VOLUME 48NUMBER 1 ORIGINAL

BLOOD RESEARCH March 2013 ARTICLE

The prevalence and clinical characteristics of cancer among anemia

patients treated at an outpatient clinic
Soo Jeong Kim, So Young Ha, Bo Mi Choi, Mi Yeong Lee, Jong Youl Jin, Soo Jeong Yeom, Tae Wan Kim,
Young Min Kim, Keehyun Lee
Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea

p-ISSN 2287-979X / e-ISSN 2288-0011 Background

http://dx.doi.org/10.5045/br.2013.48.1.46 Anemia is the most common hematologic condition encountered in outpatient clinics.
Blood Res 2013;48:46-50.
It is often overlooked because it is common among patients; however, anemia is one of
the leading indicators of cancer. This study examined the prevalence and characteristics
Received on August 16, 2012 of cancer among anemia patients who visited an outpatient clinic.
Revised on September 12, 2012
Accepted on February 13, 2013
Methods
The data were collected by reviewing the records of an outpatient clinic from January 2007
to December 2011.
Results
In total, 502 patients (52 males, 450 females) were diagnosed with anemia. Cancer preva-
lence among anemia patients was 5.57% (25.0%, men; 3.3%, women); further, the most
frequently diagnosed cancer was colorectal cancer (22.5%), followed by advanced gastric
cancer (16.1%), breast cancer (9.6%), myelodysplastic syndrome (9.6%), cervical cancer
(6.4%), renal-cell carcinoma (6.4%), and thyroid cancer (6.4%). The prevalence of cancer
was 4.1% in those aged 4049 years, 4.2% in the subjects in their fifties, 8.0% in those
in their sixties, 21.6% in those in their seventies, and 55.6% in those aged over 80 years.
The cancer prevalence among iron deficiency anemia (IDA) patients was 6.18% (28.8%,
men; 3.5%, women). The cancer prevalence in postmenopausal and premenopausal fe-
Correspondence to male IDA patients was 16.0% and 1.6%, respectively.
Keehyun Lee, M.D., Ph.D.
Department of Internal Medicine,
Conclusion
Bucheon St. Marys Hospital, 327 Sosa-ro, Among anemia patients, male patients aged over 40 years and female patients aged over
Wonmin-gu, Bucheon 420-717, Korea 60 years, along with postmenopausal female patients, were more likely to be diagnosed
Tel: 82-32-340-7018 with cancer. Consequently, male IDA patients, and female patients aged over 60 years
Fax: 82-32-340-2255 must be carefully evaluated for the possibility of malignancy.
E-mail: [email protected]
2013 Korean Society of Hematology Key Words Anemia, Prevalence, Cancer, Outpatient clinic

ulation, and its prevalence increases with aging [2]. Anemia

INTRODUCTION
in older individuals is associated with a number of un-
favorable outcomes, including functional dependence, de-
Anemia is the most common hematologic problem en- mentia, falls, cardiovascular diseases, and death. Anemia is
countered in outpatient clinics. According to the World also one of the leading indicators of cancer [3-8]. Anemia
Health Organization (WHO) statistics, the prevalence of ane- is present in more than 60.0% of cancer patients, and the
mia is 48.0% in preschool-age children (aged less than 5 risk of becoming anemic increases with more advanced stages
years), 25% in school-age children (aged 514 years), 13% of cancer [9]. Further, both the incidence and prevalence
in male subjects (aged 1559 years), 42% in pregnant women, of cancer increase with age.
30% in women of childbearing age (aged 1549 years), and Cancer has become the most common cause of death in
24% in the elderly (aged 60 years) [1]. Korea [10]. Anemia is an independent risk factor, increasing
Anemia is a common condition affecting the older pop- morbidity and mortality and decreasing the quality of life

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Cancer prevalence in anemia patients 47

in the patient; further, it is one of the leading indicators macrocytic (100 fL) anemia [14]. As the serum iron and
of cancer, and is often overlooked because it is very common total iron-binding capacity (TIBC) were not measured in
[11, 12]. This study was conducted to define the prevalence this study, iron depletion was defined as a ferritin level15
and characteristics of cancer among anemia patients who ng/mL [15].
had visited an outpatient clinic.
Statistical analyses
All statistical analyses were conducted using SPSS 14. 0.
MATERIALS AND METHODS
The mean and standard deviation of Hb levels were
examined. The anemia patients were categorized into groups
Subjects according to sex and age. The prevalence of cancer in each
The study data were collected through a review of the group was determined.
records of an outpatient clinic from January 2007 to
December 2011. The records were derived from new patients
RESULTS
with anemia as the chief complaint who had visited the
general medicine and hematology departments of Bucheon
St. Marys Hospital, Bucheon, Korea. Medical records were The mean age of all the patients was 46.4 years (range:
collected from 502 anemia patients (52 males, 450 females). 1591 years), the mean Hb level was 8.9 g/dL, the MCV
was 77.4 fL, the WBC count was 5.6109/L, and the platelet
Methods count was 29.5109/L (Table 1).
All the patients were physically examined, and their medi-
cal histories were obtained. Additionally, menstrual histories Subjects chief complaints at the first medical examination
were obtained from female patients. Laboratory tests for The most common chief complaint among anemia patients
white blood cells (WBC), hemoglobin (Hb), mean corpus- was incidental laboratory results (66.0%), followed by dizzi-
cular volume (MCV), as well as serum ferritin and platelet ness (24.0%), dyspnea (7.0%), fatigue (1.0%), skin color
levels were performed. Based on the patients symptoms change, and syncope (2.0%).
and the results of the gynecological and physical examina-
tions, thyroid sonography, esophagogastroduodenoscopy Types of anemia
(EGD), or colonoscopy was performed on female anemia Microcytic anemia was identified in 63.1% of cases, nor-
patients. EGD, colonoscopy, or abdominal computed tomog- mocytic anemia in 32.5%, and macrocytic anemia in 4.3%
raphy (CT) was conducted in male patients based on the of the cases. The proportion of anemia patients with iron
symptoms and the results of the physical examination. depletion was 58.6%. Thirty-one subjects were excluded
This study was performed by a hematologist, who reviewed from the study because of missing data. IDA was observed
the medical records of the 502 patients retrospectively. in 36.7% and 61.1% of male and female patients, respectively.

Definition Prevalence of cancer in anemia patients

According to the WHO criteria, anemia is characterized The prevalence of cancer among anemia patients was 5.5%
by Hb level lower than 13 g/dL in men and lower than
12 g/dL in women [13]. Using MCV, patients were classified
as having microcytic (80 fL), normocytic (80100 fL), or

Table 1. Characteristics of the subjects.

Characteristics of the subjects Value

Gender (N) Male 52

Female Premenopause 375
Menopause 75
Age (yr) Male 60.3117.96
Female 44.8113.15
Total 46.4214.49
Hb (g/dL) Male 9.361.75
Female 8.973.24
MCV (fL) Male 82.7718.42
Female 76.7517.24
WBC (109/L) 5.572.42
PLT (109/L) 295.42106.75

Abbreviations: Hb, hemoglobin; MCV, mean corpuscular volume;

WBC, white blood cell; PLT, platelet.
Fig. 1. Prevalence of cancer among anemia patients by age groups.

bloodresearch.or.kr Blood Res 2013;48:46-50.

48 Soo Jeong Kim, et al.

Fig. 2. Relative frequency of malignancies among anemia patients. Fig. 3. Relative frequency of malignancies among female anemia
(Double primary tumor was AGC with bladder cancer). Abbreviations: patients. Abbreviations: MDS, myelodysplastic syndrome; AGC,
CLL, chronic lymphocytic leukemia; CML, chronic myeloid leukemia; advanced gastric cancer.
AGC, advanced gastric cancer; MM, multiple myeloma; RCC, renal cell
cancer; MDS, myelodysplastic syndrome.
Prevalence of benign disease among female anemia patients
The most common benign disease in female anemia pa-
(25.0%, men; 3.3%, women). tients was uterine myoma or adenoma (60.7%), followed
by anemia of chronic disease (ACD) (16.0%), thyroid disease
Prevalence of cancer by age group (9.0%), and peptic ulcer (6.0%).
There were no diagnoses of cancer among patients aged
less than 40 years. Cancer prevalence in anemia patients
DISCUSSION
aged 4049 years was 4.0% (33.3%, men; 3.1%, women),
4.2% in those aged 5059 years (28.5%, men; 1.5%, women),
17.9% in those aged 6069 years (27.2%, men; 14.2%, wom- According to a report by the Ministry of Health and
en), 21.6% in those aged 7079 years (33.3%, men; 13.6%, Welfare of South Korea, the prevalence of cancer within
women), and 55.5% in those aged 80 years or more (75.0%, the South Korean population was 0.3% in 2007 (0.3%, men;
men; 40.0%, women) (Fig. 1). 0.3%, women) [10]. In this study, the overall prevalence
of cancer in anemia patients was 5.6% (25.0%, men; 3.3%,
Prevalence of cancer among IDA patients women). This means that compared with the whole pop-
The prevalence of cancer among the IDA patients was ulation, more anemia patients were diagnosed with cancer.
6.2% (28.8%, men; 3.5%, women). Among premenopausal Cancer is typically accompanied by anemia. Anemia is
and postmenopausal female IDA patients, cancer prevalence present in more than 60.0% of cancer patients, and the risk
was 1.6% and 16.0%, respectively. of anemia increases with more advanced stages of cancer
[9]. However, as the subjects of this study were outpatients,
Relative frequency of malignancies among anemia patients this study had the limitation of having a small number of
The most frequently diagnosed cancer among anemia pa- subjects with gait disturbance due to old age or an advanced
tients in this study was colorectal cancer (7 of 31, 22.5%), stage of cancer.
followed by advanced gastric cancer (AGC) (5 of 31, 16.1%), The pathophysiology of cancer-related anemia is multi-
breast cancer (3 of 31, 9.6%), myelodysplastic syndrome factorial. Anemia can be caused by blood loss, hemolysis,
(MDS) (3 of 31, 9.6%), cervical cancer (2 of 31, 6.4%), re- impaired production of red blood cells, or a combination
nal-cell carcinoma (RCC) (2 of 31, 6.4%), and thyroid cancer of these mechanisms. Blood loss can result from hemorrhage
(2 of 31, 6.4%) (Fig. 2). Among male patients, the most of the tumor itself (e.g., gastrointestinal, bladder, gyneco-
frequently diagnosed cancer was colorectal cancer (2 of 15, logic) [16, 17]. Most importantly, cancer may impair ery-
13.3%), followed by AGC (2 of 15, 13.3%), MDS (2 of 15, thropoiesis. It can disturb erythrocyte production by directly
13.3%), RCC (2 of 15, 13.3%), bladder cancer (1 of 15, 6.6%), affecting the bone marrow (e.g., tumor infiltration into the
prostate cancer (1 of 15, 6.6%), and lung cancer (1 of 15, marrow), reducing the erythropoietin response, and reducing
7%). The most frequently diagnosed cancer in female patients the synthesis and release of endogenous erythropoietin [16].
was colorectal cancer (5 of 11, 31.2%), followed by AGC In this study, the most frequently observed cancer in ane-
(3 of 11, 18.7%), breast cancer (3 of 11, 18.7%), cervical mia patients was colorectal cancer, followed by AGC, breast
cancer (2 of 11, 12.5%), thyroid cancer (2 of 11, 12.5%), cancer, MDS, cervical cancer, RCC, thyroid cancer, chronic
and MDS (1 of 15, 6.2%) (Fig. 3). myelocytic leukemia (CML), chronic lymphocytic leukemia
(CLL), and multiple myeloma (MM). According to a report

Blood Res 2013;48:46-50. bloodresearch.or.kr

Cancer prevalence in anemia patients 49

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