RBC storage duration does not affect biochemical recurrence after radical prostatectomy

The relationship between red blood cell (RBC) storage duration and cancer recurrence remains controversial, with the "storage lesion" potentially amplifying transfusion-related immunomodulation effects. This retrospective cohort study examined whether RBC storage duration is independently associated with biochemical recurrence following radical prostatectomy for prostate cancer. We analyzed 316 men who underwent radical prostatectomy with perioperative allogeneic RBC transfusion at Cleveland Clinic (1998-2007). Patients were stratified by RBC storage duration: younger ([≤]13 days, n=106), middle (13-18 days, n=103), and older ([≥]18 days, n=107). Primary outcome was biochemical recurrence (PSA [≥]0.4 ng/mL). We employed Kaplan-Meier survival analysis, Cox proportional hazards regression, and multivariable logistic regression with comprehensive diagnostics. Missing data (10.8%) were handled using multiple imputation by chained equations (MICE). Over median follow-up of 36.2 months, 54 patients (17.1%) experienced biochemical recurrence. RBC storage groups demonstrated exceptional baseline balance (all p>0.05). Kaplan-Meier analysis showed virtually identical survival curves (log-rank p=0.98). In fully adjusted Cox regression, neither middle (HR=1.01, 95% CI: 0.47-2.18, p=0.987) nor older (HR=0.82, 95% CI: 0.38-1.76, p=0.569) RBC storage was associated with recurrence. Logistic regression yielded consistent results (middle: OR=0.85, p=0.692; older: OR=0.93, p=0.854). Effect estimates remained stable across progressive covariate adjustment. In contrast, tumor biology factors demonstrated powerful associations: Gleason 8-10 (OR=5.72, p=0.001), log(PSA) (OR=2.24, p=0.007), and organ confinement (OR=0.48, p=0.047). Model discrimination was excellent (C-index=0.798, AUC=0.805), driven entirely by tumor characteristics. RBC storage alone provided zero discriminative ability (AUC=0.511). RBC storage duration (10-25 days) is not associated with biochemical recurrence after radical prostatectomy. This null finding is consistent across three complementary analytical methods. Tumor biology dominates prognosis with effect sizes far exceeding any potential transfusion effects. Current blood banking practices appear oncologically safe within typical storage windows.