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Cancer-related anemia

Key sources
The following summarized guidelines for the evaluation and management of cancer-related anemia are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH/ASCO 2019) and the European Society of Medical Oncology (ESMO 2018).


1.Diagnostic investigations

Initial assessment
Elicit appropriate history, perform physical examination, and obtain diagnostic tests to identify alternative causes of anemia aside from chemotherapy or an underlying hematopoietic malignancy, and appropriately address such causes before offering ESAs.
Consider obtaining the following tests for baseline evaluation for anemia in patients with cancer receiving chemotherapy:
thorough drug exposure history
peripheral blood smear, and bone marrow examination in some cases
TIBC, transferrin saturation, ferritin, folate, vitamin B12, hemoglobinopathy screening, where indicated
reticulocyte count, occult blood loss, and assessment for renal insufficiency
baseline EPO level
serum TSH, where indicated
direct Coombs test in patients with chronic lymphocytic leukemia, non-Hodgkin's lymphoma, or history of autoimmune disease
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2.Medical management

Goals of treatment: consider increasing hemoglobin level to the lowest concentration required to avoid or reduce the need for RBC transfusions, varying by patient and condition, in adult patients with chemotherapy-associated anemia being candidates for ESAs.

More topics in this section

  • ESAs (indications)

  • ESAs (choice of agent and dosing)

  • ESAs (discontinuation)

  • Iron replacement

3.Therapeutic procedures

Red blood cell transfusion
Consider performing RBC transfusion in patients with chemotherapy-associated anemia depending on the severity of the anemia or clinical circumstances.
Consider performing blood cell transfusion in patients with non-myeloid hematologic malignancies receiving concurrent myelosuppressive chemotherapy.

4.Specific circumstances

Patients with refractory disease: reevaluate patients not responding to ESAs for underlying tumor progression, iron deficiency, or other etiologies of anemia.