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Journal of Clinical Oncology, Vol 25, No 7 (March 1), 2007: pp. 919 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.3880
Epoeitin Alfa Use in Children Undergoing Myelosuppressive ChemotherapyDepartments of Pediatric Hematology, Blood and Marrow Transplantation, and Oncology, Columbia-Presbyterian Medical Center, New York, NY To the Editor: As a current fellow in pediatric hematology-oncology, I read the article of Razzouk et al,1 with particular interest. The authors conclude that their study confirms the tolerability and hematologic benefits of once-weekly epoetin alfa (EPO) in children with cancer who are receiving myelosuppressive chemotherapy. Although I do not dispute the study conclusions that EPO use leads to reduced transfusion use and increased hemoglobin, several aspects of the study warrant further explanation. The authors state that RBC transfusion was suggested when patient hemoglobin (Hb) levels were 7 g/dL or lower, or in accordance with each institution’s policies. There is an apparent discrepancy between the suggested transfusion cutoff and the actual Hb levels at which patients were transfused, as evidenced in their Figure 2.1 In the plotting of Hb estimate versus treatment week in the figure, it seems that the lowest mean hemoglobin estimate among either the EPO or placebo groups during the entire 16-week period, censoring post-transfusion Hb levels, is 8.8 g/dL. If these data are correct, many patients likely received transfusions from week 1 onward, for Hb levels that were well above the suggested cutoff of 7 g/dL. Although the authors state that analysis of all data-censoring data within 28 days following RBC transfusion resulted in similar findings, it is worth exploring the apparent discrepancy between the usual transfusion criteria of 7 or 8 g/dL (as our institution tends to use) and the higher numbers apparently adopted by the sites involved in this study. A set transfusion cutoff of 8 g/dL, with exceptions for symptomatic anemia, would have made the data clearer. In my view, the authors also did not place sufficient emphasis on the increased number of clinically relevant thrombotic vascular events that occurred in the EPO group compared with the placebo group (six EPO-treated patients v two placebo-treated patients). Although the authors state that "clinically relevant thrombotic vascular events were reported more often in the EPO group than in the placebo group,"1 they do not include the statistical significance of this discrepancy. A statistically significant increased risk of such events in EPO-treated patients would cause most clinicians to avoid its use, and these data should have therefore been calculated and included in the article. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author indicated no potential conflicts of interest. REFERENCE
1. Razzouk BI, Hord JD, Hockenberg M, et al: Double-blind, placebo-controlled study of quality of life, hematologic end points, and safety of weekly epoetin alfa in children with cancer receiving myelosuppressive chemotherapy. J Clin Oncol 24:3583-3589, 2006
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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