Prognostic Significance of Anemia and Role of Erythropoietin in Radiation Therapy

Baseline anaemia increases locally advanced rectal cancer mortality in older patients undergoing preoperative chemoradiation

PURPOSE

The median diagnosis age of rectal cancer (RC) is 70 years old. The standard of care for locally advanced RC (LARC) is preoperative chemoradiation (CRT) followed by surgery. Anaemia is a frequent condition in older patients but is not a pure consequence of ageing.

METHODS

The patients aged 65 years or over, with clinical stage II/III LARC, and treated with preoperative concurrent CRT were retrospectively reviewed. Baseline haemoglobin (Hb) levels were collected.

RESULTS

One hundred and seven patients enrolled in this study, but 17 were excluded in relation with treatment disruption. Fifty-seven (63.3%) males and 33 (36.7%) females completed preoperative CRT whose median age at diagnosis was 73. Twenty-five (27.8%) patients presented with anaemia at rectal cancer diagnosis, and median Hb was 13.5 g/dL (IQR = 1.45) and 11.2 g/dL (IQR = 1.35), for non-anaemic and anaemic patients, respectively. For the enrolled older population, only 2 patients reported acute grade 3 toxicity. Baseline anaemia tended to decrease the LARC-free interval and was associated with a significantly higher hazard of all-cause and LARC mortality, approximately 5 times (HR = 5.25; 95% CI 1.48-18.66) and 10 times (HR = 10.09; 95% CI 2.40-42.48), respectively. Patients older than 75 presented a significantly negative impact on overall survival (OS) and LARC-specific survival (HR = 6.20, 95% CI 2.00-19.22; and HR = 7.61, 95% CI 2.08-27.87, respectively). Conversely, no significant impact was found for age-adjusted Charlson comorbidity index on OS, LARC-specific survival and LARC-free interval.

CONCLUSIONS

Overall and LARC-specific survival were significantly lower for the baseline anaemic older patients and for those aged 75 years or over.

Concurrent 5-Fluorouracil, Mitomycin C and Radiation with or without Brachytherapy in Recurrent Cervical Cancer: A Scoring System to Predict Clinical Response and Outcome

Aims and purpose

This is a prospective, phase II study aimed to evaluate the effect of concurrent 5-fluorouracil, mitomycin C, and radiation with or without brachytherapy on the clinical outcome of a series of recurrent cervical cancer patients and to determine the prognostic impact of a subset of factors.

Methods

Thirty-three patients with locally recurrent, non-metastatic cervical cancer received external beam radiation (4-week split course: 23.4 + 23.4 Gy) plus two courses of concomitant chemotherapy (5-fluorouracil, 96-h continuous infusion, days 1–4, 1 g/m2/day; mitomycin C, 10 mg/m2, bolus iv, day 1). Twelve patients with vaginal recurrence (36.4%) underwent endocavitary low-dose rate brachytherapy boost (20–25 Gy); 11 patients with lateral pelvic recurrence (33.3%) received external beam radiation boost (14–20 Gy).

Results

Fourteen complete responses (42.4%), 7 partial responses (21.2%), 5 disease stabilizations (15.1%) and 7 progressions (21.2%) were obtained. After a median follow-up of 34 months (range, 6–127), overall actuarial 3-year survival, progression-free survival and local progression-free survival were 59.7%, 48.1% and 51.7%, respectively. Patients with vaginal recurrence of less than 4 cm and negative lymph nodes proved to respond best to the treatment. Two patients (6.1%) experienced hematologic grade 3 toxicity. One patient had grade 3 intestinal toxicity (3.0%). No patient had major skin or urological acute toxicity. Severe late toxicity was infrequent Three patients had prolonged leukopenia (9.0%). Four patients showed severe vaginal stenosis (12.1%). A clinical score of 0 to 1 was assigned to each patient on the basis of the absence (score = 0) or presence (score = 1) of any of the following prognostic factors: time between surgery and recurrence shorter than 12 months, pelvic wall site of recurrence, positive lymph nodes, hemoglobin <11 g/dL. Using this system, it was clear that patients with a low total score had a significantly better outcome (clinical remission, 51% of patients with a score ≤2 vs 12% of patients with a score >2, P = 0.06), local control of the disease (65% vs 20% after 3 years, P = 0.001,) and overall survival (75% vs 30% after 3 years, P = 0.032).

Conclusions

Our data suggest that this combined modality therapy was relatively well tolerated and resulted in reasonable local control and survival. The scoring system proved to be helpful to identify patients with the greatest chance of benefiting from the treatment Further studies are probably needed to salvage the other patients, whose prognosis remains severe.

Concurrent 5-Fluorouracil, Mitomycin C and Radiation, with or without Brachytherapy, in Recurrent Endometrial Cancer: A Scoring System to Predict Clinical Response and Outcome

Aims and background

This prospective, phase II study aimed to test the efficacy of concurrent 5-fluorouracil, mitomycin C and radiation, with or without brachytherapy, on the clinical outcome of a series of recurrent endometrial cancer patients and to determine the prognostic impact of a subset of factors.

Methods

Thirty patients with locally recurrent, nonmetastatic endometrial cancer received external beam radiation (4-week split course: 23.4 + 23.4 Gy) plus two courses of concomitant chemotherapy (5-fluorouracil, 96-h continous infusion, days 1-4; 1 g/m2/day; mitomycin C, 10 mg/m2, bolus iv, day 1). Nineteen patients (63.3%) underwent endocavitary, low-dose brachytherapy boost (20-25 Gy); eight patients (26.7%) received external beam radiation boost (14-20 Gy).

Results

Eleven complete responses (36.7%), 11 partial responses (36.7%), 6 disease stabilizations (20.0%) and 2 progressions (6.6%) were observed. After a median follow-up of 27 months (range, 1-108), overall actuarial 3-year survival, progression-free survival and local progression-free survival were 46.8%, 35.2% and 41.2%, respectively. Two patients (6.7%) experienced hematological grade 3 toxicity. Two patients (6.7%) had grade 3 intestinal toxicity. Severe late toxicity was infrequent, only 3 patients showing severe vaginal stenosis (10.0%). A clinical score of 0 to 1 was assigned to each patient on the basis of the absence (score = 0) or presence (score = 1) of any of the following prognostic factors: time between surgery and recurrence shorter than 12 months, pelvic wall site of recurrence, positive lymph nodes, hemoglobin <11 g/dL. With this device, it was clear that patients with a low score had a significantly better outcome (clinical remission: 77.2% of patients with a score <2 vs 25.0% of patients with a score ≥2, P = 0.009), better local control of the disease (50.2% vs. 0 at 3 years, P = 0.014,) and better overall survival (65.8% vs 0 at 3 years, P = 0.003).

Conclusions

Our data suggest that this combined modality therapy was relatively well tolerated and resulted in reasonable local control and survival. The scoring system proved to be helpful in identifying patients with the best chance of benefiting from the treatment.

The impact of anaemia on outcome in cancer

Anaemia is not an inconsequential side effect of cancer and its treatment should not be ignored. Current practice for anaemia management varies and its role in influencing outcome in cancer patients is under recognized. As a common complication of cancer, anaemia is prevalent in virtually all tumour types to varying degrees. Predictive factors for anaemia include baseline haemoglobin concentration, decrease in haemoglobin concentration within the first month of treatment, tumour type, duration of treatment and prior blood transfusions. Interest in the prognostic significance of anaemia in cancer patients has generated extensive clinical research. Data is now published in a wide range of tumour types confirming that anaemia is a negative prognostic indicator of outcome (e.g. survival, disease-free recurrence and local relapse), with the strongest association in patients receiving radiotherapy. The association has also been documented in patients undergoing chemotherapy and chemoradiation. A retrospective meta-analysis has shown an overall 65% increased risk of death associated with anaemia in cancer patients. The impact of anaemia as an independent prognostic factor for outcome may be mediated by several factors, however the emerging consensus is on the central role of tumour hypoxia. It has been nearly 50 years since R. Thomlinson and L. Gray (British Journal of Cancer 1955, 9: 539) first documented the existence of hypoxia in tumours and it is now well accepted that tumour hypoxia protects tumour cells from therapeutic damage directly by reducing the availability of oxygen-free radicals which are necessary for optimal impact of radiotherapy, certain chemotherapeutic agents and photodynamic therapy. The indirect effects include the impact of hypoxia on gene expression, which affects genetic stability, proliferation kinetics and cellular metabolism. There has been an emergence of preclinical and circumstantial data over recent years that are suggestive of the ability to correct the negative effect of anaemia on outcome by the use of repeated blood transfusions or recombinant human erythropoietin. This has led to some attempts to measure the impact on survival in cancer patients of treating anaemia, but early attempts have served to underline the complexity of the relationship and have produced unexpected results.

Clinical and economic impact of epoetins in cancer care

Anaemia develops in most patients undergoing cancer therapy and invariably induces fatigue, which is a major determinant of QOL. Blood transfusions are reserved for patients with severe anaemia, since blood is a scarce resource and provides a short-lived benefit. Epoetins are recombinant proteins capable of alleviating therapy-related anaemia in 40-60% of cancer patients. The number of patients needed to be treated with epoetins to avoid the transfusion of one unit of blood ranges from 2.6 to 5.2; however, the absolute risk reduction depends on patients' characteristics and dose-escalation. The ratio between acquisition costs of epoetins and blood transfusion requirement is very high; thus, many thousands of dollars needs to be spent on epoetins to save 1 blood unit. Despite this, epoetins have been widely adopted by industrialised countries, where cancer patients are about 2% of the total population. The resulting budget impact of epoetins can be calculated at about 10% of the overall direct cost for cancer care, and it is expected to continue growing by about 20% each year, due to the expanding cancer population and the intensification of cancer therapies. The economic burden of epoetins needs to be weighed against the improvement of patients' QOL and society's willingness to pay for a non-life-saving therapy. All published economic evaluations of epoetins invariably report that this supportive therapy is not cost effective. Society should be made aware of the opportunity cost of treatments and should be allowed to elicit preferences for healthcare interventions and prioritisation criteria. In the near future we expect that a wider range of epoetins, drug patent expiry, a more appropriate patient selection criteria and an improved dosage schedule may help increase the efficiency of cancer-related anaemia management.

Anemia in cancer: therapeutic implications and interventions

Significant progress has been made in the prevention and management of many symptoms associated with cancer and its therapy. Anemia in cancer may be secondary to blood loss, displacement of normal bone marrow cells by malignant cells, myelotoxic therapy, or the tumor itself. Practitioners may not always adequately assess anemia unless it represents a source of significant symptoms or patient distress. Risk factors include platinum-based treatment regimens, specific tumor types, and low baseline hemoglobin levels. Anemia may have an impact on patient performance status, quality of life, clinical symptoms, and possibly therapeutic efficacy and survival. Treatment interventions, directed toward the underlying etiology of the anemia, involve iron supplementation, blood transfusion, and administration of recombinant human erythropoietin. Future advances may include new tools to assess physical or functional symptoms and predict therapeutic response more accurately, and more cost-effective, convenient agents to prevent or treat anemia in cancer. Novel approaches that may add to the armamentarium of strategies designed to address anemia in patients with cancer currently are being developed.

Effects of cancer-related anemia on clinical and quality-of-life outcomes

Significant progress has been made in the prevention and management of many symptoms associated with cancer and its therapy. However, cancer-related anemia, which may affect more than half of all patients with cancer, often is assessed and treated inadequately. Severe anemia not only causes significant symptomology but also may impair functional status and quality of life. In addition, anemia has been found to affect treatment outcomes, including disease-free and overall survival. Therapeutic strategies, based on the underlying etiology of anemia, include iron supplementation, blood transfusion, and administration of recombinant human erythropoietin. Future approaches may involve novel agents under investigation that are designed to address current concerns related to efficacy, convenience, and possible cost-effectiveness of treatment of cancer-related anemia.

The Clinical Value of Erythropoietin in Patients with Cancer

Erythropoietin has been successfully used in the treatment of cancer-related anaemia. About two-thirds of patients with the 'anaemia of chronic disorders', anaemia due to neoplastic bone marrow infiltration or therapy-related anaemia, are expected to respond to high doses of erythropoietin with a haemoglobin increase of at least 2 g/dl. In the myelodysplastic syndromes, about one-third of patients will show a response when very high doses of erythropoietin are combined with granulocyte colony-stimulating factor. The response to erythropoietin is slow, requiring several months to develop. Various factors have been reported to predict a response, but the prediction models proposed are contradictory and have not been prospectively validated. Therefore, the most common strategy to determine the responsiveness of cancer-related anaemia to erythropoietin is to subject the patient to a treatment trial of several months' duration. Treatment with erythropoietin needs to be compared with the transfusion of red blood cells, which has similar effects on the patient's haemoglobin level. Erythropoietin is a generally well tolerated drug, but it is slow to exert an effect and ineffective in a substantial proportion of patients. Red blood cell transfusion is associated with a small risk of infectious, allergic or toxic complications, but it leads to a rapid haemoglobin increase in virtually all patients treated. Cost and cost-benefit analyses from several countries indicate that, in patients with cancer-related anaemia, treatment with erythropoietin is considerably more expensive than the transfusion of allogeneic red blood cells. Thus, the choice between the two treatment options will be influenced by the financial resources of the respective healthcare systems.

The negative impact of anemia on radiotherapy and chemoradiation outcomes

In cancer patients, anemia is common and has been found to impair quality of life and reduce locoregional disease control conferred by radiotherapy. The prognostic importance of anemia in the radiation oncology setting may be related to a reduction of molecular oxygen levels, thereby attenuating radiation-induced damage and ultimate cell death. Substantially higher doses of radiation are required to eradicate malignant cells under the hypoxic conditions commonly identified in solid tumors. Consistent with this, patients with hypoxic solid tumors have been found to have shorter postradiation disease-free survival rates relative to patients with well-oxygenated tumors. An attempt to enhance intratumoral oxygenation via correction of anemia, a highly prevalent but modifiable condition, is therefore a reasonable approach to optimize radiotherapy and chemoradiation outcomes. Clinical studies investigating recombinant human erythropoietin (epoetin alfa) as an adjunct to radiotherapy have demonstrated its ability to increase and maintain hemoglobin (Hb) levels during the course of radiotherapy. In a study involving anemic patients undergoing chemoradiation for head and neck cancer, epoetin alfa extended locoregional control and survival to rates reported for patients with normal pretreatment Hb levels. Given the high prevalence and prognostic significance of anemia during radiotherapy, strategies that safely and effectively increase Hb levels may be of value for optimizing radiotherapy and chemoradiation outcomes.