Chemotherapy-induced anemia as a prognostic factor for overall survival in patients with bladder cancer treated with neoadjuvant cisplatin-based chemotherapy and cystectomy

Abstract

Introduction: Preoperative anemia (PA) and red blood cell transfusion (RBT) are associated with decreased survival in several cancers. In muscle-invasive bladder cancer (MIBC), anemia is frequent and may be worsened by neoadjuvant chemotherapy (NAC). While PA's impact is known in patients undergoing cystectomy without NAC, its prognostic value in the current multimodal approach remains unclear.

Methods: We retrospectively analyzed patients with cT2-T4 N0-N2 M0 MIBC treated with cisplatin-based NAC followed by radical cystectomy and lymphadenectomy between 2011 and 2022. We recorded the lowest hemoglobin value from NAC start to surgery (PA), use of RBT during NAC, and iron or vitamin B9/B12 supplementation.

Results: This monocentric cohort included 175 patients (77% men, median age 65); 79% received dose-dense-MVAC, 75% had ≥ 4 cycles, median follow-up was 59 months. PA was present in 95%, with 58.2% having grade > 1. Among these, 50% received ≥ 1 transfusion, and 34.7% received supplementation. PA grade > 1 was significantly associated with worse OS (HR = 2.67, p = 0.006), RFS (HR = 2.00, p = 0.019), and SS (HR = 3.35, p = 0.003) versus PA grade 0-1. Other independent prognostic factors for OS included neutrophil count > 7 G/L (HR = 2.71, p = 0.010) and ypN+ (HR = 10.35, p < 0.001). RBT had no significant impact.

Conclusion: This retrospective analysis demonstrated that PA grade > 1 negatively impacts overall survival, independent of other prognostic factors, in patients with MIBC treated with NAC. However, it remains necessary to determine whether - and how - optimizing hemoglobin levels before cystectomy could improve outcomes.