Pre-operative anemia and peri-operative transfusion are associated with poor oncologic outcomes in cancers of the esophagus: potential impact of patient blood management on cancer outcomes

Abstract

Background: Both Red Blood Cell (RBC) transfusion and anemia are thought to negatively impact cancer survival. These effects have been reported with mixed findings in cancer of the esophagus. The potential impact of the application of restrictive transfusion strategies on this patient population has not been defined.

Materials and methods: We conducted a retrospective study of esophagectomies and studied cases based on whether they were anemic or were transfused peri-operatively. Clinical characteristics and known clinicopathologic prognosticators were compared between these groups. Survival was compared by Cox proportional hazard modeling. Post-operative transfusions were assessed for compliance with restrictive transfusion thresholds.

Results: Three-hundred ninety-nine esophagectomy cases were reviewed and after exclusions 348 cases were analyzed. The median length of follow-up was 33 months (range 1-152 months). Sixty-four percent of patients were anemic pre-operatively and 22% were transfused. Transfusion and anemia were closely related to each other. Microcytic anemia was uncommon but was evaluated and treated in only 50% of cases. Most anemic patients had normocytic RBC parameters. Transfusion but not anemia was associated with a protracted/prolonged post-operative stay. Transfusion and anemia were both associated with reduced survival however only anemia was associated with decreased survival in multi-variable modeling. Sixty-eight percent of patients were transfused post-operatively and 11% were compliant with the restrictive threshold of 7 g/dL.

Conclusions: Pre-operative anemia and transfusion are closely associated, however only anemia was found to compromise survival in our esophageal cancer cohort, supporting the need for more aggressive evaluation and treatment of anemia. Adherence to restrictive transfusion guidelines offers an opportunity to reduce transfusion rates which may also improve short-term outcomes.

Keywords: Anemia; Esophagectomy; Patient blood management; Transfusion.

Fig. 1

Chi Square analysis demonstrates that anemia was equally distributed across clinical stages of disease at diagnosis but was far more likely to be present pre-operatively in patients with clinical stage III disease, who were e likely to be treated with neo-adjuvant therapy

Fig. 2

Differences in progression free survival were compared with the log-rank test with significance set at p ≤ 0.05. All p-values remained significant after correction by the Benjamini–Hochberg procedure with an FDR of 0.05. Of the clinical parameters described in Tables 1 and 2, both pre-operative anemia and peri-operative transfusion were associated with reduced progression free survival. All associations with a p < 0.1 were included in multivariable models as described in Materials and Methods and Results

Fig. 3

Differences in overall survival was compared with the log-rank test with significance set at p ≤ 0.05. All p-values remained significant after correction by the Benjamini–Hochberg procedure with an FDR of 0.05. As was seen for progression free survival, both pre-operative anemia and peri-operative transfusion were associated with reduced overall survival. All associations with a p < 0.1 were included in multivariable models as described in Materials and Methods and Results

Fig. 4

Changes in Mean Corpuscular Volume (MCV) and Hemoglobin (Hb) values during NARx. MCV for the whole group increased during treatment (A) with significantly more increase in the subjects who had treatment for iron deficiency (B). Similarly, treated iron deficiency resulted in a net gain of Hb compared to further loss of Hb in untreated patients (C)