Trip Answers

Question answered:28/01/08 Warning! this question is over two years old.

In answering this question, we do not know the treatment(s) the patients is currently undergoing, i.e. hormonal, chemotherapy and/or radiotherapy.

 

We found one small, uncontrolled study assessing the effectiveness of erythropoietin in the treatment of cancer-related anaemia in advanced prostate cancer. Beer et al report:

 

“PATIENTS AND METHODS: Sixteen patients with histologically confirmed prostate cancer with bone metastases on androgen deprivation therapy with or without chemotherapy; and a baseline hemoglobin (Hb) < or = 12 g/dL (amended to < or = 11 g/dL) were enrolled. The primary endpoints were the proportion of patients who had a baseline Hb > or = 12.5 g/dL and the proportion whose baseline Hb increased by > or = 1 g/dL. Patients were initially treated with 300 microg of darbepoetin alfa every 4 weeks. The dose was increased to 500 microg, 800 microg, and 1000 microg at each subsequent visit if the baseline Hb was not at target and had not increased by > or = 1 g/dL during the previous 4 weeks. Treatment was planned for 6 months. RESULTS: Treatment was well tolerated with no grade > or = 3 toxicities. Fourteen patients were assessable. The median Hb at study entry was 10.7 g/dL (range, 8.4-12). Serum Hb increased by > or = 1 g/dL in 10 patients (71%; 95% confidence interval, 42%-92%) and 7 patients (50%; 95% confidence interval, 23%-77%) reached an Hb of > or = 12.5 g/dL after treatment with doses that ranged from 300 microg to 1000 microg.

 

CONCLUSION: Darbepoetin alfa administration every 4 weeks is feasible and well tolerated. Target Hb increases were achieved in approximately half of the patients and required doses that ranged from 300 microg to 1000 microg.” [1]

 

Of general interest will be three guidelines on erythropoietin for the symptomatic treatment of anaemia in cancer patients. The most recent of these guidelines is one produced by the National Comprehensive Cancer Network this year that covers the assessment and suitability of patients for erythropoietin treatment. In addition, adverse effects associated with this therapy are discussed and a recommendation that patients with end-stage cancer should not be treated with ESAs. Due to copyright regulations, we cannot cut and paste sections from this guideline so will ask you to refer to this yourself, by following the link given in the references section below [2].

 

A 2007 guideline issued by the Society of Clinical Oncology and the American Society of Hematology states in its summary:

 

“RECOMMENDATIONS: For patients with chemotherapy-associated anemia, the Committee continues to recommend initiating an erythropoiesis-stimulating agent (ESA) as hemoglobin (Hb) approaches, or falls below, 10 g/dL, to increase Hb and decrease transfusions. ESA treatment continues to be recommended for patients with low-risk myelodysplasia for similar reasons. There is no evidence showing increased survival as a result of ESA treatment. Conclusive evidence is lacking that, absent clinical circumstances necessitating earlier treatment, initiating ESAs at Hb levels greater than 10 g/dL either spares more patients from transfusion or substantially improves their quality of life. Starting doses and dose modifications based on response or lack thereof should follow the package insert. Continuing ESAs beyond 6 to 8 weeks in the absence of response, assuming appropriate dose increase has been attempted in nonresponders as per US Food and Drug Administration-approved label, does not seem to be beneficial, and ESA therapy should be discontinued. The Committee recommends monitoring iron stores and supplementing iron intake for ESA-treated patients. ESAs should be used cautiously with chemotherapy, or in clinical states, associated with elevated risk for thromo-embolic complications.

 

The Committee also cautions against ESA use for patients with cancer who are not receiving chemotherapy, since recent trials report increased thromboembolic risks and decreased survival under these circumstances.” [3]

 

A French guideline on Erythropoietin in the Management of Cancer Patients with Non-Hematologic Malignancies Receiving Chemotherapy states:

 

“• Transfusion of red blood cells remains the treatment of choice in patients with rapidly developing symptomatic anemia.

 

• It is most reasonable to recommend erythropoietin to individuals who have a reasonable chance of experiencing relatively long-term survival or cure as an outcome from their chemotherapy. It is these individuals who have the greatest risk of suffering from the long-term complications of transfusion. Individuals in whom short survival is anticipated are better treated by transfusion for symptomatic anemia since erythropoietin takes approximately four weeks to start elevating hemoglobin levels.

 

• Although the evidence supporting the use of erythropoietin is stronger for patients receiving platinum-based therapy, erythropoietin is also effective in patients receiving moderately or severely myelosuppressive regimens that do not contain platinum.

 

• Several randomized trials have shown statistically significant improvements in several domains of quality of life in patients receiving erythropoietin. The clinical significance of these improvements (often of the order of 20% to 40% increase over baseline) in patients with moderate to severe baseline quality of life impairment (generally ≅ 50% of maximum scores) also needs to be considered. A clear linear relationship between fatigue and anemia has not been established.”

 

It adds:

 

“Some preliminary reports of uncontrolled studies suggest that erythropoietin is effective in raising hemoglobin and improving quality of life in cancer patients not receiving chemotherapy, or receiving only radiotherapy. These issues should be addressed in randomized trials.” [4]

 

Given the lack of specific guidance and studies on the use of erythropoietin in patients with metastatic prostate cancer, the NLH Primary Care Q & A Service can only suggest discussing this case with a local specialist.

 

References
1. Beer TM, Bergenstock M and Birt K et al. Darbepoetin alfa administered every 4 weeks for anemia in patients with advanced prostate cancer. Clin Genitourin Cancer. 2007 Jun;5(5):329-33. (http://www.hubmed.org/display.cgi?uids=17645830)
2. National Comprehensive Cancer Network. Cancer and treatment related anemia. 2008. (http://www.nccn.org/professionals/physician_gls/PDF/anemia.pdf)
3. Rizzo JD, Somerfield MR, Hagerty KL et al. Use of epoetin and darbepoetin in patients with cancer: 2007 American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update. Blood. 2008 Jan 1; 111(1): 25-41. (http://www.hubmed.org/display.cgi?uids=17954703)
4. 3. Quirt, V. Bramwell, M. Charette, T. Oliver The Role of Erythropoietin in the Management of Cancer Patients with Non-Hematologic Malignancies Receiving Chemotherapy. Practice Guideline Report #12-1. I2005. (http://www.cancercare.on.ca/pdf/pebc12-1f.pdf)

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