Blood transfusions during neoadjuvant chemotherapy for muscle-invasive urinary bladder cancer may have a negative impact on overall survival

Figures & data

Figure 1. Flow chart of inclusion of all evaluated patients. UBC: Urinary bladder cancer. MIBC: Muscle-invasive bladder cancer. cT: Clinical staging of the primary tumor; cN: Clinical staging of regional lymph nodes; cM: Clinical staging of distant metastases.

Table 1. Patient Characteristics and group comparison (%).

	Blood no	Blood yes	Total	p-Value
Sex
Female	11 (13.8)	12 (30.0)	23 (19.2)	.033^a
Male	69 (86.3)	28 (70.0)	97 (80.8)
Age
Mean	66.93	68.7	67.52	.208
Median	68	69	69
SD	7.432	6.851	7.263
cT stage
cT2	40 (50.0)	17 (42.5)	57 (47.5)	.314^a
cT3	36 (45.0)	18 (45.0)	54 (45.0)
cT4a	4 (5.0)	5 (12.5)	9 (7.5)
CACI
Mean	4.83	5.1	4.92	.251
Median	5	5	5
SD	1.23	1.236	1.234
ASA
I	8 (10.0)	4 (10.0)	12 (10.0)	.105^a
II	51 (63.8)	18 (45.0)	69 (57.5)
III	21 (26.3)	18 (45.0)	39 (32.5)
Hb before TURB
Missing data	6 (7.5)	2 (5.0)	8 (6.7)
Mean	139.46	125.37	134.68	.0001
Median	141.5	124	137.5
SD	15.422	21.869	18.993
Blood transfusions during NAC
Mean (units)	0	2.9	0.97
Median (units)	0	2	0
SD (units)	0	1.795	1.715
Peri- and postoperative blood transfusions
Yes	67 (83.8)	38 (95.0)	105 (87.5)	.079^a
Mean (units)	3.36	3.8	3.51	.455
Median (units)	3	4	3
SD (units)	3.266	2.431	3.01
pT stage
pT0	32 (40.0)	9 (22.0)	41 (34.2)	.044^b
pTis	3 (3.8)	3 (7.5)	6 (5.0)
pTa	3 (3.8)	1 (2.5)	4 (3.3)
pT1	2 (2.5)	3 (7.5)	5 (4.2)
pT2	21 (26.3)	9 (22.5)	30 (25)
pT3	15 (18.8)	7 (17.5)	22 (18.3)
pT4a	3 (3.8)	2 (5.0)	5 (4.2)
pT4b	1 (1.3)	6 (15.0)	7 (5.8)
pN stage
pN0	66 (82.5)	23 (57.5)	89 (74.2)	.007^a
pN+	10 (12.5)	9 (22.5)	19 (15.8)
pNx	4 (5.0)	8 (20.0)	12 (10.0)
Total	80 (66.7)	40 (33.3)	120 (100.0)

Patient characteristics and comparisons between the group of patients receiving (blood yes) and not receiving (blood no) blood transfusions during neoadjuvant chemotherapy (NAC). cT: Clinical staging of the primary tumor; CACI: Age-adjusted Charlson Comorbidity Index; ASA: American Society of Anesthesiologists Physical Status Classification System; Hb: Hemoglobin level; TURB: Trans-urethral resection of bladder. Peri- and postoperative blood transfusions: Patients receiving peri- and postoperative blood transfusions in conjunction with cystectomy; pT: Pathological staging of the primary tumor; pN: Pathological staging of regional lymph nodes, ‘pN+’ meaning presence of nodal metastases and ‘pNx’ unknown nodal status.

All p-values < 0.05 are in bold.

^a Tested with Chi-Square Test.

^b Tested with Fisher’s Exact Test.

Figure 2. Kaplan–Meier overall survival curve for all patients with urothelial muscle-invasive bladder cancer (cT2-T4aN0M0) undergoing neoadjuvant chemotherapy and radical cystectomy between 2008 and 2014 at four Swedish cystectomy centers (n = 120). The cohort was divided into two groups depending on if the patients received blood transfusions during NAC, or not (blood yes and blood no).

Table 2. Cox proportional hazard model.

	Univariate			Multivariate
	HR	CI (95%)	p-Value	HR	CI (95%)	p-Value
pT stage
pT0 (ref.)			<.0001			<.0001
pTis	2.07	0.672–6.370	.205	2.528	0.782–8.171	.121
pTa	0.691	0.090–5.300	.722	0.862	0.110–6.739	.887
pT1	1.264	0.285–5.605	.758	1.374	0.294–6.427	.687
pT2	1.333	0.608–2.924	.473	1.679	0.736–3.834	.218
pT3	5.905	2.843–12.265	<.0001	6.713	3.076–14.653	<.0001
pT4a	5.405	1.734–16.841	.004	7.106	2.192–23.031	.001
pT4b	12.423	4.805–32.119	<.0001	11.159	23.801–32.759	<.0001
pN stage
pN0 (ref.)			.0004			.009
pN+	2.357	1.275–4.358	.006	1.168	0.572–2.384	.671
pNx	3.589	1.723–7.476	.001	3.858	1.619–9.197	.002
Blood transfusions during NAC (blood no = ref.)	1.659	1.002–2.749	.049	1.168	0.674–2.025	.58
Age	1.021	0.984–1.060	.264
Sex (male = ref.)	1.071	0.570–2.012	.831
CACI	1.097	0.901–1.336	.355
ASA	1.124	0.760–1.664	.558
Peri- and postoperative blood transfusions (no = ref.)	0.993	0.452–2.182	.986

Uni- and multivariate analysis of proportional hazards. pT: Pathological staging of the primary tumor; pN: Pathological staging of regional lymph nodes, ‘pN+’ meaning presence of nodal metastases. Blood transfusions during NAC: blood transfusions during neoadjuvant chemotherapy (NAC); the variable was divided into two groups depending on if the patients received blood transfusions during NAC, or not (blood yes and blood no); CACI: Age-adjusted Charlson Comorbidity Index; ASA: American Society of Anesthesiologists Physical Status Classification System; Peri- and postoperative blood transfusions: Patients receiving peri- and postoperative blood transfusions in conjunction with cystectomy; CI: Confidence interval; HR: Hazard ratio.

All p-values < 0.05 are in bold.