Current Practice In Diagnosis and Treatment of Chemotherapy-Induced Anemia In Five European Countries – A Patient Record Study

The most comprehensive study on the prevalence and treatment of anemia in cancer patients in Europe (ECAS) dates from 2004. A reevaluation of treatment patterns for anemia in cancer patients (ACT, 2009) focused on patients treated with erythropoiesis-stimulating agents (ESAs). The study reported here aimed to assess current practice in the diagnosis and treatment of chemotherapy-induced anemia (CIA) as well as the role of iron therapy.

Onco-hematologists in 5 European countries (France, Germany, UK, Spain, Switzerland; Jun - Oct 2009) completed forms asking for patient demographics, TNM stage of cancer, status of anemia, tests for diagnosis or confirmation of anemia, treatment, and if applicable details of iron therapy (used product, dosing regimen, reasons for prescription). Records of the last 5 CIA patients treated for anemia within the last 6 months were analyzed. Results are presented as mean [range] across countries.

244 physicians (194 hospital-, 50 office-based) reported 1209 cases. Lymphoma (23%), myeloma (13%), lung (14%) and breast (12%) cancer were the most frequent cancer types. Metastatic disease was present in 66% of 662 patients with solid tumors. Tests to confirm anemia comprised mainly hemoglobin (Hb; 89% [85-95%]) and serum ferritin (48% [32-56%]). Transferrin saturation (TSAT) was only tested in 13% [9-23%] of patients. In 11% of patients, Hb was the only test performed. At diagnosis, 71% [62-82%] presented with Hb ≤ 10 g/dL, the EMA/FDA recommended cut-off level for ESA treatment initiation. Ferritin ≤ 30 ng/mL, commonly used as an indicator of absolute iron deficiency, was seen in 17% [8-21%] of patients. However, 29% [18-80%] of patients tested for TSAT had levels ≤ 20%, indicating insufficient available iron for effective erythropoiesis. Anemia treatment included an ESA in 48% [13-81%] of patients. Although only 15% [9-22%] of patients had a Hb ≤ 8 g/dL at diagnosis, 54% [27-80%] received at least one blood transfusion in the 6 months prior to the survey. Iron treatment (oral or i.v.) was given in 23% [8-56%] of patients of whom, 62% received iron in combination with an ESA, 31% received iron in combination with red blood cell transfusion and 23% received iron alone; 35% in these three groups received i.v. iron. ‘Quick onset of action’ was stated as main reason for the use of i.v. iron in 35% of cases. Interestingly, the decision for oral iron treatment was justified by ‘Effective when used in combination’ in 31% of cases although clinical trials have shown that oral iron in contrast to i.v. iron does not add to the benefit of ESA therapy.

Despite pivotal trials showing the efficacy of i.v. iron supplementation in ESA-treated cancer patients and the potential to reduce required ESA doses or blood transfusions, the majority of anemic cancer patients are still treated with ESAs or blood transfusions alone. Only 23% receive iron therapy in routine practice. Compared to the patients who received anemia treatment in the 2004 ECAS study, this study reveals only moderately higher rates of iron treated patients (23 vs. 17%) whereas the frequency of blood transfusions is substantially higher (54 vs. 38%). Furthermore, only one third of iron treated patients receive i.v. iron despite of international guidelines recommending i.v. iron for the treatment of absolute and functional iron deficiency in cancer patients and oral iron has not been proven effective in these patients. This gap in the awareness about iron metabolism in specific patient populations is also reflected in the underuse of TSAT determination, a reliable and widely available marker of absolute and functional iron deficiency. Diagnosis of iron deficiency is still mainly based on ferritin although NCCN guidelines consider patients with ferritin levels up to 800 ng/mL as functionally iron deficient if TSAT is <20%. This study confirms the need to increase awareness about the impact of cancer on iron metabolism and about evidence-based recommendations for i.v. iron supplementation.

Beguin:Vifor Pharma: Honoraria, Membership on an Advisory Board. Aapro:Vifor Pharma: Honoraria, Membership on an Advisory Board. Bokemeyer:Vifor Pharma: Membership on an Advisory Board. Glaspy:Vifor Pharma: Membership on an Advisory Board. Hedenus:Vifor Pharma: Honoraria, Membership on an Advisory Board. Littlewood:Vifor Pharma: Honoraria, Membership on an Advisory Board. Ludwig:Vifor Pharma: Honoraria, Membership on an Advisory Board. Österborg:Vifor Pharma: Honoraria, Membership on an Advisory Board. Mitchell:Vifor Pharma: Employment.