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

Abstract

BackgroundIn 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.ObjectiveThe 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.MethodsPreoperative 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.ResultsIron 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).ConclusionIn 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.

Associations between non-anaemic iron deficiency and outcomes following surgery for colorectal cancer: An exploratory study of outcomes relevant to prospective observational studies

“…Univariate analysis showed that severe iron deficiency (defined by a TSAT of <10%) was associated with a marked increase in the risk of complications, but once multivariate analysis was performed accounting for age, sex, ASA score, type of surgery and tumour location, this relationship was no longer statistically significant (odds ratio ¼ 1.84, 95% confidence interval 0.94-3.60, P ¼ 0.074), although the confidence interval suggested the presence of a clinically relevant result. 3 Our results suggest that non-anaemic iron deficiency is widespread, with 49% of all patients presenting for major surgery for a colorectal malignancy at our institution over the study period meeting accepted diagnostic criteria for non-anaemic iron deficiency. 10 It is not clear the extent to which this result reflects the known geographic variation in iron status, which in turn may reflect racial and socioeconomic factors.…”

“…The definition of iron deficiency is based on common criteria used in the literature. 3 We collected data describing preoperative characteristics: age; sex; height; weight; current history of diabetes mellitus, hypertension, cardiac failure or smoking; and American Society of Anesthesiologists (ASA) category. Baseline laboratory data from the time of anaesthetic pre-assessment were collected.…”

“…1 The most frequent cause of anaemia in patients undergoing surgery for colorectal cancer is iron deficiency. 2,3 Perioperative guidelines and consensus statements recommend aggressive management of iron deficiency anaemia as a key component of prehabilitation prior to major surgery, [4][5][6][7] and large, randomized, controlled trials examining the role of parenteral iron in managing preoperative iron deficiency anaemia are ongoing. 8 While negative consequences of preoperative anaemia are increasingly recognized, there is little in the literature that addresses non-anaemic iron deficiency as a target for preoperative intervention.…”

Patient blood management in colorectal cancer patients: a survey among Dutch gastroenterologists, surgeons, and anesthesiologists

“…Preoperative anemia in colorectal cancer patients is associated with an increased risk of short‐term mortality and morbidity and a decrease in long‐term tumor survival . Iron deficiency is the principal cause of preoperative anemia and is reported in almost 50% of preoperative colorectal cancer patients . Transfusion, in earlier days the default therapy to correct this anemia, however, is also known to be associated with increased morbidity and mortality, as already demonstrated by Busch and colleagues in 1993 .…”

Iron deficiency in children at the time of initial neuroblastoma diagnosis

“…6 While chronic blood loss and poor nutrition deplete iron stores and cause AID, FID evidently occurs when cancer-induced inflammation elevates hepcidin, which may result in insufficient iron availability to erythrocytes despite adequate levels of total body iron. [6][7][8] Patients with advanced cancer are likely to have FID as the predominant etiology of anemia. 9 ID anemia is also associated with shorter survival times in some types of cancers, including colon cancer, lung cancer, and breast cancer.…”