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Anaemia Management During Radical Pelvic Radiotherapy or Chemo-Radiotherapy for Cervix Cancer: An audit of 12% of UK cancer population by the South West Cancer Intelligence Service (SWCIS) I Boiangiu1, J Weeks, N Dorey, A Hong, P MacLeod, PGS Cornes1 1 Bristol Haematology & Oncology Centre, Bristol, United Kingdom. On Behalf of SWCIS Gynaecology Tumour Panel Group Contact: email@example.com Background Table 3: Stage distribution The South West Cancer Intelligence Service (SWCIS) Cancer Networks cover a population of 4.5 million and treat 12% of UK gynaecological cancer patients. The audit of SWCIS in 2001 reported significantly lower survival for patients with FIGO Stage II and III Ca-Cervix as compared with results from the FIGO Database in the similar era [King P, 2002]. Stage II Stage III Haemoglobin Levels during Radiotherapy Survival FIGO SWCIS FIGO SWCIS There was a large proportion of patients for whom a regular FBC was not recorded 1 year 92% 76% 83% 34% during external beam RT. 2 year 81% 66% 67% 28% In 8/81 cases, no record of blood count could be found. 3 year 74% 66% 60% 19% In only 14/81 cases blood tests were available for each week of radiotherapy treatment SWCIS has started a rolling programme of audit to look at all potential treatment factors that could affect outcomes by an absolute benefit of 10% of more. Where FBC was recorded on at least one occasion (73/81), the treating teams failed to keep Hb >12g/dl in 51/73 cases (69%) and failed to keep Hb >11g/dl in 27/73 Anaemia correction cases (36%). Case control studies suggest that anaemia correction during radical radiotherapy Haemoglobin was maintained above the recommended guideline of 12g/dl in only (RT) for cervix cancer could be associated with increased rates of tumour control in 27% of patients (Table 4, Fig. 1) excess of 20% absolute benefit compared with not correcting anaemia (Table 1). Table 4: Minimum Hb recorded in each patient during radiotherapy Table 1 Fig 1: Minimum Hb (g/dl) during radiotherapy A randomised trial of transfusion support in 132 patients having cervix cancer radiotherapy showed similar DFS outcomes [Bush RS. 1986]. As a result of this data, our regional guidelines group, SWCIS in its 2001 guidelines, mandated anaemia correction to a target Haemoglobin (Hb) of 12g/dl during radical external beam RT for cervix cancer. Similar guidelines have been advocated for practice in the USA [Nag S 2002] This poster shows data from an assessment of compliance with anaemia correction guidelines during radical radiotherapy or chemo-radiotherapy for cervix cancer in 2002. Conclusions Materials and Methods Taking, recording and correcting Hb levels during radical radiotherapy for cervical carcinoma was poorly performed in our survey. We reviewed retrospectively the notes of all patients with cervix cancer receiving radical pelvic radiotherapy (with or without chemotherapy) during 2002 in the Only 27% of patients had Hb (Haemoglobin) levels consistently above the SWCIS hospitals of the SWCIS Cancer Networks (following the introduction of anaemia Regional Guidelines level of 12 g/dl. guidelines). All FBC results during the 5 - 6 weeks of external beam pelvic radiotherapy were The lack of regular blood count tests in many patients means that significant anaemia collected from patient notes, haematology computer database and radiographer’s may develop during radiotherapy before it is detected and corrected. records in radiotherapy charts. Haemoglobin levels were obtained by performing a full blood count (FBC). Anaemia In the majority of cases, the Hb value was not easily accessible from the radiotherapy correction was by oral iron and transfusion. Erythropoietin was not used. prescription chart. This could lead to a delay in responding to and correcting anaemia The sample size was calculated by Gehan method, with the aim to exclude probable during treatment. protocol non-compliance of 10% or less to p<0.05 [Gehan EA. 1961]. Data was analysed using simple statistics. Despite regional and international guidelines, the compliance with anaemia correction during radical cervical cancer treatment is poor; this suggests that education about Results this issue is still needed. Demographic Data Uncorrected anaemia may contribute to poor outcomes in cervix cancer. SWCIS After checking all records, data was collected on 81 patients altogether. About plans to repeat the audit to assess change after a period of regional education. 5% of patients were excluded as they were receiving treatment for recurrences or metastatic disease, or their records could not be obtained. We recommend that other gynae-oncology treatment teams consider similar audits Patients were treated at 6 UK NHS Hospital Trusts, over 4 UK Cancer Networks. of practice to ensure that their patients receive optimum benefit from their treatment The mean age was 60 years (Range 25-86 years) 83% were squamous cell because: carcinomas (Table 2) 47% of patients were FIGO stage II (Table 3). • uncorrected anaemia is still common • the message that anaemia is an important treatable risk factor does not seem Table 2: Histopathology type to be universally appreciated, despite published evidence and guidelines in peer reviewed journals References 1. Gynaecological Cancer: Standards and Treatment Guidelines. Revised 2001, South West Cancer Intelligence Service. 2. King P, Foy C, Hirschowitz L, Weeks J. Gynaecological Carcinoma in the South West of England: Three Year Outcome Analysis for Cases Treated in 1997. South West Cancer Intelligence Service, 2002. 3. Kapp KS et al. Evaluation of the effect of routine packed red blood cell transfusion in anemic cervix cancer patients treated with radical radiotherapy. International Journal of Radiation Oncology Biology Physics 2002;54:58-66. 4. Thomas G. The effect of hemoglobin level on radiotherapy outcomes: the Canadian experience. Semin Oncol. 2001 Apr; 28 (2 Suppl 8): 60-5. 5. Bush RS. The significance of anemia in clinical radiation therapy. Int J Radiat Oncol Biol Phys. 1986;12:2047-2050 6. Gehan EA. The determination of the number of patients required in a preliminary and a follow-up trial of a new chemotherapeutic agent. J Chronic Dis 1961;13:346-353. 7. Nag S et al. The American Brachytherapy Society Recommendations for low-dose-rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2002 Jan 1;52(1):33-48.
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