Chemotherapy-induced Anaemia

Chemotherapy-induced Anaemia

Aldoss Ibrahim T, Silberstein Peter T, Wilson Sue
ASIA PACIFIC ONCOLOGY & HAEMATOLOGY - VOLUME 1
Published: April 2009
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Anaemia is a frequent complication of malignancy and is aggravated by chemotherapy.1,2 Up to 90% of cancer patients experience anaemia during the course of the disease;1 however, the frequency varies with the type and stage of the tumour and treatment. Chemotherapy reduces the haemoglobin (Hgb) level by inducing a suppressive effect on bone marrow and toxic effects on erythrocytes. The incidence of anaemia has been correlated directly with the number of chemotherapy cycles the patient receives.3 Early studies demonstrated a profound adverse impact of anaemia on a cancer patient’s functional capacity, quality of life (QOL), prognosis and survival.4–6 Pre-clinical studies have shown that anaemia is associated with antineoplastic therapy resistance,7,8 which is partially attributed to the hypoxic effect of anaemia and the reliance of ionising radiation, as well as certain types of chemotherapy agents, on adequate tissue oxygenation for their ability to kill cancer cells. Therefore, anaemia theoretically contributes to furthering malignant progression and tumour survival in the oncology anaemic patients.9–14

Treatment of CIA
In malignant patients, it is crucial to consider potential reversible aetiologies of anaemia before starting erythropoiesis-stimulating agents (ESAs). Therefore, a comprehensive history and physical examination are warranted, and the exposure list of the medications should be reviewed. Screening diagnostic tests should be conducted, which include iron studies, folate, vitamin B12 and peripheral blood smear. Patients should be evaluated for occult blood loss and renal insufficiency. In patients with underlying chronic lymphocytic leukaemia and non-Hodgkin’s lymphoma, direct Coomb’s testing may be needed to exclude an autoimmune mechanism of anaemia. Blood transfusion was the cornerstone therapy for many years in chemotherapy-induced anaemia (CIA), although this trend has changed because ESAs have decreased transfusion requirements. However, transfusion remains the first-line therapy if acute intervention is required and in patients who have failed or have contraindications to ESAs. In addition, the change in US Food and Drug Administration (FDA) indication does not allow ESAs to be given to CIA patients treated with curative intent.

The Introduction of ESAs and Their Efficacy in Reducing Transfusion Requirements
Three different recombinant erythropoietins (Epo) are available: epoetin alfa, pegzerepoetin alpha and darbepoetin alpha. Pegzerepoetin alpha is not commercially available in the US. Darbepoetin alpha has an additional Nlinked oligosaccharide chain that provides a three-fold greater terminal halflife with a five-fold lower affinity for Epo receptors compared with erythropoietin alfa.16 Trials and comprehensive systematic reviews have shown equality of the different ESAs in Hgb rise and a reduction of transfusion requirements or thromboembolic incidence;17–21 therefore, the indications, concerns and warnings are similarly applied for all ESAs. Epoetin alpha was approved by the FDA for treating CIA in patients with nonmyeloid malignancies in 1993, followed by darbepoetin alpha in 2002. Trials have established their efficacy in raising Hgb levels and reducing blood transfusion,22–25 and a systematic review by Bohlius et al. has found that treatment with ESAs increases Hgb levels and reduces the need for blood transfusions by 40%, with an average of one unit fewer of red blood cells (RBCs) transfusion in patients receiving ESAs compared with the control group.24 The advantage of ESAs over blood transfusion is their ability to induce a more sustained correction of Hgb, remove the risk of blood-borne infectious agents and confer a more convenient therapy for the patient. The use of ESAs has spread worldwide and has emerged as one of the most utilised medications in oncology, despite the fact that studies have never proved a survival benefit. The rationale behind their spread was the belief of their ability to promote QOL.

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Keywords:
Chemotherapy-induced Anaemia, Nausea and vomiting, anti-emetics, chemotherapy, chemotherapeutic agents, types of antibiotics, chemotherapy side effects, cancer vomiting, Chemotherapy induced Nausea and Vomiting, nausea vomiting,

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