T4 stage and preoperative anemia as prognostic factors for the patients with colon cancer treated with adjuvant FOLFOX chemotherapy

The role of laboratory indices on treatment response and survival in breast cancer receiving neoadjuvant chemotherapy

Neoadjuvant chemotherapy (NACT) is the standard treatment for locally advanced, high-risk breast cancer. Pathological complete response (pCR) improves survival. Peripheral blood-derived indices reflecting systemic inflammation and nutritional status have long been used as predictive and prognostic markers in solid malignancies. This retrospective study investigates whether eight commonly used indices in patients receiving NACT affect pCR and survival. This study includes 624 locally advanced breast cancer patients who received NACT. The biomarker indices were calculated from peripheral blood samples taken two weeks before starting chemotherapy. The indices' optimal cut-off values were determined using ROC Curve analysis. During a median follow-up period of 42 months, recurrence was detected in 146 patients, and 75 patients died. pCR was observed in 166 patients (26.6%). In univariate analysis, NLR, PLR, SII, PNI, HALP, and HRR were statistically significantly associated (p = 0.00; p = 0.03; p = 0.03; p = 0.02; p = 0.00; p = 0.02 respectively), but in multivariate analysis, only NLR was significantly predictive for pCR(p = 0.04). In multivariate analysis, the HGB/RDW score significantly predicted DFS(p = 0.04). The PNI score was identified as a marker predicting survival for both OS and PFS (p = 0.01, p = 0.01, respectively). In conclusion, peripheral blood-derived indices have prognostic and predictive values on pCR and survival. However, further studies are needed to validate our findings.

Preoperative anemia and long-term survival in patients undergoing colorectal cancer surgery: a retrospective cohort study

BACKGROUND

The impact of preoperative anemia on a survival outcome and the importance of correcting preoperative anemia in patients with colorectal cancer (CRC) remain controversial. This study aimed to explore how preoperative anemia affects the long-term survival of patients undergoing colorectal cancer surgery.

METHODS

This was a retrospective cohort study in which adult patients underwent surgical resection for colorectal cancer between January 1, 2008, and December 31, 2014, at a large tertiary cancer center. A total of 7436 patients were enrolled in this study. Anemia was defined according to the diagnostic criteria of China (hemoglobin level < 110 g/L for women and < 120 g/L for men). The median follow-up time was 120.5 months (10.0 years). Inverse probability of treatment weighting (IPTW) using the propensity score was used to reduce selection bias. Overall survival (OS) and disease-free survival (DFS) were compared between patients with and without preoperative anemia using the Kaplan-Meier estimator and the weighted log-rank test based on IPTW. Univariate and multivariate Cox proportional hazards models were used to assess factors associated with OS and DFS. Multivariable Cox regression was also used to assess red blood cell (RBC) transfusion associations between preoperative anemia and outcomes.

RESULTS

After IPTW adjustment, clinical profiles were similar, except that tumor location and TNM stage remained imbalanced between the preoperative anemia and preoperative non-anemia groups (p < 0.001). IPTW analysis showed that the 5-year OS rate (71.3 vs. 78.6%, p < 0.001) and the 5-year DFS rate (63.9 vs. 70.9%, p < 0.001) were significantly lower in the preoperative anemia group. Multivariate analysis showed that preoperative anemia was associated with poorer OS and DFS, while RBC transfusion may improve OS (hazard ratio [HR] 0.54, p = 0.054) and DFS (HR 0.50, p = 0.020) in CRC patients with preoperative anemia.

CONCLUSIONS

Preoperative anemia is an independent risk factor for survival in patients undergoing colorectal surgery. Strategies to reduce preoperative anemia in patients with CRC should be considered.

Antiangiogenic Drug-Induced Proteinuria as a Prognostic Factor in Metastatic Colorectal Cancer

Treatment with bevacizumab is known to cause adverse events such as proteinuria and hypertension, amongst others. However, while bevacizumab-induced hypertension has been linked to increased overall survival (OS), data on proteinuria are controversial. We performed a retrospective analysis to observe the influence of adverse events developed during treatment with bevacizumab and chemotherapy on the OS in patients with metastatic colorectal cancer (mCRC). Kaplan–Meier and log-rank analyses were used to assess differences in OS, and hazard ratios (HR) were estimated using Cox models. Out of the 3497 mCRC patients admitted to our center between 2014 and 2019, 150 met the criteria for inclusion in our analysis. Out of these, 50.7% experienced proteinuria and had reached a longer OS (40 versus 25 months, p = 0.015) and progression-free survival (15 versus 12 months, p = 0.039). The following groups were identified as having a lower risk of death: patients with proteinuria (HR 0.589; 95% CI 0.402–0.863; p = 0.007), one metastatic site (HR 0.533; 95% CI 0.363–0.783; p = 0.001), and non-metastatic stage at diagnosis (HR 0.459; 95% CI 0.293–0.720; p = 0.001). Patients with anemia and diabetes had an increased risk of death. Proteinuria emerges as a useful prognostic factor in mCRC patients undergoing bevacizumab-based systemic therapy, and it could be easily integrated into the decision-making process, thus allowing physicians to further individualize systemic treatments.

Clinical and Biological Variables Influencing Outcome in Patients with Advanced Non-Small Cell Lung Cancer (NSCLC) Treated with Anti-PD-1/PD-L1 Antibodies: A Prospective Multicentre Study

Introduction: Immune checkpoint inhibitors (ICIs) have become the standard of treatment for patients with non-small cell lung cancer (NSCLC). However, there are still many uncertainties regarding the selection of the patient who could benefit more from this treatment. This study aims to evaluate the prognostic and predictive role of clinical and biological variables in unselected patients with advanced NSCLC candidates to receive ICIs. Methods: This is an observational and prospective study. The primary objective is the evaluation of the relationship between clinical and biological variables and the response to ICIs. Secondary objectives included: safety; assessment of the relationship between clinical and biological parameters/concomitant treatments and progression-free survival at 6 months and overall survival at 6 and 12 months. Nomograms to predict these outcomes have been generated. Results: A total of 166 patients were included. An association with response was found in the presence of the high immunohistochemical PD-L1 expression, squamous cell histotype, and early line of treatment, whereas a higher probability of progression was seen in the presence of anemia, high LDH values and neutrophil/lymphocyte ratio (NLR), pleural involvement, and thrombosis before treatment. The nomogram showed that anemia, PD-L1 expression, NLR, and LDH represented the most informative predictor as regards the three parameters of interest. Conclusions: In the era of personalized medicine, the results are useful for stratifying the patients and tailoring the treatments, considering both the histological findings and the clinical features of the patients.

Lymph Node Status and Long-Term Oncologic Outcomes After Colon Resection in Locally Advanced Colon Cancer

Locally advanced colon cancer is associated with poor prognosis. The aim of this report was to examine the association between the lymph node status and prognosis of locally advanced colon cancer. Perioperative and oncologic outcomes were studied in patients who had undergone colectomy for colon cancer between June 2004 and December 2018. Locally advanced colon cancer was defined as stage T4a/T4b cancer. The long-term oncologic results were investigated in patients with non-metastatic locally advanced colon cancer. Of 195 patients operated for locally advanced colon cancer, 83 (42.6%), 43 (22.1%), and 69 (35.3%) had pN0, pN1, and pN2 disease, respectively. Preoperative serum levels of CEA and CA 19-9, as well as incidence of distant metastases were significantly higher in patients with pN2 compared to those with pN0 and pN1. In non-metastatic setting, a trend towards higher incidence of recurrence was observed in node-positive patients. Nodal stage was a significant predictor for survival in the univariable analysis but non-significant after adjusting for confounders. Subgroup analyses among the patients with T4a and T4b cancer did not demonstrate any association between the nodal stage and survival. Preoperative CA 19-9 > 37 U/ml and adjuvant chemotherapy were the only prognostic factors in T4a and T4b colon cancer, respectively. Although a trend towards higher incidence of recurrence was observed in node-positive locally advanced colon cancer, nodal stage was not associated with survival. Adjuvant chemotherapy should be strongly considered in T4b stage colon cancer.

Experimental Drugs for Chemotherapy- and Cancer-Related Anemia

Anemia in cancer patients is a relevant condition complicating the course of the neoplastic disease. Overall, we distinguish the anemia which arises under chemotherapy as pure adverse event of the toxic effects of the drugs used, and the anemia induced by the tumour-associated inflammation, oxidative stress, and systemic metabolic changes, which can be worsened by the concomitant anticancer treatments. This more properly cancer-related anemia depends on several overlapping mechanism, including impaired erythropoiesis and functional iron deficiency, which make its treatment more difficult. Standard therapies approved and recommended for cancer anemia, as erythropoiesis-stimulating agents and intravenous iron administration, are limited to the treatment of chemotherapy-induced anemia, preferably in patients with advanced disease, in view of the still unclear effect of erythropoiesis-stimulating agents on tumour progression and survival. Outside the use of chemotherapy, there are no recommendations for the treatment of cancer-related anemia. For a more complete approach, it is fundamentally a careful evaluation of the type of anemia and iron homeostasis, markers of inflammation and changes in energy metabolism. In this way, anemia management in cancer patient would permit a tailored approach that could give major benefits. Experimental drugs targeting hepcidin and activin II receptor pathways are raising great expectations, and future clinical trials will confirm their role as remedies for cancer-related anemia. Recent evidence on the effect of integrated managements, including nutritional support, antioxidants and anti-inflammatory substances, for the treatment of cancer anemia are emerging. In this review article, we show standard, innovative, and experimental treatment used as remedy for anemia in cancer patients.

"Anemia and Response to Neoadjuvant Chemotherapy in Breast Cancer Patients"

We analyzed the effect of anemia on tumor response of patients with primary invasive breast cancer (BC) receiving neoadjuvant chemotherapy (NACT). The patient collective was very homogenous; finally, 74 BC patients with identical medication and duration of NACT were enrolled. After completion of NACT, 49 patients (66.2%) had a post-NACT Hb level <12 g/dl. In the anemic group, we found a tendency of lower median tumor response compared to nonanemic patients at this time (15 versus 17 mm, retrospectively, p = 0.18). Age at diagnosis significantly correlated with the difference of Hb [before initiation - after completion of NACT] (correlation coefficient = 0.40, p < 0.001).

Iron deficiency, immunology, and colorectal cancer

Excessive gut luminal iron contributes to the initiation and progression of colorectal cancer. However, emerging evidence suggests that reduced iron intake and low systemic iron levels are also associated with the pathogenesis of colorectal cancer. This is important because patients with colorectal cancer often present with iron deficiency. Iron is necessary for appropriate immunological functions; hence, iron deficiency may hinder cancer immunosurveillance and potentially modify the tumor immune microenvironment, both of which may assist cancer development. This is supported by studies showing that patients with colorectal cancer with iron deficiency have inferior outcomes and reduced response to therapy. Here, we provide an overview of the immunological consequences of iron deficiency and suggest ensuring adequate iron therapy to limit these outcomes.

TAM-ing the CIA-Tumor-Associated Macrophages and Their Potential Role in Unintended Side Effects of Therapeutics for Cancer-Induced Anemia

Cancer-induced anemia (CIA) is a common consequence of neoplasia and has a multifactorial pathophysiology. The immune response and tumor treatment, both intended to primarily target malignant cells, also affect erythropoiesis in the bone marrow. In parallel, immune activation inevitably induces the iron-regulatory hormone hepcidin to direct iron fluxes away from erythroid progenitors and into compartments of the mononuclear phagocyte system. Moreover, many inflammatory mediators inhibit the synthesis of erythropoietin, which is essential for stimulation and differentiation of erythroid progenitor cells to mature cells ready for release into the blood stream. These pathophysiological hallmarks of CIA imply that the bone marrow is not only deprived of iron as nutrient but also of erythropoietin as central growth factor for erythropoiesis. Tumor-associated macrophages (TAM) are present in the tumor microenvironment and display altered immune and iron phenotypes. On the one hand, their functions are altered by adjacent tumor cells so that they promote rather than inhibit the growth of malignant cells. As consequences, TAM may deliver iron to tumor cells and produce reduced amounts of cytotoxic mediators. Furthermore, their ability to stimulate adaptive anti-tumor immune responses is severely compromised. On the other hand, TAM are potential off-targets of therapeutic interventions against CIA. Red blood cell transfusions, intravenous iron preparations, erythropoiesis-stimulating agents and novel treatment options for CIA may interfere with TAM function and thus exhibit secondary effects on the underlying malignancy. In this Hypothesis and Theory, we summarize the pathophysiological hallmarks, clinical implications and treatment strategies for CIA. Focusing on TAM, we speculate on the potential intended and unintended effects that therapeutic options for CIA may have on the innate immune response and, consequently, on the course of the underlying malignancy.

Flipside of the Coin: Iron Deficiency and Colorectal Cancer

Iron deficiency, with or without anemia, is the most frequent hematological manifestation in individuals with cancer, and is especially common in patients with colorectal cancer. Iron is a vital micronutrient that plays an essential role in many biological functions, in the context of which it has been found to be intimately linked to cancer biology. To date, however, whereas a large number of studies have comprehensively investigated and reviewed the effects of excess iron on cancer initiation and progression, potential interrelations of iron deficiency with cancer have been largely neglected and are not well-defined. Emerging evidence indicates that reduced iron intake and low systemic iron levels are associated with the pathogenesis of colorectal cancer, suggesting that optimal iron intake must be carefully balanced to avoid both iron deficiency and iron excess. Since iron is vital in the maintenance of immunological functions, insufficient iron availability may enhance oncogenicity by impairing immunosurveillance for neoplastic changes and potentially altering the tumor immune microenvironment. Data from clinical studies support these concepts, showing that iron deficiency is associated with inferior outcomes and reduced response to therapy in patients with colorectal cancer. Here, we elucidate cancer-related effects of iron deficiency, examine preclinical and clinical evidence of its role in tumorigenesis, cancer progression and treatment response. and highlight the importance of adequate iron supplementation to limit these outcomes.

Clinical significance of anemia as a prognostic factor in non-small cell lung cancer carcinoma with activating epidermal growth factor receptor mutations

Background

Anemia is a frequent finding in cancer patients. Pre-treatment anemia is known to be associated with poor survival after surgery or stereotactic body radiation therapy of non-small cell lung cancer (NSCLC). However, little study was conducted in NSCLC with activating epidermal growth factor receptor (EGFR) mutations.

Methods

This was a multicenter retrospective study conducted in seven university teaching hospitals in the Republic of Korea from January 2009 to February 2016. A total of 290 patients were diagnosed with NSCLC harboring sensitizing EGFR mutations and treated with EGFR-tyrosine kinase inhibitor (TKI) as 1st line. Of these patients, 104 met the exclusion criteria. Pre-treatment anemia was defined according to World Health Organization criteria (Hb concentration <13 g/dL for men and <12 g/dL for women).

Results

A total of 186 patients were finally included for analysis. Of these patients, 86 (46.2%) and 100 (53.8%) patients were classified into anemia and non-anemia groups, respectively. The anemia group had shorter median overall survival (OS) than the non-anemia group [24.83 (95% CI, 17.49–32.17) months vs. 42.10 (95% CI, 31.87–52.34) months, P=0.031]. In multivariate analysis, anemia (aHR, 2.573; 95% CI, 1.122–5.901; P=0.026) was only independent factors for poor OS.

Conclusions

Our study suggests that pre-treatment anemia is a significant poor prognostic factor for OS of NSCLC patients with EGFR mutations treated with EGFR-TKI.

Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer

Background

We investigated whether preoperative anemia and perioperative blood transfusion (pbt) are associated with overall survival and recurrence-free survival in patients with nonmetastatic colorectal cancer.

Methods

From 1 January 2009 to 31 December 2014, 1003 patients with primary colorectal cancer were enrolled in the study. Perioperative clinical and oncologic outcomes were analyzed based on the presence of preoperative anemia and pbt.

Results

Preoperative anemia was found in 468 patients (46.7%). In the anemia and no-anemia groups, pbt was performed in 44% and 15% of patients respectively. Independent predictors for pbt were preoperative anemia, higher American Society of Anesthesiologists score, laparotomy, lengthy operative time, advanced TNM stage, T4 stage, and 30-day morbidity. The use of pbt, but not preoperative anemia, was found to be an independent adverse prognostic factor for overall survival. In terms of recurrence-free survival, the presence of preoperative anemia was similarly not a significant prognostic factor, but the use of pbt was an independent factor for an unfavourable prognosis.

Conclusions

The use of pbt, but not preoperative anemia, was independently associated with worse overall and recurrence-free survival in nonmetastatic colorectal cancer. For better oncologic outcomes, our findings indicate a need to reduce the use of blood transfusion during the perioperative period.

Effects of oxaliplatin-containing adjuvant chemotherapy on short-term survival of patients with colon cancer in Dr. Sardjito Hospital, Yogyakarta, Indonesia

Background

Oxaliplatin-based adjuvant chemotherapy has been applied as standard treatment for high risk stages II and III colon cancer in many countries. There was no comprehensive report of oxaliplatin use in Indonesia. This research aimed to evaluate the short-term survival of patients with colon cancer treated with such strategy and the prognostic factors.

Methods

Medical records of patients with colon cancer receiving oxaliplatin-containing adjuvant chemotherapy were retrospectively reviewed. Demography, clinicopathological, and treatment data were collected. Two-year overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan-Meier method and survival predictors were estimated using Cox proportional hazard models.

Results

Data of 81 patients had been included with a median follow-up of 25.2 months. The estimated OS and DFS at 2 years were 75.8% and 72.7%. In multivariate analyses, the Eastern Cooperative Oncology Group (ECOG) 2 performance status [hazard ratio (HR) =2.967; 95% confidence interval (CI), 1.265 to 6.957; P=0.012], T4 stage (HR =2.669; 95% CI, 1.087 to 6.557; P=0.032), and less cycles of chemotherapy administration (HR =3.280; 95% CI, 1.333 to 8.070; P=0.010) were significant independent factors for an increased risk of death. Cases with moderately to poorly differentiated tumors had significantly worse DFS compared with those with well differentiated tumors (HR =3.503; 95% CI, 1.403 to 8.744; P=0.007).

Conclusions

Colon cancer patients receiving oxaliplatin-based adjuvant regimens in our clinical practice had 2-year OS rate of 75.8% and 2-year DFS rate of 72.7%. ECOG 2 performance status, T4 stage, and less cycles of chemotherapy administration significantly predicted a poor OS and moderately to poorly histological grade significantly predicted a poor DFS.

Pathogenesis and Treatment Options of Cancer Related Anemia: Perspective for a Targeted Mechanism-Based Approach

Cancer-related anemia (CRA) is a common sign occurring in more than 30% of cancer patients at diagnosis before the initiation of antineoplastic therapy. CRA has a relevant influence on survival, disease progression, treatment efficacy, and the patients' quality of life. It is more often detected in patients with advanced stage disease, where it represents a specific symptom of the neoplastic disease, as a consequence of chronic inflammation. In fact, CRA is characterized by biological and hematologic features that resemble those described in anemia associated to chronic inflammatory disease. Proinflammatory cytokine, mainly IL-6, which are released by both tumor and immune cells, play a pivotal action in CRA etiopathogenesis: they promote alterations in erythroid progenitor proliferation, erythropoietin (EPO) production, survival of circulating erythrocytes, iron balance, redox status, and energy metabolism, all of which can lead to anemia. The discovery of hepcidin allowed a greater knowledge of the relationships between immune cells, iron metabolism, and anemia in chronic inflammatory diseases. Additionally, chronic inflammation influences a compromised nutritional status, which in turn might induce or contribute to CRA. In the present review we examine the multifactorial pathogenesis of CRA discussing the main and novel mechanisms by which immune, nutritional, and metabolic components affect its onset and severity. Moreover, we analyze the status of the art and the perspective for the treatment of CRA. Notably, despite the high incidence and clinical relevance of CRA, controlled clinical studies testing the most appropriate treatment for CRA are scarce, and its management in clinical practice remains challenging. The present review may be useful to indicate the development of an effective approach based on a detailed assessment of all factors potentially involved in the pathogenesis of CRA. This mechanism-based approach is essential for clinicians to plan a safe, targeted, and successful therapy, thereby promoting a relevant amelioration of patients' quality of life.

Association of baseline patient characteristics with adjuvant chemotherapy toxicities in stage III colorectal cancer patients

Toxicities can affect cancer patients' quality of life resulting in poor adherence to adjuvant chemotherapy (AC). While previous studies have explored the prevalence of toxicities following AC, few have examined the associations of baseline characteristics, such as age, sex, and performance status, with toxicity outcomes. In this study, we reviewed a cohort of 371 colorectal cancer patients treated with adjuvant monotherapy (capecitabine ) or combination therapy (FOLFOX or CAPOX) within 12 weeks of curative resection, and determined the associations between baseline characteristics and toxicity outcomes. Median age was 65 years, 52% were men, and 41% received monotherapy. A number of toxicities appeared to decrease with successive AC cycles. For monotherapy, univariate analyses found that age, sex, performance status, and pre-treatment anemia were associated with hematological toxicities whereas tumor location was associated with gastrointestinal (GI) toxicities (all P < 0.05). On multivariate analyses, hematological toxicities were predicted by advanced age (≥ 70) (OR 3.30; 95% CI 1.17-9.37; P = 0.025) and pre-treatment anemia (OR 23.18; 95% CI 6.36-84.48; P < 0.001), while GI toxicities were less likely to occur among tumors at or distal to the splenic flexure (OR 0.38; 95% CI 0.15-0.99; P = 0.047). For combination therapy, sex and pre-treatment anemia were associated with hematological toxicities (all P < 0.05), but only female sex was predictive on multivariate analyses (OR 5.13; 95% CI 2.08-12.68; P < 0.001). In conclusion, few baseline characteristics were associated with treatment toxicities. These findings may better inform discussions with patients and caregivers during AC decision-making and underscore to clinicians the need for close monitoring of patients during treatment.

Anemia in Cutaneous Malignant Melanoma: Low Blood Hemoglobin Level is Associated with Nodal Involvement, Metastatic Disease, and Worse Survival

Anemia is common in cancer patients and also affects survival. However, its clinical role and prognostic significance remains unknown in cutaneous melanoma patients (CMPs). The aim of this study was to determine the clinical significance of blood hemoglobin levels in CMPs. Of 446 CMPs were enrolled into this study and were investigated retrospectively. The median value of hemoglobin levels was 13.4 g/dL (7.9-17.4 g/dL). The female patients (P < 0.001) and those with nodular histology (P = 0.040), elevated erythrocyte sedimentation rate (P < 0.001), higher serum lactate dehydrogenase (P < 0.001), lymph node involvement (P = 0.018), and metastatic disease (P < 0.001) had more likely low hemoglobin concentrations compared with other CMPs. However, serum hemoglobin levels were not significantly associated with age, anatomic localization, and various pathological features including Breslow depth, mitotic rate, and ulceration. We found that hemoglobin levels were significantly associated with outcome; the patients with low hemoglobin concentrations had worse survival than other CMPs (P < 0.001). On multivariate analyses, however, hemoglobin level lost its significance, thus, it was not found independently associated with the outcome. In conclusion, low blood hemoglobin concentration is associated with nodal involvement and metastatic disease. Although anemia in diagnosis was not an independent prognostic factor for survival in CMPs, it was associated with poor prognostic factors.

Preoperative anemia in colorectal cancer: relationships with tumor characteristics, systemic inflammation, and survival

Anemia is common in colorectal cancer (CRC) but its relationships with tumor characteristics, systemic inflammation, and survival have not been well characterized. In this study, blood hemoglobin levels and erythrocyte mean corpuscular volume (MCV) levels were measured in two independent cohorts of 148 CRC patients and 208 CRC patients, and their correlation with patient and tumor characteristics, systemic inflammatory markers (modified Glasgow Prognostic Score: mGPS; serum levels of thirteen cytokines, C-reactive protein, albumin), and survival were analyzed. We found that anemia, most frequently normocytic, followed by microcytic, was present in 43% of the patients. Microcytic anemia was most commonly associated with proximal colon tumor location. Average MCV and blood hemoglobin levels were lower in tumors with high T-class. Low blood hemoglobin associated with systemic inflammation, including high mGPS and high serum levels of C-reactive protein and IL-8. Particularly, normocytic anemia associated with higher mGPS. Normocytic anemia associated with a tendency towards worse overall survival (multivariate hazard ratio 1.61, 95% confidence interval 1.07–2.42, p = 0.023; borderline statistical significance considering multiple hypothesis testing). In conclusion, anemia in CRC patients is most frequently normocytic. Proximal tumor location is associated with predominantly microcytic anemia and systemic inflammation is associated with normocytic anemia.

Long-term prognostic value of preoperative anemia in patients with colorectal cancer: A systematic review and meta-analysis

OBJECTIVE

To evaluate the long-term prognostic factor of preoperative anemia in colorectal cancer patients.

BACKGROUND

Anemia is frequently observed in colorectal cancer patients, with a case incidence of 30 to 67 percent. Besides an indicator of tumor-induced blood loss and inflammation, anemia in cancer is also suggested to be a cause of inferior outcome, possibly via worsening of tumor hypoxia. As surgery is likely to enhance anemia, the long-term prognostic value of preoperative anemia seems most interesting.

METHODS

Comprehensive searches were carried out in all relevant databases, including MEDLINE, Embase and Web-of-Science. To include studies addressing overall survival, follow-up had to be at least 24 months or till death. For pooling of survival results, a mixed-linear (fixed-effects) model was fit to the reported hazard ratios (HRs) to calculate a pooled estimate and confidence interval.

RESULTS

We included 12 studies comprising 3588 patients to estimate the association between preoperative anemia and overall survival (OS) and disease-free survival (DFS). In a fixed-effects meta-analysis of eight studies, including both colon and rectal cancer, preoperative anemia was significantly associated with poor OS (HR 1.56; 95% CI 1.30 to 1.88; p < 0.001). A meta-analysis of seven studies also showed that preoperative anemia was significantly associated with poor DFS (HR 1.34; 95% CI 1.11 to 1.61; p = 0.002). Restricted to studies exclusively on colon cancer or rectal cancer, HRs for OS were 1.25 (95% CI 1.00 to 1.55; p = 0.05) and 2.59 (95% CI 1.68 to 4.01; p < 0.001), respectively, while HRs for DFS were 1.21 (95% CI 0.96 to 1.52; p = 0.11) and 1.61 (95% CI 1.18 to 2.21; p = 0.003).

CONCLUSION

The present meta-analysis reveals that preoperative anemia is significantly associated with decreased long-term OS and DFS in rectal cancer, but not in colon cancer patients, although this meta-analysis is mainly based on retrospective studies with high heterogeneity. These results justify raised awareness about the impact of preoperative anemia on long-term survival.

Decision Making in Bowel Obstruction: A Review

Over the last century there have not been significant changes in the anatomical location of obstruction. The age of presentation has increased along with age related co-morbidity. Management has consequently been challenging as risks keep on increasing with advanced age. Hence, clear decision making has become essential in its management. A selective review of the literature pertaining to common age related aetiologies, diagnosis methods leading to standard decision making and treatment of acute intestinal obstruction was done. The same is obtained from randomized controlled studies, meta-analysis and other related evidence based publications. Predicting the conservative or operative management of Bowel Obstruction (BO) is difficult. BO in young age, in unscarred abdomen and Large Bowel Obstruction (LBO) needs early surgery. Decision on surgery should be taken in paediatric patient by second day and preferably between 3-5 days of admission in adults. Higher American Society of Anaesthesiologists (ASA) grade correlates well with the mortalities. In this article, the timing of surgery, methods to avoid bowel resection and type of surgery in various causes are stressfully analysed and discussed.

The role of preoperative iron deficiency in colorectal cancer patients: prevalence and treatment

BACKGROUND

In preoperative blood management of colorectal cancer patients, intravenous iron therapy is increasingly used to treat anaemia and prevent red blood cell transfusions. However, while iron deficiency is the most common cause of anaemia, little is known about the prevalence and namely type of iron deficiency in this population, whereas both types of iron deficiency (i.e. absolute and functional iron deficiency) are recommended to be treated differently by international cancer guidelines.

OBJECTIVE

The aim of present study is to investigate the prevalence and namely type of iron deficiency in colorectal cancer patients, and to assess its clinical relevance.

METHODS

Preoperative iron status, clinical parameters (i.e. age, ASA classification, tumour location, tumour stage) and postoperative complications were retrospectively collected for all newly diagnosed colorectal cancer patients in our institution over a 3-year period.

RESULTS

Iron deficiency was observed in 163 (48.1%) of 339 patients. Of these iron-deficient patients, 3.7% had an isolated absolute iron deficiency (AID) and 15.3% a functional iron deficiency (FID), while the rest had a combination of AID and FID. Anaemia was present in 66.1% of iron-deficient patients. Iron deficiency was significantly associated with an increased postoperative complication rate (univariable OR 1.94, p = 0.03, multivariable OR 1.84, p = 0.07), with right-sided tumours (p < 0.001), high ASA classification (p = 0.002), advanced tumour stage (p = 0.01) and advanced age (p = 0.04). In comparing clinical parameters between patients with AID and FID, advanced age was significantly associated with FID (p = 0.03), and the presence of anaemia with AID (p = 0.02).

CONCLUSION

In preoperative colorectal cancer patients, there is a high prevalence of iron deficiency, including a high percentage of patients with-a component of-functional iron deficiency, associated with the increased postoperative complication rate. As both types of iron deficiency require a different treatment strategy, our results illustrate the therapeutic potential of especially intravenous iron supplementation in patients with severe iron deficiency and stress the urgency of routinely monitoring preoperative iron status and differentiation between types of iron deficiency. As iron therapy may also be potentially harmful in respect to stimulation of tumour growth, future clinical trials assessing the long-term effect of iron therapy are necessary.

Smaller tumor size is associated with poor survival in T4b colon cancer

AIM: To hypothesize that in patients with colon cancer showing heavy intestinal wall invasion without distant metastasis (T4bN0-2M0), small tumor size would correlate with more aggressive tumor behaviors and therefore poorer cancer-specific survival (CSS).

METHODS: We analyzed T4bN0-2M0 colon cancer patients in the Surveillance, Epidemiology and End Results (SEER) database. A preliminary analysis of T4bN0-2M0 colon cancer patients at the Fudan University Shanghai Cancer Center is also presented.

RESULTS: A total of 1734 T4bN0-2M0 colon cancer patients from the SEER database were included. Kaplan-Meier analysis revealed decreasing CSS with decreasing tumor size (P < 0.001). Subgroup analysis showed a significant association between poorer CSS with smaller tumor size in T4bN0 patients (P = 0.024), and a trend of association in T4bN1 (P = 0.182) and T4bN2 patients (P = 0.191). Multivariate analysis identified tumor size as an independent prognostic factor for CSS in T4bN0-2M0 patients (P = 0.024). Preliminary analysis of Fudan University Shanghai Cancer Center samples suggested the 5-year CSS was 50.0%, 72.9% and 77.1% in patients with tumors ≤ 4.0 cm, 4.0-7.0 cm and ≥ 7.0 cm.

CONCLUSION: Smaller tumor size is associated with poorer CSS in the T4bN0-2M0 subset of colon cancer, particularly in the T4bN0M0 subgroup.