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Jeffrey A. Gilreath and George M. Rodgers

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Jeffrey A. Gilreath, David D. Stenehjem and George M. Rodgers

The feasibility of the large, single-dose intravenous iron repletion method, which is known today as total dose infusion (TDI), has been demonstrated over decades. However, this method of iron repletion was chiefly developed for patients with large iron deficits, such as those with pregnancy-induced anemia, chronic bleeding disorders, and absolute iron-deficiency anemia (serum ferritin < 30 ng/mL, transferrin saturation < 15%) who were unable to receive frequent small doses of intravenous iron. Today, 50 years after the advent of TDI, more is known about iron metabolism and storage, but the optimal dosing strategy for intravenous iron in patients with cancer is still not well defined. The proinflammatory state of cancer, or its treatment, may influence the response to intravenous iron therapy. Additionally, the long-term adverse effects of large single doses or smaller more frequent doses have yet to be studied in the oncology population. Historically, safety concerns surrounding the administration of intravenous iron have centered on anaphylaxis. Newer concerns are being raised, such as oxidative stress, iron overload, venous thromboembolism, infection risk, and tumor growth. Therefore, with the original premise of TDI assuming low levels of inflammation, coupled with the recent data surrounding the adverse effects of blood transfusions and erythropoietic-stimulating agents, this article reviews the risks and benefits of TDI administration specifically for patients with cancer.

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Jeffrey A. Gilreath, Daniel S. Sageser, James A. Jorgenson and George M. Rodgers

Erythropoietic-stimulating agent (ESA) therapy has significantly impacted the management of chemotherapy-induced anemia (CIA) by decreasing the number of red blood cell transfusions required by patients with cancer. However, managing these patients with ESA therapy has become increasingly difficult since the release of the Centers for Medicare & Medicaid Services' new National Coverage Determination document because of the disparities between this document and recommendations from expert-reviewed national clinical guidelines on the treatment of anemia. This article describes a collaborative practice agreement between pharmacists and physicians as one approach to managing CIA in hematology-oncology patients in an anemia clinic. The goal of the pharmacist-managed anemia clinic is to improve patient satisfaction and clinical outcomes associated with the treatment of CIA. This article describes the rationale for the clinic and discusses its design and implementation in managing ESA, iron, folate, and vitamin B12 therapy for CIA in hematology-oncology patients. The pharmacist's role is justified in this clinic model through increased adherence to evidence-based practice guidelines and decreased costs associated with ESA therapy.

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Joanne E. Mortimer, Andrea M. Barsevick, Charles L. Bennett, Ann M. Berger, Charles Cleeland, Shannon R. DeVader, Carmen Escalante, Jeffrey Gilreath, Arti Hurria, Tito R. Mendoza and Hope S. Rugo

NCCN convened a committee of experts to make recommendations for future studies of cancer-related fatigue (CRF). The committee reviewed the current data on the incidence, clinical measurement, and treatment of CRF. The assessment of fatigue is largely derived from self-report questionnaires that address the symptom of fatigue, and do not correlate the presence of fatigue with change in physical activity. The committee developed a self-report questionnaire, NCCN Fatigue and Contributing Factors Inventory, which incorporates assessments of fatigue, pain, difficulty sleeping, distress, physical activity, and concurrent medications. A clinical research study using this measure in conjunction with the NCCN Breast Cancer Outcomes Database Project is planned. The committee noted a strong interaction among fatigue, pain, difficulty sleeping, and distress and recommended that future clinical research address these interactions.

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George M. Rodgers III, Pamela Sue Becker, Morey Blinder, David Cella, Asher Chanan-Khan, Charles Cleeland, Peter F. Coccia, Benjamin Djulbegovic, Jeffrey A. Gilreath, Eric H. Kraut, Ursula A. Matulonis, Michael M. Millenson, Denise Reinke, Joseph Rosenthal, Rowena N. Schwartz, Gerald Soff, Richard S. Stein, Gordana Vlahovic and Alva B. Weir III

Anemia is prevalent in 30% to 90% of patients with cancer. Anemia can be corrected through either treating the underlying cause or providing supportive care through transfusion with packed red blood cells or administration of erythropoiesis-stimulating agents (ESAs), with or without iron supplementation. Recent studies showing detrimental health effects of ESAs sparked a series of FDA label revisions and a sea change in the perception of these once commonly used agents. In light of this, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer- and Chemotherapy-Induced Anemia underwent substantial revisions this year. The purpose of these NCCN Guidelines is twofold: 1) to operationalize the evaluation and treatment of anemia in adult cancer patients, with an emphasis on those who are receiving concomitant chemotherapy, and 2) to enable patients and clinicians to individualize anemia treatment options based on patient condition.