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Supportive Care For Anemias In Cancer Patients
Ernest H. Rosenbaum, MD

The Treatment of Anemia
Additional Treatments with erythropoietin for Anemia
The Treatment of Chronic Cancer-Related Anemia

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Anemias are one of the most common problems in cancer patients, especially in those undergoing treatment. 

Cancer is an inflammatory process giving rise to many chronic conditions such as anemia. This is due to several factors:
1. Erythropoietin is a hormone produced by the kidneys that is reduced in chronic illnesses, such as cancer, uremia, and chronic inflammations.
2. In chronic illnesses, the availability of iron from the body's iron stores is reduced. There is also a decrease in iron absorption from the stomach.
3. This leads to a decrease in red blood cell production, resulting in anemia because of bone marrow suppression due either to therapy or reduced erythropoietin production.

Cancer therapies, such as radiation or chemotherapy, decrease the bone marrow's production of red blood cells as well as a decreased ability to respond to erythropoietin. Cancer patients often lose blood due to surgery or become anemic from a decreased production, and this is often associated with poor nutrition. 

Patients receiving chemotherapy have up to a 100% chance of becoming anemic. This is also common in patients receiving extensive or prolonged radiation therapy. Hormonal therapy, such as used in breast cancer, may lead to a 20-25% chance of anemia.

The Treatment of Anemia
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Thus far, we have no proven safe way of treating anemia, despite the fact that blood banking techniques have improved dramatically, making safer blood units available for transfusion. 

1. Often, enough blood is not available because of emergency situations, and thus, for many transfusions, blood needs to be ordered in advance.
2. After patients receive blood, they develop antibodies that may cause an allergic-type reaction, especially after multiple transfusions have been given.
3. With multiple transfusions, the iron in the transfused blood becomes absorbed in the body in the bone marrow and organs. Thus, iron overload toxicity is often encountered.

Recombinant erythropoietin is now becoming a common practice to help stimulate red cell production in the bone marrow to correct anemia due to the cancer itself or its treatments.

Since 1990, the use of erythropoietin has increased with the knowledge of how to administer it and the mechanisms on how it works being discovered.

Initially, it was felt that mild anemias were asymptomatic, but studies have shown that when the hemoglobin is less than 11-12 gm, the patient has complaints, such as fatigue, tiredness, weakness, and thus a reduced quality of life. 

Since 1996, many papers on fatigue showed that it is the most common complaint of cancer patients, and this, like pain, which is the number two complaint, can be treated effectively by controlling anemia and pain problems. 

When erythropoietin became available, this offered an alternate approach to transfusions for the correction of moderate or severe anemias, and erythropoietin has been shown to be effective in mild anemias. When the hemoglobin is less than 12 gm, there is impairment in quality of life.

Not all patients respond to erythropoietin, and some studies have shown up to 50% of patients may be less responsive. In addition, erythropoietin is very expensive, and the treatment of cancer-related anemias requires three times the amount of erythropoietin than used for dialysis patients. There have also been some adverse reactions with hypertension and cardiovascular and cerebrovascular illnesses.

Additional Treatments with Erythropoietin for Anemia
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It was shown in renal failure dialysis patients that parenteral (IV) iron improves the response to erythropoietin. Also noted was that the amount of erythropoietin necessary to correct anemia was less.

When patients do not respond to erythropoietin, the use of parenteral iron improves the success rate and may also reduce the amount of erythropoietin necessary to maintain the hemoglobin up to 12 gm. 

Also of note is that erythropoietin is now being used earlier for the treatment of anemia, and when non-responsive, iron is added to the program. Transfusions are still necessary in selective cases, especially when there is an inadequate response or severe anemia. 

The Treatment of Chronic Cancer-Related Anemia
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The goal, in part, is to keep the hemoglobin up to and above 12 gm, and whether it is appropriate to give erythropoietin and iron when the hemoglobin gets to 13 gm, knowing it will drop, is a debatable question.

The goal is to try to maintain the hemoglobin greater than 11-12 gm to improve quality of life and adjust the available therapeutic options as necessary. Often during therapy, the hemoglobin is maintained at a 10-11 gm level with erythropoietin and iron support, knowing it would have been lower had such therapy not been given. Thus, a benefit is still achieved, although not perfect.

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Lyman,G.H., Glaspy,J., "Are there Clinical Benefits with Early Erythropoietic Intervention for Chemotherapy-Induced Anemia?" Cancer,2006:106, 223-233.

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