Originally published as JCO Early Release 10.1200/JCO.2007.14.3396 on October 22 2007

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Use of Epoetin and Darbepoetin in Patients With Cancer: 2007 American Society of Clinical Oncology/American Society of Hematology Clinical Practice Guideline Update

J. Douglas Rizzo, Mark R. Somerfield, Karen L. Hagerty, Jerome Seidenfeld, Julia Bohlius, Charles L. Bennett, David F. Cella, Benjamin Djulbegovic, Matthew J. Goode, Ann A. Jakubowski, Mark U. Rarick, David H. Regan, Alan E. Lichtin

Medical College of Wisconsin, Milwaukee, WI; American Society of Clinical Oncology, Alexandria, VA; Blue Cross and Blue Shield Association; Northwestern University, Chicago; Evanston Northwestern Healthcare, Evanston, IL; University Hospital of Cologne, Cologne, Germany; H. Lee Moffitt Cancer Center, Tampa, FL; Patient Representative, Mesa, AZ; Memorial Sloan-Kettering Cancer Center, New York, NY; NW Kaiser Permanente, US Oncology, Portland, OR; and Cleveland Clinic Foundation, Cleveland, OH

Corresponding author: American Society of Clinical Oncology, 1900 Duke St, Suite 200, Alexandria, VA 22314; e-mail: guidelines{at}asco.org

Purpose: To update the American Society of Clinical Oncology/American Society of Hematology (ASCO/ASH) recommendations for the use of epoetin. The guideline was expanded to address use of darbepoetin and thromboembolic risk associated with these agents.

Method: An Update Committee ("Committee") reviewed and analyzed data published since 2002 through July 2007. MEDLINE and the Cochrane Collaboration Library databases were searched.

Recommendations: For patients with chemotherapy-associated anemia, the Committee continues to recommend initiating an erythropoiesis-stimulating agent (ESA) as hemoglobin (Hb) approaches, or falls below, 10 g/dL, to increase Hb and decrease transfusions. ESA treatment continues to be recommended for patients with low-risk myelodysplasia for similar reasons. There is no evidence showing increased survival as a result of ESA treatment. Conclusive evidence is lacking that, absent clinical circumstances necessitating earlier treatment, initiating ESAs at Hb levels greater than 10 g/dL either spares more patients from transfusion or substantially improves their quality of life.

Starting doses and dose modifications based on response or lack thereof should follow the package insert. Continuing ESAs beyond 6 to 8 weeks in the absence of response, assuming appropriate dose increase has been attempted in nonresponders as per US Food and Drug Administration–approved labeling, does not seem to be beneficial, and ESA therapy should be discontinued. The Committee recommends monitoring iron stores and supplementing iron intake for ESA-treated patients. ESAs should be used cautiously with chemotherapy, or in clinical states, associated with elevated risk for thromboembolic complications. The Committee also cautions against ESA use for patients with cancer who are not receiving chemotherapy, since recent trials report increased thromboembolic risks and decreased survival under these circumstances.

published online ahead of print at www.jco.org on October 22, 2007.

Approved by the ASCO Board of Directors on August 15, 2007. Approved by the Executive Committee of ASH on August 14, 2007.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

This guideline was developed through a collaboration between the American Society of Clinical Oncology and the American Society of Hematology and has been published jointly by invitation and consent in both the Journal of Clinical Oncology and Blood. Copyright © 2007 American Society of Clinical Oncology and American Society of Hematology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Society of Clinical Oncology or the American Society of Hematology.

Related Correspondence

• Reconsideration of American Society of Clinical Oncology/American Society of Hematology Erythropoiesis-Stimulating Agent Guidelines
  Nevin Murray and Richard Klasa
  JCO 2008 26: 3096-3097 [Full Text]
• Erythropoiesis-Stimulating Agents in Cancer
  Murat O. Arcasoy
  JCO 2008 26: 3097-3098 [Full Text]

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