Pre-treatment hemoglobin levels are an independent prognostic factor in patients with non-small cell lung cancer

Relationship between hemoglobin and lung cancer: evidence from Mendelian randomization and National Health and Nutrition Examination Survey

BACKGROUND

Lung cancer is the primary cause of cancer-related mortality worldwide. Hemoglobin (Hb) represents the most widely utilized test parameter in clinical settings. However, few articles have examined the causal relationship between Hb concentration and lung cancer incidence.

METHODS

Mendelian randomization (MR) was first conducted to investigate the potential causality between Hb and lung cancer. Sensitivity analyses were applied to validate the reliability of MR results. Then, the National Health and Nutrition Examination Survey (NHANES) database was used to verify the effect of Hb on the prognosis of lung cancer.

RESULTS

The MR analysis demonstrated that Hb was casually associated with the decreased risk of lung cancer in the European population (ORIVW 0.84, 95% CI 0.75-0.95, p = 0.006; ORWeighted-median 0.78, 95% CI 0.65-0.94, p = 0.008; ORMR-Egger 0.82, 95% CI 0.64-1.04, p = 0.11). The results from the NHANES database showed that a high value of Hb was associated with better outcomes for patients with lung cancer (HR 0.45, 95% CI 0.26-0.79, p = 1.6E-03).

CONCLUSIONS

Our study provides further evidence for the relationship between Hb levels and lung cancer, highlighting the potential significance of Hb as a biomarker for predicting the risk and prognosis of lung cancer.

HALP score based on hemoglobin, albumin, lymphocyte and platelet can predict the prognosis of tongue squamous cell carcinoma patients

Objective

The preoperative hemoglobin, albumin, lymphocyte, and platelet (HALP) score, a comprehensive marker of nutritional and immunological status, has been found to be robust for tumor prognosis prediction. Here, we evaluated the use of HALP in the prognostic prediction of tongue squamous cell carcinoma (TSCC).

Study design

Patients with TSCC were retrospectively recruited from the years 2009-2019. Patient clinicopathological characteristics, along with preoperative blood parameters, were recorded on admission, and the cut-off HALP value was determined by X-tile software. Kaplan-Meier curves and Cox regression analyses were used to evaluate the predictive value of HALP for patient overall survival (OS) and disease-free survival (DFS).

Results

A total of 339 TSCC patients were enrolled. The optimal HALP threshold was 56 and the patients were divided into two groups according to their scores. The Kaplan-Meier analysis showed that patients in the high-HALP group experienced longer OS (p = 0.007) and DFS (p = 0.006) than those in the low-HALP group. Multivariate analysis showed that elevated HALP (p = 0.038) was an independent predictor of OS, while age (p = 0.008), T stage (p < 0.001), N stage (p = 0.020), and degree of tumor differentiation (p < 0.001) were risk factors.

Conclusion

The findings showed that the preoperative HALP score was an independent predictor of prognosis in patients with TSCC.

Remodeling of metabolism and inflammation by exercise ameliorates tumor-associated anemia

A considerable number of patients with cancer suffer from anemia, which has detrimental effects on quality of life and survival. The mechanisms underlying tumor-associated anemia are multifactorial and poorly understood. Therefore, we aimed at systematically assessing the patho-etiology of tumor-associated anemia in mice. We demonstrate that reduced red blood cell (RBC) survival rather than altered erythropoiesis is driving the development of anemia. The tumor-induced inflammatory and metabolic remodeling affect RBC integrity and augment splenic phagocyte activity promoting erythrophagocytosis. Exercise training normalizes these tumor-associated abnormal metabolic profiles and inflammation and thereby ameliorates anemia, in part, by promoting RBC survival. Fatigue was prevented in exercising tumor-bearing mice. Thus, exercise has the unique potential to substantially modulate metabolism and inflammation and thereby counteracts pathological remodeling of these parameters by the tumor microenvironment. Translation of this finding to patients with cancer could have a major impact on quality of life and potentially survival.

Baseline anemia and anemia grade are independent prognostic factors for stage IV non-small cell lung cancer

The current study aimed to investigate baseline anemia in patients with stage IV non-small cell lung cancer (NSCLC) and its relationship with clinicopathological features and prognosis. The clinical data of 4,874 patients with stage IV NSCLC were analyzed. The incidence of baseline anemia was observed. The relationship between baseline anemia and clinicopathological features was analyzed. Kaplan-Meier method and multivariate COX regression model were used to analyze the relationship of baseline anemia and prognosis of patients with NSCLC. Anemia classification was based on the criteria established by the National Cancer Institute (NCI). The mean hemoglobin (Hb) was 123.32±20.31 g/l in patients with stage IV NSCLC. The prevalence of baseline anemia was 32.09%, among which 19.08, 10.79, 1.91 and 0.31% had mild, moderate, severe, and life-threatening anemia, respectively. The prevalence of baseline anemia was higher in patients who were >60 years old, male, had smoking history, exhibited squamous cell carcinoma and bone metastasis, and the difference was statistically significant. Univariate analysis indicated that patients without anemia had longer overall survival (OS) compared with patients with baseline anemia (median OS: 28.0 months vs. 17.4 months, P<0.001). As the grade of anemia rises, it was indicated that OS became shorter. Patients with anemia grade 0 had the longest OS (median OS: 28.0 months), followed by patients with anemia grades 1 and 2 (median OS: 17.5 months). The patients with anemia grades 3 and 4 had the shortest OS (median OS: 8.6 months; P<0.001). Multivariate analysis demonstrated that baseline anemia and anemia grade were independent prognostic factors in patients with stage IV NSCLC. In conclusion, baseline anemia and anemia grade are independent prognostic factors in patients with stage IV NSCLC.

Hospitalization and definitive radiotherapy in lung cancer: incidence, risk factors and survival impact

BACKGROUND

Unplanned hospitalization during cancer treatment is costly, can disrupt treatment, and affect patient quality of life. However, incidence and risks factors for hospitalization during lung cancer radiotherapy are not well characterized.

METHODS

Patients treated with definitive intent radiation (≥45 Gy) for lung cancer between 2008 and 2018 at a tertiary academic institution were identified. In addition to patient, tumor, and treatment related characteristics, specific baseline frailty markers (Charlson comorbidity index, ECOG, patient reported weight loss, BMI, hemoglobin, creatinine, albumin) were recorded. All cancer-related hospitalizations during or within 30 days of completing radiation were identified. Associations between baseline variables and any hospitalization, number of hospitalizations, and overall survival were identified using multivariable linear regression and multivariable Cox proportional-hazards models, respectively.

RESULTS

Of 270 patients included: median age was 66.6 years (31-88), 50.4% of patients were male (n = 136), 62% were Caucasian (n = 168). Cancer-related hospitalization incidence was 17% (n = 47), of which 21% of patients hospitalized (n = 10/47) had > 1 hospitalization. On multivariable analysis, each 1 g/dL baseline drop in albumin was associated with a 2.4 times higher risk of any hospitalization (95% confidence interval (CI) 1.2-5.0, P = 0.01), and baseline hemoglobin ≤10 was associated with, on average, 2.7 more hospitalizations than having pre-treatment hemoglobin > 10 (95% CI 1.3-5.4, P = 0.01). After controlling for baseline variables, cancer-related hospitalization was associated with 1.8 times increased risk of all-cause death (95% CI: 1.02-3.1, P = 0.04).

CONCLUSIONS

Our data show baseline factors can predict those who may be at increased risk for hospitalization, which was independently associated with increased mortality. Taken together, these data support the need for developing further studies aimed at early and aggressive interventions to decrease hospitalizations during treatment.

Development of a Survival Prognostic Model for Non-small Cell Lung Cancer

Lung cancer is a leading cause of cancer-related death, and >80% of lung cancer diagnoses are non-small-cell lung cancer (NSCLC). However, when using current staging and prognostic indices, the prognosis can vary significantly. In the present study, we calculated a prognostic index for predicting overall survival (OS) in NSCLC patients. The data of 545 NSCLC patients were retrospectively reviewed. Univariate and multivariate Cox proportional hazards regression analyses were performed to evaluate the prognostic value of clinicopathological factors. Age (hazard ratio [HR] = 1.25, 95% confidence interval [CI] = 1.02–1.54), TNM stage (III, HR = 1.64, 95% CI = 1.08–2.48; IV, HR = 2.33, 95% CI = 1.48–3.69), lung lobectomy (HR = 1.96, 95% CI = 1.45–2.66), chemotherapy (HR = 1.42, 95% CI = 1.15–1.74), and pretreatment hemoglobin level (HR = 1.61, 95% CI = 1.28–2.02) were independent prognosticators. A prognostic index for NSCLC (PInscl, 0–6 points) was calculated based on age (≥65 years, 1 point), tumor-node-metastasis (TNM) stage (III, 1 point; IV, 2 points), lung lobectomy (no, 1 point), chemotherapy (no, 1 point), and pretreatment hemoglobin level (low, 1 point). In comparison with the “PInscl = 0” subgroup (survival time = 2.71 ± 1.86 years), the “PInscl = 2” subgroup (survival time = 1.86 ± 1.24 years), “PInscl = 3” subgroup (survival time = 1.45 ± 1.07 years), “PInscl = 4” subgroup (survival time = 1.17 ± 1.06 years), “PInscl = 5” subgroup (survival time = 0.81 ± 0.78 years), and “PInscl = 6” subgroup (survival time = 0.65 ± 0.56 years) exhibited significantly shorter survival times. Kaplan-Meier survival analysis showed that patients with higher PInscl scores had poorer OS than those with lower scores (log-rank test: χ² = 155.82, P < 0.0001). The area under the curve of PInscl for predicting the 1-year OS was 0.73 (95 % CI = 0.69–0.77, P < 0.001), and the PInscl had a better diagnostic performance than the Karnofsky performance status or TNM stage (P < 0.01). In conclusion, the PInscl, which is calculated from age, TNM stage, lung lobectomy, chemotherapy, and pretreatment hemoglobin level, significantly predicted OS in NSCLC patients.

Prognostic value of baseline hemoglobin-to-red blood cell distribution width ratio in small cell lung cancer: A retrospective analysis

Background

This study aimed to investigate the prognostic value of baseline hemoglobin‐to‐red blood cell distribution width ratio (HRR) in patients with small cell lung cancer (SCLC).

Methods

We retrospectively analyzed the medical records of patients with newly diagnosed SCLC who had received first‐line chemotherapy at the Department of Pulmonary Oncology of the PLA 307 Hospital between January 2008 and October 2018. The optimal cutoff value of the continuous variables was determined using the X‐tile software. Univariate and multivariate analyses were conducted using Cox proportional hazard models. The Kaplan‐Meier method was used for survival analysis, with differences tested using the log‐rank test.

Results

A total of 146 patients were included. The cutoff value for HRR was determined as 0.985. Statistically significant differences were observed in sex, smoking history, stage, radiotherapy combination, neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, hemoglobin, and red blood cell distribution width between the high and low HRR groups. The median overall survival (OS) was nine and 17.5 months in the low and high HRR groups, respectively (P < 0.001). The median progression‐free survival (PFS) was five and 8.5 months, respectively (P < 0.001). Univariate and multivariate analyses showed low HRR to be an independent predictor of a poor prognosis for OS (hazard ratio = 3.782; 95% confidence interval, 2.151–6.652; P < 0.001) and PFS (hazard ratio = 2.112; 95% confidence interval, 1.195–3.733; P = 0.01) in SCLC.

Conclusion

Low HRR was associated with poorer OS and PFS in patients with SCLC and can be a potentially valuable prognostic factor for these patients.

Key points

The prognostic value of the baseline hemoglobin‐to‐red blood cell distribution width ratio was evaluated in patients with small cell lung cancer.

In this population, this ratio was an independent predictor of overall survival and progression‐free survival. This ratio, an inexpensive and routine parameter, can be used as a prognostic factor in small cell lung cancer.

Sex-specific Associations Between Serum Hemoglobin Levels and the Risk of Cause-specific Death in Korea Using the National Health Insurance Service-National Health Screening Cohort (NHIS HEALS)

Objectives

The purpose of this study was to determine the associations between blood hemoglobin (Hgb) levels and the risk of death by specific causes.

Methods

Using the National Health Insurance Services-National Health Screening Cohort (n=487 643), we classified serum Hgb levels into 6 sex-specific groups. Cox regression analysis was used to analyze the associations between Hgb levels and the risk of cause-specific death.

Results

Hgb levels in male population showed a U-shaped, J-shaped, or inverse J-shaped association with the risk of death from ischemic heart disease, acute myocardial infarction, liver cancer, cirrhosis and chronic obstructive pulmonary disease (COPD) (all non-linear p<0.05; hazard ratio [HR]; 95% confidence interval [CI]) for the lowest and the highest Hgb levels for the risk of each cause of death in male population: HR, 1.14; 95% CI, 0.98 to 1.34; HR, 2.87; 95% CI, 1.48 to 5.57; HR, 1.16; 95% CI, 0.96 to 1.40; HR, 3.05; 95% CI, 1.44 to 6.48; HR, 1.36; 95% CI, 1.18 to 1.56; HR, 2.11; 95% CI, 1.05 to 4.26; HR, 3.64; 95% CI, 2.49 to 5.33; HR, 5.97; 95% CI, 1.44 to 24.82; HR, 1.62; 95% CI, 1.14 to 2.30; HR, 3.84; 95% CI, 1.22 to 12.13, respectively), while in female population, high Hgb levels were associated with a lower risk of death from hypertension and a higher risk of death from COPD (overall p<0.05; HR, 1.86; 95% CI, 1.29 to 2.67 for the lowest Hgb levels for hypertension; overall p<0.01, HR, 6.60; 95% CI, 2.37 to 18.14 for the highest Hgb levels for COPD). For the risk of lung cancer death by Hgb levels, a linear negative association was found in male population (overall p<0.01; the lowest Hgb levels, HR, 1.17; 95% CI, 1.05 to 1.33) but an inverse J-shaped association was found in female population (non-linear p=0.01; HR, 1.25; 95% CI, 0.96 to 1.63; HR, 2.58; 95% CI, 1.21 to 5.50).

Conclusions

Both low and high Hgb levels were associated with an increased risk of death from various causes, and some diseases showed different patterns according to sex.

Preoperative anemia as a prognostic factor in patients with lung cancer: a systematic review and meta-analysis of epidemiological studies

The evidence of current epidemiological studies investigating the relationship between preoperative anemia and progression of lung cancer (LC) patients remains controversial. The PubMed, EMBASE, and Web of Science databases were comprehensively searched by two independent authors to identify related epidemiological studies from inception through January 31, 2019. Similarly, two researchers separately extracted data and any differences were resolved by discussion. Summarized hazard ratios (HRs) and 95% confidence intervals (CIs) were summarized with inverse variance weighted random effects meta-analysis. Heterogeneity among studies was assessed with the I² statistic. Twenty-two studies were included in this meta-analysis. As compared with LC patients without anemia, those with pre-operative anemia were at a 1.6-fold greater risk of death (summarized HR = 1.58; 95% CI = 1.44-1.75), with moderate heterogeneity (I² = 53.1%). Funnel plot and statistical analyses showed no evidence of publication bias. Associations between pre-operative anemia and OS were broadly consistent across numerous subgroups analyses stratified by the study design, geographic location, number of cases, tumor, node, and metastasis (TNM) stage, histology, quality, and adjustment for potential confounders (age, sex, body mass index, TNM stage, histology, performance status, surgery, blood transfusion, and systemic inflammatory response markers). Similar patterns were observed in the sensitivity analyses. The results of meta-regression analysis suggested no evidence of significant heterogeneity between subgroups. In conclusion, pre-operative anemia was associated with poorer overall survival among LC patients.