title: Relationship between low hemoglobin levels and outcomes after treatment with radiation or chemoradiation in patients with cervical cancer: has the impact of anemia been overstated?
abstract: OBJECTIVE
  Previous reports have suggested that anemia increases rates of recurrence after radiation therapy for cervical cancer. However, these studies may not have fully corrected for confounding risk factors. Using a well-characterized cohort of cervical cancer patients, we examined the association between anemia and outcomes before and after the introduction of chemoradiation as standard of care.
  
  
  METHODS
  We reviewed the records of 2454 patients who underwent definitive radiation therapy from 1980 through 2011. Minimum hemoglobin level (Hgbmin) was recorded for 2359 patients (96%). Endpoints included freedom from central recurrence (FFCR), freedom from distant metastasis (FFDM), and disease-specific survival (DSS).
  
  
  RESULTS
  For the entire cohort, hemoglobin concentrations of 9, 10, and 12 g/dL before and during radiation were all significantly associated with FFCR, FFDM, and DSS (all P<.001) on univariate analysis. However, on multivariate analysis, only Hgbmin less than 10 g/dL during RT (RT-Hgb<10) remained significant, and it was correlated with lower DSS (P=.02, hazard ratio [HR] = 1.28) and FFDM (P=.03, HR = 1.33) but not with FFCR. In a subset analysis of patients receiving chemoradiation (n=678), RT-Hgb<10 was associated only with DSS (P=.008, HR = 1.49), not with FFCR or FFDM. In this subgroup, despite an association between RT-Hgb<10 and DSS, the use of transfusion was not correlated with benefit.
  
  
  CONCLUSIONS
  No evidence was found supporting anemia as an independent predictor of central recurrence in patients treated with definitive radiation therapy with or without chemotherapy. Less emphasis on correcting anemia in cervical cancer patients may be warranted.
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Bishop
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Allen
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Ann H
authors.initials: AH
authors.lastname: Klopp
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Larissa A
authors.initials: LA
authors.lastname: Meyer
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: peifel@mdanderson.org.
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Eifel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000150:complications* / Q000401:mortality / Q000628:therapy; D000970:Antineoplastic Agents / Q000627:therapeutic use; D001803:Blood Transfusion; D059248:Chemoradiotherapy; D002945:Cisplatin / Q000627:therapeutic use; D015986:Confounding Factors, Epidemiologic; D005260:Female; D006441:Hemoglobin A / Q000032:analysis*; D006801:Humans; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000097:blood* / Q000401:mortality; D012016:Reference Values; D016896:Treatment Outcome; D002583:Uterine Cervical Neoplasms / Q000097:blood* / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery
chemical_list: D000970:Antineoplastic Agents; D006441:Hemoglobin A; D002945:Cisplatin