Anaemia is common in patients with cancer and is a major cause of debilitating fatigue and impaired health-related quality of life (HRQoL). Causes include infiltration of bone marrow by malignant cells, suppression of red cell production by inflammatory cytokines (as in ACD), or cytotoxic chemotherapy, nutritional deficiencies, renal damage and bleeding.
Treatment of anaemia in cancer patients centres on red cell transfusions or ESAs. The decision to treat should be based on symptoms such as fatigue, breathlessness and impaired quality of life rather than a specific Hb concentration, and relief of symptoms is the target of therapy. Radiotherapy may be less effective in the presence of anaemia (hypoxic cancer cells are less sensitive to radiation) but the benefit of red cell transfusion to reduce mild anaemia in this setting is controversial.
Treatment with ESA (e.g. rHuEpo or darbopoietin) can modestly reduce blood transfusion exposure and improve HRQoL in selected cancer patients, especially in those treated with nephrotoxic platinum compounds. The maximum improvement in fatigue and HRQoL occurs between Hb 110 and 120 g/L. However, there is increasing evidence that ESAs can promote the growth of a range of non-haematological tumours. They may also increase the already raised risk of venous and arterial thromboembolism in cancer patients. ESAs should only be used where clinical trials have shown unequivocal benefits and in accordance with consensus guidelines such as those of the American Society of Clinical Oncology (http://www.asco.org/institute-quality/asco-ash-clinical-practice-guideline-update-use-epoetin-and-darbepoetin-adult).