Iron Deficiency Anemia Coexists with Cancer Related Anemia and Adversely Impacts Quality of Life

Abstract

Cancer related anemia (CRA) adversely affects patient Quality of Life (QoL) and overall survival. We prospectively studied the prevalence, etiology and the impact of anemia on QoL in 218 Indian cancer patients attending a tertiary referral hospital. The study used the sTfR/log Ferritin index to detect iron deficiency anemia and assessed patient QoL using the Functional Assessment of Cancer Therapy-Anemia (FACT-An) tool, standardized for language. Mean patient age was 51±13 years and 60% were female. The prevalence of cancer related anemia in this setting was 64% (n = 139). As expected, plasma ferritin did not differ significantly between anemic (n = 121) and non-anemic cancer patients (n = 73). In contrast, plasma sTfR levels were significantly higher in anemic cancer patients compared to non-anemic cancer patients (31 nmol/L vs. 24 nmol/L, p = 0.002). Among anemic cancer patients, using the sTfR/log Ferritin index, we found that 60% (n = 83) had iron deficiency anemia (IDA). Interestingly, plasma sTfR levels were significantly higher in cancer patients with CRA+IDA (n = 83) compared with patients having CRA (n = 38) alone (39 nmol/L vs. 20 nmol/L, p<0.001). There was a significant linear correlation between Hb and QoL (Spearman ρ = 0.21; p = 0.001) and multivariate regression analysis revealed that every gram rise in Hb was accompanied by a 3.1 unit increase in the QoL score (95% CI = 0.19-5.33; p = 0.003). The high prevalence of anemia in cancer patients, a major portion of which is due to iron deficiency anemia, the availability of sensitive and specific biomarkers of iron status to detect IDA superimposed on anemia of inflammation, suggests an urgent need to diagnose and treat such patients. Despite the potential negative consequences of increasing metabolically available plasma iron in cancer, our clinical data suggest that detecting and treating IDA in anemic cancer patients will have important consequences to their QoL and overall survival. Clinical trials of iron therapy in these patients will be able to demonstrate the potential for benefit or harm.

Fig 1. Schematic representation of the study design Using gender adjusted WHO norms [13] patients were divided into anemic and non anemic categories.

Anemic cancer patients were further subdivided into those having only cancer related anemia (CRA) or those having cancer related anemia patients combined with iron deficiency anemia (CRA+IDA).

Fig 2. Ferritin, sTfR levels in cancer patients.

(A & B) plasma ferritin and sTfR levels in anemic (n = 121) and non anemic cancer patients (n = 73), * p< 0.05 compared with anemic group. (C) plasma sTfR levels in CRA (n = 38) and combined CRA+IDA patients (n = 83), * p< 0.05 compared with CRA patients.

Fig 3. Correlation analysis as well as FACT An scores in anemic and non-anemic cancer patients.

(A) FACT-An scores were compared between anemic (n = 139) and non anemic cancer patients (n = 79), * p< 0.05 compared with anemic group. (B) FACT-An scores was compared between CRA+ IDA (n = 83) patients and only CRA (n = 38) patients. (C) FACT-An Scores were compared between anemic (n = 52) and non anemic breast cancer patients (n = 33), * p< 0.05 compared with anemic breast cancer patients. (D) Spearman correlation was used to correlate Hb levels and FACT-An scores. Correlation coefficient was ρ = 0.21; p = 0.001.