Impact of haemoglobin levels on the outcome of cancers treated with chemotherapy

A Comparison of neoadjuvant chemotherapy and concurrent chemoradiotherapy for for FIGO 2018 stage IB3/IIA2 Cervical squamous cell carcinoma: Long-term efficacy and safety in a resource-limited setting

PURPOSE

The purpose of this research was to evaluate the effectiveness and safety of neoadjuvant chemotherapy plus radical surgery (NCRS) and concurrent chemoradiotherapy (CCRT) based on three-dimensional conformal radiation therapy (3DCRT) for FIGO 2018 stage IB3/IIA2 patients with cervical squamous cell carcinoma in a resource-limited setting.

METHODS

The clinical outcomes and incidence of complications in 137 patients who underwent NCRS with those of 163 patients who CCRT based on 3DCRT were compared. Propensity score matching (PSM) analysis was used to match the two groups to enable further statistical comparisons. Survival analysis was performed utilizing Cox proportional hazards regression analyses, Kaplan-Meier curves, and log-rank tests. Furthermore, the incidence of complications between the two groups was also compared using chi-squared tests.

RESULTS

PSM analysis identified 103 matched pairs of patients. The NCRS and CCRT groups exhibited 5-year overall survival (OS) rates of 85.4% and 91.2%, respectively (p=0.19). Additionally, the NCRS and CCRT groups exhibited 5-year disease-free survival (DFS) rates of 76.7% and 89.3% (p=0.02), and the recurrence rates were 20.4% and 9.7% (p=0.03), respectively. However, the CCRT group exhibited a higher incidence of early any-grade complications (79.6% vs 35.9%, p<0.001) and early grade 3 complications (15.5% vs 2.9%, p=0.002) compared to the NCRS group. In terms of overall late complications, there was no significant difference in the incidence between the two groups. Multivariate analysis revealed that stage IIA2 emerged as an independent risk factor for OS (aHR 8.89; p=0.033). Moreover, histologic grade 2-3 (aHR 5.3; p=0.022), stage IIA2 (aHR 2.95; p=0.043), NCRS treatment (aHR 2.41; p=0.012) were identified as independent risk factors for DFS.

CONCLUSION

In resource-limited settings, for patients with FIGO 2018 stage IB3/IIA2 cervical squamous cell carcinoma, 3DCRT-based CCRT offers superior disease-free survival and reduced recurrence rates compared to NCRS, despite increased early complication rates.

Pre-treatment nutrition-related indicators and the prognosis of patients with newly diagnosed epithelial ovarian cancer: an ambispective cohort study

Background

Few studies have explored the link between nutritional status and prognosis in patients with epithelial ovarian cancer (EOC), and existing findings are controversial. Thus, this study aimed to explore the effects of pre-treatment nutrition-related indicators on the prognosis of patients with newly diagnosed EOC.

Methods

In this ambispective cohort study, 1,020 patients with EOC diagnosed by pathology examination were enrolled and followed-up until December 31, 2023. Univariate and multivariable analyses were conducted on nutrition-related indicators, including body mass index (BMI), albumin (ALB), hemoglobin (Hb), diabetes mellitus (DM), and hyperlipidemia, along with clinicopathological characteristics that might affect patients' first-line chemotherapy response, progression-free survival (PFS), and overall survival (OS). Survival curves were created using the Kaplan-Meier method. A Cox proportional hazards model was established to obtain hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

The median follow-up duration was 48 months. Compared with patients having normal nutritional indicators, those with hypoalbuminemia had poorer first-line chemotherapy responses. The proportions of those with complete response (CR), partial response (PR), and stable disease or progressive disease (SD/PD) for the ≤30 g/L, 30 < ALB<35 g/L and normal ALB groups were 57.2, 20.6, and 22.2% vs. 62.0, 22.5, and 15.5% vs.79.5, 13.6, and 6.9%. Patients with hypoalbuminemia had shorter median PFS (mPFS): 15 vs. 19 vs. 57 months in the three groups, respectively; and shorter median OS (mOS): 36 vs. 51 vs. 124 months. Patients with hyperlipidemia also exhibited poorer first-line chemotherapy responses; CR, PR, and SD/PD rates for the hyperlipidemia and non-hyperlipidemia groups were 68.9, 19.5, and 11.6% vs. 76.4, 14.7, and 8.9%, respectively, and shorter mPFS (17 vs. 57 months) and mOS (40 vs. 119 months). Patients with anemia had poorer first-line chemotherapy responses; CR, PR, and SD/PD rates for the anemia and non-anemia groups were 68.4, 19.7, and 11.9% vs. 76.2, 14.9, and 8.9%, respectively. All differences were statistically significant (p < 0.05). Multivariable analysis identified hyperlipidemia as an independent risk factor for PFS (hazard ratio [HR] = 2.083; 95% CI:1.726-2.514; p < 0.001) and OS (HR = 2.158; 95% CI:1.746-2.666; p < 0.001), whereas hypoalbuminemia and anemia were not confirmed as independent prognostic factors. This study found no effect of BMI or DM on patient prognosis.

Conclusion

Pre-treatment hypoalbuminemia, hyperlipidemia, and anemia negatively affected the prognosis of patients with newly diagnosed EOC, with hyperlipidemia being an independent risk factor for shorter survival.

Predictors of immune-related adverse events and outcomes in patients with NSCLC treated with immune-checkpoint inhibitors

OBJECTIVE

To identify predictors of immune-related adverse events (IRAEs) in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). Assess associations between outcomes and the development of IRAEs.

METHODS

Retrospective analysis of patients with NSCLC treated with ICIs between 2016 and 2020 in the Pulmonology Department of our hospital. Patients with and without IRAEs were compared. A logistic regression analysis was performed to determine predictors of IRAEs. Progression-free survival (PFS) and overall survival (OS) curves were calculated using the Kaplan-Meier method, and the long-rank test was used to assess survival differences between groups. Univariate and multivariate Cox proportional-hazards regression models were used to identify factors associated with PFS and OS. The value considered statistically significant was p≤0.05.

RESULTS

A total of 184 patients (77.7% men, mean age 66.9±9.5 years) treated with ICIs were analyzed. During follow-up, 49 (26.6%) patients developed IRAEs and 149 (81.0%) died. According to the multivariate logistic regression analysis, treatment with statins (OR:3.15; p = 0.007), previous systemic corticosteroid therapy (OR:3.99; p = 0.001), disease controlled as response to ICI (OR:5.93; p < 0.001) and higher hemoglobin values (OR:1.28; p = 0.040) were independent predictors for the development of IRAEs. Patients who developed IRAEs had significantly longer medians of PFS (41.0 vs 9.0 weeks, p < 0.001) and OS (89.0 vs 28.0 weeks; p < 0.001).

CONCLUSIONS

Patients treated with statins, pre-ICI systemic corticosteroids, higher baseline hemoglobin value and controlled disease as initial response to ICI had a higher risk of developing IRAEs. The development of IRAEs was associated with better outcomes.

Outcome of Atezolizumab Plus Bevacizumab Combination Therapy in High-Risk Patients with Advanced Hepatocellular Carcinoma

Real-world data regarding treatment with atezolizumab plus bevacizumab in high-risk patients with advanced HCC are lacking. In this multicenter retrospective cohort study, a total of 215 patients with advanced HCC received atezolizumab plus bevacizumab treatment at four tertiary hospitals. High-risk patients were those with grade Vp4 portal vein thrombus, bile duct invasion, or more than 50% liver infiltration. In total, 98 (45.6%) were the high-risk population, 186 (86.5%) were considered to be Child-Pugh class A, and 128 (59.5%) had previously received neoadjuvant or concomitant radiation treatment. Median overall survival (OS) was 11.25 months (95% CI, 9.50-13.10), and the median progression-free survival (PFS) was 8.00 months (95% CI, 6.82-9.18). In the high-risk population, the median OS was 10 months (95% CI, 8.19-11.82) and the median PFS was 6.50 months (95% CI, 3.93-9.08). In the high-risk population, multivariate analysis indicated that radiation therapy and lower ALBI grade were associated with better OS and PFS. A total of 177 (82.3%) patients experienced adverse events of any grade, the most common being proteinuria (23.7%). Atezolizumab plus bevacizumab treatment showed consistent efficacy and tolerability in both the total and high-risk population. Radiation therapy combined with atezolizumab plus bevacizumab treatment might be helpful to improve PFS and OS in high-risk populations.

Comparison of the second-line treatments for patients with small cell lung cancer sensitive to previous platinum-based chemotherapy: A systematic review and Bayesian network analysis

Objective

It remains unclear what the best second-line treatment is for patients with small-cell lung cancer sensitive to previous platinum-based chemotherapy.

Methods

We systematically screened randomized controlled trials from several online databases. The primary outcome was objective response rate (ORR), and the secondary outcomes were disease control rate (DCR), overall survival (OS), progression-free survival (PFS), and hematological complications graded 3 to 5. The efficacy of included treatments was ranked by surface under the cumulative ranking curve (SUCRA) value.

Results

We included eleven trials involving 1560 patients in quantitative analysis. Triple chemotherapy containing platinum (TP, combination of cisplatin, etoposide, and irinotecan) was associated with favorable ORR (intravenous topotecan vs TP; odds ratio: 0.13, 95% CI:0.03-0.63; SUCRA, 0.94) and PFS (vs intravenous topotecan; hazard ratio, 0.5; 95% CI: 0.25-0.99; SUCRA, 0.90). Belotecan ranked highest for OS (SUCRA, 0.90), while intravenous topotecan plus Ziv-aflibercept ranked highest for DCR (SUCRA, 0.75). TP was more likely to cause anemia and thrombocytopenia while intravenous topotecan plus Ziv-aflibercept resulted in most neutrocytopenia.

Conclusion

TP is the first recommendation for the second-line treatment of sensitive relapsed SCLC. TP achieved priority in ORR and PFS with the most frequent adverse effects in anemia and thrombocytopenia. For patients who cannot tolerate the hematological adverse effects of triple chemotherapy, amrubicin is an optional option. Amrubicin had relatively good ORR and PFS, accompanied by fewer hematological complications. The rechallenge of the platinum doublet is inferior to amrubicin in ORR, DCR, and PFS. Oral topotecan has a similar effect compared with IV topotecan, but oral topotecan was associated with slightly higher safety and less stress in nursing. Belotecan contributed to the best PFS with slightly better safety but was not ideal in other outcomes.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358256.

Optimization of the preoperative requirements of blood units for the surgical treatment of extra-abdominal soft tissue sarcoma: the TRANSAR score

Background and objectives

Excessive preoperative blood orders frequently occur during the preoperative planning of resections of sarcomas. We aimed to develop a prediction score model that would be able to identify a patient cohort in which the cross-matching could be safely evaded.

Patients and methods

We retrospectively analyzed data of 309 consecutive patients with extra-abdominal soft tissue sarcomas treated between September 2012 and December 2014. Scorecard scores for variables were calculated and summarized to a total score that can be used for risk stratification. The score was used in a logistic regression model. Results of the optimized model were described as a receiver operating characteristic curve.

Results

Preoperative units of red blood cells were requested for 206 (66.7%) patients, of which only 31 (10%) received them. Five parameters were identified with high predictive power. In the visualized barplot, there was an increased risk of blood transfusion with a higher score of TRANSAR.

Conclusion

A TRANSAR score is a new tool that can predict the probability of transfusion for patients with sarcoma. This may reduce the number of preoperative cross-matching and blood product ordering and associated costs without compromising patient care.

Prognostic Value of the Combination of HB (hemoglobin) and CEA in Resectable Gastric Cancer

Objective: In order to investigate the prognostic value of a novel biomarker combining serum carcinoembryonic antigen (CEA) and hemoglobin (HB) levels in patients with resectable gastric cancer.

Introduction: This retrospective study assessed the relationship between CEA, hemoglobin levels, a novel combined prognostic biomarker (HB-CEA) and clinicopathological features of gastric cancer. Their prognostic values in gastric cancer were also analyzed.

Materials and Methods: This retrospective study evaluated the CEA, hemoglobin levels and clinicopathological features of patients with resectable gastric cancer. Kaplan-Meier curves, univariate and multivariate Cox proportional models were used to determine the prognostic significance of these factors for overall survival (OS) in the training and validation sets (n=353 and n=388, respectively). Based on optimal cutoff values of CEA and hemoglobin (3.395 ng/mL and 125.5 g/L, respectively), patients were stratified into three groups: HB-CEA=0, 1, and 2 (CEA <3.395 ng/mL and HB ≥125.5 g/L; CEA ≥3.395 ng/mL or HB <125.5 g/L; and CEA ≥3.395 ng/mL and HB <125.5 g/L, respectively).

Results: The area under the curve was larger for HB-CEA than for either HB or CEA alone (training set: 0.677, 0.650, and 0.629; validation set: 0.670, 0.605, and 0.605, respectively). HB-CEA was strongly associated with age, tumor size, differentiation, pathological TNM stage (pTNM), depth of tumor invasion, lymph node metastasis, and survival status (all p<0.05). A higher HB-CEA score correlated with poor survival (Kaplan-Meier curves, all p<0.05). Multivariate analysis showed that HB-CEA was an independent prognostic factor for OS (p<0.05).

Conclusion: Preoperative HB-CEA, as a potential novel hematological biomarker, can predict the progression of gastric cancer and the prognosis of patients, and is of great value in guiding clinical practice. Therefore, patients with a higher HB-CEA score should receive more extensive follow-up for early detection and intervention of tumor progression.

The Prognostic Value of Pre-treatment Hemoglobin (Hb) in Patients With Advanced or Metastatic Gastric Cancer Treated With Immunotherapy

Background

Biomarkers such as prevailing PD-L1 expression and TMB have been proposed as a way of predicting the outcome of immunotherapy in patients with advanced gastric cancer (AGC) and metastatic gastric cancer (MGC). Our study aims to investigate whether there is a link between pretreatment hemoglobin (Hb) levels and survival to immunotherapy in patients with AGC and MGC.

Methods

We retrospectively reviewed patients with AGC or MGC treated at the oncology department of the Chinese PLA general hospital receiving PD-1 inhibitor. The Propensity Score Matching (PSM) (1:1) was performed to balance potential baseline confounding factors. Progression-free survival (PFS) and overall survival (OS) was analyzed among different Hb level (normal Hb group and decreased Hb group). Objective response rate (ORR), disease control rate (DCR) were also analyzed. Univariate analysis and multivariate analysis were performed further to validate the prognostic value of Hb level.

Results

We included 137 patients with AGC and MGC who received PD-1 inhibitors (including Pembrolizumab, Nivolumab, Sintilimab, Toripalimab) in this study. After PSM matching, there were no significant differences between the two groups for baseline characteristics. Within the matched cohort, the median PFS was 7.8 months in the normal Hb level group and 4.3 months in the decreased Hb group (HR 95% CI 0.5(0.31, 0.81), P=0.004). The OS was 14.4 months with normal Hb level as compared with 8.2 months with decreased Hb level(HR 95% CI 0.59(0.37, 0.94), P=0.024). The ORR was 40.7% and DCR was 83.0% in the normal Hb group, while the ORR was 25.5% and DCR was 85.1% in the decreased Hb group. No significant differences were found in the ORR and DCR between the two groups (P=0.127, P=0.779). Univariate analysis and multivariate analysis showed that Hb level was only independent predictor for PFS and baseline Hb level was significant prognostic factor influencing the OS. Only when patients had normal Hb level, anti-pd-1 monotherapy or combined with chemotherapy was superior to anti-pd-1 plus anti-angiogenic therapy with respect to PFS (10.3 m vs 2.8 m, HR 95% CI 0.37(0.15, 0.95), P=0.031) and OS(15 m vs 5.7 m, HR 95% CI 0.21 (0.08, 0.58), P=0.001).

Conclusions

Our study have demonstrated that pretreatment Hb level was an independent prognostic biomarker in term of PFS and OS with immunotherapy for AGC and MGC patients. Correction of anemia for GC patients as immunotherapy would be a strategy to improve the survival. More data was warranted to further influence this finding.

Prevalence and associated factors of baseline anemia among cervical cancer patients in Tikur Anbesa Specialized Hospital, Ethiopia

Background

Almost one patient with cancer in two is anemic. About 40 to 64% of cervical cancer patients are anemic at time of presentation. The rate of anemia increases with the use of chemotherapy, radiotherapy, hormonal therapy and associated with poorer treatment outcome and quality of life. Therefore, the aim of this study was to assess prevalence and associated factors of baseline anemia among cervical cancer patients in Tikur Anbesa Specialized Hospital (TASH), Ethiopia.

Methods

Institutional based cross-sectional study was done from March to April 2019 at TASH cancer center. Data were collected from patient’s chart using structured checklist and analyzed using Stata14.2. Binary logistic regression model was used to identify covariates which affected the outcome variable.

Result

This is a 3-years retrospective study from 2014 to 2016. The prevalence of baseline anemia among cervical cancer patients was 50.95%. Being stage IV [AOR = 2.38, 95% CI (1.21–4.67)], having comorbidity [AOR = 3.32, 95% CI (2.25–4.90)] and using substances (patients who used one, two or all of the three substances (cigarate, chat and alcohol)) [AOR = 2.03, 95% CI (1.21–3.41)] significantly increased the occurrence of anemia while being divorced [AOR = 0.6, 95% CI (0.36–0.98)] decreased the occurrence of anemia in the current study.

Conclusion

The prevalence of baseline anemia was high in the current study compared to other literatures. Significant factors of baseline anemia of cervical cancer in the current study were advanced stage (stage IV), presence of comorbidity, substance usage and being divorced (protective). The authors recommend that it is better to give special attention to those patients with the stated factors that could interfere treatment outcome.

Folate mediated targeted delivery of cinnamaldehyde loaded and FITC functionalized magnetic nanoparticles in breast cancer: in vitro, in vivo and pharmacokinetic studies

FiCF NPs induced apoptosis in breast cancer cells, exhibited safety, reduced tumor burden in mice due to increased pharmacological efficacy.

A randomised phase 2b study comparing the efficacy and safety of belotecan vs. topotecan as monotherapy for sensitive-relapsed small-cell lung cancer

Background

This study compared the efficacy/safety of the camptothecin analogues belotecan and topotecan for sensitive-relapsed small-cell lung cancer (SCLC).

Methods

One-hundred-and-sixty-four patients were randomised (1:1) to receive five consecutive daily intravenous infusions of topotecan (1.5 mg/m²) or belotecan (0.5 mg/m²), every 3 weeks, for six cycles. Main outcomes were objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), tolerability and toxicity. The study statistical plan was non-inferiority design with ORR as the endpoint.

Results

In the belotecan vs. topotecan groups, ORR (primary endpoint) was 33% vs. 21% (p = 0.09) and DCR was 85% vs. 70% (p = 0.030). PFS was not different between groups. Median OS was significantly longer with belotecan than with topotecan (13.2 vs. 8.2 months, HR = 0.69, 95% CI: 0.48–0.99), particularly in patients aged <65 years, with more advanced disease (i.e., extensive-stage disease, time to relapse: 3–6 months), or Eastern Cooperative Oncology Group performance status 1 or 2. More belotecan recipients completed all treatment cycles (53% vs. 35%; p = 0.022).

Conclusions

The efficacy/safety of belotecan warrants further evaluation in Phase 3 trials. Belotecan potentially offers an alternative to topotecan for sensitive-relapsed SCLC, particularly in patients aged <65 years, with more advanced disease, or poor performance.

Pretreatment hemoglobin level as a predictor to evaluate the efficacy of immune checkpoint inhibitors in patients with advanced non-small cell lung cancer

Background:

Targeting immune checkpoints represents an immense breakthrough in cancer therapeutics. The prognostic value of hemoglobin (Hb) has been investigated in many malignancies including non-small cell lung cancer (NSCLC). However, the prognostic impact of pretreatment Hb count for immune checkpoint inhibitors (ICIs) in advanced NSCLC patients remains unclear.

Methods:

A total of 310 late-stage NSCLC patients who received ICI therapies between January 2015 and March 2019 were prospectively enrolled. We used a propensity score-matched cohort analysis for this study. Patients’ clinicopathological characteristics and pretreatment Hb concentration were assessed against the progression-free survival (PFS) and overall survival (OS) using the Kaplan–Meier method and Cox proportional hazards regression.

Results:

A propensity score (PS)-matched cohort analysis was applied to adjust for potential bias and to create two comparable groups according to patients’ clinicopathological characteristics. The patients with normal baseline Hb levels (⩾110 g/L) had significantly longer PFS [median: 10.0 versus 4.0 months, hazard ratio (HR): 0.63, 95% confidence interval (CI): 0.46−0.86; p = 0.001] and OS [median: 17.6 versus 10.5 months, HR (95% CI): 0.56 (0.40−0.79); p < 0.001] than those with decreased Hb count (<110 g/L) in a PS-matched cohort (n = 255). For patients with normal pretreatment Hb levels, ICI combination therapy was significantly associated with better PFS [median: 11.1 versus 8.0 months, HR (95% CI): 0.74 (0.50−1.06); p = 0.09] and OS [median: 26.0 versus 12.9 months, HR (95% CI): 0.56 (0.37−0.86); p = 0.008] than monotherapy, but there was no such trend for patients with decreased baseline Hb levels.

Conclusion:

Our findings showed that normal pretreatment Hb count served as a favorable prognostic marker in advanced NSCLC patients treated with ICIs, representing an economical biomarker with readily measuring performance among all reported ones.

Prechemotherapy Hemoglobin Levels as a Predictive Factor of Ovarian Cancer Survival: A Systematic Review and Meta-Analysis

OBJECTIVES

The impact of anemia on cancer survival has been previously mentioned in various oncological fields. To date, however, it remains unknown whether prechemotherapy hemoglobin (Hgb) levels are predictive of ovarian cancer survival (OC). The purpose of the present systematic review is to accumulate evidence in this field.

MATERIALS AND METHODS

We used the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL, and Google Scholar databases in our primary search. The date of our last search was set for July 30, 2018. Statistical meta-analysis was performed with the RevMan 5.3 software.

RESULTS

Overall, 11 articles were included that recruited 1816 women with OC. Five articles that involved 856 OC patients were included in the meta-analysis. Compared with patients with anemia, patients with Hgb levels >12 g/dL had increased odds of overall survival (odds ratio, 1.72; 95% confidence interval: 1.41, 2.10). Similarly, the progression-free survival of patients was significantly affected, although the available data could not be accumulated in a meta-analysis because of the heterogeneity in outcome reporting measures.

CONCLUSIONS

Current evidence suggests that prechemotherapy Hgb levels below the threshold of 12 g/dL can potentially predict worse overall survival of OC patients. Future research is required in the field to elucidate whether several independent variables such as the stage and histology of disease and rates of optimal debulking affect the clinical significance of this association.

Relationship between Canine Lymphocyte AgNOR Counts and Haematological Indices of Health

A modified agyrophil technique was applied to peripheral blood smears to determine the mean AgNOR counts (MAC) of lymphocytes and ultimately assess the state of the lymphoid system in various clinical conditions of dogs. Fifty dogs, from clinically normal to pets with leukaemia, presented to the Veterinary Teaching Hospital, were recruited. Blood smears from each dog were stained with routine Romanowsky and modified agyrophil stains. Signalment, clinical diagnoses and hematologic parameters of the dogs were related to the MAC. An AgNOR proliferative index (AgPI) — percentage of lymphocytes with 3 or more AgNORs, was determined, and correlated with MAC. The statistical significance was determined at P < 0.05. MAC ranged from 1.17 in clinically healthy patients to 6.00 in leukaemic patients. The MAC was 2.00 in patients (n = 26) with lymphocyte counts within reference intervals (900—2400 per microliter); 2.23 in patients (n = 4) with lymphopenia; 2.18 in patients with lymphocytosis (n = 18) and 4.73 in patients (n = 4) with lymphocytic leukemia. Also, the MAC was 2.00 in non-anemic dogs while it was 2.47, 2.49 and 3.06 in patients with mild, moderate and severe anaemia, respectively. The MAC correlated strongly with AgPI (r = 0.91). The ancillary AgNOR technique provides a cheaper, more rapid and sensitive tool than routine lymphocyte counts in assessing the state of lymphoid proliferation in a variety of conditions in the dog.

Prognostic factors from a randomized phase III trial of paclitaxel and carboplatin versus paclitaxel and cisplatin in metastatic or recurrent cervical cancer: Japan Clinical Oncology Group (JCOG) trial: JCOG0505-S1

PURPOSE

The Japan Clinical Oncology Group (JCOG) trial JCOG0505 demonstrated the statistically significant non-inferiority of paclitaxel plus carboplatin (TC) to paclitaxel plus cisplatin (TP) in terms of overall survival (OS) in metastatic or recurrent cervical cancer. In that trial, patients were randomly assigned, adjusting for institution and known prognostic factors. The objective of this ancillary study was to evaluate the appropriateness of the adjustment factors used to have randomly assigned treatments and to investigate new potentially useful prognostic factors of paclitaxel plus platinum for future randomized trials in metastatic or recurrent cervical cancer.

METHODS

The study subjects comprised 244 eligible patients in the JCOG0505 who were merged to have received either TC or TP. The effects of the following factors on OS were investigated using a Cox regression model taking into consideration the adjustment factors used in randomization in this trial (e.g., performance status [PS]) and other baseline factors, including platinum-free interval (PFI), pretreatment hemoglobin levels (PHLs), and pretreatment platelet counts (PPCs).

RESULTS

The median follow-up was 17.6 months, and median OS was 18.0 months. The hazard ratio was 1.83 in patients with a PS of 1 or 2 (vs. 0; P = 0.0004; 95 % confidence interval [CI] 1.31-2.55), 2.92 in patients with a PFI of <6 months (vs. PFI of ≥12 months; P < 0.0001; 95 % CI 1.73-4.91), 2.09 in patients with a PFI of <12 months (vs. PFI of ≥12 months; P = 0.0034; 95 % CI 1.28-3.44), and 0.69 in patients with PHL higher than or equal to the median value (vs. less than the median; P = 0.016; 95 % CI 0.51-0.93). No significant differences were obtained for PPC or the other known factors.

CONCLUSIONS

In addition to the known prognostic factor of PS, which was used as an adjusting factor, a PFI of <12 months and lower PHL were newly demonstrated to be associated with poor outcomes in patients with metastatic or recurrent cervical cancer. These new prognostic factors should be validated in future prospective trials.

CLINICAL TRIAL INFORMATION

UMIN-CTR[ http://www.umin.ac.jp/ctr/ ] ID: C000000335.

Impact of comorbidity and anemia in patients with oropharyngeal cancer primarily treated with surgery in the human papillomavirus era

BACKGROUND

Comorbidity and anemia strongly influence treatment and outcome of oropharyngeal squamous cell carcinomas (SCCs), but respective data are frequently lacking in clinical studies. We evaluated 149 cases of oropharyngeal SCC primarily treated with surgery regarding the impact of these factors on disease-free survival (DFS) and overall survival (OS).

METHODS

Data were recorded during treatment and follow-up visits. Human papillomavirus (HPV) association of oropharyngeal SCC was detected by p16 immunohistochemistry.

RESULTS

Patients with p16-positive disease were significantly less comorbid and anemic, and treated more aggressively. Comorbidity and anemia, but not p16 status, significantly influenced DFS and had more impact on OS than p16 status.

CONCLUSION

In our study, p16-positive seems a good surrogate marker for healthier patients. Patients with p16-positive disease showed improved survival, but this was limited to none/mild comorbid and/or nonanemic individuals in this group. On the basis of our results, we strongly suggest the inclusion of these factors in risk stratification for clinical studies. © 2016 Wiley Periodicals, Inc. Head Neck 39: 7-16, 2017.

Correlation Between Platelet and Hemoglobin Levels and Pathological Characteristics and Prognosis of Early-Stage Squamous Cervical Carcinoma

Background

We sought to determine the effect of pre-operative hemoglobin (HGB) and platelet (PLT) levels on the clinical features and prognosis of early-stage squamous cervical carcinoma (SCC).

Material/Methods

We performed a retrospective analysis of 380 patients with SCC who underwent hysterectomy and pelvic lymphadenectomy. SCC was confirmed post-operatively by pathological diagnosis. The relations between HGB and PLT levels and clinicopathological characteristics were observed, and a Cox regression analysis was performed to determine their influence on survival.

Results

There were significant differences in tumor staging, tumor diameter, and lymphatic metastasis between the 69 patients with PLT levels >300×10⁹/L and the 311 patients with PLT levels ≤300×10⁹/L (P<0.05). Tumor staging, extent of differentiation, and lymphatic metastasis were significantly different between 134 patients with HGB levels <120 g/L and 246 patients with HGB levels ≥120 g/L (P<0.05). The overall survival rate in the group with PLT levels >300×10⁹/L was lower than that in the group with PLT levels ≤300 × 10⁹/L, but this difference was not significant. The overall survival rate in the group with HGB levels <120 g/L was significantly lower than that in the group with HGB levels ≥120 g/L (P<0.05), and the overall survival rate in the group with PLT levels >300×10⁹/L and HGB levels <120 g/L was significantly lower than that in the group with PLT levels ≤300×10⁹/L and HGB levels ≥120 g/L (P<0.05). According to Cox regression analysis, a pre-operative HGB level <120 g/L was considered a separate risk factor affecting prognosis.

Conclusions

Close attention must be paid to pre-operative PLT and HGB levels, and anemia should be remedied to facilitate the treatment of cervical carcinoma.

Preoperative mean corpuscular hemoglobin affecting long-term outcomes of hepatectomized patients with hepatocellular carcinoma

Pretreatment anemia has been reported to be associated with survival in several solid tumor types. In terms of survival, only limited data on the hemoglobin (HGB) level in hepatocellular carcinoma (HCC) have been published and no data on mean corpuscular hemoglobin (MCH) level in HCC is available. The present study sought to examine the role of HGB and MCH levels in predicting long-term survival of patients with HCC who undergo resection. A retrospective study of 399 consecutive patients (1987-1994) who underwent hepatic resection for HCC in Sun Yat-Sen University Cancer Centre was performed. Serum HGB and MCH levels were examined preoperatively, and their prognostic capabilities were evaluated by Cox's proportional hazard model. Among the whole cohort, the HGB level appeared to be positively correlated with the MCH level (P<0.001). Survival analysis revealed that low levels of HGB (P=0.007) and MCH (P<0.001) were correlated with shorter overall survival (OS). Multivariate analysis revealed that MCH level was independently associated with OS (P<0.001), however, not HGB (P=0.278). In addition, 129 patients with large HCC (≥10 cm) tended to have a poorer OS (P<0.001) when compared with patients with smaller HCC. On subanalysis of patients with large HCC, MCH level also retained its stratified significance (P=0.001). Along with common clinicopathological variables, these results suggested that MCH, however, not HGB, may be useful in assessing prognosis for patients with HCC who undergo hepatectomy, particularly in identifying patients with large HCC who are most likely benefit from resection.

Epoetin beta for the treatment of chemotherapy-induced anemia: an update

Epoetin beta belongs to the class of erythropoiesis-stimulating agents (ESAs) that are currently available to treat anemic patients receiving chemotherapy. Chemotherapy-induced anemia affects a high percentage of cancer patients and, due to its negative effects on disease outcome and the patient’s quality of life, should be treated when first diagnosed. Initial trials with ESAs have shown efficacy in improving quality of life and reducing the need for blood transfusions in patients with chemotherapy-induced anemia. However, recent meta-analyses have provided conflicting data on the impact of ESAs on survival and tumor progression. Here we provide an overview of these recent data and review the role of epoetin beta in the treatment of chemotherapy-induced anemia over the past 20 years.

Lower mean corpuscular hemoglobin concentration is associated with unfavorable prognosis of resected lung cancer

ABSTRACT 

Background: The association of preoperative red blood cell indexes in non-anemic patients undergoing lung resections for non-small-cell lung cancer with recurrence-free survival (RFS) and overall survival (OS) has never been investigated. Methods: We retrospectively examined the impact of preoperative red blood cell indexes on RFS and OS and the relationships between the indexes and clinicopathological factors in lung cancer. Results: A total of 649 patients were evaluated. The mean corpuscular hemoglobin concentration was showed as an independent prognostic factor in all patients for OS (hazard ratio [HR]: 0.697; 95% CI: 0.502–0.969; p = 0.032) and RFS (HR: 0.688; 95% CI: 0.519–0.914; p = 0.010). The mean corpuscular volume was an independent prognostic factor in all patients for OS (HR: 0.589; 95% CI: 0.380–0.912; p = 0.018), but not for RFS (HR: 0.684; 95% CI: 0.461–1.015; p = 0.059). Conclusion: In conclusion, the results of this study suggest that mean corpuscular hemoglobin concentration is an independent prognostic factor for OS and RFS in non-small-cell lung cancer.

Prospective, randomized, controlled, and open study in primarily inoperable, stage III non-small cell lung cancer (NSCLC) patients given sequential radiochemotherapy with or without epoetin alfa

BACKGROUND AND PURPOSE

Induction chemotherapy is associated with anemia in non-small cell lung cancer (NSCLC) patients undergoing radiotherapy. This randomized, open-label study compared the effect of sequential radiochemotherapy (RCHT) versus RCHT + epoetin alfa (RCHT + EPO), with respect to 2-year overall survival (OS).

MATERIAL AND METHODS

Patients ⩾18 years received sequential RCHT; one arm also received EPO (chemotherapy day 1, when Hb<12 g/dL). Kaplan-Meier analysis with log-rank test, and Cox-regression methods were performed.

RESULTS

Of the 385 patients randomized (RCHT + EPO: n = 195; RCHT: n = 190), 78 (RCTH + EPO: 46 [23.6%]; RCHT: 32 [16.8%]) were anemic at baseline. Two-year OS was higher in RCHT + EPO-treated versus RCHT-treated (28.5% [95% CI: 22.2-35.1%] versus 20.6% [95% CI: 15.1-26.8%] [p = 0.2278]), and requirement for RBC transfusion was lower (24/195 [12.3%] versus 61/190 [32.1%]). In anemic (baseline) patients (post hoc analysis), median survival was shorter in RCTH-treated (212 days) versus RCHT + EPO-treated (343 days) (Hazard ratio = 1.62 [95% CI: 0.99-2.63], p = 0.0525). Adverse events were documented in 72.7% (RCHT + EPO: 75.0%; RCHT: 70.5%) patients, and thrombovascular events (TVEs) in 45 patients (RCHT + EPO: 16.7%; RCHT: 7.9%; p = 0.0099).

CONCLUSIONS

A statistically non-significant trend for 2-year OS was observed in a sub-group of EPO-treated NSCLC-patients with baseline anemia, although this trend was not maintained in the overall population with inoperable NSCLC.

Multiple myeloma in the very old: an IASIA conference report

Multiple myeloma (MM) in patients aged greater than 80 years poses an increasingly common challenge for oncology providers. A multidisciplinary workshop was held in which MM-focused hematologists/oncologists, geriatricians, and associated health-care team members discussed the state of research for MM therapy, as well as themes from geriatric medicine that pertain directly to this patient population. A summary statement of our discussions is presented here, in which we highlight several topics. MM disproportionately affects senior adults, and demographic trends indicate that this trend will accelerate. Complex issues impact cancer in seniors, and although factors such as social environment, comorbidities, and frailty have been well characterized in nononcological geriatric medicine, these themes have been inadequately explored in cancers such as MM, despite their clear relevance to this field. Therapeutically, novel agents have improved survival for MM patients of all ages, but less so for seniors than younger patients for a variety of reasons. Lastly, both MM- and treatment-related symptoms and toxicities require special attention in senior adults. Existing research provides limited insight into how best to manage these often complex patients, who are often not reflected in typical clinical trial populations. We hence offer suggestions for clinical trials that address knowledge gaps in how to manage very old and/or frail patients with MM, given the complicated issues that often surround this patient population.

Single measurement of hemoglobin predicts outcome of HCC patients

Anemia is a common complication in several types of cancer including hepatocellular carcinoma (HCC). The prognostic potential of hemoglobin (Hb) levels has not yet been investigated in HCC patients. One hundred and ninety-nine patients were prospectively recruited and Hb levels were determined. Hb levels were compared to the stages of liver cirrhosis and HCC stages. The association of the Hb levels and overall survival (OS) was assessed by univariate and multivariate Cox regression models. The relation of Hb levels and OS was further validated in an independent cohort of 87 HCC patients. Hb levels negatively correlated with the stage of liver cirrhosis (model of end stage liver disease score and Child-Pugh stage) and differed between stages of HCC. Low Hb levels (≤ 13 g/dl) were associated with higher mortality in the test [hazard ratio (HR) 2.422, 95 % confidence interval (CI) 1.357-4.322, P = 0.003] as well in the validation cohort (HR 2.486, 95 % CI 1.097-5.632, P = 0.029) in univariate Cox regression model. Low Hb levels were associated with mortality independently from the tumor stage, age, gender and the C-reactive protein levels in a multivariate Cox regression model. Anemia should be considered as a risk factor for mortality in HCC patients.

Impact of preoperative anemia on oncologic outcomes of upper tract urothelial carcinoma treated with radical nephroureterectomy

PURPOSE

We evaluated the impact of preoperative anemia on oncologic outcomes in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy.

MATERIALS AND METHODS

A total of 282 patients with upper tract urothelial carcinoma underwent radical nephroureterectomy. Preoperatively measured hemoglobin values were stratified into normal and anemia based on the WHO classification of 13 gm/dl or less and 12 or less considered anemia in males and females, respectively. We performed sensitivity analysis based on contemporary anemia classifications adjusted for the impact of age, gender and race with anemia considered a hemoglobin value of 13.7 gm/dl or less and 13.2 or less in white males younger than 60 and 60 years old or older, respectively, and 12.2 gm/dl or less in white females of all ages. Univariable and multivariable Cox regression analyses were done to assess the effects of anemia on oncologic outcomes.

RESULTS

Median preoperative hemoglobin was 13.2 gm/dl (IQR 11.7, 14.3). A total of 112 patients (39.7%) were anemic by the WHO classification vs 129 (45.7%) by the contemporary classification. Anemia was associated with lymph node metastasis, lymphovascular invasion, sessile tumor architecture, tumor necrosis, advanced age and a higher ECOG (Eastern Cooperative Oncology Group) performance score using the WHO and/or the contemporary definition (p ≤0.044). At a median 30-month followup anemia was associated with decreased recurrence-free (p ≤0.008) and cancer specific (p <0.001) survival on Kaplan-Meier analyses. On multivariable analysis adjusted for standard clinicopathological factors anemia remained an independent predictor of disease recurrence (HR 1.76, 95% CI 1.17-2.63 and 1.89, 95% CI 1.26-2.86) and cancer specific mortality (HR 1.88, 95% CI 1.15-3.08 and 2.04, 95% CI 1.21-3.45) by the WHO and contemporary classifications, respectively.

CONCLUSIONS

Preoperative anemia is an independent predictor of disease recurrence and cancer specific mortality. It is associated with aggressive tumor features in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. Hemoglobin is a promising marker for patient counseling and risk stratification for additional treatment decision making.

Presence of anemia and poor prognostic factors in patients with endometrial carcinoma

This study evaluated the relationship between pretreatment hemoglobin (Hb) and prognostic factors in Thai patients with endometrial cancer. Medical records of 228 patients who had undergone surgery between January 2005 and December 2007 were retrospectively reviewed. Associations between clinicopathological variables and pretreatment Hb levels were described using Pearson's chi square test or two-tailed Fisher's exact test. Survival analysis was performed with Kaplan-Meier estimates. Univariate and Cox-regression models were used to evaluate the prognostic impact of various factors, including Hb levels, in term of disease-free survival. The median duration of follow-up was 38.2 months. Eighty-nine patients (39%) had a preoperative Hb level of <12 g/dL, these having significantly higher rates of non-endometrioid histology, advanced FIGO stage, lymphovascular space invasion, cervical involvement, adnexal involvement, positive peritoneal cytology, and lymph node involvement than patients with Hb ≥12 g/dL. The 5-year disease-free and overall survival were significantly lower in patients with pretreatment Hb levels <12 g/dL compared with those with Hb ≥12 g/dL (79.3% vs. 89.2%, p=0.044 and 87.6% vs. 99.3%, p<0.001, respectively). In the multivariate analysis only histology, myometrial invasion, and lymphovascular invasion proved to be independent prognostic factors, whereas tumor grading, stage, cervical involvement, adnexal involvement, positive peritoneal cytology, lymph node involvement, and low Hb were not. In conclusion, presence of anemia before treatment may reflect poor prognostic factors in patients with endometrial cancer and low pretreatment hemoglobin level may have a prognostic impact on clinical outcome.

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.

Chemotherapy-induced anemia: the story of darbepoetin alfa

BACKGROUND

Prior to the approval of the first erythropoiesis-stimulating agent (ESA) in the early 1990s, red blood cell transfusions were the primary means of treating severe chemotherapy-induced anemia (CIA), with little recourse for those with more mild forms of the condition. The introduction of the ESAs allowed treatment of mild-to-moderate CIA in patients with cancer. It has been a decade since darbepoetin alfa (DA), a second-generation ESA with a longer half-life, became available to patients with CIA.

OBJECTIVE AND METHODS

We present a review of studies on DA in CIA, from its development through to the present day. Medline was searched for randomized clinical trials on DA. Additional trials and meta-analyses on ESAs were incorporated into this review when relevant.

RESULTS

The first publications on DA generally focused on optimal dosing, efficacy and tolerability. In these, it was shown that DA is an effective and well tolerated treatment option to achieve hematopoietic response, regardless of dosing interval. Subsequently, the focus shifted towards meta-analyses on survival data of all ESAs. These reported conflicting results regarding mortality and/or disease progression. However, guidelines for ESA use were updated and, when followed, these make ESAs a well tolerated and effective tool for managing CIA.

CONCLUSIONS

As the past decade has broadened our knowledge on the benefits and risks of CIA management, continued high-quality studies will help to optimize treatment with ESAs in order to maximize quality of life for these patients. The limitation of a literature review of this nature is the complete reliance on previously published research and the availability of these studies using the methodology outlined above.

Erythropoietin or darbepoetin for patients with cancer

BACKGROUND

Anaemia associated with cancer and cancer therapy is an important clinical factor in the treatment of malignant diseases. Therapeutic alternatives are recombinant human erythropoiesis stimulating agents (ESAs) and red blood cell transfusions.

OBJECTIVES

To assess the effects of ESAs to either prevent or treat anaemia in cancer patients.

SEARCH METHODS

This is an update of a Cochrane review first published in 2004. We searched the Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE and other databases. Searches were done for the periods 01/1985 to 12/2001 for the first review, 1/2002 to 04/2005 for the first update and to November 2011 for the current update. We also contacted experts in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials on managing anaemia in cancer patients receiving or not receiving anti-cancer therapy that compared the use of ESAs (plus transfusion if needed).

DATA COLLECTION AND ANALYSIS

Several review authors assessed trial quality and extracted data. One review author assessed quality assessment and extracted data, a second review author checked for correctness.

MAIN RESULTS

This update of the systematic review includes a total of 91 trials with 20,102 participants. Use of ESAs significantly reduced the relative risk of red blood cell transfusions (risk ratio (RR) 0.65; 95% confidence interval (CI) 0.62 to 0.68, 70 trials, N = 16,093). On average, participants in the ESAs group received one unit of blood less than the control group (mean difference (MD) -0.98; 95% CI -1.17 to -0.78, 19 trials, N = 4,715). Haematological response was observed more often in participants receiving ESAs (RR 3.93; 95% CI 3.10 to 3.71, 31 trials, N = 6,413). There was suggestive evidence that ESAs may improve Quality of Life (QoL). There was strong evidence that ESAs increase mortality during active study period (hazard ratio (HR) 1.17; 95% CI 1.06 to 1.29, 70 trials, N = 15,935) and some evidence that ESAs decrease overall survival (HR 1.05; 95% CI 1.00 to 1.11, 78 trials, N = 19,003). The risk ratio for thromboembolic complications was increased in patients receiving ESAs compared to controls (RR 1.52, 95% CI 1.34 to 1.74; 57 trials, N = 15,498). ESAs may also increase the risk for hypertension (fixed-effect model: RR 1.30; 95% CI 1.08 to 1.56; random-effects model: RR 1.12; 95% CI 0.94 to 1.33, 31 trials, N = 7,228) and thrombocytopenia/haemorrhage (RR 1.21; 95% CI 1.04 to 1.42; 21 trials, N = 4,507). There was insufficient evidence to support an effect of ESA on tumour response (fixed-effect RR 1.02; 95% CI 0.98 to 1.06, 15 trials, N = 5,012).

AUTHORS' CONCLUSIONS

ESAs reduce the need for red blood cell transfusions but increase the risk for thromboembolic events and deaths. There is suggestive evidence that ESAs may improve QoL. Whether and how ESAs affects tumour control remains uncertain. The increased risk of death and thromboembolic events should be balanced against the potential benefits of ESA treatment taking into account each patient's clinical circumstances and preferences. More data are needed for the effect of these drugs on quality of life and tumour progression. Further research is needed to clarify cellular and molecular mechanisms and pathways of the effects of ESAs on thrombogenesis and their potential effects on tumour growth.

Use of darbepoetin alfa in European clinical practice for the management of chemotherapy-induced anaemia in four tumour types: final data from the CHOICE study

OBJECTIVES

The CHOICE study was a prospective, multicentre, observational study designed to assess levels of adherence in current clinical practice to the European product label and EORTC guidelines for the treatment of chemotherapy-induced anaemia (CIA) with darbepoetin alfa (DA). Here we present data split by tumour types: breast, colorectal, ovarian and lung.

METHODS

Haemoglobin (Hb) levels and red blood cell transfusion requirements were evaluated among patients with solid tumours in 11 European countries. The primary outcome measure was the proportion of patients with a target Hb level of ≥10-≤12 g/dL.

RESULTS

The full analysis set included 1887 patients (mean ± SD 62.4 ± 11.4 years); 1585 (84%) had a current disease stage of ≥3. Common chemotherapy regimens were non-platinum + non-taxane based (n = 696 [37%]) or platinum + non-taxane based (n = 660 [35%]). Breast cancer (n = 575): The mean ± SD Hb level at baseline was 9.9 ± 0.8 g/dL (n = 568). Target Hb level was reached by 187 (55%) patients. Colorectal cancer (n = 310): At baseline the mean ± SD Hb level was 9.8 ± 0.8 g/dL (n = 306). Target Hb level was reached by 107 patients (56%). Ovarian cancer (n = 301): The mean ± SD Hb level at baseline was 9.7 ± 0.8 g/dL (n = 294). Target Hb level was reached by 81 patients (44%). Lung cancer (n = 701): At baseline the mean ± SD Hb level was 9.8 ± 0.9 g/dL (n = 692). Target Hb level was reached by 142 patients (39%).

SAFETY

Five severe or life-threatening adverse drug reactions were seen (three patients with breast cancer, one patient with colorectal cancer and one patient with ovarian cancer).

LIMITATIONS

Potential bias could not be excluded due to the study's observational nature.

CONCLUSIONS

This study demonstrates that the recommendations are adhered to in clinical practice, with the mean starting Hb level <10 g/dL irrespective of tumour type. Furthermore, DA is likely to be effective and well tolerated for the treatment of CIA in patients with breast, colorectal, ovarian or lung cancer.

Hemoglobin level significantly impacts the tumor cell survival fraction in humans after internal radiotherapy

Background

Anemia is usually not taken into account in internal radiotherapy. We investigated whether the hemoglobin (Hb) level could have an impact on the tumor response, as observed in external beam radiotherapy (EBRT).

Methods

Absorbed doses of 25 hepatic metastatic sites in eight patients who underwent a liver selective internal radiotherapy (SIRT) were computed by a 3D convolution of a dose deposition kernel with the ⁹⁰Y time-of-flight positron emission tomography (TOF-PET) images acquired following therapy. Early tumor response was assessed by comparing a follow-up FDG TOF-PET scan with a baseline scan. Hb level was measured on the day of the SIRT procedure.

Results

All patients displayed early tumor response increasing with the tumor-absorbed dose. Significant differences between patients were noted, the response slope correlating with the Hb level. After applying a global fit on all metastases using a tumor radiosensitivity modulated by a Hb enhancement factor (HEF) linearly dependent on the Hb level, a strong correlation (R = 0.96) was observed between the early response and the absorbed dose. Hb level had a major impact on tumor response by modulating HEF by a factor 6.

Conclusions

These results prove the significant impact of Hb level on the tumor response and support the study of methods for correcting tumor hypoxia, such as intensively performed in EBRT. The quantitative analysis of the relationship between tumor doses and early response has the power to allow fast screening of such correction methods in limited patient series. Internal radiotherapy could be more efficient if performed earlier in the therapy line, when the disease- and treatment-related anemia remains limited.

Clinico-pathological and biological prognostic variables in squamous cell carcinoma of the vulva

Several clinical-pathological parameters have been related to survival of patients with invasive squamous cell carcinoma of the vulva, whereas few studies have investigated the ability of biological variables to predict the clinical outcome of these patients. The present paper reviews the literature data on the prognostic relevance of lymph node-related parameters, primary tumor-related parameters, FIGO stage, blood variables, and tissue biological variables. Regarding these latter, the paper takes into account the analysis of DNA content, cell cycle-regulatory proteins, apoptosis-related proteins, epidermal growth factor receptor [EGFR], and proteins that are involved in tumor invasiveness, metastasis and angiogenesis. At present, the lymph node status and FIGO stage according to the new 2009 classification system are the main predictors for vulvar squamous cell carcinoma, whereas biological variables do not have yet a clinical relevance and their role is still investigational.

Prognostic significance of intraoperative chemotherapy and extensive lymphadenectomy in patients with node-negative gastric cancer

BACKGROUND AND OBJECTIVES

Despite a relatively better prognosis, patients with node-negative gastric cancer still suffer from metastasis and recurrence. To investigae the prognostic factors and appropriate therapies for these pN0 tumors, we analyzed the predictors and evaluated the impact of chemotherapy and extensive lymphadenectomy on survival.

METHODS

Clinicopathologic features of 153 patients with pN0 gastric cancer were studied retrospectively. The prognostic factors were analyzed stratifying by pT1 and pT2-3 stage. The 5-year survival rate (5-YSR) of patients in different groups of chemotherapy and lymph nodes retrieved were compared.

RESULTS

Multivariate analysis indicated pT, number of nodes retrieved, and chemotherapy as the independent predictors of advanced gastric cancer; anemia was the only independent predictor of early gastric cancer. Survival of patients with pT3 got improved significantly by intraoperative chemotherapy and retrieval of more than 25 nodes, but neither of them benefited patients with pT1-2. Moreover, in pT3 status, 5-YSR of patients with intraoperative chemotherapy was still poorer than those with postoperative chemotherapy and combined chemotherapy.

CONCLUSIONS

In pN0 gastric cancers, prognostic factors differed significantly between early stage and advanced stage. For patients with pT3, besides curative gastrectomy and postoperative chemotherapy, it might be beneficial to perform intraoperative chemotherapy and extensive lymphadenectomy.

Epoetin alfa treatment for patients with chemotherapy-induced anemia

Anemia (hemoglobin [Hb] < 12 g/dL) is a frequent and debilitating complication in the treatment of cancer. The negative effects of anemia include impairment of organ systems, disruption of important aspects of patient quality of life, and potential interference with completion and outcomes of cancer chemotherapy. Guidelines issued by the National Comprehensive Cancer Network and the American Society of Hematology/American Society of Clinical Oncology jointly suggest that anemia in patients with cancer be managed by restoring Hb levels to approximately 12 g/dL, thereby minimizing transfusion requirements and resolving clinical symptoms associated with anemia. Recombinant human erythropoietin (epoetin alfa) administered 150 U/kg 3 times weekly or 40,000 U once weekly has been shown in randomized, double-blind, placebo-controlled trials and large, open-label, nonrandomized, community-based studies to effectively and safely correct anemia in patients with cancer undergoing chemotherapy. Several clinical trials support that treatment with epoetin alfa results in quality of life benefits that significantly correlate with Hb increases. Areas currently being investigated with epoetin alfa in the chemotherapy setting include the following: extended dosing regimens beyond the Food and Drug Administration-approved 3-times-weekly and once-weekly dosing regimens, early intervention for mild anemia, effects on treatment outcomes and survival, and optimal administration of concurrent iron supplementation.

The prognostic impact of duration of anemia during chemotherapy in advanced epithelial ovarian cancer

OBJECTIVE

To propose a measure of anemia to be used as a prognostic factor for progression-free survival and overall survival in advanced epithelial ovarian cancer patients.

PATIENTS AND METHODS

Seventy-six patients with International Federation of Gynecology and Obstetrics stage III and stage IV epithelial ovarian cancer who had received at least six courses of platinum- and taxane-based systemic chemotherapy and achieved clinical or pathologic complete response were included. A novel prognostic factor based on the duration of anemia was proposed and the impact of anemia on progression-free and overall survival times was analyzed by a log-rank test and a Cox proportional hazards model.

RESULTS

We introduce a binary variable, Hb1020, that takes a value of 1 if the duration of a hemoglobin (Hb) level <10 g/dL is ≥20% of the total duration of chemotherapy. We propose Hb1020 as a potential prognostic factor for epithelial ovarian cancer. The 5-year progression-free survival rates were 48.4% in the Hb1020 = 0 group (duration of Hb <10 g/dL <20% of total duration) and 17.7% in the Hb1020 = 1 group (p = .026). The 5-year overall survival rates were 64.6% and 45.0%, respectively (p = .015).

CONCLUSIONS

Hb1020, based on the duration of anemia, is a potential prognostic factor for epithelial ovarian cancer. Using Hb1020, we will be able to administer highly optimized treatment for anemia to improve patient survival. Further independent studies are needed to confirm its prognostic role.

Improving the radiosensitivity of radioresistant and hypoxic glioblastoma

In spite of increasing attention on targeted therapeutics in the treatment of glioblastoma multiforme, radiation therapy remains the most clinically effective treatment modality. However, radiotherapy only offers palliation, with hypoxia representing a major mechanism of tumor resistance. Traditional strategies to overcome the therapeutic barrier to irradiation imposed by tumor tissue hypoxia consist of improving tumor oxygenation and administering agents that increase the tumor cell sensitivity to irradiation (radiosensitizers). There is also increasing evidence that tumor tissue is composed of diverse populations of cells with heterogeneous sensitivities to irradiation. The radioresistant tumor-initiating CD133-positive glioblastoma cancer stem cells are preferentially expanded in hypoxic conditions. Therefore, identifying therapies that can specifically target the glioblastoma cancer stem cells will lead to more durable responses to radiation therapy.

Supportive care for patients with early breast cancer

Breast cancer treatment currently requires the joint efforts of a multidisciplinary team to effectively combine chemotherapy, hormone therapy, biological agents, surgery and radiation therapy when needed. To develop such a treatment plan, it is important to know the benefits as well as the potential toxic effects of each therapy. Thus, many patients with early breast cancer complain of collateral adverse events such as fatigue, nausea, vomiting, loss of libido, hot flashes, night sweats or neuropathy due to the complex therapies they are receiving. To date, the treatment of such symptoms is an important issue that greatly affects the quality of life of these patients. In this review, we report the content of a multi-expert meeting where the incidence of and medical approach to some of the most common adverse events encountered during the treatment of patients with early breast cancer were analysed.

Prognostic significance of a pretreatment hematologic profile in patients with head and neck cancer

BACKGROUND

The purpose of this retrospective study was to test whether the pretreatment hematologic profile can predict the prognosis of patients with head and neck cancer.

METHODS

Medical records from 278 patients with head and neck cancer were reviewed, and 270 cases were evaluable. Clinical data including age, gender, stage, pretreatment hematologic profile (including white blood cell, platelet, and differential counts, and hemoglobin level) were recorded. Statistical analyses were performed to determine the prognostic effect of these hematologic indicators, as well as clinical variables. The association between the hematologic indicators and clinical factors was also analyzed.

RESULTS

Pretreatment monocytes >1,000 cells/microl (P = 0.028), hemoglobin <11.0 g/dl (P = 0.022), and platelet count >400 x 10(3) cells/microl (P = 0.017) were identified as independent prognostic factors in addition to the nodal status and metastasis. A significant correlation between T-stage/monocyte or platelet count and metastasis/platelet count were shown. Monocytosis, anemia, and thrombocytosis were demonstrated to have a cumulative effect on the prognosis of head and neck cancer patients (normal vs. abnormality in one lineage, P = 0.001; abnormality in one vs. more than one lineage, P = 0.005).

CONCLUSIONS

A pretreatment hematologic profile can be considered as a useful prognostic marker in patients with head and neck cancer.

Clinical relevance of hemoglobin level in cervical cancer patients administered definitive radiotherapy

The prognostic impact of pretreatment hemoglobin (Hb) level and its changes during definitive radiotherapy was evaluated by univariate and multivariate analysis in the group of 453 FIGO IB-IIIB cervical cancer patients. Pretreatment anemia (Hb < 12 g/dl) was present in 148 patients (33%), and anemia at the end of irradiation in 48%; in 64% Hb level declined during therapy. Median overall survival in patients with initial Hb >or=12 g/dl was 66 months compared to 22 months in those with lower baseline Hb levels (p = 0.0001). This difference was mainly due to increased risk of distant spread in anemic patients (40% compared to 25% in subjects with pretreatment Hb >or=12 g/dl; p = 0.001). Baseline Hb >or=12 g/dl was also associated with longer disease-free survival and improved local control. Declining Hb level during radiotherapy predicted for impaired 5-year disease-free survival and local control probability. In multivariate analysis, low pretreatment Hb level remained associated with worse overall and disease-free survival, whereas adverse impact of declining Hb level on outcome was not observed. With regard to other clinical factors, stage and tumor extension (uni- or bilateral parametrium involvement for Stage III) were the only independent determinants of prognosis.

[Impact of hemoglobin level on lung cancer survival]

BACKGROUND AND OBJECTIVE

Anemia is commonly observed in lung cancer (LC). Hemoglobin levels at the time of diagnosis could be considered a prognostic indicator in patients with LC. The aim of this trial was to analyze hemoglobin levels at the time of diagnosis as a prognostic factor in patients with LC.

PATIENTS AND METHOD

We retrospectively examined all patients with LC (cytologically or histologically confirmed) diagnosed in our health area for a period of 3 years. Correlation between hemoglobin levels and survival was assessed. All patients were divided into 2 groups: patients with low hemoglobin levels (lower than percentile 25 of the distribution), and patients who exceeded that figure. By means of Cox's regression, the influence of hemoglobin levels in survival was calculated and adjusted to other factors.

RESULTS

421 patients were included, 52.2% of them presented anemia at the time of diagnosis. Mean age was 65.8 years and 92.7% were male. The group of patients with hemoglobin levels lower than percentile 25 had a survival rate that was 41% inferior.

CONCLUSIONS

Low hemoglobin levels are associated with decreased survival in patients with LC. The evaluation of this parameter could be used for a more accurate prognosis in LC and a better adequacy of therapeutic indications.