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• W2002253368 abstract "In a recent review, Caro et al. examined the (independent) prognostic value of pretreatment anemia in various types of cancers. 1 This was an interesting review, but there were several points that should be re-examined, particularly in the review's conclusions. Inclusion and exclusion criteria are the basic and crucial steps in systematic reviews, since the very purpose of a review implies a synthesis of all the information available and the avoidance of those which have known sources of bias. 2 Some of Caro et al.'s inclusion criteria (such as survival data to be stratified by hemoglobin levels and the proportion of anemic patients to be reported) were perhaps unavoidable in performing the quantitative part of their systematic review. However, such inclusion criteria were not really necessary for the qualitative section. Indeed, if one wishes to exclude all studies addressing this topic and having possible sources of bias, it is quite likely that few or no studies would remain.2-4 Let us try to clarify this point in the specific case of small cell lung cancer (SCLC), for example. Caro et al.'s inclusion criteria enabled them to include in their review four SCLC studies written in English 5-8 and one SCLC study written in Chinese.9 Updating two of our own systematic reviews4, 10 and using Caro et al.'s own selection criteria, three additional studies11-13 (or perhaps five,11-15 depending on whether or not potential duplicates and/or studies published after December 1999 could be included) might have been included in their review. Not to mention 16 other SCLC studies that met all but the two of Caro et al.'s inclusion criteria mentioned above,16-31 other studies that mixed together SCLC and nonsmall cell lung cancer (NSCLC) patients, abstracts, and other SCLC studies not written in English, French, German, or Italian (i.e. the only languages that we can understand). Based on two other systematic reviews, 32, 33 it seems to us that similar additional studies could also have been included, or at least examined, in the specific cases of NSCLC and colorectal cancer. It is quite likely that similar figures could be extrapolated to the other types of cancer studied in Caro et al.'s review. The taking into account of all these studies would probably not have changed Caro et al.'s main conclusion that anemia has an adverse prognostic significance that can be quantified in terms of hazard rates in these patients. However, these numerous studies might have helped to better answer the probably more crucial question of whether or not this prognostic value is really independent from the other variables that are or can be used in these patients. 34 For example, in the specific case of SCLC, we summarized in Table 1 the results of the multivariate analysis from each of the 25 studies cited above5-8, 11-31 (except for the Chinese study,9 as we do not speak that language). In the table, we included in the column labeled uncertain significance a study in which pre-treatment blood hemoglobin levels were found to have an independent prognostic significance by authors who had neglected to include the following basic radio-clinical factors in their multivariate statistical analysis: weight loss, age, gender, and extension of the disease. Thus, the results summarized in the table could lead to questioning of the independent character of the prognostic significance of anemia in SCLC, particularly since, according to the two different outcomes that were considered in the two papers of Østerlind et al. that were published in 1986, i.e. long term survival12 versus overall survival,6 hemoglobin levels were12 or were not6 found to be have an independent prognostic significance in the very same series of patients. What is more, the inclusion of many more studies in Caro et al.'s review might have helped to better answer the question of whether or not the prognostic value of blood hemoglobin levels is more or less significant in more homogeneous subgroups of patients, depending not only on different types of malignancy, but also on different therapies administered. Thus, for example, when we recently updated our NSCLC systematic review, 35 even when including as many survival studies as possible, we still had difficulty in concluding on the independent prognostic value of blood hemoglobin levels in NSCLC patients considered as a whole, but less so in patients treated with radiation therapy. Indeed, as far as we know, the only three available studies on such subgroups of patients were unanimous on the adverse independent prognostic value of decreased blood hemoglobin levels in NSCLC patients treated with radiation therapy,36-38 which is in keeping with the results of ongoing erythropoietin trials which suggest that the cancer patients who would benefit the most from erythropoietin therapy are those treated with radiation therapy.39 Finally, and more importantly, Caro et al. suggest that clinicians should consider giving some of their anemic cancer patients either blood transfusions or, even better, erythropoietin. In fact, Caro et al.'s review cannot seriously answer this question, not only because the blood hemoglobin levels that were used to stratify the patients in the studies that they reviewed were heterogeneous, varying from 8.5 to 14 g/dL, and do not correspond to the levels that generally define anemia (i.e., 12 g/dL in women and 13 g/dL in men 41), but also because parallel-group randomized trials of erythropoietin and/or transfusion therapies would be the only acceptable way to answer such a question.41 Therefore, until the results of such clinical trials are available, hemoglobin levels cannot be used to decide which cancer patients should be given erythropoietin. Joseph Watine Pharm. D. Eur. Clin. Chem.*, Nordine Bouarioua M.D. , * Laboratoire de Biologie Polyvalente Centre Hospitalier, Général Rodez, France, Nordine Bouarioua, M.D. Service d'Oncologie Médicale et de Radiothérapie Centre Hospitalier, Général Rodez, France." @default.
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• W2002253368 date "2002-05-14" @default.
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• W2002253368 title "Anemia as an independent prognostic factor for survival in patients with cancer" @default.
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