Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update

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 .

Erythropoietin and its derivatives: from tissue protection to immune regulation

“…Due to the potential risks, the 2019 American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) guidelines on management of cancer-associated anemia suggested that ESA should only be used in patients with CIA whose cancer treatment was not curative in intent and whose Hb was less than 10 g/dL. ESA should not be offered to patients whose cancer treatment was curative in intent or most patients with nonchemotherapy-induced anemia 68 .…”

Clinical Management of Anemia in Patients with Myelodysplastic Syndromes: An Update on Emerging Therapeutic Options

“…10 Furthermore, the American Society of Clinical Oncology (ASCO) and American Society of Hematology (ASH) guidelines for management of cancerrelated anemia recommend consideration of ESAs in patients with lower risk MDS and serum erythropoietin levels (sEPO) below 500 IU/L. 57 This is based on numerous clinical trials, which have shown increased efficacy of ESAs in lower-risk MDS patients with lower sEPO levels; in studies using an sEPO cutoff of 500 IU/L, those with lower sEPO levels had a 48-55% response rate to ESAs versus 10-16% in those with higher sEPO levels. 58 However, data suggest poor compliance with these guidelines in use of ESAs in the community.…”

Erythropoietin in Lupus: Unanticipated Immune Modulating Effects of a Kidney Hormone

“…Current FDA-approved indications for EPO include treatment of anemia associated with chronic kidney disease (CKD) or chemotherapy (40,41). The increased risk of thrombosis and stroke associated with EPO administration (39,40,(42)(43)(44) prompted researchers to design asialoerythropoietin, a desialytated version of recombinant EPO notable for its shorter half-life which allowed for its neuroprotective effects with limited effects on erythrocyte mass (45).…”