Cancer- and Chemotherapy-Induced Anemia

Anemia is a common condition in patients with cancer, and its correction in selected patients through either transfusion with packed red blood cells or the administration of erythropoiesis-stimulating agents (ESAs) is a supportive care measure. The purpose of the guidelines is to operationalize the evaluation and treatment of anemia in patients with cancer and to enable patients and clinicians to evaluate anemia treatment options in the context of their risks and benefits. The 2008 version of the guidelines includes a number of important updates that respond to new FDA recommendations limiting the use of ESAs in cancer patients. Updates also include new tables on the risks and benefits of ESAs versus red blood cell transfusion and recommendations for administering parenteral iron products.

Hodgkin Disease/Lymphoma

Hodgkin disease/lymphoma (HD/HL) is an uncommon malignancy involving lymph nodes and the lymphatic system. In 2008, an estimated 8220 new diagnoses and 1350 deaths will occur in the United States. The past few decades have seen significant progress in the management of HL; it is now curable in at least 80% of patients. In fact, cure rates for HL have increased so extensively that the overriding treatment considerations often relate to long‑term toxicity, especially for patients with early‑ or intermediate‑stage disease. The World Health Organization classification divides HL into 2 main types: classical and lymphocyte‑predominant Hodgkin lymphoma (CHL and LPHL, respectively). These guidelines discuss the clinical management of CHL and LPHL, focusing exclusively on patients from postadolescence through the seventh decade of life who do not have serious intercurrent disease. 

Special Feature

Report on the NCCN Third Annual Patient Safety Summit
Jennifer M. Hinkel, MSc

The issues of patient safety and preventing medical errors routinely make headlines, with reports of thousands of preventable deaths and costs in the billions of dollars per year. Far less noticeable but potentially more important is the ongoing work to develop new systems and processes of safety and to leverage technology to reduce preventable adverse events. The NCCN Third Annual Patient Safety Summit examined processes central to maintaining patient safety in the oncology setting: medication reconciliation, communication during patient hand-offs, and reporting of events, including “near-miss” events that do not reach a patient or result in harm. At the NCCN Patient Safety Summit, diverse speakers shared clinical and practical experiences in implementing safety improvements with a multidisciplinary audience. As this overview article presents, common themes included transitions from paper to electronic systems, education and training as new methods are started, and the need for all members of the multidisciplinary care team to recognize their impact on patient safety.

CE/CME credit is available for this article.

Featured Articles

Erythropoiesis Stimulating Agents in Oncology
John A. Glaspy, MD

Patients who have cancer, particularly those undergoing chemotherapy, frequently become anemic. Therapy with erythropoiesis stimulating agents (ESAs) is associated with an increase in hemoglobin levels, reduction in transfusion requirements, and, according to many clinical trialists and experienced clinicians, an improvement in functional status, productivity, and quality of life. Several randomized trials of ESAs have recently reported inferior outcomes in tumor progression or survival, raising concerns about the safety of ESAs in oncology. The lack of definitive answers about the safety of ESAs for treating chemotherapy-related anemia can only be addressed with additional data. This article reviews relevant preclinical and clinical available data to help improve understanding and guide decision making.

Establishing an Anemia Clinic for Optimal Erythropoietic Stimulating Agent Use in Hematology-Oncology Patients
Jeffrey A. Gilreath, PharmD; Daniel S. Sageser, PharmD; James A. Jorgenson, RPh, MS; and George M. Rodgers, MD, PhD

Erythropoietic stimulating agent (ESA) therapy has significantly impacted the management of chemotherapy-induced anemia through decreasing the number of red blood cell transfusions required by patients with cancer. However, disparities between the Centers for Medicare & Medicaid Services’ new National Coverage Determination document and recommendations from expert-reviewed national clinical guidelines on the treatment of anemia make managing these patients using ESA therapy increasingly difficult. This article describes a collaborative practice agreement between pharmacists and physicians as one approach to managing chemotherapy-induced anemia in hematology-oncology patients in an anemia clinic. The authors describe the rationale for the clinic and discusses its design and implementation in managing ESA, iron, folate, and vitamin B12 therapy for chemotherapy-induced anemia.

Intravenous Iron in Oncology
Michael Auerbach, MD, and Harold Ballard, MD

Intravenous iron as an adjunct to therapy with erythropoiesis stimulatory agents (ESAs) is standard care in dialysis-associated anemia, adding large increments in hemoglobin and hematopoietic responses while decreasing transfusions without significant toxicity. Cost savings, decreased exposure to ESAs, and decreased times to reach target hemoglobins are realized. Although similar benefits have been seen in studies of patients with chemotherapy-induced anemia, experts are reluctant to incorporate routine use of intravenous iron into treatment, largely because of misinterpretation and misunderstanding of the clinical nature of adverse events reportedly associated with its administration. This article reviews published experience with more than 1000 patients in clinical trials involving the use of intravenous iron and presents evidence recommending its routine incorporation into treatment for chemotherapy-induced anemia. CME credit is available for this article via Medscape.

Role of PET/CT Scanning in Initial and Post-Treatment Assessment of Hodgkin Disease
Mehmet Ertuk, MD, and Annick D. Van den Abbeele, MD

Patients with Hodgkin disease can be cured with chemotherapy, radiation therapy, or combined regimens, with long-term survival rates as high as 90%. Moreover, patients experiencing relapse can be cured with second-line salvage treatments, often including high-dose chemotherapy followed by autologous stem cell transplantation. NCCN currently recommends PET/CT scanning in lymphoma for use in staging and as a baseline to assess therapeutic response, evaluate residual masses, and guide biopsy. Accurate staging and restaging during or after first-line treatment allows the selection of optimal treatment options. This article reviews the add-on value of F18-fluorodeoxyglucose positron emission tomography, particularly when combined with CT, in the initial staging and post-treatment assessment of Hodgkin disease.