Chemotherapy-induced anemia: etiology, pathophysiology, and implications for contemporary practice

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Table 1 Indications/recommendations for red blood cell transfusion

Organization	Guideline
American Association of Blood Banks (AABB)^Citation52 (2016)	Maintain hemoglobin ≥7 g/dL in hemodynamically stable hospitalized patients Consider transfusion in patients with hemoglobin ≤8 g/dL and preexisting cardiovascular disease Personalize all transfusions by both symptoms and hemoglobin levels
European Society of Medical Oncology (ESMO)^Citation29 (2018)	• Recommend transfusion in patients with hemoglobin level <7–8 g/dL and/or with severe anemia- related symptoms, regardless of hemoglobin level
National Comprehensive Cancer Network (NCCN)^Citation7 (2018)	Recommend transfusion of patients with symptomatic anemia Monitor and reevaluate patients with asymptomatic anemia who lack significant comorbidities Consider transfusion in patients who are at high risk with progressive hemoglobin decline in the setting of recent chemoradiation or asymptomatic with comorbidities such as cardiopulmonary or cerebrovascular disease

Table 2 Therapeutic interventions in CIA

Therapy	Indications	Advantages	Disadvantages/side effects
RBC transfusion	Symptomatic CIA Consider when Hb <8 g/dL Consider comorbidities Single-unit transfusion policy with administration of one unit at a time titrated to symptom resolution	Rapid hemoglobin improvement Rapid improvement in anemia symptoms Improve quality of life	Pathogen transmission Transfusion reaction Alloimmunization Increased thrombotic risk TACO May impact disease progression Iron overload
ESA administration	Symptomatic CIA Consider when Hb <10 g/dL	Reduce RBC requirements Diminished severity and duration of CIA Improve quality of life	Increased thrombotic risk Hyperviscosity-associated complications Hypertension Seizures Pure red cell aplasia Slow to improve hemoglobin
Intravenous iron supplementation	Absolute iron deficiency (TSAT <20%, ferritin <30 ng/mL)^Citation7 Functional iron deficiency (TSAT <50%, ferritin 30–500 ng/ mL)^Citation7 Consider when Hb ≤11 or has decreased by ≥2 g/dL from baseline level ≥ 12 g/dL in the setting of absolute iron deficiency as defined by serum ferritin <100 ng/mL^Citation29 Consider prior to ESA administration	Reduces RBC requirements Facilitates optimal ESA response	Iron overload Hypertension Nausea, vomiting, diarrhea Headache Dizziness Dyspnea Pruritus Slow to improve hemoglobin

Abbreviations: CIA, chemotherapy-induced anemia; TACO, transfusion associated circulatory overload; Hb, hemoglobin; ESA, erythropoietin stimulating agent; RBC, red blood cell; TSAT, transferrin saturation.

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