Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents

Publication Date: June 4, 2019
Last Updated: December 15, 2022


Depending on clinical circumstances ESAs may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to <10 g/dL. Red blood cell transfusion is also an option, depending on the severity of the anemia or clinical circumstances. ( EB , H , S )

ESAs should not be offered to patients with chemotherapy-associated anemia whose cancer treatment is curative in intent. ( EB , I , S )

ESAs should not be offered to most patients with non-chemotherapy-associated anemia ( EB , L , S )

ESAs may be offered to patients with lower risk myelodysplastic syndromes and a serum erythropoietin level ≤500 IU/L. ( EB , I , M )

In patients with myeloma, non-Hodgkin’s lymphoma, or chronic lymphocytic leukemia, clinicians should observe the hematologic response to cancer treatment before considering an ESA. Particular caution should be exercised in the use of ESAs concomitant with treatment strategies and diseases where risk of thromboembolic complications is increased (see Recommendations 4 and 8). In all cases, blood transfusion is a treatment option which should be considered. ( IC , L , M )

Before offering an ESA, clinicians should conduct an appropriate history, physical examination, and diagnostic tests to identify alternative causes of anemia aside from chemotherapy or an underlying hematopoietic malignancy. Such causes should be appropriately addressed before considering the use of ESAs. Suggested baseline investigations are listed in Table 1. ( IC , I , S )

The Expert Panel considers epoetin beta and alfa, darbepoetin, and biosimilar epoetin alfa to be equivalent with respect to effectiveness and safety. ( IC , I , M )

ESAs increase the risk of thromboembolism, and clinicians should carefully weigh the risks of thromboembolism and use caution and clinical judgment when considering use of these agents. ( EB , H , S )

It is recommended that starting and modifying doses of ESAs follow FDA guidelines (see Table 2 for specific dosing information). ( IC , I , M )

Hb may be increased to the lowest concentration needed to avoid or reduce the need for red blood cell transfusions, which may vary by patient and condition. ( IC , I , M )

ESAs should be discontinued in patients who do not respond within 6 to 8 weeks. Patients who do not respond to ESA treatment should be re-evaluated for underlying tumor progression, iron deficiency, or other etiologies for anemia. ( IC , I , S )

Iron replacement may be used to improve hemoglobin response and reduce red blood cell transfusions for patients receiving ESA with or without iron deficiency. Baseline and periodic monitoring of iron, total iron binding capacity, transferrin saturation, or ferritin levels is recommended. ( EB , I , W )

Recommendation Grading




Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents

Authoring Organizations

Publication Month/Year

June 4, 2019

Last Updated Month/Year

January 18, 2023

Document Type


External Publication Status


Country of Publication


Target Patient Population

Adults with cancer and anemia.

Target Provider Population

Oncologists, hematologists, oncology nurses, oncology pharmacists, other

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D000740 - Anemia


anemia, erythropoiesis-stimulating agents, ESAs, Cancer-Associated Anemia

Source Citation

DOI: 10.1200/JOP.19.00111 Journal of Oncology Practice 15, no. 7 (July 01, 2019) 399-402.

Supplemental Methodology Resources

Data Supplement