Pre and peri-operative erythropoeitin for reducing allogeneic blood transfusions in colorectal cancer surgery.

 

Abstract

Background

Patients with colorectal cancer are frequently anaemic and many receive allogeneic red blood cell transfusions peri and post-operatively. Transfusions are accompanied by complications and may increase the rate of recurrence in patients who have a colorectal resection. Recombinant erythropoietin was first used in dialysis patients and more recently in orthopedic surgery to facilitate autologous transfusions. Erythropoietin levels are thought to be lower in cancer patients and erythropoietin is widely used in chemotherapy to treat anaemia and improve quality of life. There may be adverse events associated with its use. Several studies have investigated erythropoietin in colorectal cancer surgery.

Objectives

The primary objective of this systematic review was to evaluate the efficacy of erythropoietin pre and peri-operatively, in reducing allogeneic blood transfusions in patients undergoing colorectal cancer surgery. Secondary objectives were to determine whether pre and peri-operative erythropoietin improves hematologic parameters (hemoglobin, hematocrit and reticulocyte count), quality of life, recurrence rate, and survival, without increasing the occurrence of thrombotic events and the peri-operative mortality.

Search methods

A literature search was performed using MEDLINE, EMBASE, abstracts from the annual meetings of the American Society of Clinical Oncology and the American Society of Colon and Rectal Surgeons until May 2008.

Selection criteria

Randomized controlled trials of erythropoietin versus placebo or no treatment/standard of care were eligible for inclusion. The study must have reported one of the primary or secondary outcomes and included anaemic patients undergoing surgery for colorectal cancer.

Data collection and analysis

The methodological quality of the trials was assessed using the information provided. Data were extracted and effect sizes were estimated and reported as relative risks(RR) and mean differences (MD) as appropriate.

Main results

Four eligible studies were identified of ten retrieved in full. There were no statistically significant differences in the proportion of patients transfused between the erythropoietin group and control group. One of the studies showed a small difference in the median number of units transfused per patient favouring treatment. Reporting of hematologic parameters was varied however, there is no evidence for clinically significant changes. There were no significant differences in post-operative mortality or thrombotic events between groups. No included study evaluated recurrences, survival, or quality of life. Studies were of fair methodologic quality and the overall sample size was small therefore results should be interpreted with caution.

Authors' conclusions

There is no sufficient evidence to date to recommend pre and peri-operative erythropoietin use in colorectal cancer surgery.

 

Plain language summary

The use of erythropoietin improve anaemia and reduces blood transfusions in surgery for cancer of the large bowel.

Patients with cancer of the large bowel are often anaemic and sometimes receive transfusions which may be harmful. The medication erythropoietin can be used to increase hemoglobin levels in a variety of situations and several studies have looked at this in patients who have surgery for their large bowel cancer. This systematic review of four studies found there is insufficient evidence to support the use of erythropoietin in the preoperative and post-operative period for improving anaemia and decreasing blood transfusions. There was also no evidence that the medication was the cause of increased complications or deaths. Future studies or erythropoietin in large bowel cancer surgery should increase the dose or duration of treatment.

 

摘要

背景

在進行大腸直腸癌手術之前和之中使用紅血球生成素來降低異體輸血(allogeneic blood transfusions)需求

大腸直腸癌患者通常具有貧血症狀並且大多在進行手術前或手術中需要接受異體紅血球輸血，輸血通常會伴隨著併發症的產生，而且會造成接受大腸直腸切除治療的患者症狀復發的機率，重組的紅血球生成素首先是使用在需要進行透析治療的患者身上，近來，則是被使用在骨科手術以促進自體輸血效率。一般認為癌症患者身上紅血球生成素的含量較低，但是紅血球生成素卻廣泛使用於化學治療中以治療患者的貧血現象並提升生活品質。使用紅血球生成素可能和許多不良事件的發生有關，有許多研究已經開始探討在大腸直腸癌手術中使用紅血球生成素的影響

目標

本研究的主要目的在於系統性的評估在手術前和手術中使用紅血球生成素對於降低大腸直腸癌手術中患者所需的異體輸血量的功效，本研究的次要目的是希望能夠瞭解是否在手術前或手術中使用紅血球生成素可以改善相關血液參數(例如血紅素(hemoglobin)、血球容積比(hematocrit)和網狀紅血球計數(reticulocyte count))、生活品質、復發率和存活率，並且不會增加血栓事件的發生率和手術中死亡率

搜尋策略

本研究係針對MEDLINE、EMBASE資料庫和American Society of Clinical Oncology以及American Society of Colon and Rectal Surgeons 的定期會議摘要進行搜尋，檢索時間到2008年5月

選擇標準

有關於使用紅血球生成素和安慰劑或不治療/不進行標準照護進行比較的隨機性對照試驗都適合納入本研究中，納入研究的試驗必須針對一種主要或次要治療成果提出報告，並且應該納入正在接受大腸直腸癌手術的貧血患者

資料收集與分析

利用提供的資訊進行試驗的方法學品質評估，針對萃取出的數據和作用規模進行評估並以相對風險(RR)和平均差異(MD)的形式呈現結果

主要結論

在10個完整的試驗中有4個試驗適合納入本研究中，在使用紅血球生成素的組別和對照組之間，接受輸血的患者比例並沒有顯著差異，有一個試驗結果顯示針對患者進行中單位量的輸血對於患者來說是有些微好處的，關於血液參數值的報告則具有相當大的變化，並沒有證據可以說明不同治療方法可以在臨床上產生顯著變化，在不同的試驗組之間，對於術後死亡率和血栓事件的發生率也沒有顯著差異，沒有被納入的試驗針對復發率、存活率或是生活品質進行評估，具有公平的方法學品質的試驗和整體試驗規模過小的試驗結果都應該更謹慎小心的進行解釋

作者結論

至今尚無證據可以建議在進行大腸直腸癌手術前或手術中使用紅血球生成素

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

使用紅血球生成素來改善貧血並且降低大腸癌手術患者的輸血需求量：患有大腸癌的患者通常都具有貧血症狀，有時候他們會接受輸血，但是輸血可能會對這些病人產生危害，醫藥用的紅血球生成素在許多情況下可以用來提升血紅素的含量，而且有很多研究已經開始注意將紅血球生成素使用於接受大腸癌手術的患者的效果，本研究針對4個試驗有系統的進行分析發現有一些不充分的證據會認為在進行手術前和手術中使用紅血球生成素可以改善貧血和減少輸血，目前也沒有證據可以說明這樣的治療方法是增加併發症和死亡率的原因，應該藉由增加紅血球生成素劑量和使用時間來瞭解對於接受大腸癌手術患者的治療效益