Anemia in cancer patients are important both in terms of quality of life as well as response to therapy. Cause of anemia is multi-factorial and its management is critical in optimizing best outcomes of cancer patients

1. Management of
anemia in cancer
patients
Dr. Ayushi Patni
Moderator: Dr Ajeet Kumar Gandhi
Dr RMLIMS, Lucknow

2. Anaemia= Hb<10gm/dl
Investigations:-
• CBC,KFT,LFT
• Iron profile {transferrin saturation(TSAT) and serum
ferritin(SF)}
• Folate and Vitamin B12 levels
• CRP
• Drug history
• Peripheral blood examination/bone marrow
examination
• Reticulocyte count, Occult blood loss and renal
insufficiency
• Coomb`s testing: CLL, NHL, AIH
• Endogenous erythropoietin levels in MDS patients
When will we treat anaemia?
• If Hb<10gm/dl and pt is symptomatic
• If Hb<8gm/dl even if asymptomatic
• If we want to give further chemotherapy or
radiotherapy

3. • Treatment options:-
– Nutritional
supplementation
• IV iron
• Vit B12
• Folic acid
– Erythropoiesis stimulating
agents (ESA)
– RBC transfusions
– Treatment of the underlying
cause eg. Cancer, bleeding,
etc.

4. TSAT <20% +
SF <100ng/ml
Absolute Iron Deficiency
IV iron
Ferric carboxy maltose:
Max. infusion dose-20mg/kg
body weight(1000mg iron per
week)
Min. infusion time-15 min
Add ESA if Hb<10gm/dl
TAST <20% +
SF-normal
Functional Iron Deficiency
ESA + IV Iron before or
during ESA therapy
No Iron Deficiency
ESA
Darbepoetin alpha:
6.75mcg/kg body
wt. every 3 weeks or
2.25mcg/kg body
wt. every week
If on follow up
iron deficiency
then add IV
Iron
If Hb <7-8gm/dl or severe anaemia related symptoms or rapid increase in Hb
required- RBC transfusion

5. Erythropoiesis
Stimulating
Agents
• Indications (ASCO/ASH Guideline):-
– symptomatic anaemia who receive
chemotherapy or combined CTRT with
Hb level <10 g/dL
– patients with asymptomatic anaemia
who receive chemotherapy with Hb
level <8 g/dL
• Hb target level : 10-12gm/dl (rise of>2g/dL
over a 4wk period should be avoided)
• ESA dose escalations and changes from one
ESA to another in patients not responding
within 4–8 weeks are not recommended. In
these patients ESA therapy should be
stopped.
• Side effects- venous
thromboembolism(VTE). Increased risk in
high haematocrit, older age, prolonged
immobilisation, malignant disease, major
surgery, multiple trauma, a previous VTE,
chronic heart failure, tumour types (e.g.
pancreatic cancer) and treatment regimens
(e.g. Lenalidomide, thalidomide, etc.)

6. Erythropoiesis
Stimulating
Agents
ESAs should be stopped:
• Desired Hb Concentration is achieved
• No response to ESAs therapy after 8 weeks of therapy
• Chemotherapy course is completed
ESAs should NOT be used for patients with cancer and
anaemia not associated with chemotherapy.
Weigh the risks of thromboembolism in patients who are
being considered for ESAs
Identify alternative causes of anaemia aside from
chemotherapy or the underlying malignancy
Some guidelines suggest not to use ESAs when intent of
treatment is cure
Epoetin alfa:
• 100-150 units/kg sc three times weekly along with supplemental iron
• 40,000 U weekly or 80,000 U every 2 weekly can also be given
Darbepoetin alfa:
• 2.25 micrograms/kg SC weekly or 500 mcg every 3 weeks
• 200 mcg every 2 weeks

7. • Indications of IV iron-
– patients on chemotherapy with Hb 11 g/dL or Hb decrease >2 g/dL from a
baseline level of 12 g/dL) and absolute ID.
– If ESA treatment is considered, iron treatment should be given before the
initiation of and/or during ESA therapy in functional ID
– Feeric carboxymaltose/ferumoxytol has less chances of anaphylactic
reactions
– Oral iron may be given and IV reserved for TS :20-50%; Ferritin 30-800
ng/ml