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Anaemia Management During Radical Pelvic Radiotherapy or Chemo


									                                 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
               Bristol Haematology & Oncology Centre, Bristol, United Kingdom. On Behalf of SWCIS Gynaecology Tumour Panel Group

  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
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.
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

                                                                                          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):
                                                                                          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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