Key Points
➤ Use of erythropoiesis-stimulating agents (ESAs) to manage anemia raises
hemoglobin levels and reduces the need for red blood cell transfusions but
increases the risk of thromboembolic events.
➤ ESAs are indicated in cancer patients who are receiving myelosuppressive
chemotherapy with non-curative intent and anemia that cannot be
adequately managed with transfusional support.
Treatment
➤ Rec. 1.1: Depending on clinical circumstances ESAs may be offered to
patients with chemotherapy-associated anemia whose cancer treatment is
not curative in intent and whose hemoglobin has declined to <10 g/dL. Red
blood cell transfusion is also an option, depending on the severity of the
anemia or clinical circumstances. (Strong recommendation; EB-H)
➤ Rec. 1.2: ESAs should not be offered to patients with chemotherapy-
associated anemia whose cancer treatment is curative in intent. (Strong
recommendation; EB-I)
➤ Rec. 2.1: ESAs should not be offered to most patients with non-
chemotherapy-associated anemia. (Strong recommendation; EB-L)
➤ Rec. 2.2: ESAs may be offered to patients with lower risk myelodysplastic
syndromes and a serum erythropoietin level ≤500 IU/L. (Moderate
recommendation; EB-I)
➤ Rec. 3: In patients with myeloma, non-Hodgkin's lymphoma, or chronic
lymphocytic leukemia, clinicians should observe the hematologic response
to cancer treatment before considering an ESA. Particular caution should
be exercised in the use of ESAs concomitant with treatment strategies and
diseases where risk of thromboembolic complications is increased (see
Recommendations 4 and 8). In all cases, blood transfusion is a treatment
option which should be considered. (Moderate recommendation; IC-L)
➤ Rec. 4: Before offering an ESA, clinicians should conduct an appropriate
history, physical examination, and diagnostic tests to identify alternative
causes of anemia aside from chemotherapy or an underlying hematopoietic
malignancy. Such causes should be appropriately addressed before
considering the use of ESAs. Suggested baseline investigations are listed
in Table 1. (Strong recommendation; IC-I)
