Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents
Publication Date: June 4, 2019
Treatment
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 )
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ESAs should not be offered to patients with chemotherapy-associated anemia whose cancer treatment is curative in intent. ( EB , I , S )
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ESAs should not be offered to most patients with non-chemotherapy-associated anemia ( EB , L , S )
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ESAs may be offered to patients with lower risk myelodysplastic syndromes and a serum erythropoietin level ≤500 IU/L. ( EB , I , M )
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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 )
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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 )
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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 )
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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 )
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It is recommended that starting and modifying doses of ESAs follow FDA guidelines (see Table 2 for specific dosing information). ( IC , I , M )
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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 )
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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 )
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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 )
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Recommendation Grading
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Overview
Title
Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents
Authoring Organizations
American Society of Clinical Oncology
American Society of Hematology
Publication Month/Year
June 4, 2019
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
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
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D000740 - Anemia
Keywords
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.