Incidence of anemia in patients diagnosed with solid tumors receiving chemotherapy, 2010-2013

Comprehensive analysis of nationwide anticancer drug-related complications in Korea: incidence, types, and cancer-specific considerations in contemporary oncology

Background

The rising global incidence of cancer has increased the demand for chemotherapy, which is a crucial treatment modality. Recent advancements in cancer treatment, including targeted agents and immunotherapy, have introduced complications owing to their specific mechanisms. However, comprehensive studies of the combined complications of these approaches are lacking.

Objectives

This study aimed to comprehensively assess and analyze the overall incidence of anticancer drug-related complications in a nationwide patient cohort, utilizing a customized National Health Insurance Sharing Service database in Korea.

Design

Retrospective cohort study.

Methods

We included patients who were prescribed anticancer drugs (excluding endocrine agents) and diagnosed with cancer. For the type of cancer classification, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) was used and anticancer drugs were classified based on the Anatomical Therapeutic Chemical code. We classified cancer into 18 types based on the ICD-10 code and delineated cancer-related complications into 12 categories. Complications included hematological, gastrointestinal, infectious, cardiovascular, major bleeding, endocrine, neurotoxic, nephrotoxic, dermatological, pulmonary, musculoskeletal, and hepatotoxic effects.

Result

We included 294,544 patients diagnosed with cancer and administered anticancer drugs between 2016 and 2018, with follow-up continuing until 2021. We identified 486,929 anticancer drug-related complications, with an incidence of 1843.6 per 1000 person-years (PY). Anemia was the most common complication, with a rate of 763.7 per 1000 PY, followed by febrile neutropenia (295.7) and nausea/vomiting (246.9). Several complications peaked during the first months following the initiation of anticancer drug therapy; however, herpes, skin infection, heart failure, and peripheral neuropathy peaked at 6-12 months. Among major cancers, breast cancer had the lowest overall incidence of complications. Targeted therapies revealed lower complication rates than cytotoxic chemotherapy; however, they also required careful monitoring of rash.

Conclusion

This study highlights the importance of the proactive management of anticancer drug-related complications for patient care improvement.

Efficacy of ferric carboxymaltose or darbepoetin alfa for chemotherapy-induced anemia in patients with esophagogastric or pancreaticobiliary cancer: a retrospective comparative study

Background

Esophagogastric and pancreaticobiliary cancers are associated with chronic blood loss, poor nutrition, and surgical interventions that interfere with iron absorption. Patients with these cancers often have a higher incidence of chemotherapy-induced anemia (CIA) than patients with other malignancies.

Objectives

To investigate the efficacy of intravenous iron or erythropoietin-stimulating agents (ESA) for CIA treatment in patients with esophagogastric or pancreaticobiliary cancer.

Design

Retrospective, comparative chart review of patients with esophagogastric or pancreaticobiliary cancer who received ferric carboxymaltose (FCM), or darbepoetin alfa (DA), and myelosuppressive chemotherapy at Chungbuk National University Hospital between June 2018 and December 2022.

Methods

To assess the efficacy of FCM or DA over time, data on hemoglobin (Hb) levels were collected from the time of administration of FCM or DA (baseline) until 6 months post-baseline, when available.

Results

In total, 214 patients (124 in the FCM and 90 in the DA group) were included in the analysis. The FCM group had a higher maximum Hb level and Hb changes for 3 months (mean ± standard deviation) following FCM or DA administration from baseline than the DA group (11.3 ± 1.5 versus 10.9 ± 1.2 g/dL, p = 0.02 and 2.0 ± 1.4 versus 1.5 ± 1.1 g/dL, p = 0.004, respectively). The FCM group had a higher proportion of Hb responders than the DA group (83.9% versus 68.9%, p = 0.013). Based on multivariable analysis, only the CIA treatment group was a significant factor for Hb response (odds ratio = 2.06, 95% confidence interval = 1.05-4.06, p = 0.036).

Conclusion

Both FCM and DA are effective, and FCM showed a higher Hb response than DA for CIA treatment in patients with esophagogastric or pancreaticobiliary cancer. Therefore, further randomized controlled trials should determine the optimal treatment for CIA in patients with these cancers undergoing myelosuppressive chemotherapy.

Determinants of anemia among patients receiving cancer chemotherapy in Northwest Ethiopia

Background

Chemotherapy-induced anemia (CIA) is a hematologic complication that frequently affects patients with cancer undergoing chemotherapy. It is associated with worse treatment outcomes, higher rates of morbidity and mortality, worse quality of life, and higher healthcare costs. The incidence and predictors of CIA in Ethiopia, particularly in Northwest Ethiopian oncology centers, are poorly understood. This study was conducted at Northwest Ethiopian oncology centers to evaluate the incidence and determinants of chemotherapy-induced anemia in adult patients with cancer undergoing chemotherapy.

Methods

This 3-year hospital-based retrospective follow-up study included adult patients with cancer receiving chemotherapy between 2019 and 2021 at two oncology centers in Northwest Ethiopia. Data were collected from October to December 2021. A binary logistic regression model was used to select variables and determine the Crude Odds Ratio (COR). Variables with P-value < 0.2 were entered into the multivariable logistic regression and Adjusted odds ratio (AOR) with 95% Confidence intervals (CI) for variables with P-value < 0.05 were estimated to show determinants of chemotherapy-induced anemia among cancer patients who received chemotherapy.

Results

A total of 402 patients were included in the final analysis. The overall incidence of CIA was 75.4% (95% CI 70.7, 79.8). Older age [AOR = 1.8, 95% CI (1.4-3.5); P = 0.043], hematologic cancer [AOR = 3.7, 95% CI (3.2-5.7), P = 0.021], obesity [AOR = 3.4, 95% CI (2.3-6.9); P = 0.028], ≥6 chemotherapy cycles [AOR = 3.8, 95% CI (3.2-5.1), P = 0.019], cancer metastasis to bone [AOR = 2.9, 95% CI (1.2-4.7), P = 0.025] were statistically significant predictors of chemotherapy-induced anemia.

Conclusion

Chemotherapy-induced anemia persisted in a significant percentage of cancer patients. Chemotherapy-induced anemia developed in three-quarters of patients undergoing chemotherapy. Chemotherapy-induced anemia was significantly associated with older age, hematologic malignancy, obesity, a greater number of chemotherapy cycles, and cancer metastasis to bone. To lower the risk of morbidity related to anemia, patients with chemotherapy-induced anemia should be regularly evaluated and treated with appropriate treatment.

NTCP Modeling and Dose-Volume Correlations of Significant Hematocrit Drop 3 Months After Prostate Radiation Therapy

Purpose

Our purpose was to determine and model the dose-response relations of different parts of the pelvis regarding the endpoint of hematocrit level drop after pelvic radiation therapy (RT).

Methods and Materials

Two hundred and twenty-one patients treated with RT for prostate adenocarcinoma between 2014 and 2016 were included. All patients had complete blood counts collected at baseline and 3 months post-RT. The net difference of hematocrit level post-RT versus baseline was calculated, and the level of the 15th percentiles defined the thresholds of response in each case. The doses to 8 different pelvic structures were derived and fitted to the hematocrit levels using the relative seriality normal tissue complication probability model and the biologically equivalent uniform dose (D = ).

Results

Pelvic structures that correlated with significant decreases in hematocrit were the os coxae bilaterally superior to the acetabulum (OCUB), the total os coxae bilaterally, and the bone volume of the whole pelvis. The structure showing the highest correlation was OCUB with a maximum area under the curve (AUC) of 0.74. For V20 Gy < 30% the odds ratio was 9.8 with 95% CI of 2.9 to 32.9. For mean dose (Dmean) to OCUB, an AUC of 0.73 was observed where the dose threshold was 23 Gy and the odds ratio was 2.7 and 95% CI 1.3 to 5.6. The values for the D50, γ, and s parameters of the relative seriality model were 26.9 Gy (25.9-27.9), 1.3 (1.2-2.2), and 0.12 (0.10-0.83), respectively. The AUC of D = was 0.73 and patients with D = to OCUB ≥ 27 Gy had 8.2 times higher rate of significant hematocrit drop versus <27 Gy.

Conclusions

These findings confirm the association of radiation-induced damage to pelvic bone marrow with a drop in hematocrit. A threshold of V20 Gy < 30%, Dmean < 23 Gy, or D = < 27 Gy to OCUB may significantly reduce the risk for this endpoint.

Iron Surveillance and Management in Gastro-Intestinal Oncology Patients: A National Physician Survey

PURPOSE

Iron deficiency (ID) is a complication of gastrointestinal (GI) cancers that may manifest as iron deficiency anemia (IDA). Serum ferritin monitoring and oral iron supplementation have the limitations of being falsely elevated and poorly absorbed, respectively. This study aims to assess the discordance in surveillance, treatment practices, and awareness of ID/IDA in GI cancer patients by Canadian physicians treating these patients.

METHODS

From February 2020 to September 2021, a 22-question electronic survey was sent to medical oncologists (MOs), surgical oncologists (SOs), and gastroenterologists (GEs). The survey collected information about four domains: physician demographics, surveillance practices, treatment practices, and awareness of ID/IDA in GI cancer patients and ASCO/ASH guidelines.

RESULTS

A total of 108 (34 MOs, 19 SOs, and 55 GEs) of the 872 (12.4%) invited physicians completed the survey. Of these, 26.5% of MOs, 36.8% of SOs, and 70.9% of GEs measured baseline iron parameters, with few continuing surveillance throughout treatment. Ferritin was widely measured by MOs (88.9%), SOs (100%), and GEs (91.4%). Iron was supplemented if ID/IDA was identified pre-treatment by 66.7% of MOs, 85.7% of SOs, and 94.2% of GEs. Parenteral iron was prescribed by SOs (100%), while oral iron was prescribed by MOs (83.3%) and GEs (87.9%). Only 18.6% of physicians were aware of the ASCO/ASH guidelines regarding erythropoiesis-stimulating agents with parenteral iron for treating chemotherapy-induced anemia.

CONCLUSION

Results illustrate variations in practice patterns for IDA management across the different physician specialties. Moreover, there appeared to be gaps in the knowledge and care surrounding evidence-based IDA management principles which may contribute to poor clinical outcomes.

Characterization of pre-operative anemia in patients undergoing surgery by a gynecologic oncologist and association with post-operative complications

OBJECTIVE

Anemia is prevalent in patients with gynecologic cancers and is associated with increased peri-operative morbidity. We aimed to characterize risk factors for pre-operative anemia and describe outcomes among patients undergoing surgery by a gynecologic oncologist to identify potential areas for impactful intervention.

METHODS

We analyzed major surgical cases performed by a gynecologic oncologist in the National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2019. Anemia was defined as hematocrit <36%. Demographic characteristics and peri-operative variables for patients with and without anemia were compared using bivariable tests. Odds of peri-operative complications in patients stratified by pre-operative anemia were calculated using logistic regression models.

RESULTS

Among 60 017 patients undergoing surgery by a gynecologic oncologist, 23.1% had pre-operative anemia. Women with ovarian cancer had the highest rate of pre-operative anemia at 39.7%. Patients with advanced-stage cancer had a higher risk of anemia than early-stage disease (42.0% vs 16.3%, p≤0.001). In a logistic regression model adjusting for potential demographic, cancer-related, and surgical confounders, patients with pre-operative anemia had increased odds of infectious complications (odds ratio (OR) 1.16, 95% CI 1.07 to 1.26), thromboembolic complications (OR 1.39, 95% CI 1.15 to 1.68), and blood transfusion (OR 5.78, 95% CI 5.34 to 6.26).

CONCLUSIONS

There is a high rate of anemia in patients undergoing surgery by a gynecologic oncologist, particularly those with ovarian cancer and/or advanced malignancy. Pre-operative anemia is associated with increased odds of peri-operative complications. Interventions designed to screen for and treat anemia in this population have the potential for significant impact on surgical outcomes.

Anemia Profiles in Cancer Patients: Prevalence, Contributing Factors, and Insights From a Retrospective Study at a Single Cancer Center in Saudi Arabia

BACKGROUND

Anemia, a common complication of cancer and its treatments, significantly affects cancer patients' survival and quality of life. Nevertheless, there is limited research conducted in the southern region of Saudi Arabia regarding its effects. This study aims to assess the prevalence of anemia, as well as its associated factors, among cancer patients undergoing active chemotherapy treatment.

METHOD

This retrospective study analyzed adult cancer patients who underwent chemotherapy at King Khaled Hospital's oncology department in Najran, Saudi Arabia, between 2017 and 2022. We aimed to determine the prevalence and contributing factors of anemia through comprehensive demographic and clinical assessment. Univariate analysis was performed to assess factors necessitating blood transfusion.

RESULT

A total of 95 cancer patients received chemotherapy, with a mean age of 52.2 ± 16.5 years. The majority were females (65.3%) aged between 18 and 64 years (74.7%). Gastrointestinal (42.1%) and breast (17.9%) cancers were the most prevalent malignancies. Most patients (56.8%) were in locally advanced stages. Anemia was present at admission in 48 (50.5%) patients with a higher prevalence among colorectal and genitourinary tract cancer patients. The mean hemoglobin (Hb) drop during treatment was 9.1 ± 2.1 g/dL. Anemia severity was stratified as follows: life-threatening (7.4%), severe (33%), moderate (31%), and lower limited (29%). Blood transfusions were required in 79% of cases. Advanced age, increased chemotherapy cycles, and anemia of chronic disease (ACD) were significantly associated with increased anemia severity (p<0.05). Increasing chemotherapy cycles also correlated with an increased need for blood transfusion (p<0.001). Older patients (≥65 years) had higher anemia at admission, poor Eastern Cooperative Oncology Group (ECOG) performance status, more Hb decrease during treatment, and increased need for blood transfusions (p<0.05) compared to younger patients (<65 years).

CONCLUSION

The study noted a high prevalence of anemia (50.5%) in patients receiving active cancer treatment, specifically in the context of genitourinary and gastrointestinal tract cancers. Advanced age, frequent chemotherapy cycles, and ACD were associated with increased severity of anemia. Furthermore, older patients displayed a higher frequency of anemia, poorer performance status, and an increased requirement for transfusions with an escalating number of chemotherapy cycles.

Waldenström macroglobulinemia with secondary pure red cell aplasia in a patient with metastatic castrate resistant prostate cancer receiving an immune checkpoint inhibitor: a case report

BACKGROUND

Hypoproliferative anemia is a frequently encountered adverse event in cancer patients receiving immune checkpoint inhibitors (ICI). Secondary pure red cell aplasia (PRCA) is a rare but recognized immune related adverse event. With the burgeoning use of ICIs, the association of secondary PRCA with an underlying lymphoproliferative disorder is often overlooked.

CASE PRESENTATION

We report a case of a 67-year-old non-Hispanic Caucasian male with metastatic castrate resistant prostate cancer, who developed severe transfusion dependent anemia with reticulocytopenia while receiving treatment with olaparib and pembrolizumab. His bone marrow findings demonstrated erythroid hypoplasia, in addition to a CD5-negative, CD10-negative monotypic B-cell population and a somatic MYD88L265P mutation. With a presence of an IgM-paraprotein, he was diagnosed with Waldenström macroglobulinemia (WM) with secondary PRCA and treated with 6 cycles of bendamustine and rituximab. He achieved a complete response with this regimen and was transfusion independent.

CONCLUSION

In this case, underlying WM was uncovered through systematic investigation of anemia caused by ICI therapy. This report highlights the possibility of a lymphoproliferative disorder in patients with concerns for PRCA with prior ICI exposure. If identified, treating the underlying lymphoproliferative disorder is highly efficacious in the management of the secondary PRCA.

Anticancer Drugs Paclitaxel, Carboplatin, Doxorubicin, and Cyclophosphamide Alter the Biophysical Characteristics of Red Blood Cells, In Vitro

Red blood cells (RBCs) are the most numerous cells in the body and perform gas exchange between all tissues. During the infusion of cancer chemotherapeutic (CT) agents, blood cells are the first ones to encounter aggressive cytostatics. Erythrocyte dysfunction caused by direct cytotoxic damage might be a part of the problem of chemotherapy-induced anemia-one of the most frequent side effects. The aim of the current study is to evaluate the functional status of RBCs exposed to mono and combinations of widely used commercial pharmaceutical CT drugs with different action mechanisms: paclitaxel, carboplatin, cyclophosphamide, and doxorubicin, in vitro. Using laser diffraction, flow cytometry, and confocal microscopy, we show that paclitaxel, having a directed effect on cytoskeleton proteins, by itself and in combination with carboplatin, caused the most marked abnormalities-loss of control of volume regulation, resistance to osmotic load, and stomatocytosis. Direct simulations of RBCs' microcirculation in microfluidic channels showed both the appearance of a subpopulation of cells with impaired velocity (slow damaged cells) and an increased number of cases of occlusions. In contrast to paclitaxel, such drugs as carboplatin, cyclophosphamide, and doxorubicin, whose main target in cancer cells is DNA, showed significantly less cytotoxicity to erythrocytes in short-term exposure. However, the combination of drugs had an additive effect. While the obtained results should be confirmed in in vivo models, one can envisioned that such data could be used for minimizing anemia side effects during cancer chemotherapy.

Open-label, Phase 2 study of roxadustat for the treatment of anemia in patients receiving chemotherapy for non-myeloid malignancies

Anemia is a common side effect of myelosuppressive chemotherapy; however, chemotherapy-induced anemia (CIA) management options are suboptimal. We evaluated the efficacy and safety of roxadustat in this setting. This open-label Phase 2 study included patients with non-myeloid malignancies and CIA (hemoglobin [Hb] ≤10 g/dL) who had planned concurrent myelosuppressive chemotherapy for ≥8 additional weeks. Oral roxadustat was administered for ≤16 weeks (starting dose 2.0 or 2.5 mg/kg, then titrated every 4 weeks). The primary efficacy endpoint was mean maximum change in Hb within 16 weeks of baseline without red blood cell (RBC) transfusion. Patients were assigned to roxadustat 2.0 (n = 31) or 2.5 mg/kg (n = 61) starting doses, and 89 were assessed for efficacy. The mean (standard deviation) maximum Hb change from baseline without RBC transfusion was 2.4 (1.5) and 2.5 (1.5) g/dL in the roxadustat 2.0 and 2.5 mg/kg groups, respectively. Median (range) time to Hb increase of ≥2 g/dL was 71 (57-92) days. Twelve patients (14.5%) had RBC transfusions (Week 5 to the end of treatment). Roxadustat was efficacious regardless of tumor type and chemotherapy regimen. Deep vein thrombosis (DVT) and pulmonary embolism (PE) occurred in 14 (15.2%) and nine (9.8%) patients, respectively, and three had serious adverse events attributed to roxadustat in the opinion of the investigators (PE: n = 2 [2.2%]; DVT: n = 1 [1.1%]). Roxadustat increased Hb in patients with CIA regardless of tumor type and chemotherapy regimen. Adverse events were consistent with observations in patients with advanced-stage malignancies.

Incidence of anemia and red blood cell (RBC) transfusion requirement in breast cancer

Background

Cancer-related anaemia is one of the main burdens in oncology, although the available data on its prevalence and treatment options such as blood transfusion are often contradictory. This study aimed to evaluate the prevalence of anaemia and the requirement for packed red blood cell (PRBC) transfusion among women with breast cancer (BC) and to determine the associated factors for chemotherapy-induced anaemia (CIA).

Methods

This cross-sectional retrospective study conducted in Kelantan involved 104 newly diagnosed female BC patients from 2015 to 2016 who underwent chemotherapy. For statistical analysis, chi-square was used to compare between CIA and non-CIA groups. In addition, simple and multiple logistic regression were used to determine the association of the CIA.

Results

Our study revealed that 34.6% (n=36) of patients had mild anaemia, and 59.6% (n=62) had normal haemoglobin at pre-chemotherapy. The prevalence of anaemia increased from 40.4% to 77% at the end of our study. About 30.8% of patients received PRBC transfusion during chemotherapy with mean haemoglobin before the first transfusion of 7.9 g/dl. CIA was observed in 54.8% of cases. There was no significant association between CIA concerning the patient characteristic, cancer characteristic, or cancer treatment.

Conclusion

We concluded that a significant proportion (40.4%) of BC patients was anaemic even before chemotherapy, with the red blood cell requirements up to 30.8% throughout chemotherapy. A larger prospective study is needed to determine the predictors for the CIA and subsequently improve patient management.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Iron imbalance in cancer: Intersection of deficiency and overload

Iron, an essential trace element, plays a complex role in tumour biology. While iron causes cancer clearance through toxic free radical generation, iron‐induced free radical flux also acts as a cancer promoter. These fates majorly guided through cellular response towards pro‐oxidant and antioxidant settings in a tumour microenvironment, designate iron‐induced oxidative stress as a common yet paradoxical factor in pro‐tumorigenesis as well as anti‐tumorigenesis, posing a challenge to laying down iron thresholds favouring tumour clearance. Additionally, complexity of iron's association with carcinogenesis has been extended to iron‐induced ROS's involvement in states of both iron deficiency and overload, conditions identified as comparable, inevitable and significant coexisting contributors as well as outcomes in chronic infections and tumorigenesis. Besides, iron overload may also develop as an unwanted outcome in certain cancer patients, as a result of symptomatic anaemia treatment owed to irrational iron‐restoration therapies without a prior knowledge of body's iron status with both conditions synergistically acting towards tumour aggravation. The co‐play of iron deficiency and overload along with iron's pro‐tumour and antitumour roles with intersecting mechanisms, thus presents an unpredictable regulatory response loop in a state of malignancy. The relevance of iron's thresholds beyond which it proves to be beneficial against tumorigenesis hence becomes questionable. These factors pose a challenge, over establishing if iron chelation or iron flooding acts as a better approach towards antitumour therapies. This review presents a critical picture of multiple contrasting features of iron's behaviour in cancer, leading towards two conditions lying at opposite ends of a spectrum: iron deficiency and overload in chronic disease conditions including cancer, hence, validating the critical significance of diagnosis of patients' iron status prior to opting for subsequent therapies.

Prevalence and Associated Factors of Anemia among Breast Cancer Patients Undergoing Chemotherapy: A Prospective Study

Purpose

The purpose of this study was to ascertain the prevalence and factors associated with anemia (hemoglobin [Hb] 12 g/dL) in breast cancer patients undergoing chemotherapy.

Materials and Methods

We conducted a prospective longitudinal study to collect demographic and clinical data on adult breast cancer patients with or without anemia who were admitted to HKL, UMMC, and NCI. The incidence of anemia was determined by detecting whether or not anemia developed during the course of chemotherapy. Mild, moderate, or severe anemia was defined. A chi-squared and logistic regression model were used to assess the effect of demographic and clinical factors on the incidence of anemia and multiple logistic regression analysis was used to evaluate the associations of potential risk factors with the presence of CRA.

Results

The study enrolled a total of 292 breast cancer patients. Anemia occurred at a rate of 41.1% (n = 120). Our findings indicated that clinical factors such as the number of chemotherapy regimens, dose reduction, and type of chemotherapy, for example, docetaxel, as well as demographic covariates such as age and BMI, all contribute to the incidence of anemia in cancer patients.

Conclusions

According to this study, the prevalence of anemia in breast cancer patients is high. Patients' age, BMI, number of chemotherapy regimens, and docetaxel were risk factors; thus, protocols are needed to identify subgroups of breast cancer likely to benefit from novel management strategies.

Anemia Management in the Cancer Patient With CKD and End-Stage Kidney Disease

Anemia is a common medical problem among patients with cancer and chronic kidney disease (CKD). Although anemia in patients with CKD is often treated with iron and erythropoietin-stimulating agents, there are controversies with regard to the use of erythropoietin-stimulating agents in cancer patients. In this article, we review the treatment of anemia in patients with cancer and CKD, in addition to summarizing the current guidelines in treatment of anemia in these patients.

Prevalence of Anemia Among Gynecologic Cancer Patients Who Received Chemotherapy, Radiotherapy, or a Combination of Both at King Abdulaziz Medical City, Jeddah

OBJECTIVE

The aim of this study is to calculate hemoglobin (Hb) levels and find the prevalence of anemia in gynecological cancer patients undergoing cancer treatments including chemotherapy and radiotherapy attending Princess Noorah Oncology Center in King Abdul Aziz Medical City in Jeddah.

METHOD

A cross-sectional chart review study was conducted in gynecological cancer patients receiving chemotherapy/radiotherapy to find the prevalence of anemia in the period between 2016 and 2018. All data were collected from the electronic medical records using a data collection sheet.

RESULTS

A total of 107 female patients who had gynecologic cancers and received chemotherapy/radiotherapy were included. Ninety percent (90.7%) of them developed anemia during the treatment course.

CONCLUSION

The prevalence of anemia in patients with gynecological cancers during their active treatment was high. This is attributed to the chemotherapy and radiotherapy they were receiving that affected their Hb levels. Better monitoring and, in severe cases, blood transfusion could be beneficial.

An Applicable Inflammation-Joined and Nutrition-Related Prognostic Indicator in Patients With Colorectal Cancer

Purpose

This study aimed to elucidate the prognostic significance of a novel inflammation-joined and nutrition-related clinicopathological marker for colorectal cancer (CRC).

Methods

Various factors from preoperative fasting blood samples from 2471 patients with CRC were retrospectively analyzed. Factors related to prognosis were evaluated using univariate and multivariate analyses. The Kaplan–Meier method was used to generate survival curves, while the log-rank test was used to measure survival differences between groups.

Results

Univariate analysis revealed that C-reactive protein (CRP)/mean corpuscular volume (MCV) ratio, TNM stage, differentiation, right-sided tumor, age, carcinoembryonic antigen (CEA) level, and CRP level were significantly associated with poor prognosis in CRC. In contrast, adjuvant chemotherapy is regarded as a protective factor. Elevation of CRP/MCV ratio (odds ratio [OR]: 1.535, 95% confidence interval [CI]: 1.121–2.104, P = 0.008), TNM stage (OR: 2.747, 95% CI: 2.175–3.469, P < 0.001), and differentiation (OR, 1.384; 95% CI, 1.150–1.666; P = 0.001) were prognostic risk factors in the multivariate analyses. Subgroup analysis showed that CRP/MCV, TNM staging system, and differentiation also independently affected survival in patients with lymph node-positive CRC. The nomogram based on these three indicators showed that CRP/MCV had a greater prognostic value and clinical significance for lymph node-positive patients with poorly differentiated tumors at the late stage.

Conclusion

A novel nomogram using the clinicopathologic index of inflammation and nutrition was constructed to predict the prognosis of CRC. Early interventions should be emphasized for advanced-stage patients with severe inflammation and poor nutritional status.

A national level estimation of population need for blood in India

BACKGROUND

The population need for blood is the total volume required to transfuse all the individuals who need transfusion in a defined population over a defined period. The clinical demand will arise when people with a disease or condition who require transfusion, access healthcare services, and subsequently the clinicians request blood. Essentially, the conversion of need to demand must be maximum to avoid preventable mortality and morbidity. The study estimated the population need for blood in India.

METHODS

The methodology included a comprehensive literature review to determine the diseases and conditions requiring transfusion, the population at risk, and prevalence or incidence; and Delphi method to estimate the percentage of people requiring transfusion, and the quantum.

RESULTS

The estimated annual population need was 26.2 million units (95% CI; 17.9-38.0) of whole blood to address the need for red cells and other components after the separation process. The need for medical conditions was 11.0 million units (95% CI:8.7-14.7), followed by surgery 6.6 million (95% CI:3.8-10.0), pediatrics 5.0 million (95% CI:3.5-7.0), and obstetrics and gynecology 3.6 million units (95% CI:1.9-6.2). The gap between need and demand which depends upon the access and efficiency of healthcare service provision was estimated at 13 million units.

CONCLUSION

The study brings evidence to highlight the gap between need and demand and the importance of addressing it. It cannot be just the responsibility of blood transfusion or health systems, it requires a multi-sectoral approach to address the barriers affecting the conversion of need to clinical demand for blood.

Safety of Marketed Cancer Supportive Care Biosimilars in the US: A Disproportionality Analysis Using the Food and Drug Administration Adverse Event Reporting System (FAERS) Database

BACKGROUND

Since the approval and availability of the first biosimilar in 2015 in the United States (US), evidence regarding the post-marketing safety of cancer supportive care biosimilars remains limited.

OBJECTIVE

The aim was to explore the adverse event (AE) reporting patterns and detect disproportionate reporting signals for cancer supportive care biosimilars in the US compared to their originator biologics.

METHODS

The US Food and Drug Administration Adverse Event Reporting System database (January 1, 2004-March 31, 2020) was used to identify AE reports for filgrastim, pegfilgrastim, and epoetin alpha by type of product (originator biologics vs. biosimilars) and report characteristics. Plots of AE reports against years were used to reveal the reporting patterns. Disproportionality analyses using reporting odds ratios (RORs) were conducted to detect differences in serious and specific AEs between studied drugs and all other drugs. Breslow-Day tests were used to determine homogeneity between the originator biologic-biosimilar pair RORs for the same AE.

RESULTS

Total numbers of AEs for all studied biosimilars increased after marketing. More AE reports were from female patients for all of the studied drugs. More AEs for originator biologics and filgrastim biosimilar were reported by health professionals, while the highest proportion of reports came from consumers for pegfilgrastim and epoetin alpha biosimilars (29% and 44.1%, respectively). Signals of disproportionate reporting in serious AEs were detected for a pegfilgrastim biosimilar (Fulphila^®) compared to its originator biologic.

CONCLUSION

Our findings support the similarity in the signals of disproportionate reporting between cancer supportive care originator biologics and biosimilars, except for Fulphila^®.

Toxicity profile of Doxorubicin-Cyclophosphamide and Doxorubicin-Cyclophosphamide followed by Paclitaxel regimen and its associated factors among women with breast cancer in Ethiopia: A prospective cohort study

BACKGROUND

Management of patients with breast cancer undergoing chemotherapy is complicated by a very high rate of adverse drug reactions which is even more challenging in developing countries like Ethiopia where the toxicity profile of chemotherapy is lacking. The present study aimed at evaluating the toxicity profile of Doxorubicin-Cyclophosphamide (AC) and Doxorubicin-Cyclophosphamide→Paclitaxel (AC→T) regimens among 146 patients with breast cancer in Ethiopia.

METHODS

This prospective cohort study, with the median of six months' follow-up, was conducted from January 1 to September 30, 2017 GC at the only nationwide oncology center, Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia. Seventy-one patients received AC, while 75 received AC-T regimen. The toxicity with the highest grade during any cycle was considered as the toxicity grade for that patient. SPSS version 22 was used for analysis.

RESULTS

The overall frequent non-hematological adverse drug reactions reported for both regimens were fatigue 144 (98.7%), dysgeusia 142 (97.3%), skin hyperpigmentation 141 (96.6%), nausea 136 (93.2%), vomiting 129 (88.4%), gastritis 122 (83.6%), peripheral neuropathy 108 (74%), and myalgia/arthralgia 110 (75.3%). Neutropenia 107 (73.3%), leukopenia 102 (69.9%), and anemia 51 (34.9%) were the most frequent overall grade hematological toxicities reported. However, those received AC regimen suffered more from grade 2 and above leukopenia (35.2% vs. 17.3%, P = 0.014), anemia (16.9% vs. 2.7%, P = 0.004), and alkaline phosphatase increment (11.3% vs. 2.7%, P = 0.039) than AC-T regimen. On the contrary, those received AC-T regimen suffered more from severe arthralgia/myalgia (2.8% vs. 2%, P = 0.001), peripheral neuropathy (1.4% vs. 36%, P = 0.000), and gastritis (14.1% vs. 29.3%, P = 0.026) than AC regimen. Pretreatment blood cell counts, having stage IV breast tumor, older age, and lower body surface area were significant predictors of grade 2 to above hematological toxicities. Older age, arthralgia/myalgia, and skin hyperpigmentation occurred during the cohort were significant predictors of grade 2 to above oral mucositis, peripheral neuropathy, and fatigue, respectively.

CONCLUSION

Patients who received the AC regimen suffered more from hematological abnormalities, while those on the AC-T regimen experienced more of non-hematological toxicities. Overall, we report high incidences of AC and AC-T regimens-induced toxicities in Ethiopian women with breast cancer, and they may require prior support based on pretreatment blood counts, age and body surface area, and close follow-up during chemotherapy.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

Ferric Carboxymaltose in the treatment of chemotherapy-induced anaemia: an effective, safe and cost- sparing alternative to blood transfusion

Anaemia is highly prevalent in cancer patients, adversely affects quality of life and impacts survival. The pathogenesis is multifactorial, with iron deficiency being a major and potentially treatable contributor. This study aimed to assess the effectiveness and economic impact of ferric carboxymaltose in chemotherapy-induced anaemia. This prospective cohort study between 2015–2016 of chemotherapy-treated patients for solid tumours, grade ≥2 anaemia and iron deficiency evaluated hematopoietic response four weeks after ferric carboxymaltose treatment. Transfusion rate of all cancer patients treated at our ambulatory unit during the two-year study period (2015–2016) was compared to a retrospective cohort (2013–2014) who received blood transfusion only. Between 2015–2016, 99 patients were included and treated with ferric carboxymaltose, the majority of whom (n = 81) had relative iron deficiency. Mean haemoglobin concentrations improved from 9.2 [6.7–10.8] g/dL to 10.6 [7.8–14.2] g/dL four weeks after treatment. A 26% reduction in the transfusion rate was observed from control retrospective to the prospective study group including ferric carboxymaltose treated patients [relative risk 0.74 (95% CI:0.66–0.83)]. The cost analysis showed a benefit for the use of ferric carboxymaltose in chemotherapy-induced anaemia. This study shows that ferric carboxymaltose is an effective, cost-saving support treatment, reducing the need for allogeneic transfusions saving blood units which are a limited resource.

Evaluation of Iron Status in Patients of Solid Organ Malignancies: Study from a Cancer Research Centre

Anemia associated with cancer is a major public health issue. The gravity of this problem is likely to be higher in India due to already existing malnutrition in the general population. Iron deficiency anemia (IDA) as a subset has not been evaluated in Indian population of cancer patients. This study was undertaken to evaluate iron status among newly diagnosed advanced-stage cancer patients with anemia at a cancer research institute in India. Sixty-four patients of anemia were identified who fulfilled the inclusion criteria. Iron status was noted. Absolute iron deficiency (AID) was identified in 8 (12.5%) patients. Functional iron deficiency (FID) was seen in 48 (75%) patients. Probable functional iron deficiency (PFID) was seen in 2 (3.1%) patients while no iron deficiency (NID) was seen in 6 (9.3%) patients. FID is seen in majority of advanced-stage solid organ cancer patients in India. Large sample studies are required to better define the exact prevalence of iron deficiency, chemotherapy-induced anemia, and anemia in cancer subtypes.

Affinity and Effect of Anticancer Drugs on the Redox Reactivity of Hemoglobin

Hemoglobin's redox reactivity is affected by anticancer drugs of the antitubulin class. Direct binding of these drugs to hemoglobin, with biomedically relevant affinities, is demonstrated. While this interaction is mostly allosteric, in the case of docetaxel, a direct redox reaction is also observed-correlating well with structural differences between the four compounds. A role for Tyr145 in this reactivity is proposed, in line with previous observations of the importance of this amino acid in the reactivity of Hb toward agents of oxidative stress. A susceptibility of vinorelbin (and to a lower extent of paclitaxel) toward peroxide and peroxidase is shown.

Age-Associated Hematological Toxicity in Patients with Metastatic Castration-Resistant Prostate Cancer Treated with Docetaxel in Clinical Practice

BACKGROUND

Older patients with metastatic castration-resistant prostate cancer (mCRPC) may be more prone to chemotherapy-induced hematological toxicity, but tailored docetaxel dosing guidelines in older patients are lacking because of conflicting data.

OBJECTIVE

This study aims to evaluate the impact of older age on the incidence of hematological toxicity in patients with mCRPC treated with docetaxel in daily clinical practice.

METHODS

This study included patients with mCRPC treated with docetaxel between January 2006 and January 2016 at the Netherlands Cancer Institute and Medical Center Slotervaart for whom dosing and hematological toxicity data were available from electronic patient records. We evaluated the impact of age on the incidence of grade 3 and 4 hematological toxicity.

RESULTS

In total, 175 patients treated with docetaxel were included in the analysis, with a median age of 67 years (range 47-86). Baseline hematological laboratory values were not age related. After the first treatment cycle, hematological toxicity occurred significantly more frequently in the oldest age quartile (25%, p = 0.02) than in the younger age quartiles (9%, 11%, and 7%, respectively, for age quartiles 1, 2, and 3).

CONCLUSION

The risk of hematological toxicity was significantly higher in the oldest age quartile than in younger patients with mCRPC treated with docetaxel in daily clinical practice.

Erythropoiesis-Stimulating Agents in the Management of Anemia in Chronic Kidney Disease or Cancer: A Historical Perspective

Anemia is common in patients with cancer or with chronic kidney disease (CKD). Although the introduction of erythropoiesis-stimulating agents (ESAs) has transformed the management of anemia, their use has been complicated by a number of factors including frequent guideline updates, safety concerns and, in the United States, a Risk Evaluation and Mitigation Strategy (REMS) program, which aimed to ensure that the benefits of ESAs outweigh the risks. Many previous concerns around ESA use in cancer and CKD have been addressed by the reassuring results of post-approval studies, and biosimilar ESAs have been used in Europe for many years, with safety and efficacy profiles similar to originator products. This review describes the evolution of the use of ESAs from approval to the present day, discussing results from clinical studies of ESAs in cancer and CKD, and the influence of these findings on product labeling and guideline updates. We also discuss the impact of the introduction of ESA biosimilars in Europe, bringing cost savings and increased access to patients.

Iron deficiency anemia in gastric cancer: a Canadian retrospective review

BACKGROUND

Gastric cancer is highly prevalent amongst men and women. Previous studies have described the high prevalence of iron deficiency anemia (IDA) in gastrointestinal cancer patients, but few have focused on the gastric cancer population. We aimed to determine the point prevalence of patients with gastric cancer who developed IDA and chemotherapy-induced anemia, and to identify types and frequencies of IDA therapies.

PATIENTS AND METHODS

A retrospective review was carried out for 126 gastric cancer patients from 2006 to 2016 at St Michael's Hospital, Toronto, Canada. Patient demographics, laboratory (ferritin, iron parameters) and clinical data regarding IDA were reviewed. IDA was defined as transferrin saturation less than 20%, ferritin less than 100 μg/l, and hemoglobin less than 130 g/l in men and less than 120 g/l in women.

RESULTS

Of the 126 patients with gastric cancer identified (median age 70, interquartile range: 59-77), 64.3% were men. Only 18.3% of patients had a self-reported history of IDA, 40% had IDA at the time of gastric cancer diagnosis, and 58.7% were anemic. A total of 77 patients received chemotherapy, and of these, 54.2% developed chemotherapy-induced anemia. At the final follow-up, 21.4% of patients were diagnosed with IDA along their treatment course, and 79.4% were anemic. Red blood cell transfusions were most frequently prescribed (48.4%; median: 4 U; interquartile range: 2-6), compared with oral (31.8%) or intravenous iron (16.7%) therapy.

CONCLUSION

The point prevalence of IDA was high in our gastric cancer patients despite inconsistent screening for IDA. Our findings indicate the need for a consistent diagnostic and therapeutic approach to IDA in this vulnerable patient population.