved question of whether erythropoietin use affects survival in cancer patients, new concerns about the risk of thromboembolism in cancer patients with higher hemoglobin levels who are receiving epoetin, and possible immunosuppressive effects of blood product transfusions that may have relevance to neoplasia progression.
Collapse
Affiliation(s)
- David P Steensma
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| |
Collapse
|
23
|
Abstract
Stage IIB-IVA cancer of the cervix represents locally advanced-stage disease that has extended beyond the cervix without clinical evidence of extrapelvic metastasis. Localized surgery is seldom used as the extent of the disease precludes and an adequate surgical margin. Both sophisticated imaging and surgical staging have been utilized to accurately assess the extent of disease for treatment planning. Careful attention to radiation technique and the use of brachytherapy impact survival and treatment morbidity. Concurrent cisplatin-based chemotherapy has become the accepted standard based on randomized clinical trials (level 1 evidence). Further improvements may be achieved with combination chemotherapy, hyperthermia or prophylactic extended field radiation. However, these improvements, currently practiced in developed countries, must be implemented in underdeveloped countries which have the greatest burden of this disease.
Collapse
Affiliation(s)
- Peter G Rose
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio 44109, USA.
| |
Collapse
|