Anemia in Hematologic Malignancies
Anemia is extremely common in
hematologic malignancies occurring in nearly all patients with multiple myeloma,
in which the median hemoglobin level is 10 g/dL, and 25% of patients have less
than 8 g/dL.[12,13] In non-Hodgkin's lymphoma, a
recent survey presented at the European Cancer Conference in 1999 showed that
40% of patients were anemic at the time of diagnosis. This increased to 70% by
the time patients had completed their chemotherapy.[14]
There are several additional considerations for anemia and hematologic
malignancies that may be more frequent than in patients with solid tumors, such
as increased frequency of autoimmune hemolytic anemia and direct marrow
infiltration by the tumor. Myeloma and associated disorders are frequently
associated with renal insufficiency, which may aggravate anemia. In addition,
patients can have associated gastrointestinal blood loss and iron deficiency or
vitamin B12 and folic acid deficiency. But, as in most forms of anemia
associated with malignancy, the major components are still the anemia of chronic
disorders as well as the hematopoietic-suppressive effect of chemotherapy. The 3
major management options for cancer anemia after excluding other treatable or
reversible causes are (1) no intervention, (2) use of blood transfusions, and
(3) use of erythropoietin. Until the recent improvements in our understanding of
anemia in this population, both cancer patients and their physicians chose
option one. But this passive approach is changing as we understand better where
and how erythropoietin can be effective in the management of anemia in patients
with hematologic malignancies.
The benefits deriving from administration of erythropoietin alpha depend on
the hematologic malignancy being treated. Unfortunately, in myelodysplasia, the
response rate to epoetin alpha is approximately 19%.[15]
This may be increased by the addition of G-CSF to erythropoietin
alpha, to achieve a response rate of 45%.[16]
Enhancement of the erythropoietic response by G-CSF in myelodysplasia is of
interest, although it has not been thoroughly investigated in patients with
solid tumors or other diseases.
