This document summarizes information on malignancy-associated anemia, including its prevalence, potential etiologies, diagnostic criteria, and treatment approaches. It discusses how anemia is common in cancer patients, often due to iron deficiency. The main goals of treatment are to improve quality of life and reduce blood transfusions. It provides algorithms for diagnosing and predicting response to iron therapy for cancer-associated anemia. Risks of intravenous iron therapy are addressed, along with strategies for risk minimization and managing potential hypersensitivity reactions. Monitoring of patients after IV iron treatment is also summarized.

1. MALIGNANCY
ASSOCIATED ANEMIA
Dr Pritish Chandra Patra
Associate Professor
Department of Clinical Hematology
IMS & SUM Hospital, Bhubaneswar

2. Introduction
• Anemia is a frequent complication in cancer patients, both at diagnosis and during
treatment, with a multifactorial etiology in most cases
• Iron deficiency is among the most common causes of anemia nearly half of patients
with hematologic malignancies and solid tumors
• The prevalence of iron deficiency associated with malignancies ranges from 7 to 42%
• The main therapeutic goal is to improve the QoL, in addition to trying to reduce the
number of blood transfusions
Rev Bras Hematol Hemoter. 2016 Oct-Dec; 38(4): 325–330.

3. POTENTIAL ETIOLOGIES FOR CANCER-ASSOCIATED ANEMIA
(Blood. 2020;136(7):801-813)
Drugs
Bugs
Disease

4. CRITERIA FOR GRADING CANCER ASSOCIATED
ANEMIA
• (WHO) criteria and the CTCAE
(v5.0) grading system for anemia, a
definition for cancer-associated
anemia was established: grade 1
anemia was defined as Hb ≤11.9
g/dL for women with cancer and
Hb ≤12.9 g/dL for men with cancer.
• Severity of anemia increases with
increasing grade up to grade 5
(death).
CTCAE Common Terminology Criteria for Adverse Events

5. DIAGNOSIS OF CANCER-ASSOCIATED ANEMIA
• Definition: We define anemia as cancer-associated anemia when it results from
malignancy or its treatment
• The most widely available and frequently used tests to assess iron status are
• Serum Ferritin & Transferrin Saturation (TSAT %)
• TSAT%= [ Serum iron / TIBC (Total iron binding capacity)] x 100
• Ferritin- acute phase reactant- may be falsely elevated in cancers
• Ferritin is a biomarker of total body iron stores, and low ferritin is a reliable indicator of
absolute iron deficiency
(Blood. 2020;136(7):801-813)

6. Algorithm using serum ferritin and transferrin saturation to predict response to
iron in cancer-associated anemia
(Blood. 2020;136(7):801-813)

7. RISK OF ANAPHYLAXIS FOR IV IRON THERAPY
Factors increasing risk and/or severity of hypersensitivity reactions
doi:10.3324/haematol.2014.111492

8. RISK OF ANAPHYLAXIS FOR IV IRON THERAPY
• Reactions may include vasodilation, nausea, flushing, urticaria, and wheezing.
• Sternal chest pain and lower back pain may be a consequence of erythropoiesis and
marrow expansion
• Requires meticulous observation, and, in the event of an adverse reaction, prompt
recognition and severity-related interventions by well-trained medical and nursing
staff

9. HYPERSENSITIVITY REACTIONS RISK
MINIMIZATION AND MANAGEMENT
• Hypersensitivity reactions may occur in anyone given IV iron, and it is essential that every
effort is made to prevent these being poorly managed if they occur, whether due to
inadequate facilities or staff being undertrained
• The following factors require attention before and during any IV iron infusion.
• Location
• Personnel
• Patient
• Administration of intravenous iron

10. ALGORITHM
OUTLINING
GRADING AND
MANAGEMENT OF
ACUTE
HYPERSENSITIVITY
REACTIONSTO
INTRAVENOUS
IRON INFUSIONS

11. PATIENT MONITORED AFTER IV IRON THERAPY
• Monitor monthly
• CBC
• Iron studies (Ferritin, TSAT%)
• Phosphate levels (if FCM is used): hypophosphatemia typically resolves within 3-6 wks
• Repeat IV iron treatment if
• AIDA returns
• Ferritin plateaus and declines to <100 ng/mL
• TSAT remains <20%

12. Summary
Jeffrey A. Gilreath,George M. Rodgers, How I treat cancer-associated anemia, Blood, 2020

13. Conclusion
• Cancer-associated anemia leads to poor quality of life in patients with cancer
• Possible mechanisms of cancer-associated anemia are decreased erythropoiesis,
increased destruction, and blood loss
• Strategy should be first identifying all contributing causes before treatment is
considered
• Severe adverse events due to IV iron administration are exceedingly rare but should
not be ignored