title: Perioperative blood transfusion and radical cystectomy: does timing of transfusion affect bladder cancer mortality?
abstract: BACKGROUND
  While perioperative blood transfusion (BT) has been associated with adverse outcomes in multiple malignancies, the importance of BT timing has not been established.
  
  
  OBJECTIVE
  The objective of this study was to evaluate whether intraoperative BT is associated with worse cancer outcomes in bladder cancer patients treated with radical cystectomy (RC).
  
  
  METHODS
  Outcomes from two independent cohorts of consecutive patients with bladder cancer treated with RC were analyzed.
  
  
  METHODS
  Recurrence-free survival, cancer-specific survival (CSS), and overall survival were estimated and multivariate analyses were performed to evaluate the association of BT timing with cancer outcomes.
  
  
  CONCLUSIONS
  In the primary cohort of 360 patients, 241 (67%) received perioperative BT, including 162 intraoperatively and 79 postoperatively. Five-year CSS was 44% among patients who received an intraoperative BT versus 64% for patients who received postoperative BT (p=0.0005). After multivariate analysis, intraoperative BT was associated with an increased risk of cancer mortality (hazard ratio [HR]: 1.93; p=0.02), while receipt of postoperative BT was not (p=0.60). In the validation cohort of 1770 patients, 1100 (62%) received perioperative BT with a median postoperative follow-up of 11 yr (interquartile range: 8.0-15.7). Five-year RFS (p<0.001) and CSS (p<0.001) were significantly worse among patients who received an intraoperative BT. Intraoperative BT was independently associated with recurrence (HR: 1.45; p=0.001), cancer-specific mortality (HR: 1.55; p=0.0001), and all-cause mortality (HR: 1.40; p<0.0001). Postoperative BT was not associated with risk of disease recurrence or cancer death.
  
  
  CONCLUSIONS
  Intraoperative BT is associated with increased risk of bladder cancer recurrence and mortality.
  
  
  RESULTS
  In this study, the effects of blood transfusion on bladder cancer surgery outcomes were evaluated. Intraoperative blood transfusion, but not postoperative transfusion, was associated with higher rates of recurrence and cancer-specific mortality.
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. Electronic address: abel@urology.wisc.edu.
authors.forename: E Jason
authors.initials: EJ
authors.lastname: Abel
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Linder
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Tyler M
authors.initials: TM
authors.lastname: Bauman
authors.affiliation: Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Bauer
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: R Houston
authors.initials: RH
authors.lastname: Thompson
authors.affiliation: Department of Health Science Research, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Prabin
authors.initials: P
authors.lastname: Thapa
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Octavia N
authors.initials: ON
authors.lastname: Devon
authors.affiliation: Department of Health Science Research, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Tarrell
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Igor
authors.initials: I
authors.lastname: Frank
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: David F
authors.initials: DF
authors.lastname: Jarrard
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Tracy M
authors.initials: TM
authors.lastname: Downs
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
mesh_terms: D000368:Aged; D001803:Blood Transfusion; D002277:Carcinoma / Q000401:mortality* / Q000601:surgery*; D002423:Cause of Death; D015653:Cystectomy; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D011182:Postoperative Care; D015996:Survival Rate; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000601:surgery*
keywords: Bladder cancer; Intraoperative blood transfusion; Outcomes; Transfusion; Urothelial carcinoma