Obstet Gynecol Sci.  2014 Nov;57(6):471-477. 10.5468/ogs.2014.57.6.471.

An association between preoperative anemia and poor prognostic factors and decreased survival in early stage cervical cancer patients

• Lim S
• Lee CM
• Park JM
• Jung SY
• Lee KB

• KMID: 2314013
• DOI: http://doi.org/10.5468/ogs.2014.57.6.471

Abstract

OBJECTIVE
To evaluate correlation of preoperative anemia with clinical outcomes in patients with early stage cervical cancer who were treated with radical hysterectomy and lymph node dissection.
METHODS
Patients who underwent radical hysterectomy and lymph node dissection for cervical cancer from January 2001 to February 2012 were included in this study. Clinicopatholgoical factors included in univariate and multivariate analysis were age, tumor histology, FIGO (International Federation of Gyneocology and Obstetrics) stage, preoperative hemoglobin, depth of invasion, tumor size, parametrial involvement, resection margin, and lymph node status.
RESULTS
A total of 387 patients were retrospectively analyzed in this study; 141 patients (36.4%) had preoperative anemia (hemoglobin <12 g/dL) and 16 out of 141 patients (11.3%) received blood transfusion for correction of preoperative anemia. Patients with preoperative anemia showed significant association with age <50 years, more advanced stage, non-squamous cell carcinoma histology, larger tumor size, deeper stromal invasion, and lymph node metastasis (P<0.05). Both relapse-free survival and overall survival were worse in patients with preoperative anemia in univariate analysis. In multivariate analysis, overall survival was worse in patients with preoperative anemia, but relapse-free survival was not associated with preoperative anemia. In the intergroup analysis of anemic patients for the effect of preoperative blood transfusion, preoperative anemia correction did not affect survival.
CONCLUSION
Preoperative anemia was not an independent prognostic factor for survival in patients with early cervical cancer. However, it was associated with poor prognostic factors. Further study in large population is needed.

Keyword

Anemia; Hysterectomy; Uterine cervical neoplasms

MeSH Terms

Anemia*
Blood Transfusion
Humans
Hysterectomy
Lymph Node Excision
Lymph Nodes
Multivariate Analysis
Neoplasm Metastasis
Retrospective Studies
Uterine Cervical Neoplasms*

Figure

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  Fig. 1 Recurrence-free survival based on preoperative anemia (P=0.027). Hb, hemoglobin.

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  Fig. 2 Overall survival based on preoperative anemia (P=0.002). Hb, hemoglobin.

Reference

1. Logsdon MD, Eifel PJ. FIGO IIIB squamous cell carcinoma of the cervix: an analysis of prognostic factors emphasizing the balance between external beam and intracavitary radiation therapy. Int J Radiat Oncol Biol Phys. 1999; 43:763–775.

2. Mundt AJ, Connell PP, Campbell T, Hwang JH, Rotmensch J, Waggoner S. Race and clinical outcome in patients with carcinoma of the uterine cervix treated with radiation therapy. Gynecol Oncol. 1998; 71:151–158.

3. Tamussino KF, Gucer F, Reich O, Moser F, Petru E, Scholz HS. Pretreatment hemoglobin, platelet count, and prognosis in endometrial carcinoma. Int J Gynecol Cancer. 2001; 11:236–240.

4. Obermair A, Handisurya A, Kaider A, Sevelda P, Kolbl H, Gitsch G. The relationship of pretreatment serum hemoglobin level to the survival of epithelial ovarian carcinoma patients: a prospective review. Cancer. 1998; 83:726–731.

5. Li AJ, Madden AC, Cass I, Leuchter RS, Lagasse LD, Karlan BY. The prognostic significance of thrombocytosis in epithelial ovarian carcinoma. Gynecol Oncol. 2004; 92:211–214.

6. Varlotto J, Stevenson MA. Anemia, tumor hypoxemia, and the cancer patient. Int J Radiat Oncol Biol Phys. 2005; 63:25–36.

7. De Los Santos JF, Thomas GM. Anemia correction in malignancy management: threat or opportunity? Gynecol Oncol. 2007; 105:517–529.

8. Fyles AW, Milosevic M, Pintilie M, Syed A, Hill RP. Anemia, hypoxia and transfusion in patients with cervix cancer: a review. Radiother Oncol. 2000; 57:13–19.

9. Harrison LB, Chadha M, Hill RJ, Hu K, Shasha D. Impact of tumor hypoxia and anemia on radiation therapy outcomes. Oncologist. 2002; 7:492–508.

10. Hockel M, Schlenger K, Hockel S, Vaupel P. Hypoxic cervical cancers with low apoptotic index are highly aggressive. Cancer Res. 1999; 59:4525–4528.

11. Obermair A, Cheuk R, Horwood K, Neudorfer M, Janda M, Giannis G, et al. Anemia before and during concurrent chemoradiotherapy in patients with cervical carcinoma: Effect on progression-free survival. Int J Gynecol Cancer. 2003; 13:633–639.

12. Chen MH, Chang PM, Chen PM, Tzeng CH, Chu PY, Chang SY, et al. Prognostic significance of a pretreatment hematologic profile in patients with head and neck cancer. J Cancer Res Clin Oncol. 2009; 135:1783–1790.

13. Grogan M, Thomas GM, Melamed I, Wong FL, Pearcey RG, Joseph PK, et al. The importance of hemoglobin levels during radiotherapy for carcinoma of the cervix. Cancer. 1999; 86:1528–1536.

14. Dunst J, Kuhnt T, Strauss HG, Krause U, Pelz T, Koelbl H, et al. Anemia in cervical cancers: impact on survival, patterns of relapse, and association with hypoxia and angiogenesis. Int J Radiat Oncol Biol Phys. 2003; 56:778–787.

15. Girinski T, Pejovic-Lenfant MH, Bourhis J, Campana F, Cosset JM, Petit C, et al. Prognostic value of hemoglobin concentrations and blood transfusions in advanced carcinoma of the cervix treated by radiation therapy: results of a retrospective study of 386 patients. Int J Radiat Oncol Biol Phys. 1989; 16:37–42.

16. Panagopoulos ND, Karakantza M, Koletsis E, Apostolakis E, Sakellaropoulos GC, Filos KS, et al. Influence of blood transfusions and preoperative anemia on long-term survival in patients operated for non-small cell lung cancer. Lung Cancer. 2008; 62:273–280.

17. Yovino S, Kwok Y, Krasna M, Bangalore M, Suntharalingam M. An association between preoperative anemia and decreased survival in early-stage non-small-cell lung cancer patients treated with surgery alone. Int J Radiat Oncol Biol Phys. 2005; 62:1438–1443.

18. Metindir J, Bilir Dilek G. Preoperative hemoglobin and platelet count and poor prognostic factors in patients with endometrial carcinoma. J Cancer Res Clin Oncol. 2009; 135:125–129.

19. Nissenson AR, Goodnough LT, Dubois RW. Anemia: not just an innocent bystander? Arch Intern Med. 2003; 163:1400–1404.

20. Harrison LB, Shasha D, Homel P. Prevalence of anemia in cancer patients undergoing radiotherapy: prognostic significance and treatment. Oncology. 2002; 63:Suppl 2. 11–18.

21. Barkati M, Fortin I, Mileshkin L, Bernshaw D, Carrier JF, Narayan K. Hemoglobin level in cervical cancer: a surrogate for an infiltrative phenotype. Int J Gynecol Cancer. 2013; 23:724–729.

22. Vaupel P, Mayer A. Hypoxia in cancer: significance and impact on clinical outcome. Cancer Metastasis Rev. 2007; 26:225–239.

23. Khan AA, Klonizakis M, Shabaan A, Glynne-Jones R. Association between pretreatment haemoglobin levels and morphometric characteristics of the tumour, response to neoadjuvant treatment and long-term outcomes in patients with locally advanced rectal cancers. Colorectal Dis. 2013; 15:1232–1237.

24. Rofstad EK, Sundfor K, Lyng H, Trope CG. Hypoxia-induced treatment failure in advanced squamous cell carcinoma of the uterine cervix is primarily due to hypoxia-induced radiation resistance rather than hypoxia-induced metastasis. Br J Cancer. 2000; 83:354–359.

25. Yamaji H, Iizasa T, Koh E, Suzuki M, Otsuji M, Chang H, et al. Correlation between interleukin 6 production and tumor proliferation in non-small cell lung cancer. Cancer Immunol Immunother. 2004; 53:786–792.