Christy Chuang

Relation between recurrence of cancer of the colon and blood transfusion

Data suggest that blood transfusion can cause immunosuppression. The incidence of recurrence of tumours was examined retrospectively in patients who had undergone potentially curative operations for cancer of the colon during 1970-81. Tumours recurred in six of 68 patients (9%) who had not been given transfusions and in 56 of 129 patients (43%) who had (p much less than 0.0001). Transfusion was also found to be significantly associated with the time to recurrence after adjustment for other baseline prognostic factors (p less than 0.05). Perioperative transfusion may be a significant risk factor in the prognosis of cancer of the colon. Whether this association is causal is unknown.

Association between transfusion of whole blood and recurrence of cancer

Transfusion affects the immune response to renal transplantation and may be associated with recurrence of various human neoplasms. Data from patients with colonic, rectal, cervical, and prostate tumours showed an association between transfusion of any amount of whole blood or larger amounts of red blood cells at the time of surgery and later recurrence of cancer. Recipients of one unit of whole blood had a significantly higher incidence of recurrence (45%) than recipients of a single unit of red cells (12%) (p = 0.03). Recipients of two units of whole blood also had a higher rate of recurrence (52%) than those receiving two units of red cells (23%) (p = 0.03). Recipients of any amount of whole blood had similar recurrence rates (38-52%). Recipients of four or more units of red blood cells had a higher rate of recurrence (55%) than those receiving three or fewer units of red blood cells (20%) (p = 0.005). Mortality due to cancer in patients receiving three or fewer units of red blood cells (2%) was similar to that in patients who did not have transfusions (7%) and significantly lower than that observed in patients receiving three or fewer units of whole blood (20%) (p = 0.003). A proportional hazards risk analysis showed that transfusion of any whole blood or more than three units of red blood cells was significantly associated with earlier recurrence and death due to cancer. These data support an association between transfusion and recurrence of cancer. They also suggest that some factor present in greater amounts in whole blood, such as plasma, may contribute to the increased risk of recurrence in patients who have undergone transfusion. Until the questions raised by retrospective studies of cancer recurrence and transfusion can be answered by prospective interventional trials with washed red blood cells, red blood cells should be transfused to patients with cancer in preference to whole blood when clinically feasible.

Further evidence supporting a cause and effect relationship between blood transfusion and earlier cancer recurrence.

Studies of associations between periopcrativc blood transfusions and later recurrence of solid tumors have yielded conflicting results. A previous analysis of transfused patients suggested that recurrence was associated with transfusion of whole blood as opposed to red blood cell concentrates. Additional analyses were performed on patients with cancers of the colon, rectum, cervix, and prostate to determine if patients receiving whole blood, red blood cells only, or no transfusions had differing outcomes. Patients receiving 1 unit or more of whole blood had uniformly poor outcomes compared with nontransfused patients (p < 0.001). In contrast, patients receiving only red blood cells had progressively worse recurrence and death rates with increasing numbers of transfusions, suggesting the presence of a dose-effect relationship. Employing multivariate techniques, blood transfusions of

Order-Restricted Score Parameters in Association Models for Contingency Tables

3 units that included any whole blood were independently and significantly associated with earlier recurrence (p = 0.003) and death due to cancer (p = 0.02). Transfusions of

Outcomes after platelet transfusion in patients with heparin-induced thrombocytopenia

3 units of blood comprised solely of red blood cell concentrates were associated with no greater risk of recurrence than that seen in patients receiving no transfusions (p = 0.50). These results provide a potential explanation for the disparate results reported in studies of blood transfusion and cancer outcome. The marked difference in outcome seen between patients receiving a few units of red blood cells and comparable patients receiving even one unit of whole blood are consistent with the hypothesis that transfusion of stored blood plasma causes earlier tumor recurrence in some instances. Strategics for reducing these risks might include avoidance of whole blood transfusions when only 1–3 units are required, more conservative transfusion practice, use of autologous blood transfusions, and perhaps, use of red blood cells washed free of plasma and white cell debris. Clinical trials to test these hypotheses are urgently needed.

Leukemia in rochester (NY) a 17-year experience with an analysis of the role of cooperative group (ECOG) participation

This retrospective clinical study of patients with nonmetastatic prostate cancer demonstrates that patients transfused at the time of initial diagnosis or operation have a higher frequency of recurrence (54 percent) and death due to cancer (19 percent) than patients not receiving blood transfusions (recurrence rate 31 percent, p = 0.005; death rate 10 percent, p = 0.08). This difference is not explained by the transfused patients being older, having a less favorable clinical stage of disease, or less differentiated tumor histology. A multivariate analysis confirmed that the additional risk of dying from prostate cancer was 2.82-fold higher in transfused patients than in those not transfused. As in previous studies, the risk of recurrence may be greater in those receiving whole blood transfusions. Prospective studies of the association between perioperative blood transfusion and cancer recurrence are needed. For the present, prudent clinical practice should include avoidance of whole blood, fresh frozen plasma, and platelet transfusions and greater reliance on autologous blood transfusions.

Model-based Bayesian methods for estimating cell proportions in cross-classification tables having ordered categories

Abstract The row effects and column effects models for two-way contingency tables have parameters for the row and column categories pertaining to the association between the variables. For classifications having ordered categories, it is often reasonable to assume that the association parameters have a corresponding ordering. This article proposes order-restricted estimates of the association parameters in these models. The maximum likelihood solution can be determined by the solution of a simple isotonic regression of some of the model sufficient statistics. The models are primarily log-linear in form and can be expressed in terms of odds ratios for 2×2 subtables consisting of adjacent rows and adjacent columns. For the order-restricted solution, these local log-odds ratios have uniform sign. Goodness-of-fit statistics for this solution are related to corresponding statistics for collapsed tables and to statistics for testing equality of sets of the parameters. The row effects model discussed in this art...

Empirical bayes methods for a two-way multiplicative-interaction model

Three hundred-twenty patients with Hodgkins disease (HD) were studied retrospectively to assess the impact of treatment on survival and the development of second malignant neoplasms (SMN). All stages of HD were considered. Treatment groups included XRT only, XRT + multiagent chemotherapy (MAC), XRT + single agent chemotherapy (SAC), and chemotherapy only (Chemo). MAC was subdivided into MOPP and non-MOPP regimens. Twenty-one patients developed 23 SMN, only two of which were acute leukemias. Survival was greatest for XRT only because of a large proportion of early stage HD in this group. SMN were seen in all treatment groups except Chemo only. The XRT + MAC group had a significantly elevated observed-to-expected ratio for SMN, but it was difficult to attribute this to either MOPP or non-MOPP due to very small numbers of patients. The actuarial risk of SMN for both MOPP and non-MOPP rises dramatically between 10 and 15 years, however, extrapolation cannot be done, again because of very small numbers. We conclude that there is an increased risk of SMN in patients treated aggressively for HD, but that the exact cause of SMN is difficult to determine.