Patients undergoing radical cystectomy for bladder cancer (BCa) may be at increased risk for worse outcomes if they receive a perioperative blood transfusion (PBT), according to a new study.

The study, which led by Stephen A. Boorjian, MD, of Mayo Clinic in Rochester, Minn., included 2,060 patients who underwent radical cystectomy for BCa. Of these, 1,279 (62%) received PBT (median two units of blood). The median follow-up for the study population was 10.9 years.

Compared with patients who did not receive PBT, those who did had significantly worse five-year recurrence-free survival (58% vs. 64%), cancer-specific survival (59% vs. 72%), and overall survival (45% vs. 63%), Dr. Boorjian and colleagues reported online ahead of print in European Urology. After adjusting for multiple variables, PBT was associated with a 20% increased risk of tumor recurrence, 31% increased risk of death from BCa, and a 27% increased risk of death from any cause.

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Patients who received PBT were significantly older than those who did not (69 vs. 66 years) and were more likely to have muscle-invasive tumors (56% vs. 49%). They also had worse Eastern Cooperative Oncology Group performance status.

 “While these data require external validation,” the authors concluded, “continued efforts to limit the use of blood products in these patients are warranted; these efforts include implementing restrictive transfusion criteria or alternative strategies for blood replacement and surgical techniques to minimize blood loss.”

The investigators noted that the potential immunosuppressive effect of red blood cell transfusion was first described in a study published nearly four decades ago in the Lancet (1974;2:696-698). The study showed enhanced renal allograft survival among patients receiving a blood transfusion. Other studies have demonstrated an association between PBT and disease recurrence in patients with colon, esophageal, and hepatic carcinomas.

Dr. Boorjian’s team pointed out that the mechanism by which PBT may affect cancer-related outcomes has not been definitively established. One hypothesis is that an immunosuppressive effect of PBT results in decreased host tumor surveillance, they noted. “A potential mechanism for the immunologic activity of PBT is transfusion-induced anergy due to the presentation of large amounts of antigen in the transfused blood products,” the researchers wrote.