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ANAEMIA IN CANCER PATIENTS
UNDERGOING RADIOTHERAPY AND
CHEMOTHERAPY AT THE NATIONAL
HOSPITAL ABUJA, NIGERIA
Dr. Chinedu Simeon Aruah: MD,MPH, FWACS
INTERNATIONAL CONFERENCE ON NUCLEAR
MEDICINE AND RADIATION THERAPY, COLOGNE
GERMANY, July14th-15th ,2016
OUTLINE OF THE PRESENTATION
 Brief Background
 Rationale for the study-Why did we carry out this study





in the first place
Objectives
Methodology
Findings
Conclusion and Recommendations
Selected references
BACKGROUND
AFRICA AND CANCER BURDEN
BACKGROUND -1
 Cancer is an emerging public health problem in Africa
 According to International Agency for Research on Cancer
715,000 new cancer cases and 542,000 deaths occurred
in 2008 in Africa
 These number are projected to nearly double by 2030
simply due to aging, population growth and change in life
style modifications.
 Majority of cancers in Africa are diagnosed at an
advanced stage of disease because of lack of screening
and early detection services.
 Also limited awareness of early signs and symptoms of
cancer among the public and healthcare providers are
contributory.
BACKGROUND -2
NIGERIA POPULATION AND CANCER BURDEN
 Population in 2012 – 166.6 million
 People newly diagnosed with cancer (excluding NMSC)
/yr – 102,000
 Age – standardise rate, incidence per 100,000 people /yr
– 100.1
 Risk of getting cancer before age of 75 – 10.4%
 People die from cancer /yr – 71,600
Source – Nigeria Cancer Organization Resources/Cancer
Index.
www.cancerindex.org
NOTE:These figures are likely to increase because total
population in Nigeria
was estimated at 178.5million
people in 2014.
BACKGROUND - 3

Anaemia is commonly encountered in cancer patients undergoing therapy
in Radiation Oncology centres.

Aetiology and pathophysiology of anaemia in cancer patients are usually
mutifactorial.

Apart from the disease burden, commonly used treatment modalities such
as radiotherapy, chemotherapy and chemoradiation in these centres are
known to contribute to already existing anaemia.

Many cancer patients present with anaemia prior to radiotherapy and
chemotherapy and may even experience anaemia or worsening of anaemia
at some point during treatment.

However, the problem of anaemia is often ignored because patients may
experience only functional anaemia defined as haemoglobin level less than
12g/dl especially among Caucasians.

However, this Hb value tend to be less in Africans because of underlying
aneamia ab nitio.

Currently, haemoglobin level of 10g/dl is being used as borderline value
and administration of radiotherapy or chemotherapeutic agents without
adequate haematological support may tilt the patient into clinical anaemia.
BACKGROUND -4




Ludwig et al.3 examined 9,118 cancer patients using
Hb concentration level less than 12g/dl as the baseline
value to study frequency of anaemia in various cancer
types.
The results of these studies were expressed in
percentages: Breast cancers - 26%, Lung cancer 48%,
Colorectal 33%, Head and Neck - 46%, Gynaecological
- 43%, Lymphoma and Myeloma - 47%, Leukaemia 53%, Urogenital - 43% and others - 37%.
Also, studies done by Ludwig et al3 on anaemia
prevalence in patient receiving different cancer
treatment with anaemia defined as Hb concentration
level less than 12g/dl was quite significant.
The results were as follows: chemotherapy - 75%,
combination of chemotherapy and radiotherapy - 72%,
concomitant chemotherapy and Radiotherapy - 62%,
No treatment - 40% and radiotherapy alone - 38%.
Rationale-Why this study?
 Anaemia is one of the predisposing factors to poor




patient outcome in cancer treatment
More than 50% of cancer patients will receive either
radiotherapy or Chemotherapy or both in the course of
their treatment
It has been difficult to establish global or National
benchmark on the baseline haemoglobin of patients
selected for cancer therapy especially at different stages
of the tumours
Various centers use different levels but there is a need
to establish a national cut-off point
Establishing a uniform benchmark will inform a global
best practice and increase the patient’s outcome and
quality of life
AIMS AND OBJECTIVES:
 The aim of the study was to carry out a prospective
study on pattern of anaemia in cancer
undergoing Radiotherapy and Chemotherapy.
patients
METHODOLOGY:
 The research was a prospective study
 The study consisted of 201 cancer patients of both
sexes with histopathologically confirmed malignancies
(solid cancers).
 Ethical
clearance was
obtained
from
the
National
Hospital Abuja
 Study was completed within a period of 8 months
 Those who met the inclusion criteria were selected and
followed up in the course of the study.
 The patient were encouraged to fill consent form
 Patients’ baseline or pre-treatment Haemoglobin(Hb) were




taken on the first day of consultation.
Patients were distributed into three treatment arms,
Radiotherapy
alone,
Chemotherapy
alone
and
Chemoradiation therapy.
Their Hb were measured once every 2 weeks during
therapy.
The blood film pictures of the patients were examined in
the course of treatment.
The whole process was terminated after 3 consecutive Hb
reading or after week 6
Anaemia was classified for this study into:
 Less than 10g/dl
 10 - 10.9g/dl
 11 - 12 g/dl
 12 g/dl and above
-
Severe anaemia
moderate anaemia
mild anaemia
no anaemia.
RESULTS AND ANALYSIS
Table 1A: Demographic of the study population
Variable
Chemotherapy
Radiotherapy
Chemo radiotherapy
Age
Number
%
Number
%
Number
%
25 – 34
17
17.0
11
17.5
7
18.4
35 – 44
36
36.0
19
30.2
9
27.7
45 – 64
22
22.0
10
15.9
8
21.1
55 – 64
21
21.0
11
17.5
10
26.3
65 – 74
3
3.0
8
12.7
3
7.9
75+
1
1.0
4
6.3
1
2.6
Total
100
100
63
100
38
100
Table lB is demography of the study population
based on sex distribution.
Chemotherapy
Radiotherapy
Chemo radiotherapy
Male
12
12.0
5
7.9
11
28.9
Female
88
88.0
58
92.1
27
71.1
Total
100
100
63
100
38
100
Variable
Sex
Table 2: Percentage Distribution of Tumour site and treatment type
Tumour Site
Chemotherapy
Radiotherapy
Chemo radiotherapy
Number
%
Number
%
Number
%
Breast
68
68.0
30
47.6
-
-
Gastrointestinal
9
9.0
-
-
-
-
Head and Neck
4
4.0
5
7.9
14
36.8
Urogenital
6
6.0
10
15.9
-
-
Gynaecological
6
6
14
22.2
24
63.2
Musculoskeletal
(Sarcomas)
5
5.0
2
3.2
-
-
Lung
3
3.0
2
3.2
-
-
Total
100
100
63
100
38
100
TABLE 3: The result showed majority of the patients presented
with stage III tumour in chemotherapy group, radiotherapy
group and chemoradiation with a percentage of 72%, 74.6%
and 71.1% respectively.
Stage
Chemotherapy
Chemo
radiotherapy
Radiotherapy
Number
%
Number
%
Number
%
1
2
2.0
1
1.6
1
2.6
2
24
24.0
15
23.8
10
26.3
3
72
72.0
47
74.6
27
71.1
4
2
2.0
-
-
-
-
Total
100
100
63
100
38
100
Table 4a: Percentage distribution of Hb by duration
of treatment for patients undergoing Chemotherapy,
Radiotherapy and Chemoradiation
The table showed treatment from week 0 – week6; where week 0 was defined as time
from initial administration of chemotherapy or Radiotherapy or Chemoradiation to the
first 2weeks.
CHEMOTHERAPY
Hb g/dl
TREATMENT DURATION
Week 0
%
Week 2
%
Week 4
%
Week 6
%
<10
-
-
-
-
6
6.0
2
2.0
10 – 10.9
-
-
-
-
10
10.0
14
14.0
11 – 12
61
61.0
80
80.0
74
74.0
62
62.0
12+
39
39.0
20
20.0
10
10.0
12
12.0
Total
100
100
100
-
100
100
100
100
Mean
12.6
11.92
-
11.29
-
10.89
-
Standard
Deviation
0.98
1.40
1.05
1.18
RADIOTHERAPY
Hb g/dl
TREATMENT DURATION
Week 0
%
Week 2
%
Week 4
%
Week 6
%
<10
-
-
-
-
1
1.6
3
4.8
10 – 10.9
13
20.6
15
23.8
21
33.4
20
31.7
11 – 12
38
60.3
42
66.7
35
55.5
35
55.6
12+
12
19.1
6
9.5
6
9.5
5
7.9
Total
63
100
63
100
63
100
63
100
Mean
12.6
11.92
11.29
10.89
Standard
Deviation
0.98
1.40
1.05
1.18
CHEMORADIATION
Hbg/dl
TREATMENT DURATION
Week 0
%
Week 2
%
Week 4
%
Week 6
%
<10
1
2.6
1
2.6
4
10.5
7
18.4
10 – 10.9
2
5.3
2
5.3
13
34.2
15
39.5
11 – 12
15
39.5
25
65.8
18
47.4
12
31.6
12+
20
52.6
10
26.3
3
7.9
4
10.5
Total
38
100
38
100
38
100
38
100
Mean
12.34
11.78
11.31
11.17
Standard
Deviation
0.81
0.91
0.93
0.88
Table 4B: Showing percentage distribution of patients on chemotherapy,
Radiotherapy and Chemoradiation blood film picture pattern from week 0 to
week 6; while week 0 was defined as the time of initial therapy to the first
2week.
CHEMOTHERAPY ALONE
Blood Film Picture
Treatment Duration (Chemotherapy Alone)
Week 0
% of Patients
Week 2
% of Patients
W
%
eek of
4
W
% of Patients
eek
Pat 6
ien
ts
1.
Normocytic
73
73.0
53
53.0
45
Normochromic
2.
Hypochromic
45. 28
28.0
0
13
13.0
20
20.0
33
33. 37
37.0
0
3.
Macrocytosis
5
5.0
5
5.0
1
1.0 5
5.0
4.
Microcytosis
2
2.0
1
1.0
2
2.0 1
1.0
5.
Poikliocytosis
1
1.0
-
-
-
-
1.0
6.
Anisocytosis
2
2.0
14
14.0
7
7.0 11
11.0
7.
Elliptocytosis
-
-
1
1.0
-
-
2
2.0
8.
Dimorphic Picture
1
1.0
3
3.0
5
5.0 6
6.0
9.
Target Cells
3
3.0
3
3.0
7
7.0 9
9.0
Blast cells
-
-
-
-
-
-
-
10.
1
-
RADIATION ALONE
Blood Film Picture
Treatment Duration (Radiation Alone)
Week 0
% of Patients
Week 2
% of Patients
W %
W % of Patients
ee
ee
of
k 4 Pat k 6
ien
ts
1.
Normocytic
48
76.2
42
66.7
36 57 36 57.1
Normochromic
2.
Hypochromic
.1
6
9.5
11
17.5
16 25 17 27.0
.4
3.
Macrocytosis
2
3.2
-
-
2
3.
-
-
2
4.
Microcytosis
2
3.2
-
-
-
-
-
-
5.
Poikliocytosis
1
1.6
2
3.2
-
-
-
-
6.
Anisocytosis
1
1.6
2
3.2
5
7.
2
3.2
4
6.3
4
6.4
9
7.
Elliptocytosis
1
1.6
1
1.6
1
1.
6
8.
Dimorphic Picture
2
3.2
5
7.9
3
4.
8
9.
Target Cells
-
-
-
-
-
-
-
-
10.
Blast cells
-
-
-
-
-
-
-
-
CHEMO-RADIATION ALONE
CHEMO-RADIATION
Blood Film Picture
Week 0
Treatment Duration (Chemoradiation Alone)
W %
% of Patients
Week 2
% of Patients
ee of
k Pa
4 ti
en
ts
73.7
22
57.9
10 26
.3
W % of Patients
ee
k
6
1.
Normocytic
Normochromic
28
2.
Hypochromic
5
13.2
10
26.3
23 60 16 42.1
.5
3.
Macrocytosis
1
2.6
2
5.3
3 7.9
4.
Microcytosis
Poikliocytosis
1
1
2.6
2.6
-
-
6.
Anisocytosis
1
2.6
4
10.5
7.
Elliptocytosis
Dimorphic Picture 1
2.6
-
-
9.
Target Cells
-
-
-
-
1 2.
6
- 1 2.
6
2 5.
3
- 1 2.
6
- -
-
-
10.
Blast cells
-
-
-
-
-
-
-
5.
8.
-
10 26.3
1 2.6
- 6 15.8
1 2.6
1 2.6
Table 5: Distribution of Means and Standard
Deviation of HB by Sex and type of treatment
Sex
MEAN STANDARD DEVIATION
Chemotherapy
Radiotherapy
Chemo radiotherapy
Male
11.72 (0.88)
10.82 (0.95)
12.27 (1.39)
Female
11.65 (1.21)
12.14 (1.02)
11.13 (1.14)
95% C.I Mean
difference
0.07 ± 2.73
-1.32 ± 2.73
1.14 ± 3.52
t
0.53
-2.96
2.41
P-value
p>0.05 (NS)
p>0.05 (NS)
p>0.05 (NS)
Table 6: Percentage Distribution of Hb by
prevalence group
Hbg/dl
Number
%
<10
40
11.1
10 – 10.9
37
10.3
11 – 12
133
36.9
12+
150
41.7
Total
360
100
Table 7: Distribution of mean HB, Stand deviation and
confidence interval by type of treatment
Types of Treatment
Mean
Standard Deviation
Week
Week 0
Week 2
Week 4
Week 6
Week 0
Week 2
Week4
Week6
Chemotherapy
13.42
12.42
11.99
11.35
1.2
1.51
1.50
1.32
Radiotherapy
12.55
12.18
12.02
11.83
.90
.93
1.1
1.5
Chemo radiotherapy
12.34
11.78
11.31
11.17
.81
.90
.93
.88
95% C.I
Chemotherapy
Radiotherapy
Chemo radiotherapy
Week 0
12.12 – 12.85
12.31 – 12.80
12.17- 12.52
Week 2
11.10 – 11.91
11.93 – 12.42
11.59 – 11.97
Week 4
9.91 – 10.95
11.73 – 12.31
11.11 – 11.51
Week 6
9.60 – 10.62
11.52 – 12.13
10.98 – 11.36
Table 8: Comparison of Prevalence Hb group level
and the Baseline Hb of the study group
Therapy
Baseline
Prevalence
Chemotherapy
13.42
40
Radiotherapy
12.55
37
Chemo
12.34
133
t-test
1.604
radiotherapy
150
p-value
0.109
Remark
Not significant >0.05
DISCUSSION-1
 It was found from the study that the prevalence of anaemia in
cancer patients undergoing Radiotherapy and Chemotherapy at
National Hospital Abuja was 63% of the study group (ie average of
72%, 42.9%, 73.7%).
 Majority (62.0%) of the 100 patients on chemotherapy had Hb
level at the range of 11-l2g/dl by week 6.
 This agreed with study by Barrett-Lee et al16 which observed that
when the patients were analyzed to determine relative risk of
anaemia, 62% of patients experienced a Hb decline of 1.5g/dl
within a median of 6.1 to 7.2 weeks and 51% had a Hb decline of
2g/dl with a median of 7.3 to 8.3 weeks.
 . The Hb range at the end of the week 6 study showed that
chemotherapy Hb range was 9.60 – 10.62, Radiotherapy 11.52 –
12.13, and Chemoradiation 10.98 – 11.36g/dl.
 This study was also in agreement with report by Ludwig et al16
which found that cancer patients treated and evaluated after; that
anaemia occurred in 50.5% of those who received chemotherapy,
43.5% of patients who received chemoradiation and 28.7% in
patients who received radiotherapy.
 The above observation helped to strengthen our earlier
report that chemotherapy had greatest impact on Hb
level during therapy.
 This assertion was supported by three different studies
elsewhere (Ludwig et al3 ,Grossi et a119 and Jassen et a1
20) which showed that chemotherapy is a well known
bone marrow depressant and acute cytotoxic agent:
 At the completion of radiotherapy at week 6, 55.6% of
the patients had haemoglobin value at the range of 1112g/dl.
 There was gradual decline in Hb level as the
radiotherapy treatment proceeded from week 0 to week
6.
 The result of this study was in agreement with work
done by Harrison et al17 which reported that 41% of
patients were anaemic with Hb level less than l2g/dl
before starting radiotherapy
 Out of 38 patients analyzed on Chemoradiation only 4 had Hb
level greater than 12g/dl
 This study was in agreement with studies done by Morris et
a115 who studied cancer patients who had chemoradiation
involving gynaecological and head and neck tumours.
 This report was in agreement with study done by MacRae et
al18 following evaluation of 104 cancer patients with stage III
non-small
cell
chemoradiotherapy.
lung
cancer
(NSCLC)
undergoing
Conclusion and key Recommendation
 While
pre-treatment Hb level measurement is very
important, it is the on-treatment Hb level that is very
critical as patients with initial adequate Hb value may
easily be tilted into anaemia as their treatment progress.
 At 95% confidence interval, evaluation of effect of
therapy on Hb level in the three arms showed that none
of the values reached statistical significance ie P-value <
0.05.
 However, the impact of Chemotherapy on Hb level was
more significant than in other treatment arms, hence
Chemotherapy – 9.60-10.62g/dl, Radiotherapy 11.5212.13g/dl, and Chemoradiation 10.98-11.36g/dl.
 We recommend a benchmark of 11g/dl minimum
for
any
patient
being
selected
for
both
radiotherapy, chemotherapy and chemoradiation in
Nigeria.
LIMITATIONS:
 Paucity of published data in this area in Nigeria was a




major challenge
The sample size also might not be adequate for
generalization
The type of patients in the study may also be a
challenge and bias considering that the center is in a big
urban city and constitute patients with well-fed families
This results might show a different finding if done in a
poor rural community
Financial limitation did not allow the expansion of this
research to hospitals in poor rural settings in Nigeria
AUTHORS
DR. ARUAH S.C1 (Corresponding author)
DR. OYESEGUN R2. (Radiation Oncology Department, NHA)
DR. OGBE OCHE3, (Haematology Department, NHA)
DR. IGBINOBA F4. (Radiation Oncology Department, NHA)
DR JAWA Z.M.5, (Nuclear Medicine Department NHA)
DR. OKOYE O.G.6, (Surgery Department, NHA)
DR. AISHA ISMAILA7, (Nuclear Medicine Department NHA)
DR. ONYISHI T.N.8 (HistoPathology Department ESUTTH,
Enugu)
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Practice Guideline in Oncology Cancer and
Chemotherapy induced anaemia V3. 2009.
 Ludwig H, Van Belles, Barrett-lee P et al. The European
Cancer Anaemia Survey (ECAS): A large multinational
prospective survey defining the prevalence, incidence
and treatment of anaemia in cancer patients Eur J
Cancer (2004); 40:2293-2306.
 Daniel Santini, Bruno Vincenzi, Annalisa Navajas et al. A
new Dose-Intense epoietin Alfa Regimens Effective in
Anaemia Cancer Patients Receiving Chemotherapy: An
open-label, Non Randomized pilot study. Anti Cancer
Research 2005; 25:669—674.
 Natacha Verbeke, Yves Beguin, Hans Wildiers, J.L Canon, Greet
Bries, Andre Bosly, Simon Van Belle. Hight prevalence of anaemia
and limited use of therapy in cancer patients: a Belgium Survey
(Anaemia day 2008). Support Care Cancer, 2012; 20:23 —28.

S.A Laurie, K. Ding, M. Whitehead, R. Feid, N. Murray, F.A
Shepherd and L. Seymour. The impact of anaemia on outcome of
chemoradiation for limited small-cell lung cancer: a combined
analysis of studies of the National Cancer Institute of Canada
Clinical 2007; 18:1051 — 1055.
 Pilar M, Samper Ots, Julia Munoz, Albert Biete, Maria Jose Ortiz et
al. PITASOR Epidemiological study: Prevalence, incidence and
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in Spain. Clin Transl Oncol 2011; 13:322-327.
 Laura Doni, Alessandra Penn, Luigi Manzione, Vittorio Gebbia,
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