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Review
. 2019 Apr 23;3(8):1197-1210.
doi: 10.1182/bloodadvances.2018030387.

Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update

Julia Bohlius  1 , Kari Bohlke  2 , Roberto Castelli  3 , Benjamin Djulbegovic  4 , Maryam B Lustberg  5 , Massimo Martino  6 , Giannis Mountzios  7 , Namrata Peswani  8 , Laura Porter  9 , Tiffany N Tanaka  10 , Gianluca Trifirò  11 , Hushan Yang  12 , Alejandro Lazo-Langner  13
Affiliations
Review

Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update

Julia Bohlius et al. Blood Adv. .

Abstract

Purpose: To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.

Methods: PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed.

Results: The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited.

Recommendations: ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines.

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Conflict of interest statement

Conflict-of-interest disclosure: B.D. received research funding from GlaxoSmithKline (to the author's institution [Inst]). M.B.L. served in a consulting or advisory role for Tempus, PledPharma, and Hologic/Cynosure. M.M. served in a consulting or advisory role for Italfarmaco, Kyowa Hakko Kirin, Teva, Sandoz-Novartis, Amgen, and Takeda; and received travel, accommodations, or expense compensation from Takeda, Janssen-Cilag, Celgene, and Sanofi. G.M. received honoraria from Roche, Boehringer Ingelheim, AstraZeneca, Merck Sharp & Dohme, and AstraZeneca Greece; was on the speakers’ bureau for AstraZeneca; and received travel, accommodations, or expense compensation from AstraZeneca and Ipsen. G.T. served in a consulting or advisory role for Bayer, Novartis, Servier, Sandoz-Novartis, Ipsen, Sanofi, Grünenthal Group, Otsuka, and Biogen; and received research funding from Amgen (Inst), Daiichi Sankyo (Inst), IBSA (Inst), and AstraZeneca (Inst). A.L.-L. received research funding from Alexion Pharmaceuticals (Inst), Bayer (Inst), Daiichi Sankyo (Inst), Pfizer (Inst), and Bristol-Myers Squibb (Inst). The remaining authors declare no competing financial interests.

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