AUA 2018: Perioperative Blood Transfusion is Not an Independent Predictor of Survival After Radical Cystectomy

San Francisco, CA USA (UroToday.com) Patients with bladder cancer undergoing radical cystectomy are an inherently comorbid population. Additionally, many will suffer from preoperative anemia secondary to several factors including neoadjuvant chemotherapy, disease burden, etc. Prior studies have suggested reducing perioperative transfusion among patients undergoing radical cystectomy secondary to an association of blood transfusion and inferior survival outcomes [1]. However, the literature is somewhat controversial as to the role perioperative blood transfusions have on survival outcomes, not just among patients with bladder cancer but also patients with other solid organ malignancies. At AUA bladder cancer epidemiology session, Dr. Meng and colleagues presented a single institutional analysis of patients undergoing radical cystectomy to investigate the effect of perioperative blood transfusion on overall (OS) and disease-free survival (DFS).

For this study, the authors identified 479 patients who underwent radical cystectomy at Barnes-Jewish Hospital in St. Louis, MO from January 2010 to December 2016. A perioperative blood transfusion was defined as packed red blood cells transfused within 30 days of radical cystectomy date. Major complications were defined as Clavien-Dindo grade III or higher. The co-primary end points were OS and DFS, and patient-specific variables and outcomes were analyzed in relation to administration of perioperative blood transfusion. Kaplan-Meier curves were constructed to evaluate associations between perioperative blood transfusion and survival outcomes. Multivariable analyses were performed using Cox proportional hazards models to assess predictors of OS and DFS.

Among patients meeting inclusion criteria, 64% (n=308) received a perioperative blood transfusion. Patients receiving perioperative blood transfusions were significantly older and more likely to have a Charlson Comorbidity Index (CCI) of 3 or greater compared to those not receiving a transfusion. Perioperative blood transfusions were more likely associated with open compared to robotic radical cystectomies, longer operative times, and higher estimated blood loss. Transfused patients stayed ~2 days longer post-radical cystectomy (p<0.001) and were more likely to have ≥Grade 3 complications within 30 days of surgery (p=0.005). Higher pathological stage (T2-T4) and variant histology were more frequently observed in patients who received perioperative blood transfusion. Kaplan Meier curves for OS and DFS comparing patients receiving vs not receiving perioperative blood transfusion demonstrates an early splitting of the curves and statistically significant differences in outcomes, favoring patients not receiving perioperative blood transfusions:

On multivariable analysis, perioperative blood transfusion was not an independent predictor of OS [HR 1.28, p=0.15] and DFS (HR 1.19, p=0.39) when adjusting for age, BMI, CCI, variant histology, neoadjuvant chemotherapy and T stage.

The current study adds to the growing body of literature assessing perioperative blood transfusions and its role in survival outcomes among patients undergoing radical cystectomy. A limitation of the current study is likely the sample size and survival event rates, as the authors were able to demonstrate impressive Kaplan-Meier curves but did not demonstrate perioperative blood transfusions as a predictor of survival on multivariable analysis. Perhaps this is a true finding, however the sample size and event rate may not have the power to detect an association. The authors concluded that perioperative blood transfusions were associated with worse OS and DFS, and that transfusions received should serve as a clinical surrogate for older and frailer patients with more advanced disease.

Presenter(s): Yifan Meng, Barnes-Jewish Hospital, St. Louis, MO

Co-Authors: Joel Vetter, Alexander Parker, Robert Grubb, Eric Kim, St. Louis, MO

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

References:
1. Wang YL, Jiang B, Yin FF, et al. Perioperative blood transfusion promotes worse outcomes of bladder cancer afer radical cystectomy: A systematic review and meta-analysis. PLoS One 2015;10(6):e0130122.
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