Original StudyPreoperative Anemia and Low Hemoglobin Level Are Associated With Worse Clinical Outcomes in Patients With Bladder Cancer Undergoing Radical Cystectomy: A Meta-Analysis
Introduction
Bladder cancer is a major health problem in the United States. In 2016, an estimated 76,960 new cases of bladder cancer will be diagnosed, and 14,880 patients will die from the disease.1 Level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) with pelvic lymph node dissection (PLND) for patients with muscle-invasive bladder cancer (MIBC).2 However, the 5-year survival rate after RC only ranges from 40% to 60%.3 Treatment decision-making for MIBC is of great significance but sometimes challenging. More specifically, clinical, radiologic, and pre-RC pathologic information has significant accuracy limitations and currently is a limitation for optimal clinical decision making.4, 5, 6 There is still a glaring need to identify other potential prognostic markers, in particular, preoperative ones, to improve the stratification of patients with MIBC.
Recently, there has been increasing interest in the prognostic role of hematologic biomarkers in patients undergoing RC. Neutrophil-lymphocyte ratio has been widely reported as an efficient biomarker to predict oncologic outcomes in patients undergoing RC for bladder cancer.7, 8, 9 Other biomarkers, including lymphocyte-monocyte ratio, lymphocyte-monocyte ratio, and platelet count, have also been reported.10, 11, 12 Most of the biomarkers focused on the leukocytes, and the prognostic role of hemoglobin have not been clearly defined. Anemia and low hemoglobin level are quite common in patients with malignant tumors, including bladder cancer.13, 14, 15 Although the number of studies exploring the prognostic role of anemia and hemoglobin level has been increasing, the results are inconsistent and often based on small samples.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 Here, we performed a meta-analysis to pool currently available evidence on this topic and further define the prognostic role of anemia status and hemoglobin level in patients with MIBC undergoing RC.
Section snippets
Literature Search
This meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.33 A systematic search of the literature was conducted on May 13, 2016 using the PubMed and EMBASE database. The following search strategy was employed to both PubMed and EMBASE: (radical cystectomy) AND (anemia OR hemoglobin OR hematocrit OR transfusion OR blood cell OR hematology). No restrictions on publication type, publication language, or publication year
Literature Search
Figure 1 shows the flow diagram of the selection of studies. A total of 1222 references were identified in the preliminary search. After excluding 209 duplicate publications, 1013 references were identified for screening. By reviewing the titles and abstracts, 899 references were excluded and 114 studies were identified for full-text review. After reading the full-text, 97 studies were excluded. Finally, 17 studies fulfilled the inclusion criteria and provided the data for meta-analyses.16, 17,
Main Findings
In this comprehensive meta-analysis of 17 cohort studies, we identified a possible association between preoperative anemia/hemoglobin and clinical outcomes in patients with MIBC undergoing RC. Our meta-analysis firstly shows that compared with non-anemia status, preoperative anemia is associated with increased ACM (HR, 1.75; 95% CI, 1.48-2.05), CSM (HR, 1.80; 95% CI, 1.45-2.25), and DR (HR, 1.37; 95% CI, 1.16-1.62) in patients undergoing RC. Our meta-analysis also indicates that higher
Conclusions
Preoperative anemia and low hemoglobin level are associated with earlier recurrence and shorter survival of patients with MIBC undergoing RC. However, well-designed prospective studies with large sample size and limited confounding factors are still needed to confirm and update our findings.
Disclosure
The authors have stated that they have no conflicts of interest.
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Cited by (33)
Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations
2023, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Prospective studies on management of preoperative anemia within oncology primarily focus on colorectal cancer patients, but data remains limited in GU malignancies. High prevalence rates of preoperative anemia (∼30–45%), extensive postoperative blood transfusion rates, and association with worse clinical outcomes have most commonly been reported in patients with bladder cancer undergoing radical cystectomy [36–41]. Preoperative anemia rates are approximately 35 to 40% for patients with kidney cancer requiring nephrectomy and 8% of patients requiring radical prostatectomy [13,24,42,43].
Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy
2023, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :This visit was scheduled to coordinate with the patient's postoperative check-up to reduce additional patient burden. Malnutrition is prevalent in patients undergoing RC, and data supporting preoperative correction of malnutrition, anemia, and vitamin deficiency is more robust [20–23]. As part of the preoperative assessment, participating patients had standardized lab work performed.
Hemoglobin, albumin, lymphocyte, and platelet (HALP) score and cancer prognosis: A systematic review and meta-analysis of 13,110 patients
2023, International ImmunopharmacologyCitation Excerpt :Pretreatment low hemoglobin (anemia) is a common clinical feature in cancer patients and might contribute to hypoxia [49], which could drive cancer progression and therapeutic resistance [50]. Clinical studies have shown that anemia is closely related to poor survival [51–54]. In addition, serum albumin is a component of serum total proteins, and its level represents host inflammation and nutritional status [55,56].
Patterns and timing of perioperative blood transfusion and association with outcomes after radical cystectomy
2021, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Thus, conflicting evidence on PBT and clinical outcomes may in part be due to lack of specificity of PBT timing. Other confounding factors should be considered, such as preoperative anemia, which could predispose patients to increased need for PBT, and has been associated with poor survival and recurrence outcomes in urothelial carcinoma [19]. In this manuscript, we explore the association of PBT with 90-day postoperative morbidity and oncologic outcomes among patients undergoing RC for bladder cancer.
Impact of anemia on the survival of patients undergoing radical cystectomy for bladder cancer
2020, Actas Urologicas Espanolas