Early Treatment of Anemia: Improving Therapeutic Effectiveness for the Cancer Patient
Paper Symposium
Activity Date: May 2007  — Activity Info: Volume 4, (5)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Early Treatment of Anemia: Improving Therapeutic Effectiveness for the Cancer Patient
Anthony P. Morreale, PharmD, MBA, BCPS*

The challenges of delivering supportive care in oncology have differed somewhat through the ages. In the past, the goal was to slow tumor growth, at any cost. As a result, adverse effects of chemotherapy were an inevitable and untreated part of the course. Today's oncology practice focuses not only on remission and cure, but also on minimizing the negative impact of cancer treatment. As a result, supportive care therapy has become a critical component of all chemotherapy regimens. Yet there are still instances when clinicians who try desperately to cure patients with aggressive, dose-intense regimens lose sight of how these treatments can impact a patient's day-to-day life. Although considerable progress has been made in preventing or alleviating many of the common toxicities associated with cancer and its therapy, some complications, such as anemia, are often overlooked, left untreated, or considered of lesser importance by healthcare providers. Many patients with hemoglobin (Hgb) levels less than the recommended target of 11 g/dL to 12 g/dL are never treated with erythropoietic therapy.1 

One of the major myelosuppressive effects of chemotherapy, anemia may be secondary to blood loss, displacement of normal bone marrow cells by malignant cells, myelotoxic therapy, or the tumor itself. Practitioners may not always adequately assess anemia unless it represents a source of significant symptoms or patient distress. Risk factors include platinum-based treatment regimens, specific tumor types, and low baseline Hgb levels. Anemia may have an impact on patient performance status, clinical symptoms, and possibly, therapeutic efficacy and survival.  The economic burden of anemia is substantial, with costs of untreated anemia arising from lost wages, increased hospitalization stays, and increased morbidity and mortality. Correction of anemia in patients with cancer has been demonstrated to result in substantial clinical improvements, in addition to diminished need for transfusions and possibly chemotherapy dose reductions and delays in chemotherapy administration. Therapeutic interventions, directed toward the underlying etiology of the anemia, involve iron supplementation, blood transfusion, and administration of recombinant human erythropoietin. Prior to the development of erythropoietic agents, transfusions were a mainstay of anemia treatment, often employed at significantly higher Hgb concentrations than that of today's levels. Erythropoietic agents have been shown in numerous well-controlled studies to increase Hgb levels, reduce the need for transfusions, and minimize anemia-related symptoms in patients with chemotherapy-induced anemia (CIA). However, these agents are also associated with substantial costs, consistently ranking as one of the highest annual drug expenditures. As a result, many healthcare providers have been charged with identifying the most cost-effective therapy, without compromising efficacy, patient safety, and convenience.

More than ever before, pharmacists have become immersed in oncology supportive care services, managing the often unavoidable and complicated adverse effects of today's intense chemotherapy regimens. At many institutions, a rounding pharmacist is often a catalyst for initiation of growth factors for anemia, thrombocytopenia, and neutropenia. Pharmacists are frequently charged with reviewing pertinent laboratory values, evaluating symptoms, and making therapeutic recommendations. Hospital and managed care pharmacists, in particular, are often given the responsibility of minimizing costs and optimizing efficient utilization of erythropoietic therapy. Therefore, it is critical for these providers to be well versed in the clinical and economic aspects of managing CIA.

This issue of University of Tennessee Advanced Studies in Pharmacy is dedicated to educating hospital and managed care pharmacists on the latest clinical strategy for assessing and managing CIA, in addition to the pharmacoeconomic evaluations that are pertinent in making therapeutic decisions. J. Michael Hayes, PharmD, RPh, provides an extensive discussion on the pathophysiology and management of CIA. A drug information coordinator at H. Lee Moffitt Cancer Center, Dr Hayes cites studies indicating that 70% to 90% of patients receiving myelosuppressive therapy experience anemia. He also refers to ongoing research on identification of certain risk factors that may be used to predict the development of CIA prior to administration of chemotherapy. The section on management of CIA includes direction from several treatment guidelines on diagnosing CIA, the use of appropriate therapeutic strategies (eg, erythropoietic agents, blood transfusions, and iron therapy), and current methods to assess response to therapy. Once anemia is identified (Hgb levels ≤11 g/dL), an initial risk assessment should include the severity of anemia, consideration of symptoms such as chest pain or dyspnea, and comorbidities. Although treatment guidelines differ somewhat on the Hgb concentration at which erythropoietin should be administered, there is general consensus that patients with Hgb levels of less than or equal to 10 g/dL, with or without accompanying symptoms, should receive therapy. Dr Hayes also addresses recent concerns regarding potential adverse effects of erythropoietic therapy.

Jon D. Herrington, PharmD, BCPS, BCOP, offers an economic perspective on the burden of anemia and its treatment. An assistant professor of internal medicine at Texas A&M University System Health Science Center, Dr Herrington cites multiple studies assessing healthcare utilization patterns (eg, hospital costs, medical treatment, and disability) associated with untreated anemia. In one analysis, the 6-month expenditures were $62 499 for anemic patients versus $36 871 for nonanemic patients, primarily as a result of hospitalization costs. His discussion on the pharmacoeconomic comparison of available therapies includes numerous studies looking at the impact of various erythropoietic dosing regimens on economic (direct and indirect costs), clinical (Hgb response, transfusions rates), and humanistic outcomes. Dr Herrington also discusses synchronization of therapy, the benefits of early treatment, and the role of the pharmacist in the management of CIA. He emphasizes the need for pharmacists to question patients about symptoms; assess patient-specific factors (eg, age and comorbidities) and chemotherapy regimens (platinum vs nonplatinum, dose intensity); apply current treatment guidelines to each patient individually; and follow up on patients' therapy.

The economic stakes of untreated anemia are high, but the costs of treatment are substantial as well. Hospital and managed care pharmacists are well positioned in making formulary decisions based on the available economic and clinical literature. Therefore, it is imperative for them to be well informed to make decisions that will benefit patients, healthcare providers, and medical institutions.


1.    National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: cancer- and treatment-related anemia. Available at: Accessed March 6, 2007.

*Chief, Pharmacy Services, VA San Diego Healthcare System, San Diego, California.
Address correspondence to: Anthony P. Morreale, PharmD, MBA, BCPS, Chief, Pharmacy Services, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.
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