Impact of Packed Red Blood Cells and Fresh Frozen Plasma Given During Radical Cystectomy and Urinary Diversion on Cancer-related Outcome and Survival: An Observational Cohort Study

Abstract

Background: The relationship between blood transfusion and cancer-related outcome and mortality is controversial.

Objective: To assess if perioperative administration of packed red blood cell (PRBC) and fresh frozen plasma (FFP) units affects disease progression and survival after radical cystectomy for bladder cancer.

Design, setting, and participants: We conducted an observational single-centre cohort study of a consecutive series of 885 bladder cancer patients, between 2000 and 2015. Perioperative blood transfusion was defined as need for PRBCs and FFP transfusion within the first 24h after the beginning of surgery.

Outcome measurements and statistical analysis: Disease recurrence-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier technique and log-rank test.

Results and limitations: A total of 267/885 patients (23%) were transfused; 187/267 patients (70%) received only PRBCs (median 2 units [interquartile range: 1-2]) and 80/267 patients (30%) received PRBCs (2 [2-3]) plus FFP (2 [2-2]). Receipt of PRBCs or PRBCs+FFP was associated with a higher 90 d mortality (7.0% vs 7.5% vs 2.9%; p=0.016), inferior 5 yr recurrence-free survival (no transfusion 92%, PRBCs 74%, p=0.005; PRBCs+FFP 49%, p=0.002), 5 yr cancer-specific survival (no transfusion 74%, PRBCs 60%, PRBCs+FFP 49%, all p<0.001), and 5 yr overall survival (no transfusion 90%, PRBCs 70%, PRBCs+FFP 34%, all p<0.001). In multivariate analysis, blood transfusion was predictive for all-cause mortality (PRBCs [hazard ratio; HR 1.610; p<0.001] and PRBCs+FFP [HR 1.640; p=0.003]) and cancer-specific mortality (PRBCs [HR 1.467; p=0.010] and PRBCs+FFP [HR 1.901; p=0.021]). Limitations include selection bias and lack of standardised transfusion criteria.

Conclusions: Administration of PRBCs and FFP was associated with significantly inferior cancer-specific and overall survival. Relevant preoperative factors for receiving blood transfusion were neoadjuvant chemotherapy, preoperative anaemia, older age, and American Society of Anesthesiologists score ≥3, and these factors emphasise the importance of preoperative optimisation of patients undergoing cystectomy.

Patient summary: Blood transfusion during radical cystectomy was associated with inferior survival.

Keywords: Bladder cancer; Cancer-related outcome; Cystectomy; Fresh frozen plasma; Packed red blood cell.