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Anemia Treatment and the Radiation Oncologist: Optimizing Patient Outcomes

Anemia Treatment and the Radiation Oncologist: Optimizing Patient Outcomes

This article reviews the recent literature documenting
that anemia is one of the important prognostic factors among cancer patients.
The authors suggest that anemia could be correlated with quality of life in
addition to outcomes factors such as locoregional control and disease-free
survival. They emphasize articles published between 1989 and 2001 that report
the significance of anemia among patients treated with radiation therapy and
describe the potential strategies for overcoming hypoxia by correcting the

Original Reports

The main criticism of this review is that the authors neglected the original
articles describing the relationship between hemoglobin levels and local control
rate in patients with carcinoma of the cervix and larynx.[1,2] Anemia associated
with high risk of local failure was thought to be related to decreased oxygen
supply to the tumor, which reduced radiosensitivity in patients with cervical or
head and neck cancer. Therefore, the suggestion by Drs. Shasha and Harrison that
"the prevalence and nature of anemia in the radiation oncology setting have
been inadequately characterized" is not quite correct.

More recent articles have documented quality of life and prognostic factors
associated with anemia among patients receiving chemotherapy, with or without
other treatment modalities. I would like to remind oncologists to read the
original study published by Dr. Raymond S. Bush and his colleagues in 2,803
patients with cervical cancer treated by radiation therapy at the Princess
Margaret Hospital.[3] These investigators clearly noted that anemia was related
to patient outcomes especially among those with more advanced disease (eg, stage
IIB and III). In their randomized trial, intervention to increase hemoglobin
levels prior to initiating radiation therapy produced markedly positive results.

Study patients had stage IIB or III carcinoma of the uterine cervix and
hemoglobin levels between 10 and 12.5 g/dL. They were randomized to receive a
red blood cell transfusion to raise their hemoglobin levels above 12.5 g/dL
prior to standard pelvic radiation therapy vs observation. Patients given
transfusions showed a significant increase in local control and disease-specific
survival rates, compared to those who were observed without transfusion (P < .01).[3] However, this improvement was not significant among
those with early-stage cervical cancer.


Over the next decade, major concerns developed regarding blood transfusions
because of the transmission of hepatitis and HIV.[4] Moreover, whether the
improvement in locoregional control would lead to improvement in outcome was
also questioned. It was suggested that patients who presented with low
hemoglobin levels may have a poor outcome despite subsequent improvement in
hemoglobin levels via transfusion. These concerns became less important once
recombinant human erythropoietin (Epogen, Procrit) with ferrous sulfate was
shown to significantly increase hemoglobin levels (without a blood
transfusion).[5] Over 400 anemic cancer patients were enrolled in prospective
randomized clinical trials that compared subcutaneous erythropoietin to placebo.
Some patients received chemotherapy concurrently. In one such trial, the quality
of life of patients who received erythropoietin improved significantly, compared
to patients given placebo.[6]


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