Date Published: 
Friday, 14 March, 2014

Assessment of iron status should be considered for symptomatic patients with cancer-related anaemia, according to new recommendations

Dr Yves Beguin

Iron status assessment may be beneficial in cancer-related anaemia, researchers suggest, while evaluation of nutritional deficiency should be reserved for patients with clinical signs or symptoms of deficiency or when insurance mandates testing.

Cancer-related anaemia is due to multiple aetiologies, including chemotherapy-induced myelosuppression, blood loss, functional iron deficiency and erythropoietin deficiency. The most common treatment options include intravenous iron therapy, erythropoietin stimulating agents (ESAs), and blood/platelet transfusion. However, recent safety concerns surrounding ESA therapy have resulted in a reduction in its use, and many clinicians are not familiar with intravenous iron therapy.

The authors of a new article highlight the need for first assessing severity and cause of anaemia in cancer patients, including whether patients have absolute iron deficiency anaemia (transferrin saturation <20%; ferritin <30 ng/mL) or functional iron deficiency anaemia.

However, the authors’ description of absolute iron deficiency (transferrin saturation <20%; ferritin <30 ng/mL) does not take into account that, in cancer patients, absolute iron deficiency is observed with ferritin up to 100 ng/ml. In addition, the delineation of functional iron deficiency (transferrin saturation 20–50%; ferritin 30–800 ng/mL) and iron repletion (transferrin saturation >50%; ferritin >800 ng/mL) are not in line with current definitions: these cut-offs are those defining iron repletion and iron overload, respectively. Furthermore, functional iron deficiency is usually defined as transferrin saturation <20% with a ferritin value within or even above the normal range.

A figure is also presented in which the criteria for functional iron deficiency are different, including many patients whom the authors suggest would not benefit from iron therapy. A key benefit from making this classification is that patients with the absolute form may not require ESAs: iron therapy may be tested first and ESAs used only in case of failure. The respective roles of ESA therapy and red blood cell transfusions are also discussed within the context of palliative versus curative care.

The authors conclude that their sub-classification of cancer-related anaemia will help clinicians develop a systematic approach to managing treatment options for these patients. The determination of iron status should be considered for symptomatic patients, while nutritional deficiency assessment should be reserved for patients with clinical signs or symptoms of deficiency or for insurance purposes.

The full article can be found in the February 2014 issue of the American Journal of Hematology. For further information on treating iron deficient patients with cancer, please click here.