Anemia is associated with lower local-regional control and survival after radiation therapy for head and neck cancer: a prospective study.

Dubray, Bernard; Mosseri, Véronique; Brunin, F.; Jaulerry, C; Poncet, P; Rodriguez, J; Brugère, J; Point, D; Giraud, P.; Cosset, Jean‐Marc

doi:10.1148/radiology.201.2.8888257

Cited by 126 publications

(98 citation statements)

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“…In this study, those with anemia had functional, not physiologic, anemia. All but 3 of 63 patients with anemia-defined as hemoglobin <13.5 g/dl for men and hemoglobin <12.0 g/dl for women-had hemoglobin >10 g/dl [17]. Because most of our patients also had anemia that was modest and "functional," we believe the same opportunities exist to improve outcomes.…”

Section: Understanding the Impact Of Anemiamentioning

confidence: 84%

Radiotherapy-Associated Anemia: The Scope of the Problem

Harrison

2000

The Oncologist

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The impact of anemia on cancer patients undergoing chemotherapy is well established, but only recently has the prevalence of anemia in patients receiving radiotherapy received much attention. Many cancer patients present with anemia prior to radiotherapy, and even more experience anemia or a worsening of anemia at some point during treatment. However, the problem of anemia is often ignored because patients may experience only functional anemia, defined as a hemoglobin level less than 12 g/dl. Unless physiologic anemia (hemoglobin = 8 g/dl) is discovered, efforts to correct anemia are often not made. Because hemoglobin levels <12 g/dl seem to be associated with tumor hypoxia and poorer outcomes of radiotherapy in a number of patient populations, ignoring even modest anemia can result in decreased locoregional control, overall survival, and quality of life (QOL). Because increasing hemoglobin levels 1-2 g/dl is usually easily accomplished, there exists the potential for improving outcomes by paying greater attention to this problem. This article focuses on the prevalence of anemia, particularly functional anemia, and discusses the impact of anemia on locoregional control, overall survival, and QOL. INTRODUCTIONContinuing advances in oncology care, including new radiotherapy technologies and recent developments with multimodal therapies, have significantly improved clinical outcomes and quality of life (QOL) for many patients with cancer. However, the prevalence and impact of cancer-associated anemia is not widely appreciated. Emerging data demonstrate that cancer-related anemia is unexpectedly common in cancer patients receiving radiotherapy and/or chemotherapy and that even modest anemia (hemoglobin <12 g/dl) substantially impairs QOL. In addition, a growing body of literature suggests that hemoglobin concentrations of less than 12-13 g/dl during cancer therapy are associated with reduced local tumor control and decreased survival [1,2]. Although anemia of this magnitude can be easily managed, it is often overlooked or considered clinically insignificant. However, restoration of normal hemoglobin concentrations in patients undergoing radiotherapy has the potential to improve local tumor control and survival and produce sizable improvements in patient QOL.

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Section: Understanding the Impact Of Anemiamentioning

confidence: 84%

Radiotherapy-Associated Anemia: The Scope of the Problem

Harrison

2000

The Oncologist

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“…Other studies have shown a statistically significant association between anaemia and reduced local control or survival in cervical cancer or head and neck cancer (Fein et al, 1995;Dubray et al, 1996;Warde et al, 1998;Grogan et al, 1999). Dubray et al (1996) found that even moderate anaemia significantly correlated with a worse treatment outcome in squamous cell carcinoma of the head and neck (Figure 2). However, it is unclear whether low haemoglobin directly contributes to reduced tumour control and survival after radiotherapy, or whether it is merely a marker of advanced disease in patients for whom successful treatment outcomes are less likely, regardless of tumour oxygenation.…”

Section: Possibilities For Improved Treatment Outcomesmentioning

confidence: 87%

“…Many studies have found that inadequate oxygenation at the tumour site and/or low haemoglobin values are associated with poor treatment outcome after curative radiotherapy (Fein et al, 1995;Dubray et al, 1996;Fyles et al, 1998;Grogan et al, 1999). Adequate tumour oxygenation is known to be necessary for an optimal response to radiotherapy (Glaspy and Cavill, 1999), thus it is theoretically possible that decreased haemoglobin (which may contribute to lowered oxygenation at the tumour site) may also have an effect on the success of therapy.…”

Section: Possibilities For Improved Treatment Outcomesmentioning

confidence: 99%

“…The haemoglobin cut-off level for anaemia was 13.5 g dl -1 for men and 12 g dl -1 for women. Reproduced with kind permission of the Radiological Society of North America Inc. from Dubray et al (1996) Recombinant human erythropoietin Despite the well-documented efficacy of rHuEPO in increasing haemoglobin and reducing the need for transfusions, this agent is still not used routinely for the management of patients receiving chemotherapy as it is for the support of haemoglobin levels in patients with other chronic diseases such as renal failure. This under-use may be due in part to the limitations of this therapy, including less-than-optimal response rates and the lack of adequate reliable predictors of response (Table 2).…”

Section: Inadequacies In the Current Treatment Optionsmentioning

confidence: 99%

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Anaemia and its functional consequences in cancer patients: current challenges in management and prospects for improving therapy

Demetri

2001

Br J Cancer

100

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Anaemia is a common occurrence in patients with cancer and contributes to the clinical symptomatology and reduced quality of life (QOL) seen in cancer patients. Many aspects of reduced QOL, including fatigue, are known to be associated with suboptimally low levels of haemoglobin. Even mild-to-moderate anaemia adversely affects patient-reported QOL parameters. Red blood cell transfusions are associated with many real and perceived risks, inconveniences, costs, and only temporary benefits. Recombinant human erythropoietin (rHuEPO) is an effective therapy to increase haemoglobin values in over half of anaemic cancer patients receiving concurrent chemotherapy. These increased haemoglobin values are closely correlated with improvements in QOL. Despite these objectively defined benefits, less than 50% of anaemic patients undergoing cytotoxic chemotherapy receive rHuEPO, in contrast to patients with chronic renal failure on dialysis, where anaemia is universally and aggressively treated to more optimal haemoglobin values. However, there are several barriers that may limit more widespread use of rHuEPO. These include inconvenience associated with frequent dosing; failure of a large proportion (40 to 50%) of patients to respond; relatively slow time to response; absence of reliable early indicators of response; and current lack of rigorous pharmacoeconomic data demonstrating cost-effectiveness. Darbepoetin alfa is a novel erythropoiesis stimulating protein (NESP) that is biochemically distinct from rHuEPO, and which has been proven to stimulate red blood cell production. The molecule has a 3-fold longer half-life and increased biological activity that will allow less frequent dosing, facilitating improved management of the anaemia of cancer. With this new option for therapy, further avenues of investigation should lead to renewed interest in the clinical benefits of optimal haemoglobin levels for patients with cancer. © 2001 Cance Cancer Research Campaign

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“…Most of the literature concerns malignancies of the uterine cervix (Evens and Bergso, 1965;Hierlihy et al, 1969;Vigerio et al, 1973;Bush et al, 1978;Dische et al, 1983;Mendenhall et al, 1984;Bush, 1986;Girinski et al, 1989;Rader, 1990) and head and neck (Blitzer et al, 1984;Overgard et al, 1989;Dubray et al, 1996). How anaemia is causally related to poor outcome is not entirely clear but it is probably both a marker of advanced tumour and indicative of some degree of tissue hypoxia.…”

Section: Discussionmentioning

confidence: 99%

Effect of subcutaneous recombinant human erythropoetin in cancer patients receiving radiotherapy: final report of a randomized, open-labelled, phase II trial

Sweeney

Nicolae²,

Ignacio³

et al. 1998

Br J Cancer

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Summary The purpose of this study was to determine the safety, efficacy and impact on quality of life of recombinant human erythropoietin (r-HuEPO) for cancer patients undergoing radiotherapy (RT). An open-labelled randomized design was used, with patients randomized to either treatment or control arms. Patients in the treatment arm received r-HuEPO given by subcutaneous injection at a dose of 200 units kg-' day-' plus oral iron supplements (ferrous sulphate 325 mg p.o. t.i.d.). Entry was restricted to patients with carcinoma of the lung, uterine cervix, prostate or breast who presented for RT with anaemia parameters reflective of 'the anaemia of chronic disease'. Radiotherapy policies (portals, doses, fraction size, etc.) were determined by the site and stage of disease. Complete blood counts (CBCs) were obtained weekly. The target level of haemoglobin was 15 g dl-1 for men and 14 g dl-1 for women. Quality of life (QOL) was assessed weekly by using an analogue scale to judge energy, activities of daily living and overall quality of life. Forty-eight patients were entered in the study, 24 in the treatment arm and 24 in the control arm. The prerandomization demographic characteristics and mean laboratory values were comparable in both arms. The mean haemoglobin at completion was 13.6 g dl-1 for r-HuEPO-treated patients compared with 11.0 g dl-1 for control subjects (P= 0.0012). Patients who received r-HuEPO demonstrated a mean weekly haemoglobin increase of 0.41 g dl-1 compared with a decrease in mean haemoglobin level in controls for 6 of the 7 weeks of the study (mean weekly decrease of 0.073 g dl-'). Target levels of haemoglobin were achieved by 41.6% of r-HuEPO-treated patients compared with none of the control subjects. The mean platelet count declined in both arms of the study with RT but the decline from pretreatment was less rapid in r-HuEPO-treated patients (11.2% decrease) compared with controls (26.3% decrease) and was statistically significant during weeks 4-6. Toxicity was minor with only mild irritation at the injection site. Mean quality of life end points were superior in the treatment arm but not statistically significant. r-HuEPO had a beneficial effect on weekly haemoglobin levels in patients undergoing RT with response rates similar to other studies. There was also a less rapid decline in weekly platelet counts in r-HuEPO-treated patients compared with control subjects. Further studies are needed to address the optimum dose and scheduling as well as the impact of r-HuEPO on clinical outcomes.

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Anemia is associated with lower local-regional control and survival after radiation therapy for head and neck cancer: a prospective study.

Abstract: Moderate anemia appeared to be an independent prognostic factor in squamous cell carcinoma of the head and neck treated with radiation therapy alone.

Cited by 126 publications

References 0 publications

Radiotherapy-Associated Anemia: The Scope of the Problem

Radiotherapy-Associated Anemia: The Scope of the Problem

Anaemia and its functional consequences in cancer patients: current challenges in management and prospects for improving therapy

Effect of subcutaneous recombinant human erythropoetin in cancer patients receiving radiotherapy: final report of a randomized, open-labelled, phase II trial

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