Hematology/Oncology Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 09, 2018

In This Article

Cancer and Anemia and Iron Deficiency

European Society of Medical Oncology

Patients with solid tumors or hematologic malignancies

Treatment of anemia with an erythropoiesis-stimulating agent (ESA) should be considered in patients under chemotherapy (ChT) after correction of iron deficiency (ID) and other underlying causes other than the cancer or its treatment.

ESA therapy is recommended in patients with symptomatic anemia who receive ChT or combined RT-ChT and present with an Hb level <10 g/dL, as well as patients with asymptomatic anemia who receive ChT and present with an Hb level <8 g/dL.

ESA treatment is not recommended in patients who are not on ChT.

Dosing should follow the approved labels of the individual products; the currently recommended dosage is approximately 450 IU/week/kg body weight for epoetins alpha, beta and zeta; 6.75 µg/kg body weight every 3 weeks or 2.25 µg/kg body weight weekly for darbepoetin alpha; and 20 000 IU once weekly for epoetin theta.

Except for patients receiving epoetin theta (given at an intentionally low starting dose), ESA dose escalations and changes from one ESA to another in patients not responding within 4-8 weeks are not recommended. Patients who do not show evidence of at least an initial Hb response at this time should stop ESA therapy. The epoetin theta dose may be doubled after 4 weeks if Hb has not increased by at least 1 g/dL, unless functional ID is detected.

Patients receiving ongoing ChT who present with anemia (Hb ≤11 g/dL or Hb decrease ≥2 g/dL from a baseline level ≤12 g/dL) and absolute ID (serum ferritin <100 ng/mL) should receive iron treatment with an IV iron preparation to correct ID. If ESA treatment is considered, iron treatment should be given before the initiation of and/or during ESA therapy in the case of functional ID (transferrin saturation [TSAT] <20% and serum ferritin >100 ng/mL).

IV iron without additional anemia therapy may be considered in individual patients with functional ID (TSAT <20% and serum ferritin >100 ng/mL).

Iron treatment should be limited to patients on ChT. In patients receiving cardiotoxic ChT, IV iron should either be given before or after (not on the same day) administration of ChT or at the end of a treatment cycle.

In patients with Hb <7-8 g/dL and/or severe anemia-related symptoms (even at higher Hb levels) and the need for immediate Hb and symptom improvement, the administration of RBC transfusions without delay is justified.

Patients with myelodysplastic syndromes (MDS)

Treatment of anemia with an ESA should be considered in MDS patients with symptomatic anemia, Hb <10 g/dL, low to intermediate-1 risk (IPSS) or very low to intermediate risk (IPSS-R), less than two RBC transfusions per month, and/or serum erythropoietin [EPO] <500 IU/L.

ESAs should be given as fixed-dose, weekly, subcutaneous treatment at an initial dose in the range of 30,000 to 80,000 IU recombinant human EPO (epoetin theta starting dose is 20,000 IU) or up to 300 µg darbepoetin alpha.

In patients not responding to ESA treatment after 8-12 weeks, G-CSF should be added at ∼300 µg/week, given in 2-3 doses. RBC transfusions or investigational medicinal products should be considered as second-line treatment in patients without a 5q deletion, and lenalidomide in patients who acquired a 5q deletion.

Patients who require 2 or more RBC transfusions per month should be considered for treatment with an investigational agent or supportive care with RBC transfusions if they have no 5q deletion, or for lenalidomide if they have a 5q deletion.



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