Assessment of iron status and the role for iron-replacement therapy in anaemic cancer patients under the care of a specialist palliative care unit

Abstract

Anaemia is common in advanced cancer, may develop for several reasons, and is not always symptomatic. Our observations of the seemingly indiscriminate prescription of iron-replacement therapy (IRT) for anaemic palliative care patients, and our practice of discontinuing IRT in patients with normal red-cell indices, prompted a study to determine (1) the prevalence of anaemia in our patients, (2) what proportion had iron deficiency, (3) the prevalence and benefits of IRT and (4) the prevalence of side effects attributable to IRT. The prevalence of anaemia was 65%. We found a 9% prevalence of iron deficiency, and suggestive but inconclusive evidence of iron deficiency in a further 41%, but only three (27%) of these patients had typical iron deficiency red-cell indices. Only two patients within the study population were taking IRT. Haemoglobin increased significantly in one, but fell in the other, and both experienced side effects attributable to iron. IRT should neither be indiscriminately prescribed nor withheld for anaemic palliative care patients, and the decision should not be based on red-cell indices alone. When symptomatic anaemia is found in patients whose general condition indicates that IRT would be acceptable, iron status should be fully assessed. A therapeutic trial of IRT may be justified where ferritin is elevated, but other parameters suggest iron deficiency.

Keywords

anaemia iron-replacement therapy palliative care

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References

1 Dunn A Carter J Carter H . Anemia at the end of life: prevalence, significance, and causes in patients receiving palliative care. J Pain Symptom Manage 2003; 26: 1132–1139.

2 Turner AR . Clinical management of anaemia, cytopenias, and thrombosis in palliative medicine. In: D Doyle G Hanks N Cherny K Calman , (eds), Oxford textbook of palliative medicine. Oxford: Oxford University Press; 2005. p. 568–573.

3 Wetherall DJ . Anaemia: pathophysiology, classification, and clinical features. In: DA Warrell TM Cox JD Firth EJ Benz , (eds), Oxford textbook of medicine, vol 3. Oxford: Oxford University Press; 2005. p. 639–644.

4 Cox TM . Iron metabolism and its disorders. In: DA Warrell TM Cox JD Firth EJ Benz , (eds), Oxford textbook of medicine, vol 3. Oxford: Oxford University Press; 2005. p. 648–657.

5 Crawford J Cella D Cleeland CS Cremieux PY Demetri GD Sarokhan BJ . Relationship between changes in hemoglobin level and quality of life during chemotherapy in anemic cancer patients receiving epoetin alfa therapy. Cancer 2002; 95: 888–895.

6 Gleeson C Spenser D . Blood transfusion and its benefits in palliative care. Palliat Med 1995; 9: 307–313.

7 Monti M Castellani L Berlusconi A Cunietti E . Use of red blood cell transfusions in terminally ill cancer patients admitted to a palliative care unit. J Pain Symptom Manage 1996; 12: 18–22.

8 Ferguson BJ Skikne BS Simpson KM Baynes RD Cook JD . Serum transferrin receptor distinguishes the anemia of chronic disease from iron deficiency anemia. J Lab Clin Med 1992; 119: 385–390.

9 Wians FH Urban JE Keffer JH Kroft SH . Discriminating between iron deficiency anemia and anemia of chronic disease using traditional indices of iron status vs transferrin receptor concentration. Am J Clin Pathol 2001; 115: 112–118.

10.

10 Munch TN Zhang T Willey J Palmer JL Bruera E . The association between anemia and fatigue in patients with advanced cancer receiving palliative care. J Palliat Med 2005; 8: 1144–1149.

11.

11 Davis MP . Anaemia at the end of life. J Pain Symptom Manage 2004; 27: 392–393.

12.

12 Mystakidou K Kalaidopoulou O Katsouda E Parpa E Kouskouni E Chondros C . Evaluation of epoetin supplemented with oral iron in patients with solid malignancies and chronic anemia not receiving anticancer treatment. Anticancer Res 2005; 25: 3495–3500.

13.

13 Drüeke T . Hyporesponsiveness to recombinant human erythropoietin. Nephrol Dial Transplant 2001; 16(Suppl. 7): 25–28.

14.

14 Lönnroth C Svensson M Wang W Körner U Daneryd P Nilsson O . Survival and erythropoietin receptor protein in tumours from patients randomly treated with rhEPO for palliative care. Med Oncol 2008; 25: 22–29.

15.

16.

16 Provan D . Iron deficiency anaemia. In: D Provan , (ed), ABC of clinical haematology, 3rd ed. Oxford: BMJ Books. Blackwell Publ; 2007.