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Cancer- and Chemotherapy- Induced Anemia NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Cancer- and Chemotherapy- Induced Anemia Version 2.2018 — November 21, 2017 NCCN.org Continue Version 2.2018, 11/21/17 © National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 7:04:17 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2018 Panel Members NCCN Guidelines Index Table of Contents Cancer- and Chemotherapy-Induced Anemia Discussion *George M. Rodgers, III, MD, PhD/Chair ‡ Benjamin Djulbegovic, MD, PhD † ‡ x Rekha Parameswaran, MD ‡ Huntsman Cancer Institute Moffitt Cancer Center Memorial Sloan Kettering at the University of Utah Cancer Center Jennifer R. Green, MD ‡ Jeffrey A. Gilreath, PharmD/Vice Chair ∑ ‡ Vanderbilt-Ingram Cancer Center Rita Paschal, MD ‡ Þ Huntsman Cancer Institute University of Alabama at Birmingham ∑ at the University of Utah Stefanie L. Houseknecht, PharmD † Comprehensive Cancer Center UC San Diego Maureen M. Achebe, MD, MPH ‡ Moores Cancer Center Candido Rivera, MD ‡ Dana-Farber/Brigham and Mayo Clinic Cancer Center Women's Cancer Center Eric H. Kraut, MD ‡ The Ohio State University Comprehensive Joseph Rosenthal, MD ‡ € Laura Alwan, PharmD ∑ Cancer Center - James Cancer Hospital City of Hope Comprehensive Fred Hutchinson Cancer Research Center/ and Solove Research Institute Cancer Center Seattle Cancer Care Alliance Michael Kroll, MD ‡ Satish Shanbhag, MBBS, MPH † ‡ Murat Arcasoy, MD ‡ The University of Texas The Sidney Kimmel Comprehensive Duke Cancer Institute MD Anderson Cancer Center Cancer Center at Johns Hopkins Seema Ali Bhat, MD † ‡ Michael M. Millenson, MD ‡ Þ † Ari VanderWalde, MD, MPH Þ † Roswell Park Fox Chase Cancer Center St. Jude Children`s Cancer Institute Research Hospital/ ∑ Tim Miller, PharmD The University of Tennessee Rondeep Brar, MD † ‡ University of Wisconsin Health Science Center Stanford Cancer Institute Carbone Cancer Center NCCN Erica Campagnaro, MD ‡ Anne Neff, MD ‡ Jennifer Burns University of Michigan Case Comprehensive Cancer Center/ Lenora A. Pluchino, PhD Comprehensive Cancer Center University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute x David Cella, PhD q Bone marrow transplantation ∑ ‡ Hematology/Hematology oncology Robert H. Lurie Comprehensive Cancer Cindy L. O'Bryant, PharmD † Þ Internal medicine Center of Northwestern University University of Colorado Cancer Center † Medical oncology # Nursing Peter F. Coccia, MD ≠ ‡ € ≠ Pathology Fred & Pamela Buffett Cancer Center € Pediatric oncology Continue ∑ Pharmacology/Pharmacotherapy q Psychiatry/Psychology * Discussion Writing Committee Member NCCN Guidelines Panel Disclosures Version 2.2018, 11/21/17 © National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 7:04:17 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2018 Table of Contents NCCN Guidelines Index Table of Contents Cancer- and Chemotherapy-Induced Anemia Discussion NCCN Cancer- and Chemotherapy-Induced Anemia Panel Members Clinical Trials: NCCN believes that Summary of the Guidelines Updates the best management for any cancer patient is in a clinical trial. Participation in clinical trials is Evaluation of Anemia (ANEM-1) especially encouraged. To find clinical trials online at NCCN Risk Assessment and Indications for Initial Transfusion in Acute Setting (ANEM-2) Member Institutions, click here: Risks and Goals of ESA Use Versus Red Blood Cell Transfusion (ANEM-3) nccn.org/clinical_trials/physician.html. NCCN Categories of Evidence and Special Categories in Considering ESA Use (ANEM-4) Consensus: All recommendations are category 2A unless otherwise Evaluation of Iron Deficiency (ANEM-5) indicated. See NCCN Categories of Evidence Indications for Red Blood Cell Transfusion in Patients (ANEM-A) and Consensus. Erythropoietic Therapy - Dosing, Titration, and Adverse Effects (ANEM-B) Parenteral Iron Preparations (ANEM-C) Management of Cancer- and Chemotherapy-Induced Anemia For Patients Who Refuse Blood Transfusions (ANEM-D) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2017. Version 2.2018, 11/21/17 © National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 7:04:17 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2018 Updates NCCN Guidelines Index Table of Contents Cancer- and Chemotherapy-Induced Anemia Discussion Updates in Version 2.2018 of the NCCN Guidelines for Cancer- and Chemotherapy-Induced Anemia from Version 1.2018 include: MS-1 • The Discussion section has been updated to reflect the changes in the algorithm. Updates in Version 1.2018 of the NCCN Guidelines for Cancer- and Chemotherapy-Induced Anemia from Version 2.2017 include: General ANEM-A • All details about the REMS program have been removed. Former • Last bullet and sub-bullet removed: "Anemia in setting of acute page ANEM-C has been deleted. coronary syndromes or acute myocardial infarction: Transfusion ANEM-1 goal is unclear and is being evaluated. Consider clinical context • The following has been added to the list of possible causes of and published guidelines." anemia to consider: "Hormone dysfunction (ie, hypogonadism, ANEM-B (4 of 5) adrenal dysfunction, hyper/hypothyroidism)." • Under ESA-Neutralizing Antibodies, the last line has been • The last line of footnote "d" has been revised: "Fasting is preferred revised: "Patients should not be immediately switched to other when testing for serum iron and total iron-binding capacity, and ESA products as antibodies may cross-react." serum ferritin." ANEM-C (2 of 3) ANEM-3 • For dosage administration of total dose infusion of low- • Revision to line above the table: "Listed below are Discuss the molecular-weight iron dextran, added: "Calculated total iron following risks and goals with patients when considering of each dextran dose in 500 mL of 0.9% NaCl solution administered at anemia treatment options:" 175 mL/h." Addition was made based on the following reference: • Bullets added below the table: Auerbach M, Ballard H, Trout JR, et al. Intravenous iron optimizes Discuss the risks of ESAs with patients including the potential for the response to recombinant human erythropoietin in cancer tumor growth, death, blood clots, and serious heart problems. patients with chemotherapy-related anemia: A multicenter, Refer patients to the following medication guides for more open-label, randomized trial. Journal of Clinical Oncology information on the benefits and risk of ESAs: Epoetin Alfa 2004;22:1301-1307. Medication Guide and Darbepoetin Alfa Medication Guide ANEM-D ANEM-4 • Bullet revised: "Consider use of ESAs for select patients by FDA • For patients undergoing palliative treatment, added clinical trial as indications/dosing/dosing adjustments, under REMS guidelines, an option for patients to consider based on preference. • The following option has been revised where recommended for with informed consent of patient." special categories in considering ESA use: "Consider ESAs by FDA • Bullet removed: "In addition, prior approval from third-party indications/dosing/dosing adjustments, under REMS guidelines, payers should be sought to prevent increasing the financial with informed consent of patient." burden of the patient." • Footnote removed: "Health care providers prescribing ESAs need to enroll in the ESA APPRISE Oncology Program. See REMS: Risk Evaluation and Mitigation Strategy for Erythropoiesis-Stimulating Agents (ESAs) (ANEM-C)." Version 2.2018, 11/21/17 © National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. UPDATES Printed by Anton Kabakov on 3/5/2018 7:04:17 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2018 NCCN Guidelines Index Table of Contents Cancer- and Chemotherapy-Induced Anemia Discussion HEMOGLOBIN EVALUATION OF ANEMIAa,b CONCENTRATION
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