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Chemotherapy often lowers the red blood cells, causing tiredness and breathlessness. Your team should first look for other causes such as low iron or blood loss. If the treatment is not aimed at cure, injections that stimulate red cell production (ESAs) or a blood transfusion are options; if the aim is cure, ESAs are not used because of their risks.
ASCO/ASH (2019) ask clinicians first to look for and treat other causes of anaemia (drug history, blood film, iron studies including ferritin and transferrin saturation, folate, vitamin B12, reticulocytes, occult blood loss, renal function, erythropoietin level, thyroid where indicated). ESAs may be offered for chemotherapy-associated anaemia when treatment is not curative in intent and haemoglobin has fallen below 10 g/dL, with red cell transfusion as an alternative (evidence based, high quality, strong); they should not be offered when treatment is curative (strong), nor to most people whose anaemia is not chemotherapy-associated (strong), except lower-risk myelodysplastic syndromes with erythropoietin 500 IU/L or below.
ESAs raise the risk of venous thromboembolism (high quality, strong), so the risk is weighed for each person. Doses follow the product's licence; haemoglobin is raised only to the lowest level that avoids transfusion; ESAs stop if there is no response in 6 to 8 weeks, prompting a search for progression or iron deficiency (strong). Iron replacement may be used with an ESA, with baseline and periodic iron studies (weak). In myeloma, non-Hodgkin lymphoma and CLL the response to cancer treatment is observed before an ESA is considered. NICE TA323 recommends ESAs within their licences for anaemia in people having chemotherapy, choosing the cheapest suitable product. Epoetin alfa and beta, darbepoetin and biosimilar epoetin alfa are considered equivalent.
Why: Anaemia during cancer care often has a treatable cause, such as iron deficiency or bleeding, that an ESA would not fix.
“Before offering an ESA, clinicians should conduct an appropriate history, physical examination, and diagnostic tests to identify alternative causes of anemia aside from chemotherapy or an underlying hematopoietic malignancy.”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · informal consensus; evidence quality intermediate; strength strong
Why: ESAs reduce the need for transfusions; a transfusion works faster when symptoms are severe.
“Depending on clinical circumstances, ESAs may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin (HgB) has declined to < 10 g/dL.”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · evidence based; evidence quality high; strength strong
Why: ASCO/ASH judged the possible harms of ESAs not worth taking when the aim of treatment is cure.
“ESAs should not be offered to patients with chemotherapy-associated anemia whose cancer treatment is curative in intent”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · evidence based; evidence quality intermediate; strength strong
Why: ASCO/ASH found no case for routine use outside chemotherapy and lower-risk MDS.
“ESAs should not be offered to most patients with nonchemotherapy-associated anemia”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · informal consensus; evidence quality low; strength strong
Why: ESAs increase the risk of venous thromboembolism, which is already raised in cancer.
“ESAs increase the risk of thromboembolism, and clinicians should carefully weigh the risks of thromboembolism and use caution and clinical judgment when considering use of these agents”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · evidence based; evidence quality high; strength strong
Why: ASCO/ASH set no fixed target; the aim is to avoid transfusion, not to reach a normal count.
“HgB may be increased to the lowest concentration needed to avoid or reduce the need for RBC transfusions, which may vary by patient and condition”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · informal consensus; evidence quality intermediate; strength moderate
Why: Iron improves the response to an ESA and reduces transfusions, with or without measured iron deficiency.
“Iron replacement may be used to improve HgB response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency.”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · evidence based; evidence quality intermediate; strength weak
Why: If it has not worked by then, continuing adds risk and cost without benefit.
“ESAs should be discontinued in patients who do not respond within 6 to 8 weeks.”
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · informal consensus; evidence quality intermediate; strength strong
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
ASCO/ASH (2019), read in full, is the most detailed current guideline: investigate other causes first, offer an ESA or transfusion for chemotherapy-associated anaemia below 10 g/dL only when treatment is not curative, weigh the clot risk, aim for the lowest haemoglobin that avoids transfusion, stop after 6 to 8 weeks without response, and consider iron alongside. NICE TA323 (2014) recommends ESAs within their marketing authorisations for people having chemotherapy and does not repeat ASCO/ASH's restriction to non-curative treatment; the licences themselves were not read. ESMO's 2018 guideline, which covers intravenous iron in more detail, could not be read.
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 · NICE 2014 · ESMO, Annals of Oncology 2018
Where it differs: Recommends epoetin alfa, beta, theta and zeta and darbepoetin alfa within their marketing authorisations for anaemia in people having chemotherapy, and the product with the lowest acquisition cost where several are suitable.
Evidence: A NICE technology appraisal of cost-effectiveness; NICE does not grade it. ASCO/ASH likewise consider the products equivalent (informal consensus, moderate).
NICE 2014 · ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019
Where it differs: In myeloma, non-Hodgkin lymphoma and chronic lymphocytic leukaemia, observes the blood count response to cancer treatment before considering an ESA.
Evidence: ASCO/ASH recommendation 3; the response to treatment may correct the anaemia without an ESA.
ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019
| Recommendation | Grade, as printed | Source |
|---|---|---|
| ESA or transfusion for chemotherapy-associated anaemia below 10 g/dL, non-curative treatment | evidence based; high; strong | ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 |
| No ESA when treatment is curative | evidence based; intermediate; strong | ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 |
| ESA for lower-risk MDS with erythropoietin 500 IU/L or below “ESAs may be offered to patients with lower risk myelodysplastic syndromes and a serum erythropoietin level ≤ 500 IU/L” | evidence based; intermediate; moderate | ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 |
| ESAs increase thromboembolism risk | evidence based; high; strong | ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 |
| Iron with an ESA | evidence based; intermediate; weak | ASCO and the American Society of Hematology, Blood Advances (also published in J Clin Oncol) 2019 |
Shares Epoetin theta, Darbepoetin alfa, Epoetin alfa, Anaemia.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares Epoetin theta, Darbepoetin alfa, Epoetin alfa, Anaemia.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares Darbepoetin alfa, Epoetin alfa, Anaemia.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, supportive-care.
Shares National Institute for Health and Care Excellence and the tags protocol, supportive-care.