Guideline sources The following summarized guidelines for the evaluation and management of cancer-related anemia are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH/ASCO 2019) and the European Society of Medical Oncology (ESMO 2018). 1 2 Guidelines 1. Diagnostic investigations Initial assessment: Elicit appropriate history, perform physical examination, and obtain diagnostic tests to identify alternative causes of anemia aside from chemotherapy or an underlying hematopoietic malignancy, and appropriately address such causes before offering ESAs. B Consider obtaining the following tests for baseline evaluation for anemia in patients with cancer receiving chemotherapy: thorough drug exposure history peripheral blood smear, and bone marrow examination in some cases TIBC, transferrin saturation, ferritin, folate, vitamin B12, Hgbopathy screening, where indicated reticulocyte count, occult blood loss, and assessment for renal insufficiency baseline EPO level serum TSH, where indicated https://web.pathway.md/diseases/reco6JCPQ8r0pcXSF 1/4 6/29/23, 3:25 AM Cancer-related anemia Pathway direct Coombs test in patients with chronic lymphocytic leukemia, non-Hodgkin lymphoma, or history of autoimmune disease. B 2. Medical management Goals of treatment: Consider increasing Hgb level to the lowest concentration required to avoid or reduce the need for RBC transfusions, varying by patient and condition, in adult patients with chemotherapy- associated anemia being candidates for ESAs. C Target Hgb stable level of ~12 g/dL without RBC transfusions. A Erythropoiesis-stimulating agents, indications: As per ASH/ASCO 2019 guidelines, offer ESAs in patients with chemotherapy-associated anemia and Hgb level of < 10 g/dL, if their cancer treatment is not curative in intent. A Show 5 more As per ESMO 2018 guidelines, consider offering ESAs in patients with anemia receiving chemotherapy, after correction of iron deficiency and other underlying causes other than cancer or its treatment. B Show 3 more Erythropoiesis-stimulating agents, choice of agent and dosing: As per ASH/ASCO 2019 guidelines: Recognize that epoetin beta and alpha, darbepoetin, and biosimilar epoetin alpha are equivalent with respect to effectiveness and safety. B Start and modify doses of ESAs according to U.S. FDA guidelines. B As per ESMO 2018 guidelines, follow the approved labels of the individual products for dosing: Situation Guidance 450 IU/week/kg body weight Epoetins alpha, beta and zeta 6.75 g/kg body weight every 3 weeks or 2.25 g/kg body weight weekly Darbepoetin alpha 20,000 IU once weekly. A Epoetin theta Show 3 more Erythropoiesis-stimulating agents, discontinuation: As per ASH/ASCO 2019 guidelines, discontinue ESAs in patients not responding within 6-8 weeks. B As per ESMO 2018 guidelines, discontinue ESAs in patients not showing evidence of at least an initial Hgb response within 4-8 weeks. A Iron replacement: https://web.pathway.md/diseases/reco6JCPQ8r0pcXSF 2/4 6/29/23, 3:25 AM Cancer-related anemia Pathway Consider offering iron replacement to improve Hgb response and reduce RBC transfusions in patients receiving ESAs with or without iron deficiency. Obtain baseline and periodic monitoring of: iron TIBC transferrin saturation ferritin. C Limit iron therapy to patients receiving chemotherapy. B Show 6 more 3. Therapeutic procedures Red blood cell transfusion: Consider performing RBC transfusion in patients with chemotherapy-associated anemia depending on the severity of the anemia or clinical circumstances. B Consider performing blood cell transfusion in patients with non-myeloid hematologic malignancies receiving concurrent myelosuppressive chemotherapy. C Consider performing RBC transfusion without delay in patients with Hgb < 7-8 g/dL and/or severe anemia-related symptoms (even at higher Hgb levels) and requiring immediate Hgb and symptom improvement. C Consider performing RBC transfusions as second-line therapy in patients with myelodysplastic syndromes not responding to ESAs, in the absence of 5q deletion. B 4. Specific circumstances Patients with refractory disease: Reevaluate patients not responding to ESAs for underlying tumor progression, iron deficiency, or other etiologies of anemia. B Consider offering the following therapies in patients with myelodysplastic syndromes requiring 2 RBC transfusions per month: investigational agent in the absence of 5q deletion supportive care with RBC transfusions in the absence of 5q deletion lenalidomide in the presence of 5q deletion. B Show 2 more References 1. Aapro M, Beguin Y, Bokemeyer C et al. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Oct 1;29 Suppl 4):iv96-iv110. Open https://web.pathway.md/diseases/reco6JCPQ8r0pcXSF 3/4 6/29/23, 3:25 AM Cancer-related anemia Pathway 2. Julia Bohlius, Kari Bohlke, Roberto Castelli et al. Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update. J Clin Oncol. 2019 May 20;37 15 1336 1351. Open https://web.pathway.md/diseases/reco6JCPQ8r0pcXSF 4/4