Guideline Update on the Use of Epoetin and Darbepoetin in Adult Patients With Cancer

American Society of Clinical Oncology/American Society of Hematology Clinical Practice Guideline Update on the Use of Epoetin and Darbepoetin in Adult Patients With Cancer
J. Douglas Rizzo, Melissa Brouwers, Patricia Hurley, Jerome Seidenfeld, Murat O. Arcasoy, Jerry L. Spivak,
Charles L. Bennett, Julia Bohlius, Darren Evanchuk, Matthew J. Goode, Ann A. Jakubowski, David H. Regan,
and Mark R. Somerfield

From the Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA; Duke University School of Medicine, Durham, NC; Johns Hopkins University School of Medicine, Baltimore, MD; South Carolina College of Pharmacy, Columbia, SC; Institute of Social and Preventive Medicine/University of Bern, Bern, Switzerland; Commonwealth Hematology Oncology PC, Stoneham, MA; patient representative,
Mesa, AZ; Memorial Sloan-Kettering Cancer Center, New York, NY; and Northwest Cancer Specialists, Vancouver, WA.

Approved by the American Society of Clinical Oncology Board of Directors on July 7, 2010. Approved by the Executive
Committee of the American Society of Hematology on July 14, 2010.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.
Corresponding author: American Society of Clinical Oncology, 2318 Mill Rd,
Suite 800, Alexandria, VA 22314; e-mail: guidelines@asco.org.
© 2010 by American Society of Clinical Oncology and the American Society of Hematology

A B S T R A C T
Purpose
To update American Society of Clinical Oncology/American Society of Hematology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.

Methods
An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched.

Results
The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews.

Recommendations
For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration–approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic
agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.
This guideline was developed through a collaboration between the American Society of Clinical Oncology and the American Society of Hematology and has been published jointly by invitation and consent in both Journal of Clinical Oncology and Blood. Copyright © 2010 American Society of Clinical Oncology and American Society of Hematology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Society of Clinical Oncology or the American Society of Hematology.

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