Abstract
BackgroundHaemoglobin levels and tissue oxygenation influence tumour outcome in carcinoma cervix radiotherapy. The clinical impact of haemoglobin levels on acute normal tissue toxicity during radiation and interaction with chemotherapy in carcinoma of the cervix is underexplored. This paper aims to explore this issue.MethodsTreatment toxicity among 227 patients with squamous cell carcinoma of the cervix stages II B–IV A, receiving pelvic radiotherapy or chemoradiation at our institute, were studied prospectively. The baseline and weekly haemoglobin levels during treatment were recorded. Acute toxicities were recorded using Radiation Therapy Oncology Group (RTOG) acute toxicity and Common Terminology Criteria for Adverse Events (CTCAE) criteria, version 4. For the analysis, patients were divided into two groups, depending on nadir haemoglobin levels. A cut-off value for anaemia was selected at 12 gm/dL. Toxicity was compared between anaemic and non-anaemic groups.ResultsPatients on chemoradiation and having haemoglobin levels >12 gm/dL suffered significantly higher dermatitis (two-tailed p value = 0.0288) and vaginal mucositis (two-tailed p value = 0.0187) of at least RTOG acute toxicity grade 2, compared with the anaemic group. In contrast patients receiving radiotherapy alone did not experience any significantly greater mucocutaneous toxicity if haemoglobin was >12 gm/dL. Anaemia had significantly greater impact on malaise and neutropenia (two-tailed p value <0.0001) of CTCAE grade 1 and above among chemoradiation patients, as opposed to those receiving radiotherapy alone (two-tailed p values = 0.0012 for neutropenia and 0.0422 for malaise).ConclusionHaemoglobin values >12 gm/dL significantly worsen acute mucocutaneous toxicity in locally advanced cervical cancer patients receiving chemoradiation. Similar effects are not observed in the absence of chemotherapy.
Highlights
Carcinoma of the cervix is a common cancer in women in developing countries, usually presenting at advanced stages where surgery is no longer a treatment option [1]
Among 210 patients, 86 patients had received pelvic radiotherapy alone owing to comorbidities that prevented use of Cisplatin or refusing chemotherapy, and 124 patients received concurrent chemoradiation to the pelvis
The normal tissue impact of the interaction between these factors has been relatively underexplored, it is relevant in terms of clinical outcomes. It was the aim of this study to explore the differences in normal tissue toxicity between groups of patients during treatment who had differences in two factors, chemotherapy and anaemia
Summary
Carcinoma of the cervix is a common cancer in women in developing countries, usually presenting at advanced stages where surgery is no longer a treatment option [1]. The World Health Organisation defines a value of 12 gm/dL as the cut-off value for anaemia in non-pregnant females above 15 years [3]. Anaemia is defined variably in different oncology studies, 12 gm/dL was chosen as the cut-off point for anaemia in this paper to ensure that patients who were being deemed anaemic for the purposes of this paper were uniformly considered anaemic by National Community Health Programmes that follow WHO guidelines. An estimated third of carcinoma of the cervix patients at our institute have haemoglobin levels below 12 gm/dL at presentation, prior to start of treatment. Haemoglobin levels and tissue oxygenation influence tumour outcome in carcinoma cervix radiotherapy. The clinical impact of haemoglobin levels on acute normal tissue toxicity during radiation and interaction with chemotherapy in carcinoma of the cervix is underexplored.
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