An updated joint guideline by the American Society of Hematology (ASH) and the American Society of Clinical Oncology (ASCO) advises physicians about the appropriate use of erythropoiesis-stimulating agents (ESAs), a class of drugs that stimulate the bone marrow to produce more red blood cells, to treat cancer patients with chemotherapy-induced anemia. While the guideline cautions that ESAs are associated with shorter survival and increased risk of thromboembolism -- blood clots -- and tumor progression, it also recognizes their major benefit of reducing the need for red blood cell transfusions, which can potentially cause serious infections and adverse reactions in the immune system.
"This updated guideline offers clinicians the latest synthesis of the medical evidence surrounding use of ESAs in patients with cancer, including appropriate cautions where evidence is lacking or where risks may outweigh the use of ESAs," said J. Douglas Rizzo, MD, MS, Co-Chair of the guideline panel and Professor of Medicine at the Medical College of Wisconsin.
Those risks may include thromboembolism or even death, according to new data cited in the guideline, which suggests that physicians avoid the use of ESAs in cancer patients who are not receiving chemotherapy, except for those with myelodysplastic syndrome (MDS). At the same time, the guideline confirms the effectiveness of ESAs in sparing patients the need for transfusions, which can substantially impact quality of life. By recommending that physicians discuss individual risks and benefits of ESAs and blood transfusion with patients prior to therapy, the guideline recognizes the critical role of shared decision-making between the patient and the physician.
In addition to outlining the clotting risks of ESAs, the guideline makes specific recommendations on usage and provides insights into disease progression and patient survival. The guideline also details new thresholds for initiation and modification of ESAs, which are consistent with current FDA labeling.
Originally published in 2002 and last updated in 2007, the guideline was derived from analysis of individual patient data, various medical literature, and systematic reviews of published clinical trials. In developing the update, panel members considered all relevant literature published between January 2007 and January 2010. Additional evidence was considered when it was considered pertinent to each section of the updated guideline.
"These guidelines touch on almost all aspects of the use of ESAs in patients with cancer and MDS, as well as secondary issues, such as the role of iron supplementation," said Samuel Silver, MD, a member of ASH's Committee on Practice and Professor of Internal Medicine at the University of Michigan. "These are issues that confront practicing hematologists and oncologists on a daily basis, and we hope that these evidence-based recommendations will influence practice standards and result in better care for patients."
The guideline will be published ahead of print on the websites of Blood (bloodjournal.org), ASH's scientific journal, and ASCO's Journal of Clinical Oncology (jco.org) at 4:00 p.m. on October 25. The guideline will be published in print in Blood on November 18 and in the Journal of Clinical Oncology on November 20.
- J. D. Rizzo, M. Brouwers, P. Hurley, J. Seidenfeld, M. O. Arcasoy, J. L. Spivak, C. L. Bennett, J. Bohlius, D. Evanchuk, M. J. Goode, A. A. Jakubowski, D. H. Regan, M. R. Somerfield. American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer. Blood, 2010; DOI: 10.1182/blood-2010-08-300541
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