Anemia requiring transfusion in breast cancer patients on dose-dense chemotherapy: Prevalence, risk factors, cost and effect on disease outcome

Abstract

Purpose Dose-dense chemotherapy improves survival but with increased toxicity and treatment-related cost. We report the prevalence of anemia and the possible risk factors associated with chemotherapy-related anemia and determine the cost and time-delay associated with transfusion requirement in Indian patients with non-metastatic breast cancer on dose-dense preoperative chemotherapy. Methods In this study, triple-negative breast cancer (TNBC) patients were treated preoperatively with docetaxel and cyclophosphamide alternating with epirubicin and cisplatin every 2 weeks. Patients were evaluated for anemia pre- and post-chemotherapy. We examined trends in the red cell indices, transfusion requirement, time to transfusion, as well as risk factors associated with transfusion during treatment, along with delay in treatment due to anemia and the additional cost incurred. Results A total of 116 consecutive women with nonmetastatic TNBC were treated with preoperative chemotherapy. The median age was 44.5 years. 56.1% of patients had stage III disease. Anemia was detected at baseline in 54 (46.5%) patients with mild anemia (10–12 g/dl) in 42 (36.2%) patients and moderate anemia (8–10 g/dl) in 12 (10.3%) patients. During the course of treatment, all patients developed anemia. A total of 44 patients (37.9%) required transfusion during chemotherapy, with 55(47.4%) patients developing grade 1–2 anemia and 40 (34.5%) patients developing grade 3 anemia. The factors associated with anemia requiring transfusion were a steeper decline in hemoglobin after two cycles (OR 1.65, p = 0.02), low-grade tumor (OR 2.48, p = 0.03), and thrombocytopenia grade 3 or 4 (OR 4.35, p = 0.034), of which tumor grade and thrombocytopenia remained significant in multivariate analysis. Nearly one-fourth of the study population had a delay between two cycles of chemotherapy due to anemia. A median additional cost of INR 7000 was incurred among those requiring blood transfusion. Conclusion Anemia is a common toxicity associated with dose-dense chemotherapy during curative breast cancer treatment leading to delay in treatment and increased cost. Low-grade tumor, grade 3 or 4 thrombocytopenia, and grade 2 or higher anemia after two cycles of chemotherapy are risk factors for blood transfusions during treatment.

Author's reply – Out-of-pocket payment and financial risk protection for breast cancer treatment: a prospective study from India

“…We are also limited by the paucity of cost data in the cited publication from further comments. 1 , 3 As per Table S3 of supplementary material in our paper, the median total cost of treatment was ₹ 0.21 million with a third interquartile value of ₹ 0.35 million. 2 The authors have misread the total medical cost in the table as total cost of treatment.…”

“…Dr. Sharma and colleagues’ publication is a great insight into anaemia during dose dense chemotherapy for breast cancer in Indian patients and its effect on continuation of treatment with focus on clinical factors affecting the outcome. 3 However, it does not provide a disaggregated cost of treatment or details regarding total cost incurred. Our paper is solely focused on estimating the cost, out-of-pocket payment, and financial risk protection mechanisms of breast cancer patients, with continued capture and breakdown of cost data at successive visits.…”

Preoperative dose-dense docetaxel and cyclophosphamide alternating with epirubicin and cisplatin(ddDCEP): an effective, novel way of incorporating platinum in the treatment of early TNBC

“…We have previously reported a detailed analysis of anemia, transfusion requirement, predictors of severe anemia, and nancial burden due to transfusion in this cohort of patients. (48) Our study does have its limitations, primarily due to its retrospective design. The clinical toxicity data (nausea, vomiting, neuropathy) collected from the electronic medical records is most likely an underestimate of the actual gures due to under-reporting.…”

The cost of cancer care in India requires careful reporting and interpretation

“…In contrast, we had reported the cost of delivering a standard dose-dense chemotherapy regimen where the cost of systemic therapy alone (excluding radiation therapy and surgery) for Triple Negative Breast Cancer (TNBC) to be Rs 0.17 million in another charitable institute in India. 5 As this difference indicates, the costs of treatment at TMC are heavily subsidized and not representative of the true cost of treatment. It is also relevant to report the proportion of patients with adverse events during treatment as that can increase the cost of treatment.…”