A recent study examined how the APPRISE guidelines for ESA use affected patients with epithelial ovarian cancer, who often experience chemotherapy-induced anemia.9 The study compared matched sets of 88 patients undergoing first- or second-line chemotherapy before or after APPRISE was instituted. Before APPRISE, 51% of the patients received ESA injections, while none did after APPRISE. Transfusion thresholds did not change, and the rates of red blood cell transfusions were similar both before and after APPRISE (8.3% vs 14.8%, P=0.28). However, the cost-savings from omitting ESAs in the post-APPRISE group was estimated at $700,000.9

Another study focusing on the impact of warnings about the use of ESAs also found that blood transfusion rates were not significantly changed, even as the use of ESAs dropped.10 When patients with a cancer diagnosis who received chemotherapy were compared before and after the clinical alert about ESAs was issued, the difference was slight; 52% received a blood transfusion before the FDA alert, and 48% did after the FDA alert.10

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When ESAs are given, adding intravenous iron can limit iron-restricted erythropoiesis, even in patients who are iron-replete, and can improve the response to ESAs.2,11 Patients with the most significant iron-restricted erythropoiesis are most likely to respond to intravenous iron. Functional iron deficiency, meaning iron-restricted erythropoiesis, can be defined as serum ferritin greater than 20 μg/L, transferrin saturation less than 20%, and serum iron less than 60 μg/dL.2 Iron repletion may limit the need for ESAs and also maximize symptom improvement.2

While anemia in cancer patients is concerning, there is a medical need to manage this condition. Fortunately, treatment options are available to help improve patient outcomes in the oncology setting. ESAs are an example of an effective drug class for the management of anemia. However, appropriate use and consideration should be given when opting to use ESAs for managing anemia.


1. Spivak JL, Gascón P, Ludwig H. Anemia management in oncology and hematology. Oncologist. 2009;14 Suppl 1:43-56.

2. Henry DH. Parenteral iron therapy in cancer-associated anemia. Hematology Am Soc Hematol Educ Program. 2010;2010:351-356.

3. Owusu C, Tew WP, Hardt M, et al. Anemia and functional disability in older adults with cancer. J Clin Oncol. 2012;30(15_suppl):Abstract 9109.