Compliance With NCCN Guidelines for Evaluation and Treatment of Anemia Among Patients With Solid Tumors

Authors:
Demetra Hypatia Hufnagel Vanderbilt University School of Medicine, Nashville, TN
Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA

Search for other papers by Demetra Hypatia Hufnagel in
Current site
Google Scholar
PubMed
Close
 MD
,
Lia Manfredi Bos Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama, Birmingham, AL

Search for other papers by Lia Manfredi Bos in
Current site
Google Scholar
PubMed
Close
 MD
,
Alaina Johnson Brown Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN

Search for other papers by Alaina Johnson Brown in
Current site
Google Scholar
PubMed
Close
 MD, MPH
, and
Lauren Shore Prescott Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN

Search for other papers by Lauren Shore Prescott in
Current site
Google Scholar
PubMed
Close
 MD, MPH
Restricted access

Background: NCCN Guidelines for Hematopoietic Growth Factors recommend evaluation and treatment of anemia in patients with cancer. However, a paucity of data exists regarding compliance with these recommendations. Methods: A retrospective cohort study was performed of patients diagnosed with any solid tumor at Vanderbilt University Medical Center from 2008 to 2017. Tumor registry–confirmed cancer cases were identified by ICD-O codes using the Synthetic Derivative database. Anemia was defined as hemoglobin (Hgb) level ≤11 g/dL and graded according to CTCAE version 5.0. Absolute, functional, and possible functional iron deficiency were defined based on NCCN Guidelines. Results: A total of 25,018 patients met inclusion criteria. Median age was 60 years. The most common malignancies were respiratory tract, prostate, and nonprostate urologic (11% each). Among 8,695 patients with Hgb levels available prior to diagnosis, 1,484 (17%) were noted to be anemic proximal to diagnosis. Of the 25,018 patients, 11,019 (44%) were anemic within 6 months of diagnosis. Of these patients, 4,686 (43%) had grade 2 (moderate) anemia and 9,623 (87%) had normocytic anemia. Patients with retroperitoneal/peritoneal cancers had the highest prevalence of anemia (83/110; 75%). A total of 4,125 (37%) underwent any evaluation of their anemia, of whom 1,742 (16%) had iron studies performed and 1,528 (14%) had vitamin B12 or folate studies performed. Fewer than half of patients with anemia received treatment (n=4,318; 39%), including blood transfusion (n=3,528; 32%), oral iron supplementation (n=1,279; 12%), or intravenous iron supplementation (n=97; 1%). Anemia treatment was significantly more frequent as the grade of anemia increased (any treatment among grade 1/mild: 12%; grade 2/moderate: 31%; grade 3/severe: 77%; χ2 [2, n=11,019]=3,020.6; P<.001). Patients with penile and testicular cancers had the highest prevalence of anemia evaluation (n=57; 79%). Conclusions: Anemia is common in patients with solid tumors; yet, compliance with NCCN Guidelines for evaluation and treatment of anemia remains low. There are opportunities to improve compliance with guidelines across the spectrum of cancer care.

Submitted March 6, 2023; final revision received October 16, 2023; accepted for publication November 8, 2023. Published online March 15, 2024.

Author contributions: Conceptualization: Brown, Prescott. Collection and assembly of data: Hufnagel, Prescott. Data analysis and interpretation: Hufnagel, Bos, Prescott. Manuscript writing: Hufnagel, Prescott. Manuscript editing and final approval: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This project was supported by the Vanderbilt Institute for Clinical and Translational Research (VICTR) Voucher VR54036 (L.S. Prescott). VICTR is funded by the National Center for Advancing Translational Sciences Clinical Sciences of the National Institutes of Health under award number UL1TR000445.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.

Supplementary material: Supplementary material associated with this article is available online at doi:10.6004/jnccn.2023.7108. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: Lauren Shore Prescott, MD, MPH, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, 1301 Medical Center Drive, Nashville, TN 37203. Email: lauren.prescott@vumc.org

Supplementary Materials

    • Supplemental Materials (PDF 919 KB)
  • Collapse
  • Expand
  • 1.

    Knight K, Wade S, Balducci L. Prevalence and outcomes of anemia in cancer: a systematic review of the literature. Am J Med 2004;116(Suppl 7A):11S26S.

  • 2.

    Birgegård G, Aapro MS, Bokemeyer C, et al. Cancer-related anemia: pathogenesis, prevalence and treatment. Oncology 2005;68(Suppl 1):311.

  • 3.

    Caro JJ, Salas M, Ward A, et al. Anemia as an independent prognostic factor for survival in patients with cancer: a systemic, quantitative review. Cancer 2001;91:22142221.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Becker PS, Griffiths EA, Alwan L. NCCN Clinical Practice Guidelines in Oncology: Hematopoietic Growth Factors. Version 2.2023. Accessed November 1, 2023. To view the most recent version, visit https://www.nccn.org

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Gilreath JA, Stenehjem DD, Rodgers GM. Diagnosis and treatment of cancer-related anemia. Am J Hematol 2014;89:203212.

  • 6.

    Prescott LS, Taylor JS, Enbaya A, et al. Choosing wisely: decreasing the incidence of perioperative blood transfusions in gynecologic oncology. Gynecol Oncol 2019;153:597603.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Hufnagel DH, Mehta ST, Ezekwe C, et al. Prevalence of anemia and compliance with NCCN Guidelines for evaluation and treatment of anemia in patients with gynecologic cancer. J Natl Compr Canc Netw 2021;19:513520.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Roden DM, Pulley JM, Basford MA, et al. Development of a large-scale de-identified DNA biobank to enable personalized medicine. Clin Pharmacol Ther 2008;84:362369.

  • 9.

    National Cancer Institute. Common terminology criteria for adverse events (CTCAE). Accessed March 1, 2020. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/ctc.htm

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Busti F, Marchi G, Ugolini S, et al. Anemia and iron deficiency in cancer patients: role of iron replacement therapy. Pharmaceuticals (Basel) 2018;11:94.

  • 11.

    Fraenkel PG. Understanding anemia of chronic disease. Hematology Am Soc Hematol Educ Program 2015;2015:1418.

  • 12.

    Ludwig H, Van Belle S, Barrett-Lee P, et al. The European Cancer Anaemia Survey (ECAS): a large, multinational, prospective survey defining the prevalence, incidence, and treatment of anaemia in cancer patients. Eur J Cancer 2004;40:22932306.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Xu H, Xu L, Page JH, et al. Incidence of anemia in patients diagnosed with solid tumors receiving chemotherapy, 2010–2013. Clin Epidemiol 2016;8:6171.

  • 14.

    Ludwig H, Müldür E, Endler G, et al. Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia. Ann Oncol 2013;24:18861892.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    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;29(Suppl 4):iv96110.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Dangsuwan P, Manchana T. Blood transfusion reduction with intravenous iron in gynecologic cancer patients receiving chemotherapy. Gynecol Oncol 2010;116:522525.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Kim YT, Kim SW, Yoon BS, 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;105:199204.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Steinmetz T, Tschechne B, Harlin O, et al. Clinical experience with ferric carboxymaltose in the treatment of cancer- and chemotherapy-associated anaemia. Ann Oncol 2013;24:475482.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Rodgers GM, Gilreath JA. The role of intravenous iron in the treatment of anemia associated with cancer and chemotherapy. Acta Haematol 2019;142:1320.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 1277 1277 242
PDF Downloads 864 864 237
EPUB Downloads 0 0 0