The primary outcomes of interest were mortality, frequency of RBC transfusion, thromboembolic risk, and progression-free survival. For the biosimilars, HgB response and immunogenicity were primary outcomes of interest. Secondary outcomes of interest were quality of life, fatigue, and overall survival.
The primary literature review identified 15 meta-analyses of RCTs and 2 RCTs. Three meta-analyses covered the addition of iron supplementation to an anemia treatment plan using ESAs. The other 12 meta-analyses assessed ESAs compared with placebo or best standard therapy. One RCT was in metastatic breast cancer, and the other was in MDS. For biosimilars, 2 meta-analyses and 2 RCTs, 1 of which involved patients with CKD, were included.
The panel developed the updated recommendations based upon the answers to each of the 10 clinical questions and defined the type of evidence, evidence quality, and strength of the recommendation. Six of the 12 total recommendations were considered strong recommendations.
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Although the use of ESAs reduces the need for transfusions, it is associated with increased complications, including greater risk for thromboembolic and cardiovascular events, faster tumor growth, and higher mortality. However, ESAs are preferable for some patients, and the expert panel encouraged health care providers to have open and thorough discussions with patients who are considering ESA use about “each patient’s preferences, priorities, values, and spiritual needs” and “to help them make informed decisions by considering the scientific evidence and weighing their individual risks with potential harms and benefits of ESA therapy.”
“[Instead of] transfusions, some patients prefer to be treated with ESAs. Additionally, transfusion availability may be limited for certain patients in remote settings or rural communities, and some individuals or groups may not accept any form of blood products. So in those patients, ESAs are probably preferred,” said Dr Lazo-Langner.
The authors referred health care providers to the “Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline” for recommendations and strategies for patient-clinician communication.3
The report also highlighted the difficulty of using evidence-based guidelines to inform the treatment of patients with multiple chronic conditions (MCC), as patients with MCCs are often excluded from clinical trials. Thus, treating patients with MCCs necessitates additional considerations and shared decision-making with discussions between the patient and clinician about the uncertainties associated with applying evidence-based guidelines in the context of MCCs.
References
1. Bohlius J, Bohlke K, Castelli R, et al. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update [published online April 10, 2019]. Blood Adv. doi:10.1182/bloodadvances.2018030387.
2. Bohlius J, Bohlke K, Castelli R, et al. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update [published online April 10, 2019]. J Clin Oncol. doi:10.1200/JCO.18.02142
3. Gilligan T, Coyle N, Frankel RM, et al. Patient-clinician communication: American Society of Clinical Oncology consensus guideline [published online September 11, 2017]. J Clin Oncol. doi:10.1200/JCO.2017.75.2311
