Diagnosis and management of anaemia and iron deficiency in patients with haematological malignancies or solid tumours in France in 2009-2010: the AnemOnHe study

OBJECTIVE

To describe the management of anaemia in 2009-2010 in France in patients with haematological malignancies (HM) or solid tumours (ST).

METHODS

Retrospective observational study in 57 centres, enrolling adult patients with HM or ST treated for an episode of anaemia (duration of the episode ≥ 3 months occurring in the last 12 months).

RESULTS

220 patients with ST (breast, 18%; lung, 18%) and 56 with HM (lymphoma, 60%) were included (median age, 68 years; female, 53%). Mean haemoglobin level at anaemia diagnosis was 9.3 ± 1.4 g/dL (<8 g/dL for 16%) and 9.8 ± 1.1g/dL (<8 g/dL for 6%) in HM and ST patients, respectively. At least one parameter of iron deficiency (ferritin, transferrin saturation) was assessed in 26% of HM and 19% of ST patients. Treatment of anaemia included erythropoiesis-stimulating agents (ESA) for 98% of HM and 89% of ST patients. Iron was prescribed to 14% (oral, 12%; intravenous, 2%) of HM patients and to 42% (oral, 17%; intravenous, 25%) of ST patients. The rates of blood transfusions were high: 70% in HM and 46% in ST patients; transfusions alone or administrated with ESA were more frequent in patients with Hb <8 g/dL.

CONCLUSION

Although recent guidelines recommend evaluating iron deficiency and correcting anaemia by using intravenous iron, our study in cancer patients evidenced that ESA and blood transfusions are still frequently used as the treatment of anaemia in cancer patients. Iron deficiency is insufficiently assessed (only one patient among five) and as a consequence iron deficiency is most likely insufficiently treated.

Iron replacement therapy in cancer-related anemia

PURPOSE

The incidence, etiology, and management of cancer-related anemia is reviewed and the role of i.v. iron therapy in its treatment is described.

SUMMARY

Between 30% and 90% of patients with cancer develop anemia due to direct effects of the disease, its treatment, underlying nutritional deficiencies, and the inflammation that characterizes chronic disease. Although the use of erythropoiesis-stimulating agents (ESAs) increases hemoglobin levels and decreases the need for transfusions, up to 50% of patients do not to respond to these drugs, usually due to the presence of absolute or functional iron deficiency. Multiple clinical trials have demonstrated that i.v. iron supplementation in patients with cancer-related anemia improves the response rate to ESAs, reduces the time to target hemoglobin levels, decreases ESA requirements, reduces costs, and is more efficacious than oral iron. These benefits are seen without increased toxicity. Nonetheless, i.v. iron remains underused in patients with cancer, partly due to misinformation and misinterpretation of the clinical nature of adverse events.

CONCLUSION

Intravenous iron is underutilized in patients with cancer-related anemia. Based on published evidence, i.v. iron supplementation in patients with absolute or functional iron deficiency can improve patient responses to ESAs and reduce ESA requirements and may also reduce the need for transfusions and improve quality of life.

Impact of erythropoiesis-stimulating agent prescribing at an Asian cancer center, after release of safety advisories

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) provide symptom relief and decrease blood transfusion support among patients with chemotherapy-induced anemia. However, due to increased cardiovascular events associated with off-labeled usage of ESAs, the FDA incorporated black box warnings in 2007 to include the following key points: (a) ESAs should be used only to treat anemia due to concomitant chemotherapy of a noncurative intent and (b) target hemogloblin level should not exceed 12 g/dL. Thus, this study was designed to compare the prescribing of epoetin alfa at National Cancer Centre Singapore before and after FDA black box updates. The secondary objective of this study was to evaluate the appropriateness of efficacy and toxicity monitoring of epoetin alfa.

METHODS

This was a retrospective, single-centered, drug utilization review. Patients who received at least one dose of epoetin alfa were included in this study. Utilization of epoetin alfa was segregated into two time periods: January 1, 2005 to October 15, 2007 (S1, Pre-safety advisories changes) and October 16, 2007 to December 10, 2009 (S2, Post-safety advisories changes).

RESULTS

A total of 171 patients were prescribed epoetin alfa at NCCS during the two time periods. However, only 139 patients were eligible for analysis, with 91 and 48 patients in S1 and S2 respectively. After safety advisory changes, there were more (18.2%) metastatic patients and fewer (19.1%) patients with cardiovascular co-morbidities who were prescribed epoetin alfa, the mean hemogloblin level when epoetin alfa was initiated was lowered by 0.46 g/dL, more (43%) dose adjustments were made for 'excessive' responders and more (40.7%) patients had fewer blood transfusions after epoetin alfa therapy (p < 0.05). However, blood pressure control, iron studies, and supplementation did not improve (p > 0.05).

CONCLUSION

This study suggested that oncologists have generally adopted the new ESA safety warnings and adjusted prescribing habits.

Parenteral iron therapy in cancer-associated anemia

Anemia is common in cancer patients. Its cause is multifactorial, so a brief workup is always necessary to rule out simple, reversible causes. Anemia of chronic disease/inflammation and chemotherapy-induced anemia are the most common causes. Symptomatic or clinically severe anemia may require treatment with blood transfusion or an erythropoiesis-stimulating agent (ESA). If ESA therapy is chosen, developing evidence now suggests that, similar to chronic renal failure patients on hemodialysis, the addition of intravenous iron can improve the response to ESA because of iron-restricted erythropoiesis, even in the iron-replete patient.