paywalled: Treatment of Chemotherapy-Induced Anemia in Ovarian Cancer Patients: Does the Use of Erythropoiesis-Stimulating Agents Worsen Survival?

Treatment of Chemotherapy-Induced Anemia in Ovarian Cancer P... : International Journal of Gynecological Cancer

Abstract

Objective: 

Considering the paucity of data relating erythropoiesis-stimulating agent (ESA) use to ovarian cancer survival, our objective was to evaluate the effect of ESA as used for the treatment of chemotherapy-induced anemia (CIA) on survival in ovarian cancer patients.

Materials and Methods:  

A multi-institution retrospective chart review was performed on ovarian cancer patients. Data collection included patient demographic, surgicopathologic, chemotherapy, ESA, and survival data. Patients were stratified by ever-use of ESA and were compared using appropriate statistical methods.

Results: A total of 581 patients were eligible for analysis with 39% (n = 229) patients with ever-use of ESA (ESA-YES) and 61% (n = 352) never-use ESA (ESA-NO). Mean age was 60.4 years with most patients having stage IIIC (60%) of papillary serous histological diagnosis (64%) with an optimal cytoreduction (67%). Median follow-up for the cohort was 27 months. Both ESA-YES and ESA-NO groups were similar regarding age, body mass index, race, stage, histological diagnosis, and debulking status. Compared with the ESA-NO group, ESA-YES patients were significantly more likely to experience recurrence (56% vs 80%, P < 0.001) and death (46% vs 59%, P = 0.002). Kaplan-Meier curves demonstrated a significant reduction in progression-free survival for ESA-YES patients (16 vs 24 months, P < 0.001); however, overall survival was statistically similar between the 2 groups (38 vs 46 months, P = 0.10). When stratifying by ever experiencing a CIA, ESA-YES patients demonstrated a significantly worse progression-free survival (17 vs 24 months, P = 0.02) and overall survival (37 vs 146 months, P < 0.001).

Conclusions: 

Our data evaluating the use of ESA as a treatment of CIA in ovarian cancer patients are similar to reports in other tumor sites. Considering that patients who used ESA were more likely to experience recurrence and death and to have decreased survival, the use of ESA in ovarian cancer patients should be limited.

Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of i.v. iron

Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of i.v. iron

Background: Chronic diseases reduce the availability of iron for effective erythropoiesis. This review summarises clinical consequences of iron deficiency (ID) and anaemia in cancer patients, mechanisms how impaired iron homeostasis affects diagnosis and treatment of ID, and data from clinical trials evaluating i.v. iron with or without concomitant erythropoiesis-stimulating agents (ESAs).......

Blogger's Note: table includes solid tumors

Table 1.

Reported prevalence of iron deficiency in different cancer patient populations

"potential role for i.v. iron as first-line therapy for CIA?

Guidelines recommend treatment of underlying causes of anaemia such as ID before initiation of an ESA. However, studies examining i.v. iron as sole anaemia treatment in cancer patients are only just starting to emerge. Two relevant small (N = 44 and 75 patients), controlled, randomised clinical trials have been published. Both studies involved patients with gynaecologic cancers receiving chemotherapy or radiochemotherapy, and in both, i.v. iron supplementation significantly reduced the number of required blood transfusions [15, 16]. In one study, significantly higher Hb levels were observed in the i.v. iron compared with the oral iron group at the end of the study period, although mean Hb levels included data from patients who received transfusions as well as those who did not [15]. The other study, comparing i.v. iron versus no anaemia treatment, achieved a lower rate in transfusions despite a higher baseline proportion of anaemic patients in the study group [16]. Both studies missed to assess iron status parameters such as TSAT and serum ferritin; thus, the proportion of patients with either functional or absolute ID could not be determined."

cross references:

1. 15.↵
   1. Dangsuwan P,
   2. Manchana T

   . Blood transfusion reduction with intravenous iron in gynecologic cancer patients receiving chemotherapy. Gynecol Oncol 2010;116:522-525.

   CrossRefMedline

   1. 16.↵
      1. Kim YT,
      2. Kim SW,
      3. Yoon BS,
      4. et al

      . Effect of intravenously administered iron sucrose on the prevention of anemia in the cervical cancer patients treated with concurrent chemoradiotherapy. Gynecol Oncol 2007;105:199-204.

      CrossRefMedline

       Concluding remarks

      The high prevalence of ID and anaemia in cancer patients suggests that these complications may need more attention in clinical practice. Current guidelines for treating anaemic cancer patients recommend that ID should be considered as underlying cause of anaemia before initiating ESA treatment and acknowledge that i.v. iron supplementation is superior to oral iron. .....................Published randomised controlled trials show that i.v. iron enhances response rates to ESA therapy and may be effective in reducing ESA doses and blood transfusion requirements, even if long-term safety remains to be examined. Available early reports on the use of i.v. iron as first-line anaemia therapy suggest that some patients could benefit from i.v. iron even without concomitant ESA. However, larger randomised controlled studies with long-term follow-up are necessary to confirm long-term efficacy and safety.

Survivin Small Interfering RNA Transfected With a Microbubbl... : International Journal of Gynecological Cancer

Conclusions: Delivery of survivin siRNA using a microbubble contrast agent combined with ultrasound exposure can effectively inhibit survivin expression and induce apoptosis, providing a new promising approach for siRNA delivery in vivo.

ESAs (erythropoiesis-stimulating agents) not cost effective in cancer patients with anemia | HemOncToday

Blogger opinion: more concerning than cost is the recent research regarding increased mortality rates with the use of ESAs

"The use of erythropoiesis-stimulating agents to reduce the need for blood transfusions and improve quality of life in cancer patients with anemia was found to be economically unattractive by an analysis using the Canadian public health care system."

Previous work has shown that erythropoiesis-stimulating agents (ESAs) are preferred by patients compared with transfusion and can improve short-term disease-specific quality of life in patients with cancer, but there are concerns over toxicity and cost of the agents. Researchers created a decision analytic model incorporating resource utilization and health outcomes to test the cost-effectiveness of ESA use in patients with anemia related to cancer. Using a model cohort, treatment with epoetin resulted in incremental costs of $8,643 over 15 weeks compared to no ESA use. This gave an incremental cost per quality-of-life-year (QALY) gained of $267,000. Even when a model overemphasizing the potential benefits of ESAs was used, the cost per QALY gained remained greater than $100,000.
Finally, separate analyses were conducted using data from studies that followed the most recent American Society of Hematology/ASCO guidelines for ESA use; these guidelines are more conservative in their recommendations for using ESAs. The results did show lower costs than the base case, but the cost per QALY remained greater than $70,000. In three of 10 models, ESA use had more cost and less benefit than no ESA use.
“ESA use in patients with [anemia related to cancer] does not appear to be economically attractive, even when used in the more conservative fashion recommended by current guidelines,” the researchers wrote. “Available evidence suggests that using ESA to treat anemia related to cancer does not represent a good value for the money.”

link to abstract: 
http://www3.interscience.wiley.com/journal/123359351/abstract?CRETRY=1&SRETRY=0