Blood utilization and hemoglobin levels in cancer patients after label and coverage changes for erythropoiesis-stimulating agents

Abstract

A comprehensive literature search was performed to examine the influence of changes in erythropoietin-stimulating agent (ESA) label and reimbursement policies on utilization of red blood cell transfusions and patient hemoglobin levels in US cancer patients receiving chemotherapy or anemia management. Studies conducted in ESA-treated patients showed an increase in transfusion rates when comparing the post-intervention period with pre-intervention period (range of relative change: 15–125%). Results from studies conducted in patients receiving chemotherapy irrespective of anemia treatment were variable; single-institution-based studies tended to show a decrease in transfusion rates (range of relative change: −3.2 to −24.1%), while multiple-institution-based studies suggested an increase in transfusion rates (range of relative change: 12–182%). Studies showed decreases in hemoglobin levels during chemotherapy or at ESA initiation, and decreased ESA utilization.

Keywords::

• anemia
• erythropoiesis-stimulating agents
• hemoglobin
• red blood cell transfusion
• review

Acknowledgements

This study was funded by Amgen Inc. L Lanza (RTI Health Solutions) assisted in reviewing publications and abstracting data for the analysis.

Financial & competing interests disclosures

H Xu and E Gasal are employees and shareholders of Amgen Inc. JA Kaye and CW Saltus are employees of RTI Health Solutions, which received funding for this study from Amgen Inc. J Crawford received institutional research funding and serves on an advisory board for Amgen Inc. LT Goodnough is a consultant for Liutpold/American Regent/Vifor, Amgen Inc., Octapharm and CSL Behring. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

S Lee (Amgen Inc.) and JR Gage (on behalf of Amgen Inc.) assisted with editing the manuscript.

Key issues

• Restriction of erythropoiesis-stimulating agent (ESA) use has raised concerns that patients with chemotherapy-induced anemia may be undertreated or required to undergo a greater number of red blood cell transfusions.

• Studies suggest that the ESA restriction resulted in decreased hemoglobin levels among cancer patients receiving chemotherapy.

• The variations in transfusion use after ESA restriction likely stem from variations in clinical practice, methodology and the patient population evaluated.

• Care must be taken to consider the limitations of each published report.

• There is a need for more rigorous studies assessing changes in anemia management and its impact on the patients’ outcomes.