EP.TU.269Management of preoperative anemia with Iron Therapy in colorectal cancer patients- a Systematic Review and Meta-Analysis

Abstract

Introduction: Nearly half of colorectal cancer (CRC) patients are diagnosed with anemia at the initial assessment (Ferlay et al., 2015). Anemic patients require blood transfusion, which increases cancer recurrence (Acheson et al., 2012). Hence iron therapy for anemia correction reduces postoperative morbidity and mortality. Aims & Methods: Aims: To review randomized controlled trials on management of preoperative anemia with iron therapy in CRC patients. Primary objective: To evaluate the effect of preoperative iron therapy in reducing the need for allogenic blood transfusion in patients undergoing colorectal cancer surgery. Secondary objective: To assess whether intraoperative blood transfusion aggravates postoperative morbidity and mortality. To analyse whether anaemia correction would reduce postoperative complications namely disease recurrence, venous embolism, nosocomial infection and increased hospital stay. Methodology: Includes formulating a review question, analyzing, quantifying the inclusion and exclusion criteria, literature search, quality assessment, data extraction and data synthesis, bias rectification, results interpretation and summarizing the evidence. Cochrane Handbook of Systematic Reviews and acronym PICO has been used for formulating review questions and study design (O'Connor et al., 2011). Selection Criteria: Systematic reviews and RCTs with higher level of evidence were included in this review Data Extraction: Quality assessment and data collection were done using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist. Data extraction and analysis done by REVMAN Manager (Higgins et al., 2011). Results: After a detailed search, three RCTs were found to be appropriate for review and analysis namely Lidder et al., 2007, Edwards et al., 2009 and Keeler et al., 2017. Two studies compared the use of oral iron versus placebo (Lidder and Edwards) and one study (Keeler) compared the use of intravenous versus oral iron formulations. Two trials reported that iron therapy reduces the need for blood transfusion, but with insignificant result. All three studies showed that hemoglobin rise occurs with iron therapy postoperatively. None of the studies analyzed the quality of life. Conclusion: The common cause of anaemia is found to be iron deficiency, caused by bleeding from gastrointestinal tract, unless otherwise proven. The most common adverse effects of blood transfusion include transmission of infectious diseases, anaphylactic reaction, iron overload, volume overload and transfusion-related acute lung injury (TRALI). Two trials reported that the blood transfusion rate is lowered with administration of iron therapy, but the result was not statistically significant. Additionally all the studies show that haemoglobin rise occurs with iron therapy postoperatively. None of the studies analysed the quality of life, short term and long term mortality and morbidity. Thus based on the trials we could conclude that these trials fail to prove that iron therapy reduce the rate of allogenic blood transfusion in CRC patients presenting with preoperative anaemia. But it could be concluded that iron therapy would reduce the units of blood transfusion in anaemic CRC patients Recommendations: RCTs with larger sample size to be done for more relevant and accurate reports, aiming at the primary and secondary outcomes like morbidity, mortality and quality of life. Oral iron with fewer side effects has to be experimented for best efficacy.