Treatment Thresholds for Anemia

Definition and Classification of Anemia

Anemia is defined as a reduction of hemoglobin concentration, red-cell count, or packed cell volume below normal levels, and can be categorized by severity, including mild anemia (Hemoglobin ≤11.9 g/dL and ≥10 g/dL), moderate anemia (Hemoglobin ≤9.9 g/dL and ≥8.0 g/dL), and severe anemia (Hemoglobin <8.0 g/dL) 2
Treatment-related anemia is graded according to the National Cancer Institute-Common Toxicity Criteria, with grades ranging from 0 (within normal limits) to 4 (less than 6.5 g/dL) 2

The American Society of Clinical Oncology recommends treatment with erythropoiesis-stimulating agents (ESAs) when hemoglobin ≤10 g/dL in patients receiving chemotherapy, with a goal to increase hemoglobin by less than 2 g/dL or prevent further decline, and primary aims to prevent red blood cell transfusions and improve quality of life 1
The European Society for Medical Oncology suggests that ESAs are not indicated and may increase mortality risk when targeting Hb of 12-14 g/dL in cancer patients not receiving chemotherapy 3

A thorough evaluation should be conducted before initiating treatment for anemia, including complete blood count with reticulocyte count, iron studies, inflammatory markers, vitamin B12 and folate levels, peripheral blood smear examination, assessment for occult blood loss, evaluation of renal function, and bone marrow examination when indicated 2, 4
The National Comprehensive Cancer Network recommends Coombs testing in patients with chronic lymphocytic leukemia, non-Hodgkin's lymphoma, or history of autoimmune disease 2, 4

All causes of anemia should be identified and addressed before using ESAs, according to the American Society of Hematology 2, 4
The American College of Physicians suggests that ESAs should be used cautiously in patients being treated with curative intent due to potential risks 3