IVICA: Intravenous Iron in Colorectal Cancer Associated Anaemia

• To determine if the use of intravenous ferric carboxymaltose can reduce the need for allogeneic blood transfusion compare to oral ferrous sulphate in patients with colorectal adenocarcinoma related anaemia [ Time Frame: 0 - 6 to 12 weeks ] [ Designated as safety issue: Yes ]
  To investigate if the number of units transfused per participant, the number of participants whom receive a blood transfusion and the total number of units of blood transfused differs between the two study arms. This period monitored will begin at enrolment into the study, and cease at review in outpatient clinic 6 - 12 weeks post operatively.
  
  

• To determine differences in haemoglobin and haematinic markers between the groups. [ Time Frame: Enrolment to 6-12 weeks postoperatively ] [ Designated as safety issue: No ]
  Hematinic markers include ferritin, iron, transferrin, transferrin saturation, erythropoietin.
  
  
• To determine differences in hepcidin levels in relation to blood profile changes in participants in the intravenous group. [ Time Frame: Enrolment to 6-12 weeks postoperatively. ] [ Designated as safety issue: No ]
  To review the use of hepcidin as a biomarker to predict response to therapy.
  
  
• To determine differences in colonic mucosal expression of iron transport proteins, C-myc and NKD1 between the groups [ Time Frame: At point of operation only ] [ Designated as safety issue: No ]
  Iron transport proteins include DMT TFR1, Ferroportin, Ferritin. As acquired from examination of pathology tissue specimen excised.
  
  
• To determine differences in postoperative outcomes between the groups. [ Time Frame: Enrolment to 6-12 weeks postoperatively ] [ Designated as safety issue: No ]
  Post-operative outcomes include morbidity, mortality, length of stay.
  
  
• To determine differences in anemia symptomatology response between groups. [ Time Frame: Enrolment to 6-12 weeks postoperatively ] [ Designated as safety issue: No ]
  Quality of Life questionnaires will be used (SF-36, EQ-5D)
  
  

Patients who are anemic at the time of operation have been shown to have an increased frequency of complications including wound infection and longer post-operative admissions. Similarly, patients who are anemic at the time of their cancer operation are more likely to require a blood transfusion which may increase the risk of recurrence of the cancer.

At present, oral iron is often used to treat anemia preoperatively in an attempt to minimise the risk above. This drug is often poorly tolerated due to the side effect profile. Blood transfusions can also be administered but expose the patient to other risks including infection and transfusion associated reactions. In order to overcome these issues, intravenous iron preparations have been developed and have improved in safety.

This is a mutli-center, randomised, open label clinical trial, which looks to investigate the efficacy of intravenous iron is in the treatment of preoperative anemia in colorectal patients. Patients will be randomised to receive intravenous ferric carboxymaltose (treatment group) or oral ferrous sulphate (control). The outcomes reviewed will include the amount and frequency of blood transfusions received, changes in patient blood profiles, patient quality of life scores, operative complications and hospital length of stay. The role of hepcidin as a biomarker of treament response will also be assessed.

The primary hypothesis to be tested is that intravenous iron will decrease transfusion rates. To detect a significant clinical difference in blood transfused consistent with previous published data (1 unit), 58 patients will be required in each arm of the study with 90% power (alpha 0.05).

Randomisation will be performed independently to the trial team using a computer generated variable block randomisation program.

All data will be confidentially recorded on a CRF, as will drug reactions and side effects.