Increased incidence of symptomatic venous thrombosis in patients with cervical carcinoma treated with concurrent chemotherapy, radiation, and erythropoietin

Radioresistance or/and radiosensitivity of head and neck squamous cell carcinoma: biological angle

OBJECTIVE

This narrative review aimed to compile and summarize clinically relevant literature in radiation therapy and to discuss the potential in radioresistant and radiosensitive head and neck squamous cell carcinoma (HNSCC).

METHODS AND MATERIALS

Google Scholar, PubMed, and the Cochrane Library were retrieved using combined key words such as "radiotherapy" and "head and neck cancer." Search strings additionally queried were "radioresistant," "radiosensitive," "head and neck region," "squamous cell carcinoma," in combination with Boolean operators 'AND' and 'OR.' Subsequently, the resulting publications were included for review of the full text.

RESULTS

Radiotherapeutic responses currently in clinical observation referred to HNSCC scoping were selected into this review. The compiled mechanisms were then detailed concerning on the clinical significance, biological characteristics, and molecular function.

CONCLUSIONS

Brachytherapy or/and external-beam radiotherapy are crucial for treating HNSCC especially the early stage patients, but in some patients with locally advanced tumors, their outcome with radiation therapy is poor due to obvious radioresistance. The curative effects mainly depend on the response to radiation therapy so an updated review is needed to optimize further applications in HNSCC radiotherapy.

A radiobiological perspective on radioresistance or/and radiosensitivity of head and neck squamous cell carcinoma

Background

This article aimed to compile and summarize clinically relevant literature in radiation therapy, and to discuss the potential in radioresistant and radiosensitive head and neck cancer.

Study Design

Narrative review.

Materials and methods

Google Scholar, PubMed and the Cochrane Library were retrieved using combined key words such as "radiotherapy" and "head and neck cancer". Search strings additionally queried were "radioresistant", "radiosensitive", "head and neck region", "squamous cell carcinoma", in combination with Boolean Operators 'AND' and 'OR'. Subsequently, the resulting publications were included for review of the full text.

Results

Radiotherapeutic response currently in clinical observation referred to HNSCC scoping were selected into this review. The compiled mechanisms were then detailed concerning on the clinical significance, biological characteristics, and molecular function.

Conclusions

Brachytherapy or/and external-beam radiotherapy are crucial for treating HNSCC, especially the early stage patients, but in patients with locally advanced tumors, their outcome with radiation therapy is poor due to obvious radioresistance. The curative effects mainly depend on the response of radiation therapy, so an updated review is needed to optimize further applications in HNSCC radiotherapy.

Repurposing radiosensitising medicines for radiotherapy: an overview

Repurposing established non-cancer drugs for the treatment of cancer offers potential benefits such as speed of clinical translation and financial efficiencies. In this study, we assess the landscape of repurposing drugs for combined use with radiotherapy (RT) based on their capacity to increase tumour radiosensitivity. Using a literature-based approach, we identified 42 radiosensitising drugs with varied non-cancer indications and mechanisms of action, that have entered or completed clinical trials in combination with RT or with chemoradiotherapy. Two compounds, nicotinamide and nimorazole, have entered routine but limited clinical use in combination with radiotherapy. We provide an overview on these successfully repurposed drugs, and highlight some examples of unsuccessful repurposing efforts and drug candidates with an uncertain prospect of success. Upon reviewing the trials, we identified some common themes behind the unsuccessful efforts, including poor trial reporting, absence of biomarkers and patient selection, sub-optimal pharmacological properties, inappropriate trial design, lack or inadequate consideration of pre-clinical and clinical data, and limited funding support. We point out future directions to mitigate these issues and increase the likelihood of success in repurposing drug treatments for radiotherapy.

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.

Intranasal injection of recombinant human erythropoietin improves cognitive and visual impairments in chronic cerebral ischemia rats

The present study aimed to study the protective effect of intranasally delivered recombinant human erythropoietin (rhEPO) on cognitive and visual impairments in a permanent bilateral common carotid artery occlusion (2VO)-induced chronic cerebral ischemia (CCI) rat model. Male Sprague-Dawley rats (age, 6 months) with 2VO-induced CCI were treated with intranasal rhEPO (50 U/100 g) once per week for 8 weeks. A Morris water maze was used to evaluate the spatial learning and memory of the rats. Flash visual evoked potentials were measured to assess retinal function. Hematoxylin and eosin staining was performed to visualize and evaluate histopathological changes in the cerebral cortex, the hippocampus CA1 region and the retina. CCI-induced learning, memory and visual impairments were significantly alleviated in rats treated with rhEPO compared with those treated with a saline vehicle control. This was evidenced by remarkably decreased escape latency, increased frequency of crossing the hidden platform and elevated amplitude of primary wave in the rats treated with rhEPO. In addition, the rats experienced CCI-induced histopathological alterations, demonstrated by thinning of the cerebral cortex and retina, and losses of neurons and retinal ganglion cells. These alterations were significantly reversed in response to rhEPO administration compared with the saline vehicle control group. rhEPO may exert a protective role against cognitive and visual impairments in rats with CCI at least partially through preventing the thinning of the cerebral cortex and retina, as well as by inhibiting the loss of neurons and retinal ganglion cells.

Erythropoietin-Induced Thrombosis as a Result of Increased Inflammation and Thrombin Activatable Fibrinolytic Inhibitor

Chronic inflammation is a major cause of morbidity and mortality in end-stage renal disease. The associated anemia in these patients due to renal cortical atrophy and erythropoietin deficiency is treated with recombinant erythropoietin. Recent reports suggest a growing incidence of symptomatic venous thrombosis in cancer patients treated with recombinant erythropoietin. Several investigators have reported on different mechanisms of thrombosis in these patients. We hypothesize that thrombosis in patients with end-stage renal disease due to increased expression of C-reactive protein (CRP) as a result of chronic inflammation promotes the release of thrombin activatable fibrinolytic inhibitor causing fibrinolytic deficit and eventually thrombosis. Furthermore, because endothelial nitric oxide is responsible for the maintenance of the normal vascular function, the decreased levels of nitric oxide in chronic inflammation cause endothelial damage and result in thrombosis. To test this hypothesis, blood samples were collected from 106 patients (49 male and 57 female, aged 59.8±15.7 years) with end-stage renal disease undergoing hemodialysis and treated with recombinant erythropoietin at a mean dose of 201.8 U/kg/week. Blood samples were drawn in 5-mL tubes containing 3.2% sodium citrate just before the hemodialysis procedure. These blood samples were immediately centrifuged to obtain platelet-poor plasma, which was aliquoted and frozen at -70°C until further analysis. Erytropoietin antibodies were measured using an anti-EPO enzyme-linked immunosorbent assay (ELISA) method developed in our laboratory. Nitric oxide was measured using a NO analyzer (Sievers 280I, Ionics, Boulder, CO). Plasma CRP levels were measured with a highly sensitive ELISA method IMUNOCLONE CRP ELISA (American Diagnostica, Greenwich, CT). TAFI antigen levels in plasma were analyzed with an IMUCLONE TAFI ELISA kit (American Diagnostica, Greenwich, CT). TAFI functional activity was assayed with an ACTICHROME TAFI activity kit. The measured levels of nitric oxide, CRP, TAFI antigen, and TAFI functional were 37.36±36.8 (normal value, 37.49±18.96; range, 19.3-102 μM), 12.27±10.6 (normal value, < 1 μg/mL), 146.9±28.4% NHP (normal, 100% NHP), and 102.55±37% NHP (normal range, 22.3-165.7; mean, 89.5% NHP), respectively. The erythropoietin antibody was detected in 9.4% of the patient group. While 20% of the erythropoietin antibody-positive and 27.1% of the erythropoietin antibody-negative patients experienced chest pain, thrombotic events developed in 9.4% of the erythropoietin antibody-negative patients. These data provide the rationale for a novel mechanism of thrombosis through increased activity of CRP, nitric oxide, and TAFI, leading to fibrinolytic deficit and thrombosis in patients treated with erythropoietin.

Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone

We observed the outcomes of chemotherapy with radiotherapy (CR) or radiotherapy (RT) alone for cancer patients of larynx, breast, blood and brain origins through complete blood count (CBC). Following were more depressed in CR patients: mean corpuscular hemoglobin-MCH & lymphocytes-LYM, hematocrit, mean corpuscular hemoglobin concentration-MCHC, hemoglobin-HB and red blood cells-RBC. In RT patients, following were more depressed: LYM, MCH and MCHC. Overall, in all cancer patients, the lymphocytes were depressed 52%. There existed a significant difference between white blood cells and RBC in both CR and RT patients. A significant moderate negative correlation is found in HB with the dose range 30-78 (Gray) given to the CR cancer patients. More number of CBC parameters affected in patients treated with CR and RT; but in less percentage as compared to patients who treated with RT alone. The cancer patients suffered from anemia along with immune modulations from the treatments.

Use of Hematopoietic Growth Factors and Risk of Thromboembolic and Pulmonary Toxicities in Elderly Patients with Advanced Ovarian Cancer

OBJECTIVE

To evaluate the risk of thromboembolic and pulmonary toxicities associated with hematopoietic growth factor (HGF) use (i.e., erythropoietin-stimulating agent [ESA] and/or colony-stimulating factor [CSF]) in a community-dwelling cohort of elderly patients with advanced ovarian cancer.

METHODS

We studied 8,188 women, 65 years and older from the Surveillance, Epidemiology and End Results-Medicare linked database, diagnosed from January 1, 2000 to December 31, 2009. Patients were categorized into five groups: no chemotherapy and no ESA/CSF (n = 2,616), chemotherapy but no ESA/CSF (n = 1,854), ESA only (n = 1,313), CSF only (n = 743), and ESA + CSF (n = 1,662). We reported the cumulative incidence of toxicities for 2, 6, and greater than 6 months, and the incidence density for the overall follow-up. Cox-proportional hazards regression was performed to determine risk of toxicities.

RESULTS

Of the 5,572 patients receiving chemotherapy, 66.7% (n = 3,718) received HGF supportive treatment, 29.8% received ESA + CSF, 23.6% received ESA only, and 13.3% received CSF only. Patients who received chemotherapy and also ESA + CSF had a 14.1% cumulative incidence of thromboembolic event (TEE) at 6 months of follow-up compared with 8.0% in those who received chemotherapy without growth factor and 3.2% in those with neither chemotherapy nor growth factor. Those with chemotherapy who received ESA + CSF had a significantly higher risk of TEE (adjusted hazard ratio, 1.22; 95% confidence interval, 1.01-1.47) as compared with patients with chemotherapy and no ESA/CSF, although patients aged 85 years and older may experience up to a five-fold increased risk. The risk of pulmonary toxicities did not significantly differ by HGF use.

CONCLUSIONS

An increased risk of TEEs was observed in elderly patients with ovarian cancer who received ESA + CSF. The risk-benefit ratio for administering HGF should be carefully evaluated, especially among those 85 years and older.

[Radiosensitivity and/or radioresistance of head and neck cancers: Biological angle]

Radiation therapy is a cornerstone of head and neck cancer management. Technological improvements in recent years in radiation therapy, with intensity-modulated techniques, reinforce even more its role. However, both local and locoregional relapses are still observed. Understanding biological mechanisms of treatment resistance is a topic of major interest. From the cancer cell itself, its ability to repair and proliferate, its microenvironment and oxygenation conditions, migratory and invasive capacity, to biological parameters related to the patient, there are many mechanisms involving radiosensitivity and/or radioresistance of head and neck cancer. The present study explores the main biological mechanisms involved in radiation resistance of head and neck cancer, and describes promising therapeutic approaches.

Low Oxygen Tension Primes Aortic Endothelial Cells to the Reparative Effect of Tissue-Protective Cytokines

Erythropoietin (EPO) has both erythropoietic and tissue-protective properties. The EPO analogues carbamylated EPO (CEPO) and pyroglutamate helix B surface peptide (pHBSP) lack the erythropoietic activity of EPO but retain the tissue-protective properties that are mediated by a heterocomplex of EPO receptor (EPOR) and the β common receptor (βCR). We studied the action of EPO and its analogues in a model of wound healing where a bovine aortic endothelial cells (BAECs) monolayer was scratched and the scratch closure was assessed over 24 h under different oxygen concentrations. We related the effects of EPO and its analogues on repair to their effect on BAECs proliferation and migration (evaluated using a micro-Boyden chamber). EPO, CEPO and pHBSP enhanced scratch closure only at lower oxygen (5%), while their effect at atmospheric oxygen (21%) was not significant. The mRNA expression of EPOR was doubled in 5% compared with 21% oxygen, and this was associated with increased EPOR assessed by immunofluorescence and Western blot. By contrast, βCR mRNA levels were similar in 5% and 21% oxygen. EPO and its analogues increased both BAECs proliferation and migration, suggesting that both may be involved in the reparative process. The priming effect of low oxygen tension on the action of tissue-protective cytokines may be of relevance to vascular disease, including atherogenesis and restenosis.

Guidelines for treatment and prevention of venous thromboembolism among patients with cancer

The association between cancer and thrombosis has been recognized for more than 150 years. Not only are patients with cancer at a substantially increased risk of developing venous thromboembolism (VTE), the link between several coagulation factors and tumor growth, invasion, and the development of metastases has been established. Reported rates of VTE in patients with cancer have increased in recent years likely reflecting, in part, improved diagnosis with sophisticated imaging techniques as well as the impact of more aggressive cancer diagnosis, staging, and treatment. Various therapeutic interventions, such as surgery, chemotherapy, hormonal therapy, targeted therapeutic strategies as well as the frequent use of indwelling catheters and other invasive procedures also place cancer patients at increased risk of VTE. The increasing risk of VTE, the multitude of risk factors, and the greater risk of VTE recurrence and death among patients with cancer represent considerable challenges in modern clinical oncology. The American Society of Clinical Oncology (ASCO) originally developed guidelines for VTE in patients with cancer in 2007. ASCO recently updated clinical practice guidelines on the treatment and prevention of VTE in patients with cancer following an extensive systematic review of the literature. Revised 2013 guidelines have now been presented and will be discussed in this review. Although several new studies were identified and considered, many important questions remain regarding the relationship between thrombosis and cancer and the optimal care of patients at risk for VTE.

Intravenous iron monotherapy for the treatment of non-iron-deficiency anemia in cancer patients undergoing chemotherapy: a pilot study

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.

Prevalence and management of anaemia in patients with non-myeloid cancer undergoing systemic therapy: a Spanish survey

BACKGROUND

The present study aimed to provide updated data on anaemia prevalence and management in cancer patients undergoing systemic therapy in Spain.

METHODS

This was a multicenter, observational, cross-sectional study performed in 2008. Eligible patients were ≥18 years, with non-myeloid malignancies treated with systemic therapy [chemotherapy (CT), hormonal therapy or immunotherapy]. Anaemia was defined according to WHO as haemoglobin (Hb) < 12 g/dL.

RESULTS

The study included 214 patients with a median age of 63 years (range 20-91), 58 % women, 73 % with solid tumours, and 79 % with advanced disease. CT was used in 91 % of patients (26 % with platinum compounds), hormonal therapy in 8.5 %, and immunotherapy in 8.5 %. In our study, 48.1 % of patients [95 % confidence interval (CI) 45.2-58.6] showed anaemia (31 % symptomatic): 42.0 % mild (10 ≤ Hb ≤ 11.9 g/dL), 5.6 % moderate (8 ≤ Hb ≤ 9.9 g/dL), and 0.5 % severe (Hb < 8 g/dL). A higher prevalence was observed in patients treated with CT (51 vs. 20 %, p = 0.01), platinum-based CT (70 vs. 47 %, p = 0.01) or palliative CT (61 vs. 39 %, p = 0.003). Anaemia was also more frequent in patients with more than three lines of CT (83 %) and in the fourth or subsequent CT cycle (58 %). Management in the previous 4 weeks in patients with anaemia was: 62 % did not receive treatment (92 % mild), 24 % received erythropoiesis-stimulating agents (ESAs), 14 % received iron and 8.7 % received transfusion.

CONCLUSIONS

In Spanish hospitals, about half of patients with non-myeloid malignancies undergoing systemic therapy fulfilled anaemia criteria (87 % mild). Approximately two-third of patients with anaemia do not receive specific treatment and ESA use is below current guidelines.

Erythropoietin treatment in chemotherapy-induced anemia in previously untreated advanced esophagogastric cancer patients

BACKGROUND

The impact of erythropoiesis-stimulating agents in chemotherapy-induced anemia has been a constant topic of debate over recent years. We prospectively assessed the efficacy of epoetin beta (Epo-b) in improving hemoglobin (Hb) levels and outcome in patients within an open label, randomized clinical phase II trial with advanced or metastatic gastric/esophagogastric cancer.

METHODS

Previously untreated patients were randomized to receive 3-weekly cycles of capecitabine (1000 mg/m(2) bid) for 14 days plus on day 1 either irinotecan 250 mg/m(2) or cisplatin 80 mg/m(2). Epo-b (30000 IU once weekly) was initiated in patients with Hb <11 g/dl and continued until Hb ≥12 g/dl was reached. If after 4 weeks the Hb increase was <0.5 g/dl, Epo-b was increased to 30000 IU, twice weekly.

RESULTS

Of 118 patients enrolled, 32 received Epo-b treatment; of these, 65 % achieved an increase in Hb levels of at least 2 g/dl, with 74 % achieving the target Hb of ≥12 g/dl. Within the study population, patients receiving Epo-b showed better overall survival (median 14.5 vs. 8.0 months, P = 0.056) as well as a significantly improved disease control rate (78 vs. 55 %, P = 0.025). Patients in the irinotecan group profited significantly (P < 0.05) in terms of progression-free survival and overall survival under Epo-b treatment (median 6.5 vs 4.1 months and median 15.4 vs 8.4 months, respectively).

CONCLUSIONS

Epo-b was effective in raising Hb levels in patients with advanced esophagogastric cancer. Patients receiving Epo-b had a significantly increased response to chemotherapy and a clear trend to improved survival.

Biomolecular markers of cancer-associated thromboembolism

Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism) is associated with a poor prognosis in most malignancies and is a major cause of death among cancer patients. Universal anticoagulation for primary thromboprophylaxis in the outpatient setting is precluded by potential bleeding complications, especially without sufficient evidence that all patients would benefit from such prophylaxis. Therefore, appropriately targeting cancer patients for thromboprophylaxis is key to reducing morbidity and perhaps mortality. Predictive biomarkers could aid in identifying patients at high risk for VTE. Possible biomarkers for VTE include C-reactive protein, platelet and leukocyte counts, D-dimer and prothrombin fragment 1+2, procoagulant factor VIII, tissue factor, and soluble P-selectin. Evidence is emerging to support the use of risk assessment models in selecting appropriate candidates for primary thromboprophylaxis in the cancer setting. Further studies are needed to optimize these models and determine utility in reducing morbidity and mortality from cancer-associated thromboembolism.

Incidence of venous thromboembolism before treatment in cervical cancer and the impact of management on venous thromboembolism after commencement of treatment

INTRODUCTION

Silent venous thromboembolism (VTE) often occurs before treatment in ovarian or endometrial cancer and management can decrease VTE after treatment. However, the incidence of VTE before treatment and the impact of management are still unclear in cervical cancer.

MATERIALS AND METHODS

We investigated the incidence of VTE before treatment in 272 consecutive patients with cervical cancer, and the impact of management on prevention of VTE during and after treatment. D-dimer levels before treatment were examined in all patients. Venous ultrasonography of the lower extremities was performed in patients with D-dimer ≥1.5μg/ml. Deep vein thrombosis (DVT) in the pelvis or abdomen was diagnosed by enhanced computed tomography.

RESULTS

Thirteen patients (4.8%; 3 preoperatively, 10 before radiotherapy or concurrent chemoradiotherapy) were diagnosed with DVT, although DVT was symptomatic in only 1 patient. None of the 13 patients showed pulmonary embolism on pulmonary scanning. Although 4 of 128 patients (3.1%) developed VTE after radical hysterectomy, none of the 124 patients who underwent radiotherapy or concurrent chemoradiotherapy developed VTE during or after treatment.

CONCLUSIONS

These data suggest that VTE before treatment occurs less frequently with cervical cancer than with ovarian or endometrial cancer. However, management may decrease VTE during and after treatment, especially radiotherapy.

Primary venous thromboembolism prophylaxis in ambulatory cancer patients

OBJECTIVE

To summarize and review current medical literature regarding the efficacy and safety of antithrombotic therapy for primary venous thromboembolism (VTE) prophylaxis in various ambulatory cancer populations.

DATA SOURCES

A literature search was conducted in PubMed (1966-September 2012) and International Pharmaceutical Abstracts (1970-September 2012) using the terms venous thromboembolism, primary prophylaxis, anticoagulation, antithrombotic agents, cancer, and ambulatory. The bibliographies of pertinent studies and topic articles were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION

All English-language articles were evaluated for inclusion. All randomized trials were included in the review.

DATA SYNTHESIS

Malignancy has been identified as a major independent risk factor for the development of VTE in the surgical, medically ill, and ambulatory populations. Primary VTE prophylaxis has been identified as an area of great impact in cancer patients because of the difficulties associated with the treatment of VTE and the greater risk for its recurrence in this population. Although primary VTE prophylaxis is recommended in all surgical and hospitalized cancer patients without contraindications to anticoagulants, its role in ambulatory cancer patients is less certain because of varying patient, cancer, and treatment-related factors. Fourteen randomized studies have investigated the use of antithrombotic agents for primary VTE prophylaxis in ambulatory cancer patients. Strong evidence for primary prophylaxis exists for several populations with advanced or metastatic cancer considered to be at high risk, including those with pancreatic cancer, lung cancer, or multiple myeloma. Evidence is inconsistent or lacking for lower risk cancer populations, such as those with breast cancer, or for those with malignant glioma, which carries a high risk for VTE and bleeding relative to the general ambulatory cancer population.

CONCLUSIONS

Use of antithrombotic agents has reduced the rate of primary VTE, with minimal increases in bleeding risk in specific ambulatory cancer populations. Further investigation is needed to guide and narrow recommendations for primary VTE prophylaxis in ambulatory cancer patients.

Cytokine use and survival in the first-line treatment of ovarian cancer: a Gynecologic Oncology Group Study

BACKGROUND

Granulocyte colony stimulating factor (G-CSF) and erythropoietin stimulating agents (ESA) may be used to support patients during chemotherapy. We assessed whether G-CSF or ESA were associated with progression or death in patients with ovarian cancer.

METHODS

Patients with ovarian cancer following surgery, were on a protocol to evaluate bevacizumab with chemotherapy. Guidelines for administering G-CSF and ESA were specified in the protocol. Overall survival (OS) was analyzed with landmark procedures and multivariate, time-dependent hazard models.

RESULTS

Eighteen-hundred-seventy-three women were enrolled, with no differences in clinical and pathologic variables among treatment group. Performance status, hemoglobin, and white cell counts were associated with G-CSF and/or ESA usage during treatment. Nine patients received no protocol directed therapy, leaving 1864 patients for this review. One-thousand-one-hundred-twenty-five patients received neither ESA nor G-CSF; 311 received G-CSF but no ESA; 241 received ESA but no G-CSF; and 187 received both. Median survival following a five month landmark from the start of treatment was 34 versus 38 months for those who did versus did not receive ESA (multivariate hazard ratio: 0.989; 95% confidence interval: 0.849-1.15) and 40 versus 37 months for those who did versus did not receive G-CSF (multivariate hazard ratio: 0.932; 95% confidence interval: 0.800-1.08).

CONCLUSIONS

Neither ESA nor G-CSF had a negative impact on survival after adjustment of prognostic factors among patients with ovarian cancer receiving chemotherapy. ESA may appear to be associated with shorter survival in univariate analyses because factors prognostic for ESA use are also prognostic for progression-free survival.

Evaluation of clinical use and effectiveness of darbepoetin alfa in cancer patients with chemotherapy-induced anemia

PURPOSE

To investigate the patterns of use of darbepoetin alfa in Spanish centers, and to evaluate its effectiveness in the treatment of chemotherapy-induced anemia under clinical practice conditions.

METHODS

This was an observational, retrospective, multicenter study in adult patients with non-myeloid malignancies who initiated chemotherapy and darbepoetin alfa. Data was collected for up to 16 weeks or until treatment discontinuation.

RESULTS

A total of 685 patients (72.7% with solid tumors and 27.3% with hematologic malignancies) were included in the study. Median age was 64.7 years (range 18.5-88.9 years), 50.7% were women, 82.4% had ECOG status 0-1 and 80.5% had stage III/IV cancer. At darbepoetin initiation, mean hemoglobin (Hb) was 100 g/L (SD 10), with 11.0% and 23.1% of patients below 90 g/L in solid and hematologic malignancies, respectively. A decrease in transfusion requirements was observed between weeks 5-16 with respect to weeks 0-16 (13.3% [95% CI: 10.7 to 15.9] versus 19.0% [95% CI: 16.0 to 22.0]). Hb levels were significantly increased during the treatment (mean change of 10.4 g/L for solid tumors [p < 0.001], and 16.6 g/L for hematologic malignancies [p < 0.001]). The percentage of patients with baseline Hb level <110 g/L who achieved an Hb level ≥110 g/L during the study was 66.5% (95% CI: 62.5% to 70.5%). Six serious adverse reactions were considered related to darbepoetin alfa (thromboembolic events, 1.0%).

CONCLUSIONS

With the limitation of a retrospective design, our results suggest that darbepoetin alfa is a well tolerated treatment that increases hemoglobin levels and reduces the need for transfusion in cancer patients receiving chemotherapy in clinical practice.

Epidemiology, risk and outcomes of venous thromboembolism in cancer

Cancer is associated with a fourfold increased risk of venous thromboembolism (VTE). The risk of VTE varies according to the type of malignancy (i. e. pancreatic cancer, brain cancer, lymphoma) and its disease stage and individual factors (i. e. sex, race, age, previous VTE history, immobilization, obesity). Preventing cancer-associated VTE is important because it represents a significant cause of morbidity and mortality. In order to identify cancer patient at particularly high risk, who need thromboprophylaxis, risk prediction models have become available and are under validation. These models include clinical risk factors, but also begin to incorporate biological markers. The major American and European scientific societies have issued their recommendations to guide the management of VTE in patients with cancer. In this review the principal aspects of epidemiology, risk factors and outcome of cancer-associated VTE are summarized.

Randomized Phase III Trial of Sequential Adjuvant Chemoradiotherapy With or Without Erythropoietin Alfa in Patients With High-Risk Cervical Cancer: Results of the NOGGO-AGO Intergroup Study

Purpose

This open-label, randomized phase III study was designed to investigate the effects of erythropoietin alfa (EPO) in addition to adjuvant chemotherapy and pelvic radiotherapy (CRT) in patients with stage IB to II cervical cancer who had undergone radical hysterectomy.

Patients and Methods

Two hundred fifty-seven patients were randomly assigned to four cycles of carboplatin/ifosfamide chemotherapy followed by external-beam pelvic radiotherapy (CRT group) or four cycles of carboplatin/ifosfamide chemotherapy and EPO followed by pelvic radiotherapy and EPO (CRT + EPO group). The primary end point was recurrence-free survival (RFS). Secondary end points included overall survival (OS), change in hemoglobin levels, and safety, including thromboembolic events.

Results

The estimated 5-year RFS rates were 78% for patients receiving CRT + EPO and 70% for patients receiving CRT. There was no statistically significant difference in RFS, although a trend favoring patients treated with CRT + EPO was observed (hazard ratio [HR], 0.66; 95% CI, 0.39 to 1.12; log-rank P = .06). Exploratory analyses suggest a benefit with CRT + EPO for patients with stage IB to IIA disease (HR, 0.39; 95% CI, 0.18 to 0.85; P = .014) or patients with complete resection (HR, 0.55; 95% CI, 0.31 to 0.98; P = .039). OS was similar in both groups (HR, 0.88; 95% CI, 0.51 to 1.50; log-rank P = .63). Patients treated with EPO maintained higher hemoglobin levels throughout CRT. No significant differences in safety profiles were observed between the two groups. Incidence of thrombovascular events was low (2%) and comparable between both groups.

Conclusion

This study confirms that EPO can be added safely to CRT in patients with cervical cancer, but it failed to demonstrate a significant benefit in RFS and OS.

Ten years of meta-analyses on erythropoiesis-stimulating agents in cancer patients

BACKGROUND

Since erythropoiesis-stimulating agents (ESAs) were licensed in 1993, more than 70 randomized controlled trials and more than 20 meta-analyses and systematic reviews on their effectiveness were conducted. Here, we present a systematic review on the meta-analyses of trials evaluating ESAs in cancer patients.

METHODS

We included all published meta-analyses of at least five randomized controlled trials that evaluated the effects of ESAs versus control in patients with any type of cancer or myelodysplastic syndrome.

RESULTS

We included a total of 23 systematic reviews and meta-analyses (16 literature based and 7 based on individual patient data (IPD)) that assessed several outcomes. All 12 meta-analyses reporting on transfusion risks demonstrated that ESAs significantly reduce the risk of transfusions. Eleven meta-analyses (nine based on published data and two on IPD) evaluated thrombovascular events. An increased risk of thrombovascular events was observed in all but two meta-analyses (relative risks (RRs) ranging from 1.57 to 1.69). However, potential reporting and publication bias as well as detection bias call for a cautious interpretation of these results. Survival and mortality were evaluated in 18 meta-analyses, with the observed effect changing over time. While meta-analyses on studies conducted before 2002 showed beneficial effects of ESAs on survival, contrary results, i.e. worsened survival, was seen in meta-analyses including more recent studies.

DISCUSSION

The results from several meta-analyses show that ESAs in cancer patients reduce the risk for red blood cell transfusions and increase the risk for thrombovascular events and mortality. The effect of ESAs on mortality risk in patients receiving chemotherapy remains unclear. In clinical practice, the benefits and risks of ESAs should be carefully considered and decisions should be made based on each patient's situation and preferences.

Erythropoiesis-stimulating agents and heart failure

Anemia is a common comorbidity in heart failure (HF) patients. Its occurrence and severity are associated with worse prognosis. Although the etiology of anemia is multifactorial, inappropriate erythropoietin (EPO) production and/or bone-marrow resistance to EPO appear crucial in majority of anemic HF patients. Consequently, treatment based on this pathophysiological background may prove to be most effective and beneficial. In a number of smaller clinical studies, administration of erythropoiesis-stimulating agents (ESAs) to anemic HF patients improved a number of surrogate endpoints, including left ventricular function, exercise capacity, renal function, and different quality of life parameters. However, two larger, phase II studies, did not fully confirm these promising results. Furthermore, many concerns have been raised on the safety of ESAs after the recent publication of studies correcting anemia in patients with chronic kidney disease (CKD). On the other hand, chronic HF population varies significantly from CKD patients, with different comorbidities, renal function, and etiology of anemia. Moreover, ESAs have been shown to possess robust nonhematopoietic effects in the heart, namely inhibition of apoptosis and stimulation of neovascularization. Therefore, large-scale trials with ESAs are required to examine the effect and safety of anemia treatment in HF patients.

Thromboprophylaxis during chemotherapy in patients with advanced cancer

Venous thromboembolism is a common and potentially fatal complication in patients with advanced cancer. In these patients chemotherapy has been identified as an independent risk factor for venous thromboembolism. The annual incidence of venous thromboembolism in cancer patients who receive chemotherapy is estimated to be about 10%. This risk increases up to 15-20% depending on type and combination of anticancer agents. The occurrence of venous thromboembolic events in cancer patients is associated with a poor prognosis. The benefit of antithrombotic prophylaxis for venous thromboembolism in cancer patients who receive chemotherapy has been recently evaluated in a randomized, placebo-controlled, double-blind trial (the PROTECHT study). The aim of this study was to evaluate the efficacy and safety of the low molecular weight heparin nadroparin in the prevention of venous and arterial thromboembolic events during chemotherapy. The results of the PROTECHT study demonstrated that nadroparin reduces by 50% the rate of thromboembolic events in ambulatory patients with metastatic or locally advanced cancer while they receiving chemotherapy. The antithrombotic effect was more evident in patients with lung and gastrointestinal cancer. In future studies the clinical benefit of antithrombotic prophylaxis should be evaluated in cancer patients at particularly high risk for thromboembolism.

Enhanced Delivery of Erythropoietin Across the Blood-Brain Barrier for Neuroprotection against Ischemic Neuronal Injury

Due to limited penetration of the BBB, many therapeutic agents in clinical use require higher doses in order to reach effective concentrations in brain. In some instances, these high doses elicit severe side effects. In the case of erythropoietin (EPO), an established neuroprotectant against ischemic brain injury, its low BBB permeability requires such a high therapeutic dose that it can induce dangerous complications such as polycythmia and secondary stroke. The purpose of this study is to generate a modified EPO that has increased facility crossing the BBB without losing its neuroprotective element. We have engineered a fusion protein (EPO-TAT) by tagging a protein transduction domain derived from HIV TAT to the EPO protein. This sequence enhanced the capacity of EPO to cross the BBB in animals at least twofold when IP administered and up to five-fold when IV administered. In vitro experiments showed that this EPO fusion protein retained all its protective properties against neuronal death elicited by oxygen-glucose deprivation and NMDA insults. The needed therapeutic dose of the EPO-TAT was decreased by ~10-fold compared to that of regular EPO to achieve equivalent neuroprotection in terms of reducing volume of infarction induced by middle cerebral artery occlusion in mice. Our results support the approach of using a protein transduction domain coupled to therapeutic agents. In this way, not only can the therapeutic doses be lowered, but agents without BBB permeability may now be available for clinical applications.

Erythropoiesis stimulating agents, thrombosis and cancer

Venous thromboembolism (VTE) is common in cancer and is associated with both morbidity and mortality. Erythropoiesis stimulating agents (ESAs) were originally developed to correct anemia. Recent trials in cancer patients however, raise concerns over both increased VTE rates and the possibility of worse tumour outcomes and increased mortality with ESA use. The most common reason offered for explaining the possible negative impact of ESAs on cancer outcomes has been the stimulation of erythropoietin receptors on tumour cells. Despite an extensive literature, it is unlikely that most practicing appreciate the intricate relationship and interaction between the coagulation pathways, angiogenesis and tumour progression and ESA effects. This paper will review these connections and interactions and examine the hypothesis that other mechanisms may underlie the possible negative impact of ESAs on cancer outcomes.

Anaemia: a rare but neglected problem among Finnish patients receiving chemotherapy for solid tumours

GOALS OF THE WORK

Anaemia is very frequently diagnosed among cancer patients. Use of erythropoietins has proved to be effective in reducing the need of transfusions and enhancing patients' quality of life, but may also have detrimental effects in treating nonanemic asymptomatic patients. We assessed the frequency of anaemia and the frequency with which it was diagnosed and treated in different types of solid tumours treated at outpatient chemotherapy policlinics.

MATERIALS AND METHODS

During the study period, altogether 733 consecutive subjects received chemotherapy at the five Finnish University Hospitals. Their data were collected. The physician who was responsible for the chemotherapy treatment was unaware of the survey. The response to anaemia (treated or not, the modality of treatment) were established from patients records; 69% were females, mean age was 61 years (range, 24-92).

RESULTS

The median haemoglobin level was 12.7 g/dL (range, 8.9-15.5 g/dL). About one third of the patients (200/733, 27%) had a value less than 12 g/dL. In only 15% of these cases was there any documentation of response or a possible treatment option for anaemia. On the other hand, only 12% of all patients (N=91) had a haemoglobin value less than 11 g/dL. However, in most of them anaemia had not been considered; in only 25% of cases was an active treatment option selected.

CONCLUSIONS

According to our survey, anaemia was less common in our patients than in the European Cancer Anaemia Survey. Only a minority of chemotherapy patients receiving their treatments as outpatients would need active treatment for their anaemia.

A pilot prospective randomized trial of postoperative epoetin alfa in patients undergoing major operation for upper gastrointestinal malignancy

INTRODUCTION

Strategies to reduce red blood transfusion utilization in cancer patients undergoing operation are needed.

HYPOTHESIS

Postoperative epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) is associated with improved hematologic parameters in patients undergoing major abdominal surgery for malignancy.

MATERIALS AND METHODS

Prospective, blinded, randomized trial of epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) versus placebo in patients undergoing major abdominal operation for malignancy. Primary endpoints were immature reticulocyte fraction, reticulocyte count, and hemoglobin, which were measured on postoperative days 4, 7, and between 14 and 20. Secondary endpoints were transfusions and complications in the 2 groups.

RESULTS

Forty patients were enrolled. There were no significant differences in immature reticulocyte fraction (P = 0.78), reticulocyte count (P = 0.42), or hemoglobin (0.35) in patients randomized to receive epoetin alfa versus placebo. There was no significant difference in red blood cell transfusion rate or postoperative complications in patients who received epoetin alfa compared with placebo.

DISCUSSION

The use of postoperative epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) in patients undergoing major operation for abdominal or pelvic malignancy is not supported by this randomized trial.

[Erythropoietin and radiotherapy]

Erythropoietin (EPO) is a glycoprotein hormone. This hormone is a growth factor for red blood cells precursors in the bone marrow. The decrease of oxygen partial pressure, a reduced number of erythrocytes caused by bleeding or excessive destruction, or increased tissues oxygen requirements lead to increased secretion of EPO. Its action takes place on bone marrow erythroblastic cells through specific receptors. EPO stimulates the proliferation of red cell precursors stem cells in the bone marrow, thus increasing their production in one to two weeks. The effectiveness of EPO at increasing haemoglobin and improving patients' quality of life has been demonstrated by several studies. However, its use in radiotherapy remains controversial. While tumour hypoxia caused by anaemia is a factor of radio resistance and thus a source of local failure, tumour expression of EPO receptors presents a significant risk for tumour progression and neo-angiogenesis, which would be increased during the administration of EPO. The purpose of this article is to answer the question: is there a place for EPO in combination with radiotherapy in the management of cancer?

Erythropoietin or Darbepoetin for patients with cancer--meta-analysis based on individual patient data

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) reduce anemia in cancer patients and may improve quality of life, but there are concerns that ESAs might increase mortality.

OBJECTIVES

Our objectives were to examine the effect of ESAs and identify factors that modify the effects of ESAs on overall survival, progression free survival, thromboembolic and cardiovascular events as well as need for transfusions and other important safety and efficacy outcomes in cancer patients.

SEARCH STRATEGY

We searched the Cochrane Library, Medline, Embase and conference proceedings for eligible trials. Manufacturers of ESAs were contacted to identify additional trials.

SELECTION CRITERIA

We included randomized controlled trials comparing epoetin or darbepoetin plus red blood cell transfusions (as necessary) versus red blood cell transfusions (as necessary) alone, to prevent or treat anemia in adult or pediatric cancer patients with or without concurrent antineoplastic therapy.

DATA COLLECTION AND ANALYSIS

We performed a meta-analysis of randomized controlled trials comparing epoetin alpha, epoetin beta or darbepoetin alpha plus red blood cell transfusions versus transfusion alone, for prophylaxis or therapy of anemia while or after receiving anti-cancer treatment. Patient-level data were obtained and analyzed by independent statisticians at two academic departments, using fixed-effects and random-effects meta-analysis. Analyses were according to the intention-to-treat principle. Primary endpoints were on study mortality and overall survival during the longest available follow-up, regardless of anticancer treatment, and in patients receiving chemotherapy. Tests for interactions were used to identify differences in effects of ESAs on mortality across pre-specified subgroups. The present review reports only the results for the primary endpoint.

MAIN RESULTS

A total of 13933 cancer patients from 53 trials were analyzed, 1530 patients died on-study and 4993 overall. ESAs increased on study mortality (combined hazard ratio [cHR] 1.17; 95% CI 1.06-1.30) and worsened overall survival (cHR 1.06; 95% CI 1.00-1.12), with little heterogeneity between trials (I(2) 0%, p=0.87 and I(2) 7.1%, p=0.33, respectively). Thirty-eight trials enrolled 10441 patients receiving chemotherapy. The cHR for on study mortality was 1.10 (95% CI 0.98-1.24) and 1.04; 95% CI 0.97-1.11) for overall survival. There was little evidence for a difference between trials of patients receiving different cancer treatments (P for interaction=0.42).

AUTHORS' CONCLUSIONS

ESA treatment in cancer patients increased on study mortality and worsened overall survival. For patients undergoing chemotherapy the increase was less pronounced, but an adverse effect could not be excluded.

Venous thromboembolism (VTE) in patients with cancer: epidemiology and risk factors

Although cancer is recognized as a major risk factor for venous thromboembolism, the exact magnitude of the problem and specific risk factors most strongly associated with the development of VTE is not well defined. Several recent studies have shown that the incidence of VTE is highest in patients who present with metastatic cancer, particularly cancers associated with a high one-year mortality rate, such as pancreatic cancer. The incidence rate of VTE is highest in the first few months after the diagnosis of cancer, and it decreases over time thereafter. For most cancers, it is not clear to what extent undergoing major surgery adds to the already high risk of VTE associated with the presence of the cancer. However, patients with glioma clearly have a very high incidence of VTE soon after they undergo any invasive neurosurgical procedure. Active chemotherapy, the use of erythropoetin agents, and the use of certain anti-cancer therapies such as thalidomide, high-dose steroids, and anti-angiogenic therapy also increase the risk of thrombosis. Similar to patients without cancer, the risk of VTE is higher in patients with coexisting chronic medical illnesses. Development of VTE is clearly associated with decreased survival and this effect is greater among patients initially diagnosed with local or regional stage cancer compared to patients with metastatic cancer.

Recombinant human erythropoiesis-stimulating agents and mortality in patients with cancer: a meta-analysis of randomised trials

BACKGROUND

Erythropoiesis-stimulating agents reduce anaemia in patients with cancer and could improve their quality of life, but these drugs might increase mortality. We therefore did a meta-analysis of randomised controlled trials in which these drugs plus red blood cell transfusions were compared with transfusion alone for prophylaxis or treatment of anaemia in patients with cancer.

METHODS

Data for patients treated with epoetin alfa, epoetin beta, or darbepoetin alfa were obtained and analysed by independent statisticians using fixed-effects and random-effects meta-analysis. Analyses were by intention to treat. Primary endpoints were mortality during the active study period and overall survival during the longest available follow-up, irrespective of anticancer treatment, and in patients given chemotherapy. Tests for interactions were used to identify differences in effects of erythropoiesis-stimulating agents on mortality across prespecified subgroups.

FINDINGS

Data from a total of 13 933 patients with cancer in 53 trials were analysed. 1530 patients died during the active study period and 4993 overall. Erythropoiesis-stimulating agents increased mortality during the active study period (combined hazard ratio [cHR] 1.17, 95% CI 1.06-1.30) and worsened overall survival (1.06, 1.00-1.12), with little heterogeneity between trials (I(2) 0%, p=0.87 for mortality during the active study period, and I(2) 7.1%, p=0.33 for overall survival). 10 441 patients on chemotherapy were enrolled in 38 trials. The cHR for mortality during the active study period was 1.10 (0.98-1.24), and 1.04 (0.97-1.11) for overall survival. There was little evidence for a difference between trials of patients given different anticancer treatments (p for interaction=0.42).

INTERPRETATION

Treatment with erythropoiesis-stimulating agents in patients with cancer increased mortality during active study periods and worsened overall survival. The increased risk of death associated with treatment with these drugs should be balanced against their benefits.

FUNDING

German Federal Ministry of Education and Research, Medical Faculty of University of Cologne, and Oncosuisse (Switzerland).

Retrospective review of hemoglobin and/or hematocrit levels with occurrence of thrombosis in cancer patients treated with erythropoiesis stimulating agents

BACKGROUND

No data exists that directly compares hemoglobin and hematocrit levels between cancer patients with and without occurrence of thrombosis during treatment with erythropoiesis stimulating agents (ESAs).

OBJECTIVE

To determine the association of hemoglobin and hematocrit levels with the occurrence of thrombosis in cancer patients treated with ESAs.

METHODS

A retrospective case-control study approved by the Institutional Review Board was conducted on cancer patients billed for epoetin or darbepoetin between 1 July 2002 and 30 June 2007. Cases were defined as patients billed for thrombosis while controls were defined as patients not billed for thrombosis.

RESULTS

Sixteen patients had an occurrence of thrombosis (cases) and were matched to 16 patients that did not have an occurrence of thrombosis (controls) based on age, sex, and cancer type. The mean peak hemoglobin levels for cases and controls were 12.6 +/- 1.2 g/dL versus 12.6 +/- 1.4 g/dL (p = 0.9). The mean peak hematocrit levels for cases and controls were 37.3 +/- 3.8% versus 37.9 +/- 4.3% (p = 0.8). For the 16/586 (2.7%) patients with thrombosis, the mean hemoglobin and hematocrit at time of thrombosis were 9.6 +/- 1.0 g/dL and 28.9 +/- 3.1%. A significant identifiable risk factor for thrombosis between the cases and controls was history of thrombosis 31.3% versus 0% (p = 0.04).

CONCLUSION

There was no statistical difference in peak hemoglobin and hematocrit levels between patients with thrombosis and those without thrombosis. Further study is warranted to determine if these levels are true risk factors for thrombosis.

Epidemiology of cancer-related venous thromboembolism

Recent studies have better defined the epidemiology of venous thromboembolism (VTE) in cancer patients. The incidence is highest in patients who have metastatic disease at the time of presentation and who have fast growing, biologically aggressive cancers associated with a poor prognosis. The incidence is also high in patients with haematological cancers. Other specific risk factors that affect the incidence of VTE include undergoing invasive neurosurgery, the number of underlying chronic co-morbid conditions, and being of Asian/Pacific Islander decent (lower incidence). The incidence is highest in the first few months after diagnosis, which may reflect the biology of the cancer or medical interventions such as major surgery or start of chemotherapy. The development of VTE is clearly associated with decreased survival, and this effect is greater among patients initially diagnosed with local- or regional-stage cancer compared with patients with metastatic cancer, probably because VTE reflects the presence of a biologically aggressive cancer. Finally, a small percentage of patients with idiopathic VTE and no clinical or laboratory evidence of cancer may harbour an aggressive but 'occult' malignancy likely causally linked to the development of VTE.

Allogeneic blood transfusion given before radiotherapy is associated with the poor clinical outcome in patients with cervical cancer

PURPOSE

To analyze the effect of allogeneic blood transfusion on clinical outcome in 119 patients with stage IIB cervical cancer who were treated with radiotherapy +/- chemotherapy.

PATIENTS AND METHODS

Medical records were examined for hemoglobin levels before and during radiotherapy, history of allogeneic blood transfusions and the time point when transfusions were given. These factors were retrospectively analyzed along with other clinical risk factors for influences on the patients' clinical outcomes.

RESULTS

Thirty-two patients (26.9%) received packed red blood cell transfusion (mean, 3.4 units; range, 1-12 units) before or during radiotherapy. Median follow-up period was 39.3 months (range, 7.6-58.4 months). Patients with history of transfusion showed poorer metastasis-free survival and a trend toward poorer overall survival than non-transfused patients. When patients who received transfusions were sub-divided by the time of transfusion, those who received transfusions before radiotherapy had significantly poorer clinical outcome than those who received transfusions during radiotherapy. In a multivariable analysis, patients with pretreatment transfusion showed a higher risk of distant metastasis (HR = 3.75, 95% CI: 1.28-12.15, p = 0.017) and decreased overall survival rates (HR = 4.62, 95% CI: 1.15-18.54, p = 0.031) compared with those of other patients.

CONCLUSION

Our results suggest that allogeneic blood transfusions given before radiotherapy may be associated with higher incidence of distant metastases and decreased survival in patients with stage IIB cervical cancer.

[Venous thromboembolism and cancer]

Cancer and venous thromboembolism (VTE), VTE and cancer: there is a close bond between these two diseases. On the one hand, a cancer patient runs a high risk of developing VTE. Certain cancer-specific factors, such as its metastatic nature increase this risk. The means involved in the care of cancer (insertion of a venous catheter, chemotherapy, etc.) also increase the probability of a thromboembolism. On the other hand, VTE, especially if it is idiopathic, may be the harbinger of a neoplasm. The present paper involves the dual nature of this relationship, first dealing with several points specific to the occurrence of VTE in a cancer patient, before dealing with the specific care in a curative and prophylactic situation. VTE is then considered as a clinical manifestation prior to a cancer. Several characteristics evoking an underlying neoplasm are known. However, the benefits of the screening for cancer when confronted with an episode of VTE remains to be debated.