DIPONEGORO MEDICAL JOURNAL

(Jurnal Kedokteran Diponegoro)

Online : http://ejournal3.undip.ac.id/index.php/medico
E-ISSN : 2540-8844
Volume 10, Number 6, November 2021
Afina Yuliani Putri, Yan Wisnu Prajoko,
Julian Dewantiningrum, Ch. Nawangsih Prihharsanti

THE EFFECT OF RADIOTHERAPY ON BLOOD COMPONENTS

OF CERVICAL CANCER PATIENTS

Afina Yuliani Putri1*, Yan Wisnu Prajoko2, Julian Dewantiningrum3, Ch. Nawangsih Prihharsanti4
1
Undergraduate Program, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
2
Department of Surgery, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
3
Department of Obstetry-Gynecology, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
4
Department of Radiology, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
*Corresponding Author : E-mail: [email protected]

ABSTRACT
Background: Radiotherapy exposure is known to have a lethal effect on blood cells because hematopoietic cells are very
sensitive to radiation exposure even at low doses. Cervical cancer with radiotherapy can have the effect of reducing blood
cells. Blood cells that may experience the effects of radiotherapy include haemoglobin, leukocytes and platelets.
Objective: To know the effects of radiotherapy towards blood components of cervical cancer patients. Methods: This
study was an observational pre and post test design. Secondary data were collected from medical records in the
Radiotherapy Unit of Dr. Kariadi Semarang in 2019-2020 with a total of 128 cervical cancer patients undergoing 3D
radiotherapy. The statistical test used Saphiro Wilk data normality test and the result data analysis used the paired t-test
and Wilcoxon test. Results: Hypothesis testing for Hb levels using the paired t-test showed an insignificant value of
p=0.749 and p=0.141. Hypothesis test for the number of leukocytes and platelets using the Wilcoxon test. Leukocytes
showed a significant value of p=0.000 and insignificant p=0.957. Platelets received a significant value of p=0.000 and
p=0.000. Hb value decreased by -0.44, leukocytes by -3.5, and platelets by -84.34. Conclusion: There was an insignificant
decrease in haemoglobin levels yet significant decrease in leukocyte and platelet counts in cervical cancer patients
undergoing radiotherapy where the platelets experienced the most decrease compared to haemoglobin and leukocytes.
Keywords: 3D radiotherapy, cervical cancer, haemoglobin, leukocyte, thrombocyte.

INTRODUCTION exposure to normal cells around cancer cells or in the

Cervical cancer is the fourth most malignant irradiated area.5
disease in the world. About 90% of cases of death Exposure to ionizing radiation is known to
from cervical cancer occurred in developing have lethal effect to blood cells because
countries. Based on data from Global Burden Cancer haematopoietic cells are sensitive to radiation
(Globocan) in 2018, the incidence of cervical cancer exposure even in low doses. Cervical cancer and
in Indonesia is in second place of 10.7% and the radiotherapy may kill blood cells, and the blood
mortality rate is in third place with 10.3%.1,2 components counts will decrease.6 Blood cells that
Radiotherapy is a therapeutic modality for may be influenced by radiotherapy are haemoglobin,
cancer alongside the surgery and chemotherapy. leukocytes, and platelet cells.
About 50% of cancer patients receive radiotherapy The decrease of leukocytes is associated with
during the course of their disease,3 with an estimate a decrease in body immunity system that plays an
that radiation therapy contributes about 40% to important role to fight infections. If the immunity
curative treatment.4 Radiation used to destroy cancer falls, the body will be prone to infections.7
cells is called ionizing radiation because it forms ions Thrombocytes have the role in coagulation. The
and deposits energy in the tissue cells through it. The decrease in thrombocytes is called
energy deposited can kill cancer cells or cause thrombocytopenia. At the thrombocyte level of
genetic changes that lead to cancer cell death. High <10.000/µL, spontaneous bleeding increases. At the
energy radiation can damage the genetic material of thrombocyte level of <50.000/µL, surgical
cells, such as DNA, and thus prevent the cells' ability procedures are often complicated by bleeding. At the
to further divide and proliferate. Radiation can thrombocyte level of <100.000/µL, chemotherapy
damage both normal and cancer cells, but the main and radiotherapy are given more carefully because
goal of radiotherapy is to maximize the radiation they might worsen the thrombocytopenia and higher
dose to abnormal cancer cells while minimizing the risk of bleeding. Things explained above are what
makes therapy in cancer in optimal.8

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(Jurnal Kedokteran Diponegoro)
Online : http://ejournal3.undip.ac.id/index.php/medico
E-ISSN : 2540-8844
Volume 10, Number 6, November 2021
Afina Yuliani Putri, Yan Wisnu Prajoko,
Julian Dewantiningrum, Ch. Nawangsih Prihharsanti

Erythrocyte cells contain haemoglobin which METHODS

has an important function of delivering oxygen from This research is an observational analytic
the lungs to all tissues in the body.9 Anaemia is a study with the type of study before and after design.
state of decreasing haemoglobin to <12g /dL10 and is This research was conducted at Dr. Kariadi Hospital
one of the factors that can cause tumour cells to Semarang in the period of April-September 2020.
experience hypoxia and is considered as a tumour The sample of the study was cervical cancer patients
response to radiotherapy by reducing oxygenation to who had completed 3-Dimensional (3D) external
the tumour and then causing the cells to become radiation therapy from 2019 to September 2020. The
radioresistant or the level of ionizing radiation that inclusion criteria for this study were patients aged ≤
the organism can withstand.11 Tumour hypoxia itself 80 years, cervical cancer patients stage 1 to 4A or no
can be a contributing factor to radiotherapy metastases occurred during the study period, and
unresponsiveness. Also, hypoxic tumours can cause a patients who had undergone 3-Dimensional external
tendency to become more progressive and radiation technique at a dose of 50 Gray. The
metastasize.12 exclusion criteria included recidive patients, cancer
A study on the decrease in the number of in other organs, and patients with blood disorders.
erythrocytes, leukocytes and platelets in cervical The sampling method was consecutive
cancer patients after radiotherapy from Tutut in 2012 sampling in which all subjects who meet the sample
proved that there was a decrease in the number of criteria will be taken until the sample size is met. The
erythrocyte cells, leukocytes and platelets in patients independent variable in this study was cervical
after radiotherapy. The subjects of this study were all cancer radiotherapy and the dependent variables in
cervical cancer patients who received radiation this study were Hb levels, leukocyte counts, and
therapy at the Radiotherapy Unit of Dr. Moewardi platelet counts. Before testing the hypothesis, the
Hospital period May-October 2011. In this study, data normality test was performed using Saphiro
external radiotherapy using Cobalt-60 was used.13 Wilk. Normally distributed data were tested using the
Nisa Azarina in her 2014 study regarding the Paired-T Test, otherwise, data with abnormal
Effects of Radiotherapy on Blood Cell Production in distribution was tested using the Wilcoxon test.
Patients with Ca Mammae and Ca Cervix found that
platelet and leukocyte cells experienced significant Table 1. Characteristics of the research sample
changes after exposure to radiation, while
erythrocyte and haemoglobin cells did not show any n %
significant response.14
Retianingsing in 2017 also observed the Age
Study of Standardization of Cobalt-60 Radiotherapy ≤30 1 0.8
Against Blood Cell Quantity in Cervical Cancer in 30-40 24 18.8
41-50 37 28.9
Sanglah Hospital, Denpasar. The results of this study
51-60 45 35.2
showed that erythrocytes did not show a decrease,
61-70 18 14.1
while leukocytes showed a decrease that was not >70 3 2.3
very sharp or very low, Hb was constant, and
neutrophils at the beginning showed an increase Transfusion
which then decreased.15 This research is different Yes 54 42.2
from previous studies, the previous study used a No 74 57.8
Cobalt 60 radiation source and the radiation
Stage
technique was not explained, while this study
IB 4 3.1
explained the radiation technique used was a 3- IIA 4 3.1
Dimensional technique which lessens the exposure to IIB 35 27.3
normal tissue. IIIA 4 3.1
IIIB 66 51.6
IVA 1 0.8
No details 14 10.9

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Online : http://ejournal3.undip.ac.id/index.php/medico
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Volume 10, Number 6, November 2021
Afina Yuliani Putri, Yan Wisnu Prajoko,
Julian Dewantiningrum, Ch. Nawangsih Prihharsanti

RESULTS Normality test for the number of leukocytes

This research was conducted in April - and platelets shown in Table 2. The Saphiro Wilk
September 2020 at Dr. Kariadi Hospital Semarang. test on the data before, 10th, and 25th radiation, had
The sample used had met the research requirements, shown abnormal distribution (p<0.05), so to test the
the inclusion criteria and the exclusion criteria. The hypothesis we used the Wilcoxon test. Hb level
sample data were obtained from medical records normality test showed the data was distributed
selected by consecutive sampling, where 249 cervical normally, so to test the hypothesis we used the Paired
cancer patients underwent external radiation therapy T Test.
in 2019-2020 and only 128 respondents who met the Table 3 showed the results of the hypothesis
inclusion criteria. The characteristics of the research test of the effect of radiation on the number of
sample are presented in Table 1. leukocytes using the Wilcoxon test, it is known that
Based on the history of transfusion, it was there was an effect of radiotherapy on the number of
found that patients who had a transfusion in the leukocytes in cervical cancer patients before
middle of the radiation therapy treatment to improve radiation to the 25th radiation which can be seen
the general condition of the patient. So in statistical from a significant value of 0.000 (p <0.05).
calculations, the 54 blood component levels of the However, in the 10th to 25th radiation process the
patient who received blood transfusion were only leukocyte count was not found any significant effect
calculated from before radiation until the 10th of more than 0.05.
radiation. Therefore, the total of data calculated from
before radiation until the 10th radiation was 128,
while the total of data calculated from the 10th
radiation to the 25th radiation was 74.

Table 2. Result of Shapiro Wilk normality test

Before radiation 10th radiation 25th radiation

(n=128) (n=128) (n=128)

Mean±SD p Mean±SD p Mean±SD p

(Min – Max) (Min – Max) (Min – Max)

Hb 12.2±1.6 0.010* 12±1.3 0.914 11.8±1.1 0.174

(6.9 – 15.6) (8.6 – 15.4) (9.1 – 15.8)

Leukocyte 9.3±3.1 0.000* 5.8±2.4 0.000* 5.8±2.1 0.002*

(1.9 – 24.2) (2.6 – 19.9) (2.5 – 14.1)

Thrombocyte 374.7±118.2 0.000* 258.4±78.4 0.017* 290.4±73.2 0.189

(194 – 873) (105 – 494) (140 – 516)

*Significant (p<0.05)

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Julian Dewantiningrum, Ch. Nawangsih Prihharsanti

Table 3. Result of Wilcoxon Test in Leukocytes and Platelets Counts

Negative Ranks Positive Ranks

Z p
Mean Sum of Mean Sum of
rank Rank Rank Ranks

Before radiation - Leukocyte 64.81 8037 30.33 91 -9.56 0.000*

10th radiation
(n=128)
Thrombocyte 67.38 7816.5 28.32 311.5 -9.029 0.000*

10th radiation - 25th Leukocyte 36.78 1397.5 38.26 1377.5 -0.054 0.957
radiation (n=128)
Thrombocyte 33 561 38.21 2140 -4.341 0.000*

*Significant (p<0.05)

The results of the hypothesis test of the effect To find out whether there was a decrease in
of radiation on the platelets counts were known by haemoglobin levels, leukocyte counts, and platelet
using the Wilcoxon test. We found that there was an counts in cervical cancer patients underwent
effect of radiotherapy on the platelet count in cervical radiotherapy, a negative rank value was used in the
cancer patients which could be seen from a Wilcoxon test, which indicates whether there was a
significant value of 0.000, where the value is less decrease in value after conducting the research test.
than 0.05 (p <0.05) in before radiation up to the 25th From Table 5, we could know that each
radiation. blood level had a decrease in value from before
Based on the results of the Hb level radiation to the 25th radiotherapy. It is also known
hypothesis test using the Paired T Test in Table 4, that the platelet count had decreased the most in
there was no effect of radiotherapy on Hb levels in cervical cancer patients who underwent external
cervical cancer patients because it obtained radiotherapy. The total impairment loss is presented
insignificant values of 0.749 and 0.141, where the in Table 6.
value is greater than 0.05 (p> 0.05) in the process
before radiation to the 25th radiation.

Table 4. Result of Paired T Test on Hb level

95% Confidence Interval

Mean±SD p
Mean Rank Sum of Ranks

Hb before radiation - 10th 0,046±1,626 0,749 -0,238 0,33

radiation (n=128)

Hb 10th radiation - 25th radiation 0,201±1,165 0.141 -0.069 0.471

(n=74)

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Table 5. Negative ranks value of Wilcoxon Test

N before - 10th Mean before - 10th N 10th - 25th Mean 10th - 25th

Hb 84 57.86 44 35.35

Leukocytes 124 64.81 38 36.78

Platelets 116 67.38 17 33

In the results of the calculation of the and platelet counts had the value increased on the
decrease in blood component counts in Table 6, each 25th radiotherapy. The largest decrease after
blood level had decreased from before radiotherapy radiotherapy in cervical cancer patients occurred in
to the 25th radiotherapy meanwhile the leukocyte platelet levels.

Table 6. Total Decrease of Blood Components Counts

Total value of
Mean before Mean 10th Mean 25th
decrease

Hb 12.23 12 11.79 -0.44

Leukocytes 9.3 5.76 5.8 -3.5

Platelets 374.69 258.42 290.35 -84.34

DISCUSSION The choice of therapeutic modality, such as Intensity

Radiation therapy for cervical cancer Modulated Radiotherapy (IMRT) technique,
involves exposure of significant volume of bone allowing the occurrence of haematological toxicity to
marrow to high-energy photons. The patient's ability be minimal. This may have influenced the results of
to tolerate the therapy is determined by this study. In a study by Mell et al., the external
haematological factors that reflect the potential for contours of all pelvic bones were described in
stem cells in the bone marrow to repair damage and planning CT scans for all patients with cervical
to reproduce bone marrow components.16 Bone cancer. They were able to show that leukopenia and
marrow is a radiosensitive tissue and has a strong neutropenia ≥ grade 2 were significantly reduced in
relationship between irradiated dose and volume and patients receiving 10 Gy for less than 90% of bone
the risk of hematologic toxicity. The decrease in marrow (11.1 and 5.6%) compared with patients
bone marrow hematopoietic cells is associated with receiving 10 Gy for more than 90% of bone marrow
increased adipocyte levels and inhibition of chronic (73.7 and 31.6%).19
hematopoiesis,17 as confirmed by experimental Brixey et al. analysed hematological toxicity
studies.18 in patients underwent conventional radiotherapy or
Based on the hypothesis test in this study, IMRT for gynaecological cancer. Patients receiving
decreased haemoglobin levels in cervical cancer conventional radiotherapy developed ≥ grade 2
patients were found to be statistically insignificant, leukopenia compared to patients receiving IMRT.20
which means that there was no effect of radiotherapy This benefit was achieved without marking the bone
on haemoglobin levels in cervical cancer patients. marrow as an organ at risk during treatment

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planning, but only because of the highly conformal clinical studies have shown a drastic reduction in the
properties of IMRT.21 Therefore, previous studies number of leukocytes, erythrocytes, and platelets
proved that the IMRT technique caused less during radiotherapy.25 It has also been proposed that
hematological toxicity than conventional radiotherapy may have immunosuppressive effects
radiotherapy techniques. The contour of the and this may increase the risk of tumour
radiotherapy planning of patients in this study was development as has been shown in various solid
not investigated further. tumors.26,27
Although the hypothesis was rejected, the
Wilcoxon test results with negative ranks showed CONCLUSION
significant results indicating a decrease in In summary, we found that there was an
haemoglobin levels. The results of this study are insignificant decrease in haemoglobin levels but a
consistent with the research by Majeed et al. They significant decrease in the number of leukocytes and
found that 78% of patients had a statistically platelets in cervical cancer patients underwent
significant decrease in haemoglobin levels from radiotherapy where the platelets counts dropping
before radiotherapy to mid-radiotherapy. [16] Results lower than haemoglobin and leukocytes.
of the study by Serkies et al. also showed that there Referring to the limitations of this study, it is
was a decrease in haemoglobin levels during and at necessary to read the medical records more carefully
the end of radiotherapy treatment.22 in order to obtain more complete data. It is also
Barkati et al. hypothesized that low necessary to carry out further research by analysing
haemoglobin levels during treatment reflect low bone multivariately to consider other factors that may
marrow reserves. Patients with low bone marrow affect the decrease in blood component levels, such
reserve may suffer from tumours that grow under as cancer stage, nutritional status, comparison of
hypoxic conditions leading to infiltrative phenotypes IMRT therapy modalities with conventional
such as uterine corpus invasion and lymph node radiotherapy, histopathology, age, presence of
metastases. Therefore, low haemoglobin levels, or metastases, comorbid diseases, as well as the
anaemia, during treatment are a substitute for possible prognosis of the patients.
hypoxemia subclinical nature in patients leading to
more invasive tumours. This hypothesis is consistent Ethical Approval
with their study which showing no improvement in Ethical Clearance statement from the Health
disease-free survival (the interval from the date of Research Ethics Committee, Faculty of Medicine,
diagnosis to the first known evidence of relapse or Diponegoro University and Dr. Kariadi Semarang for
death) or overall survival (death due to any cause) in this research was published on May 18, 2020. The
anaemic patients who received blood transfusions Ethical Clearance number is 62/EC/KEPK/FK-
during treatment.23 Haemoglobin levels before and UNDIP/V/2020.
during treatment have been reported to be associated
with other adverse prognostic factors related with Conflicts of Interest
other tumours, such as tumour progression and All authors have no conflicts of interest to
“bulky” disease.24 disclose.
In contrast to haemoglobin, this study found
a statistically significant decrease in the number of Funding
leukocytes and platelets in cervical cancer patients, No specific funding was provided for this
which means that there is an effect of radiotherapy article.
on the number of leukocytes and platelets of cervical
cancer patients. It was also proven statistically that Author Contributions
there was a decrease in haemoglobin levels, Writing-original draft preparation, Afina
leukocyte, and platelet counts in cervical cancer Yuliani Putri; writing-review and editing, Dr. dr. Yan
patients underwent radiotherapy where the platelet Wisnu Prajoko, Sp.B(K)Onk, M.Kes., dr. Julian
happened to be the most affected than the other. It Dewantiningrum, Sp.OG(K), M.Si.Med., and Dr. dr.
has been discussed that ionizing radiation causes Ch. H. Nawangsih P., SpRad(K)Onk.Rad.
depression of the hematopoietic system. Several

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Acknowledgments https://www.researchgate.net/publication/31384
We thank Director of RSUP Dr. Kariadi who 1668_What_is_the_Function_of_Hemoglobin_i
had given permission so that the research could be n_the_Human_Body
conducted and we thank Faculty of Medicine of 10. Zhang X, He Y, Xie X, Ji M, Ma X, Yu Z.
Diponegoro University for providing advice and Distribution of Hemoglobin and Prevalence of
infrastructure. Anemia in 10 Ethnic Minorities in China.
Medicine. 2017;96(50):e9286.
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