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Vol. 1. Issue. 1, pp. 1-100, Jan. 2007  »  Table of Contents  

 

Anemia in Patients with Advanced or
Metastatic Non-Small Cell Lung Cancer.

S. Abuzallouf1, J. Wright2, O. El Hattab1
1Kuwait Cancer Control Center, Kuwait.
2Hamilton Regional Cancer Center, Canada.

 

 

Abstract
 Objective
To determine the frequency of anemia in patients with advanced or metastatic non-small cell lung cancer (NSCLC) at the time of initial oncologic consultation.  
 

Material and Method
 We reviewed 144 consecutive charts of patients with advanced or metastatic NSCLC, who were seen in consultation at the Hamilton Regional Cancer Center (Canada) between January and June of 1998.
 

Results
 Eighty nine patients had pre-treatment hemoglobin (Hb) levels available and 30 of those patients (33.7%) had levels below 12 gm/dl. The likelihood of anemia increased with advancing stage of underlying disease, found in 25% and 40.8% of stage III and IV patients respectively.
 

Conclusion
 Although only 89/144 patients had Hb results available, 33.7% had hemoglobin level below 12 g/dl. Anemia was more common with an increased burden of disease. Shortness of breath and fatigue were more commonly reported in anemic patients.
 

 

Key words
 Frequency, Anemia, Non Small Cell Lung Cancer.
 


Introduction


Anemia of malignancy is a commonly reported consequence of cancer, yet precise estimates of anemia in specific cancers are poorly documented. Although it is associated with symptoms such as poor quality of life and declining physical function it is treatable. Fatigue is a prevalent problem in oncology patients (1-5). It is also linked to anemia and is a key component of physical function (6-8) . In addition, anemia has been shown to be an independent prognostic indicator of disease outcome (9-11). Nevertheless, the low number of patients receiving treatment for anemia indicates that the clinical importance of this disorder is not appreciated. Despite evidence supporting anemia treatment, many clinicians only commence treatment with red blood cell transfusions once the hemoglobin (Hb) level has fallen below 8 g/dL (12-14) .

 
 

Materials & Methods


All patients with primary lung cancer seen in consultation at the Hamilton Regional Cancer Center (HRCC), Canada, between January and June of 1998 were identified. The selected eligibility criteria were:

 
• NSCLC.


• Locally advanced or metastatic disease.

• Not treated with curative intent.

 

Patient’s records were retrospectively reviewed for pre-treatment hemoglobin levels, histology, stage of disease and subsequent treatment (chemotherapy or radiotherapy).
The patient records were further reviewed for reported symptoms at the time of their initial consultation (fatigue, shortness of breath, hemoptysis, and weight loss) and also whether or not they received any subsequent blood transfusions.

Statistical Analysis

Collected data were revised and data entry was done. The statistical analysis was done using an IBM compatible computer and SPSS 10.0 on Windows XP.

Descriptive statistics were presented as means +standard deviations, median, confidence intervals at 95% and number and percentage (frequency distributions). Analytical tests used included unpaired student t test (two sided) for comparing two groups. Chi square test for contingency table analysis and Fisher’s exact testing for 2x2 tables. Overall Survival (OS) were estimated by Kaplan-Meier Method. Comparison of survival curves was done by Log Rank test.


Results

A total of 144 patient’s charts were reviewed that fit our entry criteria. The obtainment of a base line complete blood count was based on disciplinary practice, as it was routinely performed by Medical Oncologist and rarely by all but one Radiation Oncologist. Of the 144 available charts only 89 had Hb results recorded.

 

The Hb levels ranged from a low of 8.6 g/dl to a high of 17.7 g/dl with a mean of 12.73 g/dl and a median of 12.6 g/dl. Of the 89 patients, 30 (33.7%) had Hb levels below 12 g/dl.

 

Anemia was less frequent in patients with stage III disease than in those with stage IV disease. 10/40 patients (25%), who had stage III cancer were anemic compared to 20/49 (40.8%) with stage IV cancer.

 

Anemia was found in 40.7% (11/27) of patients with squamous cell carcinoma, 25% (9/36) of patients with Adenocarcinoma, 22.2% (2/9) of patients with large cell carcinoma.

 

The vast majority of patients were treated with palliative radiation, but only 15% received palliative chemotherapy. According to our records, no patients received any blood transfusion.

 

An expected association between fatigue and anemia was found, as fatigue was reported more frequently in anemic patients (43.3% Vs 30.5% P=0.04).

 

Shortness of breath was reported more frequently in anemic patients versus non-anemic patients, but no statistically significant association was found (53% Vs 43%, P > 0.2). An association between reported hemoptysis and anemia was found.

 

As for weight loss, 15/89 patients (16.9%) lost up to 5% body weight and 20% of them were anemic. 20/89 patients (22.5%) had a 5-10% weight loss and 40.0% of them were anemic. Only 14/89 patients (15.7%) lost more than 10% of body weight, however, 8/14 patients (57.1%) had Hb levels below 12 g/dl. The remaining proportion of patients (19.1%) had no reported weight loss at their initial visit, and only 2 out of those 17 patients (11.8%) were anemic.

 

Overall survival (OS) of the whole group was 15.2% at 12 months of follow up. Hemoglobin level estimation prior to radiotherapy did not show a statistical significant difference in overall survival (P=5.6) (Fig. 1)


Discussion

 

The incidence of chronic anemia in cancer patients is dependent on the type of malignancy, its stage and duration, and the type and intensity of cancer treatment (15). In patients with lung carcinoma, the prevalence of anemia is high (50–60% with Hb levels < 11 g/dL), particularly when compared with its low prevalence in colorectal and breast carcinoma (approximately 10–20%) (16, 17). Approximately 43% of lung carcinoma patients receive blood transfusions, compared with only 19% of patients with breast carcinoma (16). These findings concur with those from an earlier retrospective analysis of lung carcinoma patients receiving chemotherapy, which demonstrated that the need for transfusion was higher among lung carcinoma patients (34%) compared with patients with other malignancies such as breast carcinoma (13%), genitourinary carcinomas (23%), or lymphomas (25%) (18). The incidence and severity of anemia in lung carcinoma patients has been reviewed extensively by Del Mastro et al (19). and Groopman and Itri (6) Mild-to-moderate anemia is reported to occur in 8–100% of patients with advanced NSCLC and 0–87% of patients with advanced small cell lung carcinoma (SCLC) who are receiving chemotherapy. Similarly severe (Hb ≤ 8 g/dL) or life-threatening anemia (Hb ≥ 6.5 g/dL) is reported to occur in 0–40% of patients with NSCLC and 0–55% of patients with SCLC (20).
 

There were 5 studies that reported anemia prevalence in patients with lung cancer. Song et al.(20) reported that 12% of 192 Chinese patients with small-cell lung cancer had anemia (defined as a Hb value <12 g/dl). Rassam and Anderson (21) found a 7.9% prevalence of anemia (Hb value <10g/dl) in 280 European patients with early-stage lung cancer. In a group of 202 US patients with cancer presenting for radiation therapy, Harrison et al. (22) showed that the prevalence of anemia (Hb value<12 g/dl) was 48% before treatment and 57% afterward; a second study (23) found that 55% of 64 patients with lung cancer had anemia before radiation therapy, and 77% of these patients had anemia afterward. This high prevalence may be due to more advanced disease; to the extent that patients undergoing radiation therapy are representative of patients typically seen in US oncology practices, the latter estimate may be the more relevant. Tchekmedyian (24) found that 43 (84%) of 51 patients with lung cancer had anemia defined as a Hb level <12g/dl.
 

Anemia has been associated with an increased recurrence rate and shorter survival after radiotherapy (25-29). A number of large studies involving patients with cervical and head and neck carcinomas have demonstrated a significant association between anemia and reduced locoregional tumor control and survival(25–27,29,30). Even mild anemia has been found to be correlated significantly with poorer treatment outcome(25) Analysis of 2531 patients with extensive stage NSCLC enrolled in the Southwest Oncology Group between 1974 and 1988 indicated that a Hb level ≥ 11 g/dL was a significantly favorable factor for survival (P ≤ 0.001)(31).
 

Wide variability exists in the incidence and severity of anemia in different malignant conditions. A review of the incidence of severe anemia requiring red blood cell transfusion found the highest incidence (50%–60%) in patients with lung cancer, lymphoma, gynecologic (ovarian), and genitourinary tumors(6). In a study of a single oncology practice, 31% of patients (103 of 331) required transfusion on at least one occasion during a 1-year period of cancer treatment (14). Owing to the high prevalence of clinically significant anemia and its potential impact on quality of life and patient outcomes, it is important to have a systematic approach to cancer-related anemia with regard to diagnosis, evaluation, and treatment. Such an approach could prove beneficial not only for medical oncologists, but also for other caregivers involved in managing patients with malignant conditions.


Conclusion

Although only 89/144 patients had hemo-globin results available, 33.7% had Hb level below 12 g/dL. Anemia was more common with an increased burden of disease. Shortness of breath and fatigue were more commonly reported in anemic patients.
With new therapies to correct anemia and improve quality of life, a large proportion of patients with advanced or metastatic NSCLC may potentially benefit from a more aggressive approach to anemia management.

Acknowledgement

Thanks to R. Mohamed Thahir for his secretarial contribution.
 


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