1 Pre-analysis

## Observations: 48
## Variables: 29
## $ ID                                                 <dbl> 27, 20, 6, 13…
## $ Group                                              <fct> Control, Cont…
## $ `Neoadjuvant chemotherapy`                         <dbl> 0, 0, 3, 4, 2…
## $ Stage                                              <fct> IB, IIA, IIB,…
## $ Stage.numeric                                      <dbl> 1.5, 2.0, 2.5…
## $ Dose                                               <dbl> 40, 40, 40, 4…
## $ `Concomitant chemo cycles`                         <dbl> 3, 5, 3, 2, 3…
## $ `Lost cycles`                                      <dbl> 2, 0, 2, 3, 2…
## $ `Total chemotherapy received`                      <dbl> 0.6, 1.0, 0.6…
## $ Age                                                <dbl> 56, 51, 72, 5…
## $ `Age at diagnosis`                                 <dbl> 55, 50, 71, 5…
## $ `Lowest Leucocyte count`                           <dbl> 1890, 1500, 2…
## $ `Leucopenia grade`                                 <dbl> 3, 3, 2, 3, 1…
## $ `Lowest Neutrophile count`                         <dbl> 1250, 1220, 1…
## $ `Neutropenia grade`                                <dbl> 2, 2, 1, 3, 1…
## $ `Lowest Lymphocyte count`                          <dbl> 390, 170, 410…
## $ `Lymphopenia grade`                                <dbl> 3, 4, 3, 3, 1…
## $ `Lowest Platelet count`                            <dbl> 142, 131, 140…
## $ `Thrombocytopenia grade`                           <dbl> 0, 1, 0, 0, 0…
## $ `Lowest Hemoglobin`                                <dbl> 10.0, 11.8, 9…
## $ `Anemia grade`                                     <dbl> 1, 1, 2, 1, 0…
## $ `Creatinin level`                                  <fct> normal, norma…
## $ `Urinary toxicity registered`                      <dbl> 0, 0, 1, 0, 0…
## $ `Digestive toxicity registered`                    <dbl> 1, 2, 1, 1, 1…
## $ `Type of fractination used`                        <fct> 50.4/28, 50.4…
## $ `RT given to LomboAortics`                         <fct> no, no, no, y…
## $ `Patient received Secvential Boost instead of SIB` <fct> no, no, no, n…
## $ `Brachytherapy fractions`                          <dbl> 4, 0, 4, 4, N…
## $ `Radiotherapy duration (days)`                     <dbl> 37, 41, 32, 3…

2 Abstract

2.1 Group, NAC, Stage

We included 49 patients and after removing 1 patient for incompletness of key data, the final dataset included 48 patients, of which 19 (39.6%) received neoadjuvant chemotherapy (NAC, 2 to 6 cycles, median=4). Patients stage ranged from IB to IVB with most common IIIB in NAC and IIB in controls (V=0.62, p=0.003, Mann-Whitney p<0.001). Stage is significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=0.562, p<0.001).

NAC patients received chemotherapy doses ranging from 30 to 40 (median=40) mg/mp, lower than controls (20 to 150, median=40, p=0.027). NAC patients received a statistically similar median number of chemotherapy cycles (2, ranging from 1 to 4) as the controls (3, 1 to 5, p=0.400). NAC patients lost sugnificalnty more of their planned cycles compared to controls (1 to 4, median=3 vs. 0 to 4, median=1, p<0.001). This resulted in significantly less total chemotherapy received (expresed as a fraction of the total planned dose) in NAC patients, compared to controls (20% to 80%, median=40%, vs 20% to 100%, median=60%, p<0.001). The total chemotherapy received is significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=-0.610, p<0.001).

Toxicity was measured by blood cell counts, hemoglobin and creatinin measurements and urinary and digestive toxicity.

2.2 Leucocytes

NAC patients showed insignifficant toxicity by leucocyte counts (median=2440, 850:6310 vs median=2510, 1080:5600, p=0.393) as well as grade of leucopenia (median=2, 0:4 vs median=2, 0:3, p=0.250).

Lowest leucocyte count is not significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=-0.211, p=0.149), even less after adjuting for total chemotherapy received (RSpearman=0.015, p=0.920), but showed an increased correlation after adjuting for stage (RSpearman=-0.409, p=0.004).

On average, every additional neadjuvant chemotherapy cycle decreased the neutrophile count by 107.63 ±85.4 cells/mL (non significant). After adjusting for total chemotherapy received the average WBC count decreased by 26.13 ±103.4 cells/mL (non significant) but after adjusting for stage, the average neutrophile count decreased by 244.62* ±94.7 cells/mL. However, when adjusting for both at the same time, the average neutrophile count decreased by 174.24 ±113.5 cells/mL (non significant).

There is a high degree of similarity between the Lowest Neutrophile count and the Lowest Leucocyte count (R=0.934***, the same as Lin’s CCC on standardized data) which explains the similarity of the results involving these two measurements and suggests that leucocyte toxicity is primarly based on neutrophiles.

2.3 Neutrophiles

NAC patients showed insignifficant toxicity by neutrophiles counts (median=1590, 540:5190 vs median=1690, 610:3970, p=0.292) as well as grade of neutropenia (median=1, 0:3 vs median=1, 0:3, p=0.242).

Lowest Neutrophile count is not significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=-0.235, p=0.107), even less after adjuting for total chemotherapy received (RSpearman=0.057, p=0.704), but showed an increased correlation after adjuting for stage (RSpearman=-0.423, p=0.003 ).

On average, every additional neadjuvant chemotherapy cycle decreased the neutrophile count by 95.20 ±73.31 cells/mL (non significant). After adjusting for total chemotherapy received the average neutrophile count increased by 12.22 ±86.21 cells/mL (non significant) but after adjusting for stage, the average neutrophile count decreased by 234.40** ±78.53 cells/mL. However, when adjusting for both at the same time, the average neutrophile count increased by 135.03 ±91.59 cells/mL (non significant).

2.4 Lymphocytes

NAC patients showed insignifficant toxicity by lymphocyte counts (median=400, 70:950 vs median=390, 150:660, p=0.987) as well as grade of lymphopenia (median=3, 2:4 vs median=3, 1:4, p=0.381).

Lowest lymphocyte count is not significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=0.077, p=0.601), even after adjuting for total chemotherapy received (RSpearman=-0.073, p=0.627) nor after adjuting for stage (RSpearman=0.180, p=0.225).

On average, every additional neadjuvant chemotherapy cycle increased the lymphocyte count by 2.52 ±11.1 cells/mL (non significant). After adjusting for total chemotherapy received the average lymphocyte count decreased by 9.61 ±13.36 cells/mL (non significant) and after adjusting for stage, the average lymphocyte count increased by 11.25 ±13.05 cells/mL (non significant). When adjusting for both at the same time, the average lymphocyte count decreased by 1.08 ±15.51 cells/mL (non significant).

2.5 Platelets

NAC patients showed signifficantly more toxicity by platelet counts (median=108, 36:208 vs median=165, 56:462, p=0.017) but not by grade of thrombocytopenia (median=0, 0:3 vs median=0, 0:3, p=0.987).

Lowest platelet count is significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=-0.423, p=0.003), even after adjuting for total chemotherapy received (RSpearman=-0.249, p=0.091) and after adjuting for stage (RSpearman=-0.419, p=0.003).

On average, every additional neadjuvant chemotherapy cycle decreased the platelet count by 14.11** ±5.1 cells/mL. After adjusting for total chemotherapy received the average platelet count decreased by 14.41* ±6.3 cells/mL and after adjusting for stage, the average platelet count decreased by 17.85** ±6.0 cells/mL. When adjusting for both at the same time, the average platelet count decreased by 18.79* ±7.3 cells/mL.

2.6 Hemoglobin

NAC patients showed signifficantly lower hemoglobin (median=10.2, 8.7:11.9 vs median=11.6, 9:13.4, p=0.003) as well as a higher grade of anemia (median=1, 0:2 vs median=1, 0:2, p=0.025).

Lowest hemoglobin level is significantly correlated with the number of neoadjuvant chemotherapy cycles (RSpearman=-0.484, p<0.001), even after adjuting for total chemotherapy received (RSpearman=-0.371, p=0.010) and after adjuting for stage (RSpearman=-0.001, p=0.031).

On average, every additional neadjuvant chemotherapy cycle decreased the hemoglobin level by 0.29*** ±0.08 cells/mL. After adjusting for total chemotherapy received the average hemoglobin level decreased by 0.25* ±0.10 cells/mL and after adjusting for stage, the average hemoglobin level decreased by 0.22* ±0.09 cells/mL. When adjusting for both at the same time, the average hemoglobin level decreased by 0.17 ±0.11 cells/mL (p<0.1).

2.7 Other toxicities

In both groups, 10% of the patients had elevated creatinin levels. Among cases, 31.6% had registered urinary toxicity grade 1 (none with grade 2) while among controls 31% had toxicity grade 1 and another patient had grade 2 (p=0.787).

Digestive toxicity grade > 0 were found in 68.4% on the NAT patients (with 15.8% grade 2) and 55.2% (with 10.3% grade 2) of the control patients (p=348). RT was given to Lombo-aortics in 47.4% of the NAC patients and 10.3% of the control patinents (OR=7.8, p=0.006).

2.8 Notes:

A patient had no record of stage and was removed form the analisys. Another patient had radiotherapy duration of 400 days and was left blank.

3 Results

Table. 1: Summary table for the group (NaC / control) by several predictors. Notice that several levels have been joined together.
Factor Levels Total Control NAC Statistics
1 Group 48 29 (60.4%) 19 (39.6%)
2 Neoadjuvant chemotherapy Median (range) 0 (0:6) 0 (0:0) 4 (2:6) MW: p<0.001
3 Stage IB 1 (2.1%) 1 (3.4%) 0 (0.0%) V=0.62 (p=0.003)
4 IIA 1 (2.1%) 1 (3.4%) 0 (0.0%)
5 IIB 23 (47.9%) 20 (69.0%) 3 (15.8%)
6 IIIB 18 (37.5%) 6 (20.7%) 12 (63.2%)
7 IVA 3 (6.2%) 0 (0.0%) 3 (15.8%)
8 IVB 2 (4.2%) 1 (3.4%) 1 (5.3%)
9 Stage.numeric Median (range) 2.5 (1.5:4.5) 2.5 (1.5:4.5) 3.5 (2.5:4.5) MW: p<0.001
10 Dose Median (range) 40 (20:150) 40 (20:150) 40 (30:40) MW: p=0.027
11 Concomitant chemo cycles Median (range) 2 (1:5) 3 (1:5) 2 (1:4) MW: p=0.400
12 Lost cycles Median (range) 2 (0:4) 1 (0:4) 3 (1:4) MW: p<0.001
13 Total chemotherapy received Median (range) 0.6 (0.2:1) 0.6 (0.2:1) 0.4 (0.2:0.8) MW: p<0.001
14 Age Median (range) 53 (30:74) 53 (39:74) 54 (30:72) T-test: p=0.766
15 Age at diagnosis Median (range) 51.5 (29:72) 50 (36:72) 52 (29:71) T-test: p=0.672
16 Lowest Leucocyte count Median (range) 2470 (850:6310) 2510 (1080:5600) 2440 (850:6310) MW: p=0.393
17 Leucopenia grade Median (range) 2 (0:4) 2 (0:3) 2 (0:4) MW: p=0.250
18 Lowest Neutrophile count Median (range) 1645 (540:5190) 1690 (610:3970) 1590 (540:5190) MW: p=0.292
19 Neutropenia grade Median (range) 1 (0:3) 1 (0:3) 1 (0:3) MW: p=0.242
20 Lowest Lymphocyte count Median (range) 390 (70:950) 390 (150:660) 400 (70:950) MW: p=0.583
21 Lymphopenia grade Median (range) 3 (1:4) 3 (2:4) 3 (1:4) MW: p=0.381
22 Lowest Platelet count Median (range) 142.5 (36:462) 165 (56:462) 108 (36:208) MW: p=0.017
23 Thrombocytopenia grade Median (range) 0 (0:3) 0 (0:3) 0 (0:3) MW: p=0.987
24 Lowest Hemoglobin Median (range) 10.8 (8.7:13.4) 11.6 (9:13.4) 10.2 (8.7:12.9) T-test: p=0.003
25 Anemia grade Median (range) 1 (0:2) 1 (0:2) 1 (0:2) MW: p=0.025
26 Creatinin level elevated 5 (10.4%) 3 (10.3%) 2 (10.5%) OR=0.98 [0.15, 6.50] (p=1.000)
27 normal 43 (89.6%) 26 (89.7%) 17 (89.5%)
28 Urinary toxicity registered Median (range) 0 (0:2) 0 (0:2) 0 (0:1) MW: p=0.787
29 Digestive toxicity registered Median (range) 1 (0:2) 1 (0:2) 1 (0:2) MW: p=0.348
30 Type of fractination used 45/25 12 (25.0%) 6 (20.7%) 6 (31.6%) V=0.16 (p=0.526)
31 50.4/28 35 (72.9%) 22 (75.9%) 13 (68.4%)
32 50/25 1 (2.1%) 1 (3.4%) 0 (0.0%)
33 RT given to LomboAortics yes 12 (25.0%) 3 (10.3%) 9 (47.4%) OR=7.80 [1.75, 34.83] (p=0.006)
34 Patient received Secvential Boost instead of SIB yes 6 (12.5%) 2 (6.9%) 4 (21.1%) OR=3.60 [0.59, 22.02] (p=0.197)
35 Brachytherapy fractions Median (range) 3 (0:4) 3.5 (0:4) 3 (0:4) MW: p=0.598
36 Radiotherapy duration (days) Median (range) 37 (32:72) 37 (32:42) 38 (32:72) MW: p=0.126
Note:
OR: Odds-Ratio with Wald 95% CI and p-value from Fisher test.
MW: Mann-Whitney test
V: Cramer V and p-value from Chi-square test

3.1 NAC ~ Stage

## 
##  Spearman's rank correlation rho
## 
## data:  baza_de_date$`Neoadjuvant chemotherapy` and baza_de_date$Stage.numeric
## S = 8000, p-value = 0.00003
## alternative hypothesis: true rho is not equal to 0
## sample estimates:
##   rho 
## 0.562
## 
##  Wilcoxon rank sum test with continuity correction
## 
## data:  Stage.numeric by Group
## W = 100, p-value = 0.00007
## alternative hypothesis: true location shift is not equal to 0