Mancuso, A., Migliorino, M., De Santis, S., Saponiero, A., & De Marinis, F. (2006). Correlation between anemia and functional/cognitive capacity in elderly lung cancer patients treated with chemotherapy. Annals of Oncology, 17, 146–150.

To investigate whether any association exists between hemoglobin (Hgb) levels and functional capacity, cognitive impairment, and comorbidities in older adult patients with lung cancer who were treated with chemotherapy

Patients were evaluated prior to the initiation of chemotherapy (baseline) and before each subsequent cycle (after 21 days) for quality of life, mental capacity, functional status, depression, and comorbidities.

• The study reported on a sample of 42 patients with a median age of 76.6 years (± 4.8 years).
• Participants were 73.8% male and 26.2% female.
• The patients were included if they were more than 70 years old and had a confirmed diagnosis of lung cancer for which they were undergoing chemotherapy. 
• Patients were excluded if they had symptomatic brain metastases, preexisting major neurologic or psychiatric problems, or a history of substance abuse.

• Single site
• Rome, Italy

A descriptive prospective study design was used.

• MMSE—global cognitive function
• Comprehensive Geriatric Assessment (CGA)—a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person. Includes
  • Activities of Daily Living (ADL)—scores ranging between 0–8 were used to assess functional status for self-care activities.
  • Instrumental Activities of Daily Living (IADL)—scores ranging between 0–8 were used to assess functional status for higher level activities.
  • Geriatric Depression Scale (GDS)—15-item questionnaire
  • Mini Nutritional Assessment (MNA)
• Cumulative Illness Rating Scale-Geriatric (CIRS-G)—assesses the number and severity of comorbid conditions
• Quality of life (QOL)/fatigue outcomes were measured by a visual analogue scale (VAS)

Hgb level was significantly correlated with cognitive function at baseline prior to chemotherapy (r = 0.61, p < 0.002), as well as after one (r = 0.48, p < 0.002) and two cycles (r = 0.60, p < 0.002) of chemotherapy. A significant association was discovered between the change in Hgb levels and cognitive capacity as defined by the MMSE after the first (r = 0.48, p < 0.002) and second cycle (r = 0.60, p < 0.002) of chemotherapy. Significant associations were found between Hgb levels and VAS, CIRS-G, ADL, IADL assessments, and GDS at baseline and GDS at baseline and after one and two cycles of chemotherapy (p < 0.05). The strength of these correlations varied. Change in Hgb level was associated with the change in all above parameters with the exception of IADL, which was not significant.

Although the study was not designed to demonstrate a clinical benefit of erythropoietin on cognitive function during treatment, the authors noted that 14 patients who received erythropoietin during the first two cycles of chemotherapy experienced increases in the Hgb level and CGA indexes whereas patients who did not receive erythropoietin had a lowering of the Hgb levels and worsening of their CGA scores.

• The study had a small sample size for multiple chemotherapy regimens and variability in stage of disease.
• The study included patients with brain metastases as long as they were not “symptomatic.” 
• The study was not designed to specifically evaluate the effect of erythropoietin on cognitive function in patients with cancer.
• MMSE is not sensitive enough to detect subtle cognitive changes.
• There was a lack of alternate forms for repeated administration of MMSE.
• Other factors such as performance status, chemotherapy regimen, and response to chemotherapy may have interacted with Hgb level and other examined variables.