Before the introduction of ESAs, the only treatment option for
cancer-related
anemia was red blood cell (RBC) transfusion. The use of ESAs in multiple disease states has been well established and is now considered first-line treatment for many forms of
anemia. Chang et al. evaluated the effect of
epoetin alfa (40,000 units administered subcutaneously every week) and standard-of-care
therapy on quality of life (QOL), transfusion requirements, and
hemoglobin levels in 354 patients with
breast cancer who had a baseline
hemoglobin concentration of <15 g/dL. The authors concluded that early initiation of treatment with
epoetin alfa in patients with
breast cancer is effective in maintaining
hemoglobin levels, reducing transfusions, and improving QOL. Leyland-Jones et al. conducted a study evaluating the effects of early intervention with
epoetin alfa (40,000 units administered subcutaneously every week) on survival and QOL of mainly nonanemic patients with metastatic
breast cancer. In contrast to Chang et al., this study was discontinued because of lower overall survival rates within the
epoetin alfa group. In 2008, the Food and Drug Administration issued a black-box warning for both
epoetin alfa and
darbepoetin alfa. The warning acknowledges that ESAs have shortened overall survival and time to
disease progression in patients with advanced
breast cancer who are given these agents to achieve a target
hemoglobin concentration of > or =12 g/dL.
CONCLUSION: When used in patients with
cancer-induced
anemia, ESAs should only be given at the lowest dose possible to prevent RBC transfusions. During treatment,
hemoglobin levels should be monitored closely and ESA doses need to be adjusted accordingly.