Treating chemotherapy-induced anemia following the revised labeling for ESAs

Erythropoiesis-stimulating agents (ESAs) are no longer indicated for patients with anemia of cancer not on chemotherapy and for patients receiving chemotherapy for hemoglobin levels greater than 10 g/dL. Transfusions once again appear to be the standard of care; one study showed that the transfusion rate increased just 6 months after the implementation of the new National Coverage Decision on ESAs, and further increases are expected. However, transfusions can increase the morbidity and mortality in patients with cancer, depending on the red blood cell storage conditions. The role of intravenous iron remains largely undefined despite seven randomized clinical trials demonstrating that intravenous iron added to ESAs improves outcomes compared with ESAs alone. No clear recommendation is available regarding when iron supplementation should be provided.