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Meyers M, Salmon M, Libert I, Klášterský J. A meta-analysis on the risk of infection associated with intravenous iron therapy in cancer-associated anaemia: a double-edged sword? Curr Opin Oncol 2024; 36:223-232. [PMID: 38842015 DOI: 10.1097/cco.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The increased use of i.v. iron in the treatment of cancer-associated anemia raises concerns about its risk of infectious complications. High levels of circulating iron could increase the risk of infection by compromising natural defence mechanisms and promoting pathogen growth. Since the risk of infection is particularly high in the oncological population, we have examined whether the use of i.v. iron increases the risk of infectious complications among cancer patients. FINDINGS Among 18 randomized trials in our systematic review, only 8 reported infectious complications, with no significant difference linked to the type of i.v. iron preparation. Two trials showed a statistically significant increase in infectious complications, one trial found a lower risk, while the remaining 5 reported no significant difference. Our meta-analysis revealed a numerical increase in infectious complications in the i.v. iron group, but the lack of statistical significance and significant heterogeneity among the trials limit definitive conclusions on the actual infection risk. SUMMARY Our findings suggest some increased risk in infectious complications after the administration of i.v. iron for cancer associated anaemia. However, i.v. iron therapy appears generally safe and effective in cancer-associated anaemia.
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Affiliation(s)
| | - Maurine Salmon
- Data Centre, Institut Jules Bordet and Université Libre de Bruxelles (ULB)
| | - Isabelle Libert
- Medical Oncology, Supportive Care Unit, Institut Jules Bordet, Brussels, Belgium
| | - Jean Klášterský
- Medical Oncology, Supportive Care Unit, Institut Jules Bordet, Brussels, Belgium
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Lederhuber H, Massey LH, Abeysiri S, Roman MA, Rajaretnam N, McDermott FD, Miles LF, Smart NJ, Richards T. Preoperative intravenous iron and the risk of blood transfusion in colorectal cancer surgery: meta-analysis of randomized clinical trials. Br J Surg 2024; 111:znad320. [PMID: 37994900 DOI: 10.1093/bjs/znad320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/30/2023] [Accepted: 08/27/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Hans Lederhuber
- Department of Colorectal Surgery, Royal Devon University HealthCare NHS Foundation Trust, Exeter, UK
| | - Lisa H Massey
- Department of Colorectal Surgery, St Mark's the National Bowel Hospital and Academic Institute, London, UK
| | - Sandaruwani Abeysiri
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Marius A Roman
- Department of Cardiovascular Sciences and National Institute for Health Research, Leicester, Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Niroshini Rajaretnam
- Department of Colorectal Surgery, Royal Devon University HealthCare NHS Foundation Trust, Exeter, UK
| | - Frank D McDermott
- Department of Colorectal Surgery, Royal Devon University HealthCare NHS Foundation Trust, Exeter, UK
| | - Lachlan F Miles
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Neil J Smart
- Department of Colorectal Surgery, Royal Devon University HealthCare NHS Foundation Trust, Exeter, UK
| | - Toby Richards
- Division of Surgery, University College London, London, UK
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
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Teixeira AP, Xue S, Huang J, Fussenegger M. Evolution of molecular switches for regulation of transgene expression by clinically licensed gluconate. Nucleic Acids Res 2023; 51:e85. [PMID: 37497781 PMCID: PMC10450161 DOI: 10.1093/nar/gkad600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/22/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023] Open
Abstract
Synthetic biology holds great promise to improve the safety and efficacy of future gene and engineered cell therapies by providing new means of endogenous or exogenous control of the embedded therapeutic programs. Here, we focused on gluconate as a clinically licensed small-molecule inducer and engineered gluconate-sensitive molecular switches to regulate transgene expression in human cell cultures and in mice. Several switch designs were assembled based on the gluconate-responsive transcriptional repressor GntR from Escherichia coli. Initially we assembled OFF- and ON-type switches by rewiring the native gluconate-dependent binding of GntR to target DNA sequences in mammalian cells. Then, we utilized the ability of GntR to dimerize in the presence of gluconate to activate gene expression from a split transcriptional activator. By means of random mutagenesis of GntR combined with phenotypic screening, we identified variants that significantly enhanced the functionality of the genetic devices, enabling the construction of robust two-input logic gates. We also demonstrated the potential utility of the synthetic switch in two in vivo settings, one employing implantation of alginate-encapsulated engineered cells and the other involving modification of host cells by DNA delivery. Then, as proof-of-concept, the gluconate-actuated genetic switch was connected to insulin secretion, and the components encoding gluconate-induced insulin production were introduced into type-1 diabetic mice as naked DNA via hydrodynamic tail vein injection. Normoglycemia was restored, thereby showcasing the suitability of oral gluconate to regulate in situ production of a therapeutic protein.
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Affiliation(s)
- Ana Palma Teixeira
- Department of Biosystems Science and Engineering, ETH Zurich, Mattenstrasse 26, CH-4058Basel, Switzerland
| | - Shuai Xue
- Department of Biosystems Science and Engineering, ETH Zurich, Mattenstrasse 26, CH-4058Basel, Switzerland
| | - Jinbo Huang
- Department of Biosystems Science and Engineering, ETH Zurich, Mattenstrasse 26, CH-4058Basel, Switzerland
| | - Martin Fussenegger
- Department of Biosystems Science and Engineering, ETH Zurich, Mattenstrasse 26, CH-4058Basel, Switzerland
- Faculty of Science, University of Basel, Mattenstrasse 26, CH-4058Basel, Switzerland
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Lim J, Auerbach M, MacLean B, Al-Sharea A, Richards T. Intravenous Iron Therapy to Treat Anemia in Oncology: A Mapping Review of Randomized Controlled Trials. Curr Oncol 2023; 30:7836-7851. [PMID: 37754484 PMCID: PMC10529066 DOI: 10.3390/curroncol30090569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023] Open
Abstract
Anemia is a common problem when patients present with cancer, and it can worsen during treatment. Anemia can directly impact the cognitive and physical quality of life and may impair fitness for oncological therapy. The most common cause of anemia is iron deficiency. Newer intravenous (IV) iron formulations offer a safe and rapidly effective treatment option. We performed a systematic mapping review of randomized controlled trials (RCTs) evaluating intravenous iron therapy in patients with cancer and anemia and their outcomes. A total of 23 RCTs were identified. The median number of patients enrolled was 104 (IQR: 60-134). A total of 5 were focused on surgical outcomes (4 preoperative, 1 postoperative), and 15 were in adjuvant therapies for a variety of tumor types (breast, colorectal, lung, gynecological, myeloid, and lymphomas), 10 of which were in combination with erythropoietin-stimulating agents (ESAs) therapy, 2 in radiotherapy, and 1 in palliative care. Overall, the studies reported that the use of IV iron increased hemoglobin concentration and decreased transfusion rates during different cancer treatment regimes. IV iron can be administered safely throughout the cancer treatment pathway from primary surgery to the palliative setting. More studies are needed to demonstrate net clinical outcomes.
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Affiliation(s)
- Jayne Lim
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Michael Auerbach
- Department of Medicine, Georgetown University, Washington, DC 20007, USA
| | - Beth MacLean
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Annas Al-Sharea
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Toby Richards
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
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Yuan T, Jia Q, Zhu B, Chen D, Long H. Synergistic immunotherapy targeting cancer-associated anemia: prospects of a combination strategy. Cell Commun Signal 2023; 21:117. [PMID: 37208766 DOI: 10.1186/s12964-023-01145-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/23/2023] [Indexed: 05/21/2023] Open
Abstract
Cancer-associated anemia promotes tumor progression, leads to poor quality of life in patients with cancer, and even obstructs the efficacy of immune checkpoint inhibitors therapy. However, the precise mechanism for cancer-associated anemia remains unknown and the feasible strategy to target cancer-associated anemia synergizing immunotherapy needs to be clarified. Here, we review the possible mechanisms of cancer-induced anemia regarding decreased erythropoiesis and increased erythrocyte destruction, and cancer treatment-induced anemia. Moreover, we summarize the current paradigm for cancer-associated anemia treatment. Finally, we propose some prospective paradigms to slow down cancer-associated anemia and synergistic the efficacy of immunotherapy. Video Abstract.
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Affiliation(s)
- Ting Yuan
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Qingzhu Jia
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
- Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Bo Zhu
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
- Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Degao Chen
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
- Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Haixia Long
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
- Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
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Intravenous Iron Supplementation for the Treatment of Chemotherapy-Induced Anemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2022; 11:jcm11144156. [PMID: 35887920 PMCID: PMC9317757 DOI: 10.3390/jcm11144156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 02/06/2023] Open
Abstract
Background: The pathophysiology of cancer-related anemia is multifactorial, including that of chemotherapy-induced anemia (CIA). The guidelines are not consistent in their approach to the use of intravenous (IV) iron in patients with cancer as part of the clinical practice. Materials and methods: All randomized controlled trials that compared IV iron with either no iron or iron taken orally for the treatment of CIA were included. We excluded trials if erythropoiesis-stimulating agents (ESAs) were used. The primary outcome was the percentage of patients requiring a red blood cell (RBC) transfusion during the study period. The secondary outcomes included the hematopoietic response (an increase in the Hb level by more than 1 g/dL or an increase above 11 g/dL), the iron parameters and adverse events. For the dichotomous data, risk ratios (RRs) with 95% confidence intervals (Cis) were estimated and pooled. For the continuous data, the mean differences were calculated. A fixed effect model was used, except in the event of significant heterogeneity between the trials (p < 0.10; I2 > 40%), in which we used a random effects model. Results: A total of 8 trials published between January 1990 and July 2021 that randomized 1015 patients fulfilled the inclusion criteria. Of these, 553 patients were randomized to IV iron and were compared with 271 patients randomized to oral iron and 191 to no iron. IV iron decreased the percentage of patients requiring a blood transfusion compared with oral iron (RR 0.72; 95% CI 0.55−0.95) with a number needed to treat of 20 (95% CI 11−100). IV iron increased the hematopoietic response (RR 1.23; 95% CI 1.01−1.5). There was no difference with respect to the risk of adverse events (RR 0.97; 95% CI 0.88−1.07; 8 trials) or severe adverse events (RR 1.09; 95% CI 0.76−1.57; 8 trials). Conclusions: IV iron resulted in a decrease in the need for RBC transfusions, with no difference in adverse events in patients with CIA. IV iron for the treatment of CIA should be considered in clinical practice.
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Adams A, Scheckel B, Habsaoui A, Haque M, Kuhr K, Monsef I, Bohlius J, Skoetz N. Intravenous iron versus oral iron versus no iron with or without erythropoiesis- stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2022; 6:CD012633. [PMID: 35724934 PMCID: PMC9208863 DOI: 10.1002/14651858.cd012633.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis-stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. OBJECTIVES To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta-analyses (NMAs). SEARCH METHODS We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. SELECTION CRITERIA We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. Outcomes were on-study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Ninety-six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On-study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on-study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on-study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low-certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. AUTHORS' CONCLUSIONS When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head-to-head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review.
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Affiliation(s)
- Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Benjamin Scheckel
- Institute of Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Anissa Habsaoui
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Madhuri Haque
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Zuccarini A, Cicognini D, Tancredi R, Ferrari A, Rizzo G, Lasagna A, Caccialanza R, Cavanna L, Orlandi E, Biasini C, Molinaro P, Garigliano D, Costantino A, Moroni M, Perrone L, Alessio NL, Rovati B, Ferretti VV, Klersy C, Pedrazzoli P. Randomized trial of sucrosomial iron supplementation in patients with chemotherapy-related anemia treated with ESA. Support Care Cancer 2022; 30:7645-7653. [PMID: 35678882 DOI: 10.1007/s00520-022-07184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/29/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Iron supplementation improves the erythropoiesis-stimulating agents' (ESAs) response in chemotherapy-related anemia. The primary aim of our study is to assess the efficacy of sucrosomial iron, a new oral iron formulation, in cancer patients with chemotherapy-induced anemia treated with ESAs. The secondary objectives included the efficacy into two subgroups of patients (iron replete and functional iron deficiency) between the two study arms, safety and the effect on transfusion need. METHODS In this randomized, multicentre, open-label, phase III clinical trial, 60 cancer patients were enrolled. Each patient was randomly assigned (1:1) to receive 12 weeks of oral sucrosomial iron at the dose of 30 mg daily in combination with ESAs or no supplementation to ESA treatment. The endpoint considered for efficacy was the proportion of patients achieving complete hematological response at 12 weeks (increase in Hb > 2 g/dL from baseline, without RBC transfusions in the previous 28 days or achieving Hb ≥ 12 g/dL). RESULTS There was a statistically significant association between oral sucrosomial iron supplementation in combination with ESAs and the achievement of a complete hematological response. This response was achieved within 12 weeks by 31% of patients in the control group and by 52% of patients supplemented with oral sucrosomial iron. A trend of greater response in sucrosomial iron arm was found in both subgroups. No difference was observed about safety and transfusion need. CONCLUSIONS Sucrosomial iron is well tolerated and its combination with ESAs improves the hematological response in cancer patients with chemotherapy-related anemia. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION This study has been reviewed by the Institutional Ethics Committee of the IRCCS Policlinico San Matteo Foundation, Pavia, Italy (28/04/2015; prot. N. 20,150,002,059), and by the Institutional Ethics Committee of the other Italian oncological centers involved in this study.
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Affiliation(s)
- Andrea Zuccarini
- Oncology Clinical Trial Office, Oncology Unit IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Daniela Cicognini
- Oncology Clinical Trial Office, Oncology Unit IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Richard Tancredi
- Medical Oncology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Alessandra Ferrari
- Oncology Clinical Trial Office, Oncology Unit IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gianpiero Rizzo
- Medical Oncology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Angioletta Lasagna
- Medical Oncology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Riccardo Caccialanza
- Nutrition and Dietetics Service, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Luigi Cavanna
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza, Italy
| | - Elena Orlandi
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza, Italy
| | - Claudia Biasini
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza, Italy
| | - Peppina Molinaro
- Oncology Unit Hospital "Giovanni Paolo II", Lamezia Terme, CZ, Italy
| | - Danula Garigliano
- Oncology Unit Hospital "Giovanni Paolo II", Lamezia Terme, CZ, Italy
| | - Angela Costantino
- Oncology Unit Hospital "Giovanni Paolo II", Lamezia Terme, CZ, Italy
| | - Mauro Moroni
- Oncology Division, San Carlo Borromeo Hospital, ASST Santi Paolo E Carlo, Milan, Italy
| | - Lorenzo Perrone
- Medical Oncology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Bianca Rovati
- Oncology Clinical Trial Office, Oncology Unit IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Catherine Klersy
- Clinical Epidemiology and Biometry Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Paolo Pedrazzoli
- Medical Oncology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy. .,Univerisity of Pavia, Pavia, Italy.
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9
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Tan J, Du S, Zang X, Ding K, Ginzburg Y, Chen H. The addition of oral iron improves chemotherapy-induced anemia in patients receiving erythropoiesis-stimulating agents. Int J Cancer 2022; 151:1555-1564. [PMID: 35639027 DOI: 10.1002/ijc.34142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/07/2022]
Abstract
Although many studies have shown that supplementation with iron and erythropoiesis-stimulating agents (ESA) is frequently used for managing chemotherapy-induced anemia (CIA), optimal combination therapy using these agents together to ameliorate anemia is not well characterized. To assess the effects of ESA combined with oral or intravenous (IV) iron on relieving CIA, PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI) were searched for articles. Data collected in the articles were meta-analyzed using RevMan 5.3 software with a random-effects model. Our comprehensive search yielded 1666 potentially relevant trials. A total of 41 trials randomizing 4200 patients with CIA fulfilled inclusion criteria, including 34 Chinese articles and 7 English articles. Meta-analysis showed that treatment with both ESA and iron more effectively improved CIA relative to iron supplementation alone, with increased hemoglobin, hematocrit, red blood cell count and haematopoietic response rate. Subgroup analyses revealed iron administration, both oral and IV iron, improved anemia in ESA-treated cancer patients with CIA. Our analysis demonstrates that iron supplementation combined with ESA more effectively ameliorates CIA relative to iron supplementation alone, without regard to whether IV or oral iron was used. Together, our findings may contribute to the clinical treatment of CIA using iron therapy with or without ESA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jingyong Tan
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Changsha, China
| | - Sitong Du
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Changsha, China
| | - Xueyan Zang
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Changsha, China
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Kaiyue Ding
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Changsha, China
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yelena Ginzburg
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Huiyong Chen
- Molecular Biology Research Center and Hunan Province Key Laboratory of Basic and Applied Hematology, School of Life Sciences, Central South University, Changsha, China
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Makharadze T, Boccia R, Krupa A, Blackman N, Henry DH, Gilreath JA. Efficacy and safety of ferric carboxymaltose infusion in reducing anemia in patients receiving chemotherapy for nonmyeloid malignancies: A randomized, placebo-controlled study (IRON-CLAD). Am J Hematol 2021; 96:1639-1646. [PMID: 34653287 PMCID: PMC9298873 DOI: 10.1002/ajh.26376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 12/03/2022]
Abstract
Erythropoiesis‐stimulating agents (ESA) are effective for chemotherapy‐induced anemia (CIA) but associated with serious adverse events. Safer alternatives would be beneficial in this population. The efficacy and safety of ferric carboxymaltose (FCM) as monotherapy for CIA was evaluated. This Phase 3, 18‐week, double‐blind, placebo‐controlled study randomized adults with ≥ 4 weeks of chemotherapy remaining for treatment of nonmyeloid malignancies with CIA to FCM (two 15 mg/kg infusions 7 days apart; maximum dose, 750 mg single/1500 mg total) or placebo. The primary efficacy endpoint was percentage of patients with decreases in hemoglobin (Hb) ≥ 0.5 g/dL from weeks 3 to 18; the key secondary efficacy endpoint was change in Hb from baseline to week 18. Inclusion criteria included: (Hb) 8–11 g/dL, ferritin 100–800 ng/mL, and transferrin saturation (TSAT) ≤35%. In 244 patients (n = 122, both groups), the percent of patients who maintained Hb within 0.5 g/dL of baseline from weeks 3 to 18 was significantly higher with FCM versus placebo (50.8% vs. 35.3%; p = 0.01). Mean change in Hb from baseline to week 18 was similar between FCM and placebo (1.04 vs. 0.87 g/dL) but significantly greater with FCM with baseline Hb ≤ 9.9 g/dL (1.08 vs. 0.42 g/dL; p = 0.01). The percent with ≥ 1 g/dL increase from baseline was significantly higher with FCM versus placebo (71% vs. 54%; p = 0.01), occurring in a median 43 versus 85 days (p = 0.001). Common adverse events in the FCM arm included neutropenia (17%), hypophosphatemia (16%), and fatigue (15%). FCM monotherapy effectively maintained Hb and was well tolerated in CIA.
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Affiliation(s)
| | - Ralph Boccia
- Center for Cancer and Blood Disorders Bethesda Maryland USA
| | - Anna Krupa
- College of Pharmacy and Health Sciences St. John's University Queens New York USA
| | | | - David H. Henry
- Abramson Cancer Center Pennsylvania Hospital Philadelphia Pennsylvania USA
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11
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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12
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Tasinov O, Kiselova-Kaneva Y, Ivanova D, Pasheva M, Vankova D, Ivanova D. Ferrum phosphoricum D12 Treatment Affects J774A.1 Cell Proliferation, Transcription Levels of Iron Metabolism, Antioxidant Defense, and Inflammation-related Genes. HOMEOPATHY 2021; 111:113-120. [PMID: 34634834 DOI: 10.1055/s-0041-1731312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ferrum phosphoricum (FP) is prescribed as a homeopathic remedy to treat the early stages of fever and inflammation in cases of colds or flu, muscle fatigue and anemia. We aimed to analyze the molecular mechanisms of action of FP D12 on cell proliferation and mRNA expression of iron metabolism, antioxidant defense and inflammation-related genes in mouse J774A.1 macrophages. METHODS Cell proliferation was examined using the MTT test. RT-qPCR analyses were performed to estimate gene expression changes. Relative gene expression levels were calculated using the 2-ΔΔCt method. The effect of treatment using FP D12 tablets was compared with that using placebo tablets (PT). RESULTS FP D12 in low concentrations (0.0125 mg/mL to 0.025 mg/mL) significantly stimulated proliferation of J774A.1 cells by up to 11% (p < 0.01) versus control untreated cells and by up to 40% (p < 0.01) versus PT-treated cells in the respective concentration. FP D12 versus PT induced a significant increase in mRNA expression of ferritin light chain (Ftl1) (by 8-fold, p < 0.01), β-2-microglobulin (B2m) (by 2.5-fold, p < 0.05) and iron-responsive element binding protein 2 (Ireb2) (by 4-fold, p < 0.05), and induced a slight decrease in myosin IE (Myo1e) mRNA expression levels (by 0.4-fold, p < 0.01) in macrophages. A highly significant (r2 = 0.99, p < 0.05) correlation was observed between Ireb2 and B2m transcription levels. Significant stimulation of antioxidant enzyme Gpx-1 (by 1.27-fold, p < 0.01) in cells by 0.025 mg/mL FP D12, but a slight decrease (by 0.12-fold, p < 0.05) in 0.0125 mg/mL-treated cells, was observed. A significant increase in the gene expression of IL-1β (by 3.5-fold, р < 0.05) in macrophages was also detected. CONCLUSION Ferrum phosphoricum in D12 dilution potentially exhibits iron retention, antioxidant and immunomodulation activities, possibly by modulating transcription levels of related genes in non-stimulated mouse macrophages.
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Affiliation(s)
- Oskan Tasinov
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
| | - Yoana Kiselova-Kaneva
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
| | - Desislava Ivanova
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
| | - Milena Pasheva
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
| | - Deyana Vankova
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
| | - Diana Ivanova
- Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University-Varna, Varna, Bulgaria
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13
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Gutiérrez OM. Treatment of Iron Deficiency Anemia in CKD and End-Stage Kidney Disease. Kidney Int Rep 2021; 6:2261-2269. [PMID: 34514189 PMCID: PMC8418942 DOI: 10.1016/j.ekir.2021.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 01/27/2023] Open
Abstract
Iron deficiency is common in individuals with chronic kidney disease and plays a major role in the development of anemia. Oral and intravenous iron agents are both available to replete iron in patients with chronic kidney disease diagnosed with iron deficiency. The choice of which agent to use is most often dictated by goals of therapy, tolerability, convenience, and response to prior therapy. Diminished absorption of iron in the gastrointestinal tract and a high incidence of gastrointestinal adverse effects can reduce the efficacy of oral iron agents, necessitating the use of i.v. iron formulations to treat iron deficiency anemia, particularly in patients requiring kidney replacement therapy. Newer oral agents may help to overcome these limitations and help treat iron deficiency in those not requiring kidney replacement therapy. Recent studies have provided new evidence that more aggressive repletion of iron in patients with chronic kidney disease requiring kidney replacement therapy may provide benefits with respect to anemia management and hard clinical outcomes such as cardiovascular disease and survival.
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Affiliation(s)
- Orlando M. Gutiérrez
- Division of Nephrology, Department of Medicine and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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14
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Su Y, Huo M, Hua L, Zhang Y, Yi J, Zhang S, Li J, Zhang Y. Association of Venous Thromboembolism and Early Mortality in Patients with Newly Diagnosed Metastatic Non-Small Cell Lung Cancer. Cancer Manag Res 2021; 13:4031-4040. [PMID: 34040443 PMCID: PMC8140886 DOI: 10.2147/cmar.s301088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/22/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose To explore the relationship between venous thromboembolism (VTE) and early mortality (within six months) in Chinese patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC) after entering the era of precision treatment. Methods A cohort of 706 consecutive subjects with newly diagnosed metastatic NSCLC were prospectively observed. Clinical and survival data were recorded over a six-month follow-up period. The predictive factors for the occurrence of VTE and the relationship with early mortality were evaluated through univariate and multivariate analyses. Results During the six-month follow-up period, VTE events occurred in 12.2% (86/706) of the enrolled patients. In the multivariate analyses for VTE, an age older than 70 years (vs < 70: sub-distribution hazard radio [SHR], 1.678; 95% confidence interval (CI), 1.073–2.600; P=0.022), an Eastern Cooperative Oncology Group performance status ≥2 (vs 0/1: SHR, 1.946; 95% CI, 1.277–2.970; P=0.002), and having an ALK rearrangement (vs non-rearrangement: SHR, 2.377; 95% CI, 1.186–4.760; P=0.015) were significantly associated with the occurrence of VTE. Within six months, 116 subjects (16.4%) died, and the occurrence of VTE (vs no VTE: adjusted HR: 1.863; 95% CI: 1.178–2.947, P=0.008) was remarkably associated with early mortality. Further analysis showed 98 patients (13.9%) with early mortality had EGFR/ALK wild-type genes, with a risk of early mortality 5.935-fold higher than that of patients with an EGFR mutation/ALK rearrangement. Finally, subgroup analyses showed that VTE occurrence was a significant factor for predicting early mortality in patients with EGFR/ALK wild-type genes (adjusted HR: 1.682; 95% CI: 1.023–2.768, P=0.041). Conclusion Patients with an EGFR mutation/ALK rearrangement had a significantly decreased risk of early mortality in the era of targeted therapy; however, VTE occurrence remained an important predictor for early mortality in metastatic NSCLC patients, especially in patients with EGFR/ALK wild-type genes.
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Affiliation(s)
- Yanping Su
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Meirong Huo
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Lin Hua
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Yuan Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Jiawen Yi
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Shu Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Jie Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, People's Republic of China
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15
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Aksan A, Farrag K, Aksan S, Schroeder O, Stein J. Flipside of the Coin: Iron Deficiency and Colorectal Cancer. Front Immunol 2021; 12:635899. [PMID: 33777027 PMCID: PMC7991591 DOI: 10.3389/fimmu.2021.635899] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
Iron deficiency, with or without anemia, is the most frequent hematological manifestation in individuals with cancer, and is especially common in patients with colorectal cancer. Iron is a vital micronutrient that plays an essential role in many biological functions, in the context of which it has been found to be intimately linked to cancer biology. To date, however, whereas a large number of studies have comprehensively investigated and reviewed the effects of excess iron on cancer initiation and progression, potential interrelations of iron deficiency with cancer have been largely neglected and are not well-defined. Emerging evidence indicates that reduced iron intake and low systemic iron levels are associated with the pathogenesis of colorectal cancer, suggesting that optimal iron intake must be carefully balanced to avoid both iron deficiency and iron excess. Since iron is vital in the maintenance of immunological functions, insufficient iron availability may enhance oncogenicity by impairing immunosurveillance for neoplastic changes and potentially altering the tumor immune microenvironment. Data from clinical studies support these concepts, showing that iron deficiency is associated with inferior outcomes and reduced response to therapy in patients with colorectal cancer. Here, we elucidate cancer-related effects of iron deficiency, examine preclinical and clinical evidence of its role in tumorigenesis, cancer progression and treatment response. and highlight the importance of adequate iron supplementation to limit these outcomes.
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Affiliation(s)
- Aysegül Aksan
- Institute of Nutritional Science, Justus-Liebig University, Giessen, Germany.,Institute of Pharmaceutical Chemistry, Goethe University, Frankfurt, Germany.,Interdisziplinäres Crohn Colitis Centrum, Rhein-Main, Frankfurt, Germany
| | - Karima Farrag
- Interdisziplinäres Crohn Colitis Centrum, Rhein-Main, Frankfurt, Germany.,DGD Kliniken Sachsenhausen, Frankfurt, Germany
| | - Sami Aksan
- Interdisziplinäres Crohn Colitis Centrum, Rhein-Main, Frankfurt, Germany.,DGD Kliniken Sachsenhausen, Frankfurt, Germany
| | - Oliver Schroeder
- Interdisziplinäres Crohn Colitis Centrum, Rhein-Main, Frankfurt, Germany.,DGD Kliniken Sachsenhausen, Frankfurt, Germany
| | - Jürgen Stein
- Institute of Pharmaceutical Chemistry, Goethe University, Frankfurt, Germany.,Interdisziplinäres Crohn Colitis Centrum, Rhein-Main, Frankfurt, Germany.,DGD Kliniken Sachsenhausen, Frankfurt, Germany
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16
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Al-Samkari H, Kessler CM, Auerbach M. Recognition of thrombotic risk of thrombocytosis in iron deficiency. Haematologica 2021; 106:661-663. [PMID: 33645945 PMCID: PMC7927881 DOI: 10.3324/haematol.2020.270496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Craig M Kessler
- Department of Medicine, Georgetown University School of Medicine, Washington, DC
| | - Michael Auerbach
- Department of Medicine, Georgetown University School of Medicine, Washington, DC
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17
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Tymoszuk P, Nairz M, Brigo N, Petzer V, Heeke S, Kircher B, Hermann-Kleiter N, Klepsch V, Theurl I, Weiss G, Pfeifhofer-Obermair C. Iron Supplementation Interferes With Immune Therapy of Murine Mammary Carcinoma by Inhibiting Anti-Tumor T Cell Function. Front Oncol 2020; 10:584477. [PMID: 33344239 PMCID: PMC7746876 DOI: 10.3389/fonc.2020.584477] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
Iron is both, an essential compound for many metabolic processes, and iron deficiency can impact on the proliferation of cells including lymphocytes but also tumor cells. On the other hand, excess iron-catalyzed radical formation can induce cellular toxicity which has been previously demonstrated for T cells in hereditary iron overload. Despite these interconnections, little is known on the effects of clinically approved intravenous iron supplements for curing cancer-related anemia, on T cell differentiation, tumor proliferation, anti-tumor T cell responses and, of clinical importance, on efficacy of cancer immunotherapies. Herein, we analyzed the effects of intravenous iron supplementation on T cell function and on the effectiveness of anti-cancer chemotherapy with IL-2/doxorubicin or immunotherapy with checkpoint-inhibitor anti-PD-L1 in C57Bl/6N female mice with implanted E0771 mammary carcinomas. We found that iron application resulted to an increased availability of iron in the tumor microenvironment and stimulation of tumor growth. In parallel, iron application inhibited the activation, expansion and survival of cytotoxic CD8+ T cells and of CD4+ T helper cells type 1 and significantly reduced the efficacy of the investigated anti-cancer treatments. Our results indicate that iron administration has a tumor growth promoting effect and impairs anti-cancer responses of tumor infiltrating T lymphocytes along with a reduced efficacy of anti-cancer therapies. Iron supplementation in cancer patients, especially in those treated with immunotherapies in a curative setting, may be thus used cautiously and prospective studies have to clarify the impact of such intervention on the outcome of patients.
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Affiliation(s)
- Piotr Tymoszuk
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Manfred Nairz
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Natascha Brigo
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Petzer
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Simon Heeke
- Institute for Research on Cancer and Aging, Laboratory of Clinical and Experimental Pathology (LPCE), Hôpital Pasteur, Nice, France
| | - Brigitte Kircher
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Victoria Klepsch
- Division of Translational Cell Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Igor Theurl
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria.,Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, Innsbruck, Austria
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18
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Musio F. Revisiting the treatment of anemia in the setting of chronic kidney disease, hematologic malignancies, and cancer: perspectives with opinion and commentary. Expert Rev Hematol 2020; 13:1175-1188. [PMID: 33028115 DOI: 10.1080/17474086.2020.1830371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Anemia has and will continue to be a central theme in medicine particularly as clinicians are treating a burgeoning population of complex multi-organ system processes. As a result of multiple randomized controlled trials (RCTs), meta-analyses, and societal recommendations overly restrictive paradigms and under-administration of erythropoiesis stimulating agents (ESAs) have likely been followed by clinicians among all specialties. AREAS COVERED A review of anemia in the context of chronic kidney disease, hematologic malignancies, and cancer is presented with focus on the establishment of ESAs as integral in the treatment of anemia. Multiple RCTs and meta-analyses studying the use of ESAs are presented with focus upon their application to clinical practice. A 'compendium' is proffered describing the evolution, establishment, and implications of ESA administration initially among those with CKD with rapid subsequent application to the Hematology-Oncology population of patients. Literature search methodologies have included MEDLINE (1985-2020), PubMed (1996-2020), Cochrane Central Trials (1985-2020), EMBASE (2000-2020), and ClinicalTrials.gov (2000-2020). EXPERT OPINION Upon evaluation of risks and benefits of ESAs focused opinion and commentary is made supporting more liberal use of these agents and strongly suggesting that the current underlying treatment 'pendulum' has perhaps shifted too far to the 'under-treatment' side in many cases.
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Affiliation(s)
- Franco Musio
- Senior Partner, Nephrology Associates of Northern Virginia , VA, Fairfax, Virginia, USA.,Nephrology Division Chief, Inova Fairfax Hospital, Department of Medicine, Falls Church , Virginia, VA, USA.,Associate Professor of Medicine, Virginia Commonwealth University (Inova Fairfax Hospital Campus) , Richmond, Virginia, USA
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19
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Abdel-Razeq H, Saadeh SS, Malhis R, Yasser S, Abdulelah H, Eljaber R, Kleib A, Ismael R. Treatment of anemia in cancer patients undergoing chemotherapy with intravenous ferric carboxymaltose without erythropoiesis-stimulating agents. Ther Adv Med Oncol 2020; 12:1758835920953292. [PMID: 32952616 PMCID: PMC7485004 DOI: 10.1177/1758835920953292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Anemia is commonly encountered in cancer patients receiving active
chemotherapy. Due to adverse events and presumed negative effects on
disease-progression and survival, erythropoiesis-stimulating agents are not
frequently used. In this study, we assess the efficacy and safety of
intravenous ferric carboxymaltose (FCM) to treat cancer-induced anemia
(CIA). Patients and Methods: We recruited adult cancer patients on active chemotherapy with a hemoglobin
(Hb) level ⩽11.0 g/dL. Based on serum ferritin (sFr) and transferrin
saturation (TSAT), patients were divided into 3 groups: group I (absolute
iron deficiency, n = 26) with sFr < 30 ng/mL and
TSAT < 20%; group II (functional iron deficiency,
n = 24) with sFr 30–800 ng/mL and TSAT < 20%; and
patients with TSAT ⩾ 20% were placed in group III as “others”
(n = 34). All patients were treated with intravenous
FCM. Serum hepcidin and C-reactive protein were used as biomarkers to
predict response. Results: A total of 84 patients with a median age (SD) of 53.8 (10.6) were recruited.
Baseline median Hb level was 10.2 (range: 8.3–11.0) gm/dL. At week 12, there
was a significant increment in Hb level for patients in groups I and II
(median increment: 2.35 and 1.5 gm/dL, respectively), with limited response
observed in group III, and most of the increment noted as early as week 3
(⩾1.0 g/dL). Responders tended to have lower levels of hepcidin. No
clinically significant adverse events were reported; however, asymptomatic
hypophosphatemia was observed in 39 (46.4%) patients. Conclusions: Intravenous FCM is a safe and effective treatment option for the management
of a subgroup of patients with CIA. The study was registered at ClinicalTrials.gov [Identifier: NCT04246021]
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Affiliation(s)
| | - Salwa S. Saadeh
- Department of Medical oncology, King Hussein
Cancer Center, Amman, Jordan
| | - Razan Malhis
- Department of Medical oncology, King Hussein
Cancer Center, Amman, Jordan
| | - Sameer Yasser
- Department of Medical oncology, King Hussein
Cancer Center, Amman, Jordan
| | - Hazem Abdulelah
- Department of Medical oncology, King Hussein
Cancer Center, Amman, Jordan
| | - Rana Eljaber
- Department of Pharmacy, King Hussein Cancer
Center, Amman, Jordan
| | - Amer Kleib
- Department of Nursing, King Hussein Cancer
Center, Amman, Jordan
| | - Rouba Ismael
- Office of Scientific Affairs and Research, King
Hussein Cancer Center, Amman, Jordan
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20
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Abioye AI, Andersen CT, Sudfeld CR, Fawzi WW. Anemia, Iron Status, and HIV: A Systematic Review of the Evidence. Adv Nutr 2020; 11:1334-1363. [PMID: 32383731 PMCID: PMC7490171 DOI: 10.1093/advances/nmaa037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
People living with HIV (PLWHIV) are at high risk of anemia due to inadequate iron intake, HIV and opportunistic infections, and inflammation, and as a side effect of antiretroviral therapy. Though iron supplementation can reduce iron deficiency anemia (IDA) in the general population, its role in anemia and in the health of PLWHIV is unclear due to concerns that iron supplementation may increase HIV replication and risk of opportunistic infections. We systematically reviewed the evidence on indicators of iron status, iron intake, and clinical outcomes among adults and children with HIV. The evidence suggests that anemia is associated with an increased risk of all-cause mortality and incident tuberculosis among HIV-infected individuals, regardless of anemia type, and the magnitude of the risk is greater with more severe anemia. High serum ferritin is associated with adverse clinical outcomes, although it is unclear if this is due to high iron or inflammation from disease progression. One large observational study found an increased risk of all-cause mortality among HIV-infected adults if they received iron supplementation. Published randomized controlled trials of iron supplementation among PLWHIV tend to have small sample sizes and have been inconclusive in terms of effectiveness and safety. Large randomized trials exploring approaches to safely and effectively provide iron supplementation to PLWHIV are warranted.
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Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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21
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Sbrana A, Antonuzzo A, Brunello A, Petrelli F, Pronzato P, Tralongo A, Turrini M, Zoratto F, Danova M. Management of anemia in patients with cancer: 2019 Italian Association of Medical Oncology (AIOM) guidelines. TUMORI JOURNAL 2020; 106:337-345. [PMID: 32482149 DOI: 10.1177/0300891620921942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article summarizes the latest Italian Medical Oncology Association (AIOM) guidelines on the management of cancer-related and chemotherapy-related anemia with a particular attention to the use of erythropoiesis-stimulating agents and iron supplementation.
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Affiliation(s)
- Andrea Sbrana
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.,Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Antonuzzo
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Fausto Petrelli
- Medical Oncology Unit, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Paolo Pronzato
- Medical Oncology Unit, AOU San Martino IRCCS IST, Genova, Italy
| | - Antonino Tralongo
- Medical Oncology Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Marianna Turrini
- Medical Oncology Unit, Ospedale del Valdarno, Santa Maria La Gruccia, Azienda USL Toscana Sud-Est, Montevarchi, Toscana, Italy
| | - Federica Zoratto
- Medical Oncology Unit, Ospedale S. Maria Goretti, Latina, Lazio, Italy
| | - Marco Danova
- Internal Medicine and Medical Oncology, ASST Pavia, Pavia, Lombardia, Italy
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22
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Abdulrehman J, Tang GH, Auerbach M, Santesso N, Sholzberg M. The safety and efficacy of ferumoxytol in the treatment of iron deficiency: a systematic review and meta-analysis. Transfusion 2019; 59:3646-3656. [PMID: 31762068 DOI: 10.1111/trf.15587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/14/2019] [Accepted: 09/15/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ferumoxytol is an intravenous (IV) iron formulation for treatment of iron deficiency (ID) that faced post-marketing reports of serious adverse events (SAEs). OBJECTIVES To determine the safety and efficacy of ferumoxytol compared to other iron formulations and placebo. METHODS We searched the Cochrane Library, Medline, and EMBASE from inception until February 2018 as well as trial registries and reference lists of relevant articles for randomized or quasi-randomized controlled trials. RESULTS The review included nine studies with 5691 participants. Studies were at low risk of bias. When comparing ferumoxytol to other IV iron formulations, there is moderate quality evidence (QE) of little to no difference in treatment emergent adverse events (TEAEs) (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.80-0.97), treatment related adverse events (TRAEs) (RR 0.73, 95% CI 0.61-0.88), SAEs (RR 1.13, 95% CI 0.77-1.67), hypotension or hypersensitivity reactions (RR 0.58, 95% CI 0.31-1.09), or composite cardiovascular outcomes (RR 0.56, 95% CI 0.24-1.29), low QE of little to no difference in related SAEs (RR 0.55, 95% CI 0.05-6.16), and high QE of little to no difference in the number of patients with an increase in hemoglobin by at least 1 g/dL (RR 1.04, 95% CI 0.96-1.12). Ferumoxytol had less TEAEs compared to oral iron (RR 0.78, 95% CI 0.61-0.98), but more compared to placebo (RR 1.62, 95% CI 1.01-2.61). DISCUSSION Ferumoxytol is as efficacious and safe as alternative IV iron formulations with no clear safety concerns.
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Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University Healthy Network, Toronto, Ontario, Canada
| | - Grace H Tang
- Hematology Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael Auerbach
- Department of Medicine, Georgetown University School of Medicine, Washington DC, USA.,Auerbach Hematology and Oncology, Baltimore, Maryland, USA
| | | | - Michelle Sholzberg
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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23
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Abiri B, Vafa M. Iron Deficiency and Anemia in Cancer Patients: The Role of Iron Treatment in Anemic Cancer Patients. Nutr Cancer 2019; 72:864-872. [PMID: 31474155 DOI: 10.1080/01635581.2019.1658794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anemia is a prevalent complication in patients with cancer, both at diagnosis and during treatment, with notable negative effects on quality of life and overall prognosis. Iron deficiency is the most common cause of anemia in the patients and can affect almost half of patients with solid and hematologic malignancies. The pathogenesis is complex and multifactorial, including bleeding, malnutrition, medications, and inflammation resulted from cancer and cancer treatment. In fact, either absolute or functional iron deficiency can occur. Most iron deficient cancer patients present with functional iron deficiency, a condition with adequate iron storage but insufficient iron supply for erythroblasts and other iron dependent tissues. Functional iron deficiency is the result of the cancer related cytokine release, but in absolute iron deficiency iron reserves are depleted leading to similar but often more severe symptoms of inadequate iron store. Current therapeutic options in cancer anemia consist of iron administration, erythropoietic stimulating agents, and blood transfusion. The latter should be administered to a minimum, because of problems regarding risks. Here, we present a review on the epidemiology, pathophysiology, clinical outcomes, and therapeutic options of iron deficiency as well as the effect of iron therapy on tumor progression in anemic cancer patients.
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Affiliation(s)
- Behnaz Abiri
- Department of Nutrition, Faculty of Paramedicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammadreza Vafa
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.,Pediatric Growth and Development Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
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24
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Frank SM, Chaturvedi S, Goel R, Resar LMS. Approaches to Bloodless Surgery for Oncology Patients. Hematol Oncol Clin North Am 2019; 33:857-871. [PMID: 31466609 DOI: 10.1016/j.hoc.2019.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Providing optimal care to surgical oncology patients who cannot be transfused for religious or other reasons can be challenging. However, with careful planning, using a combination of blood-conserving methods, these "bloodless" patients have clinical outcomes that are similar to other patients who can be transfused. Bloodless surgery can be accomplished safely for most patients, including those undergoing technically challenging oncologic surgery. This article reviews best practices used in a bloodless program during the preoperative, intraoperative, and postoperative periods, with the aim of achieving optimal outcomes when transfusion is not an option for surgical oncology patients.
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Affiliation(s)
- Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Center for Bloodless Medicine and Surgery, Johns Hopkins Health System Blood Management Clinical Community, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Zayed 6208, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, The Johns Hopkins Medical Institutions, Johns Hopkins Hospital, Ross Building Room 1032, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, 315 West Carpenter Street, Springfield, IL 62702, USA; Mississippi Valley Regional Blood Center
| | - Linda M S Resar
- Department of Medicine (Hematology), Oncology & Institute for Cellular Engineering, The Johns Hopkins Medical Institutions, Center for Bloodless Medicine and Surgery, Ross Building Room 1015, 1800 Orleans Street, Baltimore, MD 21287, USA
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25
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Zhao JC, Arnall JR, Martin AL, Atrash S, Bhutani M, Voorhees P, Avalos B, Copelan E, Ghosh N, Hamadani M, Usmani S, Ford P. A Review of Growth Factor Support in Bloodless Autologous Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2019; 25:e305-e309. [PMID: 31295572 DOI: 10.1016/j.bbmt.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/16/2022]
Abstract
Bloodless autologous hematopoietic cell transplantation is associated with risks of severe bleeding and profound anemia. RBC or platelet transfusions are often used to prevent these hematologic complications. However, in patients such as Jehovah's Witnesses who refuse major blood components, the lack of transfusion support is not an absolute contraindication to an autologous hematopoietic cell transplant. Pennsylvania Hospital performed the world's first bloodless hematopoietic cell transplant more than 15 years ago and has gradually improved its technique with a sizable patient population. Erythropoiesis-stimulating agents were successfully employed as part of their pretransplant regimen to prevent severe anemia. Thrombopoietin agonists' potential role in bloodless transplant is also currently being explored. Although there is limited literature, available reports in combination with physiologic reasoning may support the use of these growth factors to promote transplant success. These agents offer potential benefit and may be of utility in minimizing complications of a bloodless transplant. In this review, we summarize the available literature and offer insight into how we may incorporate growth factors to allow bloodless autologous hematopoietic cell transplantation to be an available option to patients who may otherwise be denied.
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Affiliation(s)
- Jennifer C Zhao
- Department of Hematology/Oncology, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.
| | - Justin R Arnall
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Allison L Martin
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Shebli Atrash
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Manisha Bhutani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Peter Voorhees
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Belinda Avalos
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Edward Copelan
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Mehdi Hamadani
- Department of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saad Usmani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Patricia Ford
- Pennsylvania Hospital, Center for Bloodless Medicine and Surgery, Philadelphia, , Pennsylvania
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26
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Rodgers GM, Gilreath JA. The Role of Intravenous Iron in the Treatment of Anemia Associated with Cancer and Chemotherapy. Acta Haematol 2019; 142:13-20. [PMID: 30970366 DOI: 10.1159/000496967] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/16/2019] [Indexed: 01/09/2023]
Abstract
Cancer-related anemia (CRA) is a commonly occurring problem for patients with cancer regardless of whether they are receiving treatment with chemotherapy or immunotherapy. It may result from one or more processes (decreased production, increased destruction, or increased loss of red blood cells, RBC). Perturbations in iron availability form the primary basis for anemia in many patients with cancer-related anemia. Functional iron deficiency (FID) anemia is a condition in which the patient has adequate or increased iron stores, but this iron pool is not available for erythropoiesis. Erythropoiesis-stimulating agents (ESAs) were the original treatment for FID; over time, however, if the supply of iron cannot keep pace with increased RBC synthesis driven by ESAs, FID may eventually lead to the lack or loss of ESA responsiveness. Subsequent clinical trials reported that intravenous (IV) iron could enhance the erythropoietic response to ESAs. This chapter reviews the pathogenesis of FID and summarizes the literature on the treatment of cancer- and chemotherapy-induced anemia. Clinical trials using IV iron with or without ESAs are reviewed in addition to the currently available IV iron products. The consensus conclusions from these trials, as well as guideline recommendations, support the use of IV iron in these patients to enhance ESA responsiveness, decrease ESA dosage, and reduce RBC transfusions. Little data have been published on the long-term safety of IV iron or its impact on tumor growth. This paper also briefly explores novel approaches for the treatment of FID anemia, which has relevance in treating not only cancer patients but also patients with benign inflammatory disorders.
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Affiliation(s)
- George M Rodgers
- Division of Hematology and Hematologic Malignancies, University of Utah Health Sciences Center, Salt Lake City, Utah, USA,
| | - Jeffrey A Gilreath
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
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27
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Aapro M, Beguin Y, Bokemeyer C, Dicato M, Gascón P, Glaspy J, Hofmann A, Link H, Littlewood T, Ludwig H, Österborg A, Pronzato P, Santini V, Schrijvers D, Stauder R, Jordan K, Herrstedt J. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv96-iv110. [PMID: 29471514 DOI: 10.1093/annonc/mdx758] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Y Beguin
- University of Liège, Liège
- CHU of Liège, Liège, Belgium
| | - C Bokemeyer
- Department of Oncology, Hematology and BMT with Section Pneumology, University of Hamburg, Hamburg, Germany
| | - M Dicato
- Hématologie-Oncologie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - P Gascón
- Department of Haematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - J Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - A Hofmann
- Medical Society for Blood Management, Laxenburg, Austria
| | - H Link
- Klinik für Innere Medizin I, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - T Littlewood
- Department of Haematology, John Radcliffe Hospital, Oxford, UK
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - A Österborg
- Karolinska Institute and Karolinska Hospital, Stockholm, Sweden
| | - P Pronzato
- Medica Oncology, IRCCS Asiana Pedaliter Universitaria San Martino - IST, Institutor Nazionale per la Ricercars sol Chancre, Genova
| | - V Santini
- Department of Experimental and Clinical Medicine, Haematology, University of Florence, Florence, Italy
| | - D Schrijvers
- Department of Medical Oncology, Ziekenhuisnetwerk Antwerpen, Antwerp, Belgium
| | - R Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J Herrstedt
- Department of Oncology, Zealand University Hospital Roskilde, Roskilde
- University of Copenhagen, Copenhagen, Denmark
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28
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Madeddu C, Gramignano G, Astara G, Demontis R, Sanna E, Atzeni V, Macciò A. Pathogenesis and Treatment Options of Cancer Related Anemia: Perspective for a Targeted Mechanism-Based Approach. Front Physiol 2018; 9:1294. [PMID: 30294279 PMCID: PMC6159745 DOI: 10.3389/fphys.2018.01294] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 08/28/2018] [Indexed: 01/28/2023] Open
Abstract
Cancer-related anemia (CRA) is a common sign occurring in more than 30% of cancer patients at diagnosis before the initiation of antineoplastic therapy. CRA has a relevant influence on survival, disease progression, treatment efficacy, and the patients' quality of life. It is more often detected in patients with advanced stage disease, where it represents a specific symptom of the neoplastic disease, as a consequence of chronic inflammation. In fact, CRA is characterized by biological and hematologic features that resemble those described in anemia associated to chronic inflammatory disease. Proinflammatory cytokine, mainly IL-6, which are released by both tumor and immune cells, play a pivotal action in CRA etiopathogenesis: they promote alterations in erythroid progenitor proliferation, erythropoietin (EPO) production, survival of circulating erythrocytes, iron balance, redox status, and energy metabolism, all of which can lead to anemia. The discovery of hepcidin allowed a greater knowledge of the relationships between immune cells, iron metabolism, and anemia in chronic inflammatory diseases. Additionally, chronic inflammation influences a compromised nutritional status, which in turn might induce or contribute to CRA. In the present review we examine the multifactorial pathogenesis of CRA discussing the main and novel mechanisms by which immune, nutritional, and metabolic components affect its onset and severity. Moreover, we analyze the status of the art and the perspective for the treatment of CRA. Notably, despite the high incidence and clinical relevance of CRA, controlled clinical studies testing the most appropriate treatment for CRA are scarce, and its management in clinical practice remains challenging. The present review may be useful to indicate the development of an effective approach based on a detailed assessment of all factors potentially involved in the pathogenesis of CRA. This mechanism-based approach is essential for clinicians to plan a safe, targeted, and successful therapy, thereby promoting a relevant amelioration of patients' quality of life.
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Affiliation(s)
- Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Giorgio Astara
- Department of Medical Oncology, Azienda Ospedaliero Universitaria Cagliari, Cagliari, Italy
| | - Roberto Demontis
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Elisabetta Sanna
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Vinicio Atzeni
- Hospital Medical Management, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Antonio Macciò
- Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, Cagliari, Italy
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29
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Ng O, Keeler B, Simpson JA, Madhusudan S, Brookes M, Acheson A. Feasibility of Intravenous Iron Isomaltoside to Improve Anemia and Quality of Life During Palliative Chemotherapy for Esophagogastric Adenocarcinoma. Nutr Cancer 2018; 70:1106-1117. [DOI: 10.1080/01635581.2018.1504090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Oliver Ng
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Barrie Keeler
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - John Alastair Simpson
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Srinivasan Madhusudan
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | | | - Austin Acheson
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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30
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Strauss WE, Auerbach M. Health-related quality of life in patients with iron deficiency anemia: impact of treatment with intravenous iron. PATIENT-RELATED OUTCOME MEASURES 2018; 9:285-298. [PMID: 30214332 PMCID: PMC6118263 DOI: 10.2147/prom.s169653] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Most physicians appear to be aware of the health consequences of advanced anemia, especially in the acute setting, frequently responding with a not inconsequential therapeutic default of transfusion. In contrast, the profound impact that chronic anemia, of any degree, may have on a patient’s performance is underappreciated. The focus of this review is to 1) delineate the consistent and broad impact of anemia on patient quality of life as documented by multiple well-validated patient-reported outcome instruments and 2) demonstrate the essential normalization of the debilitation as assessed by these instruments following the administration of intravenous iron.
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31
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Cortinovis D, Beretta G, Piazza E, Luchena G, Aglione S, Bertolini A, Buzzoni R, Cabiddu M, Carnaghi C, Danova M, Farina G, Ferrari V, Frascaroli M, Reni M, Tansini G. Chemotherapy-Induced Anemia and Oncologist Perception on Treatment: Results of a Web-Based Survey. TUMORI JOURNAL 2018; 99:45-50. [DOI: 10.1177/030089161309900108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Anemia prevalence and incidence in chemotherapy-treated patients is high. Erythropoiesis-stimulating agents (ESAs) are frequently employed in the management of chemotherapy-induced anemia. However, other treatments such as red blood transfusion or iron supplementation are normally used. Recent international guidelines raised some concern about ESAs employment with a possible impact in chemotherapy-induced anemia management and changes in clinical practice behavior. Methods To evaluate opinions about chemotherapy-induced anemia clinical management preference, the Associazione Italiana Oncologia Medica (AIOM) Lombardy section coordinators sent via email a 12-item questionnaire about their knowledge on CIA and usual therapeutic strategies to manage this adverse event to AIOM Lombardy onco-hematologist members. Results From January 2011 to March 2011, 81 questionnaires were collected with an approximated share of 30%. The survey was completed mainly by oncologists (91%) aged 35–50 years (50%). Chemotherapy-induced anemia was considered to have clinical impact in changing cancer therapeutic strategy by nearly 60% of the respondents. ESAs were administered largely (80%) with concomitant iron supplementation in 52%; 38% jointly used blood transfusion as part of the therapy. Nearly 20% of those who replied correctly employed transferrin saturation levels as a marker to guide iron supplementation. Physician prescribers strictly followed the guidelines to start and stop ESAs even if 14% were negatively influenced by new ASCO recommendations. ESA biosimilars were considered future substitutes of originators in 45% of the cases. Conclusions Chemotherapy-induced anemia was perceived as an adverse event with a mild impact on clinical practice. ESAs were largely employed, however the number of transfusions and lack of employment of markers of iron depletion suggested that adherence to guidelines could be theoretically met but with some discordances regarding the most appropriate strategies in daily clinical practice.
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Affiliation(s)
| | | | | | | | | | | | | | - Roberto Buzzoni
- DH & Terapia Ambulatoriale Oncologica, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Mary Cabiddu
- Oncologia Medica, Ospedale Treviglio-Caravaggio, Bergamo
| | - Carlo Carnaghi
- Oncologia Medica, Humanitas Mater Domini, Castellanza (VA), Onco-Ematologia, Humanitas Cancer Center, Rozzano (MI)
| | - Marco Danova
- Medicina oncologica, Ospedale Civile, Vigevano (PV)
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32
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Vadhan-Raj S, Dahl NV, Bernard K, Li Z, Strauss WE. Efficacy and safety of IV ferumoxytol for iron deficiency anemia in patients with cancer. J Blood Med 2017; 8:199-209. [PMID: 29263710 PMCID: PMC5724711 DOI: 10.2147/jbm.s138474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose Iron deficiency anemia (IDA) is common in cancer patients due to blood loss and inflammation. Many do not tolerate oral iron or adequately respond. Intravenous (IV) iron is commonly used as an adjunct to erythropoiesis-stimulating agents; data on the use of IV iron monotherapy in these patients are limited. This study aimed to evaluate IV ferumoxytol for the treatment of cancer patients with IDA with a history of unsatisfactory oral iron therapy or in whom oral iron could not be used. Patients and methods This post hoc analysis of pooled data from two multicenter, randomized, controlled, Phase III trials evaluating IV ferumoxytol (510 mg ×2) vs placebo or iron sucrose (200 mg ×5) included a subgroup of 98 patients with cancer that the investigator identified as the primary cause of their IDA, or with cancer whose IDA was attributed to another comorbid condition (ferumoxytol, n=75; iron sucrose, n=13; placebo, n=10). Gastrointestinal cancers were most common (42), followed by breast (14), cervix (ten), and lung (nine). The primary endpoint was the mean change in hemoglobin (Hgb) from baseline to week 5. Results At week 5, both ferumoxytol and iron sucrose produced significant increases in Hgb from baseline (1.8 g/dL [P<0.0001] and 1.9 g/dL [P=0.002], respectively). During the studies, 45 patients received chemotherapy, 19 with platinum-based regimens. Erythropoiesis-stimulating agent doses were neither increased >20% nor initiated in any treatment group. Overall rates of adverse events and serious adverse events in the cancer subgroup mirrored those in the overall study population. Conclusion Monotherapy with IV iron appears to be an effective option for cancer patients with IDA who do not respond to or cannot tolerate oral iron therapy.
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Affiliation(s)
- Saroj Vadhan-Raj
- Division of Cancer Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Zhu Li
- AMAG Pharmaceuticals, Inc., Waltham, MA, USA
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Noronha V, Joshi A, Patil VM, Banavali SD, Gupta S, Parikh PM, Marfatia S, Punatar S, More S, Goud S, Nakti D, Prabhash K. Phase III randomized trial comparing intravenous to oral iron in patients with cancer-related iron deficiency anemia not on erythropoiesis stimulating agents. Asia Pac J Clin Oncol 2017; 14:e129-e137. [PMID: 28849623 DOI: 10.1111/ajco.12762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/18/2017] [Indexed: 12/26/2022]
Abstract
AIM We aimed to find the optimal route of iron supplementation in patients with malignancy and iron deficiency (true or functional) anemia not receiving erythropoiesis stimulating agents (ESA). METHODS Adult patients with malignancy requiring chemotherapy, hemoglobin (Hb) <12 g/dL and serum ferritin <100 mcg/mL, transferrin saturation <20% or hypochromic red blood cells >10% were randomized to intravenous (IV) iron sucrose or oral ferrous sulfate. The primary endpoint was change in Hb from baseline to 6 weeks. Secondary endpoints included blood transfusion, quality of life (QoL), toxicity, response and overall survival. RESULTS A total of 192 patients were enrolled over 5 years: 98 on IV arm and 94 on oral arm. Median age was 51 years; over 95% patients had solid tumors. The mean absolute increase in Hb at 6 weeks was 0.11 g/dL (standard deviation [SD]: 1.48) in IV arm and -0.16 g/dL (SD: 1.36) in oral arm, P = 0.23. Twenty-three percent patients on IV iron and 18% patients on oral iron had a rise in Hb of ≥1 g/dL at 6 weeks, P = 0.45. Thirteen patients (13.3%) on the IV iron arm and 14 patients (14.9%) on the oral arm required blood transfusion, P = 1.0. Gastrointestinal toxicity (any grade) developed in 41% patients on IV iron and 44% patients on oral iron, P = 1.0. 5 patients on IV iron and none on oral iron had hypersensitivity, P = 0.06. QoL was not significantly different between the two arms. CONCLUSION IV iron was not superior to oral iron in patients with malignancy on chemotherapy and iron deficiency anemia.
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Affiliation(s)
- Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Vijay Maruti Patil
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Purvish M Parikh
- Department of Medical Oncology, Asian Cancer Institute, K.J. Somaiya Ayurvihar, Mumbai, Maharashtra, India
| | | | - Sachin Punatar
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Sucheta More
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Supriya Goud
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Dipti Nakti
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Mahmoudi R, Novella JL, Jaïdi Y. [Transfusion in elderly: Take account frailty]. Transfus Clin Biol 2017; 24:200-208. [PMID: 28690038 DOI: 10.1016/j.tracli.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
The conjunction of the demographic aging and the increase in the frequency of anemia with the advancing age, mean that the number of globular concentrates delivered each year increases with a consequent heavy pressure on blood collection. The etiologies of anemia in the elderly are often multifactorial and their investigation is an indispensable step and prior to any treatment. Transfusion thresholds, particularly in the elderly, are gradually evolving and a so-called restrictive strategy is now favored. Immediate and delayed complications of transfusion are more frequent in the elderly due to vulnerability factors associated with frailty and the risk of multiple transfusions. The screening of complications related to transfusion of RBCs is essential and makes it possible to avoid their recurrence. The impact of transfusion on the quality of life of elderly patients is not obvious and is a controversial issue. In addition, transfusion of red blood cells (RBCs) is accompanied by an increase in health expenditure and an increase in morbidity and mortality, whose risks can be reduced through alternatives to transfusion. Longitudinal studies, including elderly subjects, would allow a better understanding of the issues involved in the transfusion of RBCs in this population.
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Affiliation(s)
- R Mahmoudi
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France.
| | - J-L Novella
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France
| | - Y Jaïdi
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France
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Barni S, Gascòn P, Petrelli F, García-Erce JA, Pedrazzoli P, Rosti G, Giordano G, Mafodda A, Múñoz M. Position paper on management of iron deficiency in adult cancer patients. Expert Rev Hematol 2017; 10:685-695. [PMID: 28656800 DOI: 10.1080/17474086.2017.1343140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Disorders of iron metabolism are commonly seen in onco-hematological clinical practice. Iron-deficiency anemia and cancer-associated anemia are usually treated with supportive therapies. Optimal management of these conditions are discussed in this perspective paper. Areas covered: A position paper discussing a number of hot topics on anemia in cancer patients is presented. The main areas covered by experts in the field are: definitions, prevalence and consequences of anemia and iron deficiency, incidence of anemia resulting from targeted therapies, importance of anemia diagnosis and monitoring, evaluation of iron status before and during treatment, role of transfusions and erythropoiesis-stimulating agents, management of iron deficiency with or without anemia, parenteral iron supplementation, role of new oral iron formulations, safety and cost issues regarding different iron compounds and administration routes. Expert commentary: Despite the availability of newer therapeutic options for its management, anemia still represents a major complication of treatment in cancer patients (surgery, chemotherapy, radiotherapy, targeted therapies), aggravating physical impairment, and negatively affecting general outcome. The view expressed by the panelists, attendees of the 4th Mediterranean Course on Iron Anemia, summarizes what they consider optimal clinical practice for screening, diagnosis, treatment and monitoring of iron deficiency and anemia in cancer patients.
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Affiliation(s)
- Sandro Barni
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | - Pere Gascòn
- b Division of Medical Oncology , Hospital Clinic, University of Barcelona , Barcelona , Spain
| | - Fausto Petrelli
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | | | - Paolo Pedrazzoli
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giovanni Rosti
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giulio Giordano
- e General Medicine and Hematology Department , General Medicine and Hematology Regional Hospital 'A. Cardarelli' , Campobasso , Italy
| | - Antonio Mafodda
- f Medical Oncology Unit , A.O. B.M.M , Reggio Calabria , Italy
| | - Manuel Múñoz
- g Peri-operative Transfusion Medicine , School of Medicine, University of Malaga , Malaga , Spain
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Mafodda A, Giuffrida D, Prestifilippo A, Azzarello D, Giannicola R, Mare M, Maisano R. Oral sucrosomial iron versus intravenous iron in anemic cancer patients without iron deficiency receiving darbepoetin alfa: a pilot study. Support Care Cancer 2017; 25:2779-2786. [PMID: 28391437 PMCID: PMC5527057 DOI: 10.1007/s00520-017-3690-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 03/31/2017] [Indexed: 12/16/2022]
Abstract
Purpose Erythropoiesis-stimulating agents (ESAs) are often used in treatment of patients with chemotherapy-induced anemia. Many studies have demonstrated an improved hemoglobin (Hb) response when ESA is combined with intravenous iron supplementation and a higher effectiveness of intravenous iron over traditional oral iron formulations. A new formulation of oral sucrosomial iron featuring an increased bioavailability compared to traditional oral formulations has recently become available and could provide a valid alternative to those by intravenous (IV) route. Our study evaluated the performance of sucrosomial iron versus intravenous iron in increasing hemoglobin in anemic cancer patients receiving chemotherapy and darbepoetin alfa, as well as safety, need of transfusion, and quality of life (QoL). Materials and methods The present study considered a cohort of 64 patients with chemotherapy-related anemia (Hb >8 g/dL <10 g/dL) and no absolute or functional iron deficiency, scheduled to receive chemotherapy and darbepoetin. All patients received darbepoetin alfa 500 mcg once every 3 weeks and were randomly assigned to receive 8 weeks of IV ferric gluconate 125 mg weekly or oral sucrosomial iron 30 mg daily. The primary endpoint was to demonstrate the performance of oral sucrosomial iron in improving Hb response, compared to intravenous iron. The Hb response was defined as the Hb increase ≥2 g/dL from baseline or the attainment Hb ≥ 12 g/dL. Results There was no difference in the Hb response rate between the two treatment arms. Seventy one percent of patients treated with IV iron achieved an erythropoietic response, compared to 70% of patients treated with oral iron. By conventional criteria, this difference is considered to be not statistically significant. There were also no differences in the proportion of patients requiring red blood cell transfusions and changes in QoL. Sucrosomial oral iron was better tolerated. Conclusion In cancer patients with chemotherapy-related anemia receiving darbepoetin alfa, sucrosomial oral iron provides similar increase in Hb levels and Hb response, with higher tolerability without the risks or side effects of IV iron. Electronic supplementary material The online version of this article (doi:10.1007/s00520-017-3690-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonino Mafodda
- Department of Oncology, A.O. Bianchi-Melacrino-Morelli, Via Melacrino Giuseppe, 21, 89124 Reggio Calabria, (RC) Italy
| | - D. Giuffrida
- Istituto Oncologico del Mediterraneo, Via Penninazzo, 7 - 95029, Viagrande, (Catania) Italy
| | - A. Prestifilippo
- Istituto Oncologico del Mediterraneo, Via Penninazzo, 7 - 95029, Viagrande, (Catania) Italy
| | - D. Azzarello
- Department of Oncology, A.O. Bianchi-Melacrino-Morelli, Via Melacrino Giuseppe, 21, 89124 Reggio Calabria, (RC) Italy
| | - R. Giannicola
- Department of Oncology, A.O. Bianchi-Melacrino-Morelli, Via Melacrino Giuseppe, 21, 89124 Reggio Calabria, (RC) Italy
| | - M. Mare
- Istituto Oncologico del Mediterraneo, Via Penninazzo, 7 - 95029, Viagrande, (Catania) Italy
| | - R. Maisano
- Department of Oncology, A.O. Bianchi-Melacrino-Morelli, Via Melacrino Giuseppe, 21, 89124 Reggio Calabria, (RC) Italy
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Auerbach M, Macdougall I. The available intravenous iron formulations: History, efficacy, and toxicology. Hemodial Int 2017; 21 Suppl 1:S83-S92. [DOI: 10.1111/hdi.12560] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Auerbach
- Auerbach Hematology and Oncology, Private Practice; Rosedale Maryland USA
- Georgetown University School of Medicine; Washington, District of Columbia USA
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A retrospective open-label uncontrolled study of Epoetin zeta on the treatment of chemotherapy-induced anemia in solid tumors. J Cancer Res Clin Oncol 2017; 143:717-725. [PMID: 28078434 DOI: 10.1007/s00432-016-2339-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 12/27/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE This is a single-center uncontrolled retrospective study to evaluate the efficacy and safety of the biosimilar epoetin zeta after approval in chemotherapy-induced anemia (CIA). METHODS Patients screened were >18 years old suffering from solid malignancies and CIA with Hg ≤10 or <11 g/dl if symptomatic anemia. Patients had measurable disease by TNM and Eastern Cooperative Oncology Group (ECOG). Patients were treated for at least 12 weeks and the primary endpoint was to determine the incidence of blood transfusions, and secondarily, the overall safety and efficacy defined as ≥1 g/dl rise in Hb concentration or ≥40,000 cells/μl rise in reticulocyte count. Quality of life was assessed with ECOG performance status (PS) and functional assessment of cancer therapy-anemia (FACT-An) score. RESULTS 1287 patients with median Hb 9.3 g/dl (range 8.3-10.6) were enrolled and included in the evaluation. Median age was 63 years (range 33-78). 74% of patients were stage III/IV. Patients received epoetin zeta subcutaneously at fixed 40,000-IU once weekly. Blood transfusions were given in 178 patients (13.8%; 95% CI 11.9-15.6%). Appropriate response was observed in 79% patients by week 4, 87% by week 8, and 91% by week 12. A mean Hb increase of 2.5 g/dl was observed by week 12 which correlated with an improvement in PS and Fact-An score. Thrombotic events occurred in 5.2% (95% CI 3.4-7.1%) of patients. CONCLUSIONS Epoetin zeta is effective in palliation and treatment of CIA in patients with solid tumors. Overall, it is well tolerated and safe even in patients with increased disease burden.
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Luporsi E, Toledano A, Spaeth D, Scotté F, Espié M, Perot S, Duvillié L, Pithois Merli I, Bugat R. Use of iron sucrose and red blood cell transfusions in anaemic cancer patients in France (OncoFer study). Support Care Cancer 2016; 25:973-982. [PMID: 27915456 DOI: 10.1007/s00520-016-3489-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/07/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE This report describes the results of an observational, retrospective cohort study, evaluating the use of iron sucrose (IS) and red blood cell (RBC) transfusions in patients with cancer in routine clinical practice in France. A parallel investigated cohort treated with ferric carboxymaltose (FCM) has been reported earlier. METHODS Data of patients with a solid tumour or haematological malignancy who have received IS or an RBC transfusion during 2010 from 3 months prior (M-3) to 3 months post first treatment (M+3) were analysed. RESULTS Data from 46 patients who had received IS (400 mg median total iron dose) and 357 patients who had received RBC transfusions as first treatment (baseline) were included. Median haemoglobin levels improved from 9.9 g/dL (interquartile range 9.2; 11.0 g/dL) at baseline to 12.4 g/dL (11.4; 13.1 g/dL) at M+3 in IS-treated patients and from 8.2 g/dL (7.8; 8.8 g/dL) at baseline to 10.1 g/dL (8.8; 11.1 g/dL) in transfused patients. An erythropoiesis-stimulating agent was given to 54.3 and 28.9% of patients in the IS and the RBC transfusion groups, respectively, resulting in slightly better mean haemoglobin increase in both groups (2.4 vs 1.5 g/dL and 2.0 vs 1.6 g/dL, respectively). No severe nor serious adverse reaction and no hypersensitivity reactions were reported. CONCLUSION Both IS and RBC transfusions effectively increased Hb levels in patients with cancer. IS was safe and well tolerated in this population. Considering prior reported results with FCM, using FCM may reduce ESA dose requirements and the required number of infusions.
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Affiliation(s)
- Elisabeth Luporsi
- Centre Alexis Vautrin, Vandoeuvre-lès-Nancy, France.
- Oncologue médical, Biostatisticien, Généticien, PMSI Oncomed, Coordination réseau lorrain GENECAL, Institut de Cancérologie de Lorraine Alexis Vautrin, Avenue de Bourgogne, F 54511, Vandoeuvre-Les-Nancy, France.
| | | | | | | | | | | | | | | | - Roland Bugat
- Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
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Deak AT, Troppan K, Rosenkranz AR. Anemia management in cancer patients with chronic kidney disease. Eur J Intern Med 2016; 36:13-19. [PMID: 27640913 DOI: 10.1016/j.ejim.2016.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/06/2016] [Accepted: 08/19/2016] [Indexed: 12/27/2022]
Abstract
Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.
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Affiliation(s)
- Andras T Deak
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria
| | - Katharina Troppan
- Clinical Division of Haematology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria.
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Iron deficient erythropoiesis might play key role in development of anemia in cancer patients. Oncotarget 2016; 6:42803-12. [PMID: 26517509 PMCID: PMC4767472 DOI: 10.18632/oncotarget.5658] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 09/12/2015] [Indexed: 12/22/2022] Open
Abstract
Introduction Multifactorial pathogenesis is involved in anemia of cancer patients and defining the causes of anemia is not always simple. Methods The incidence of anemia among 4 major cancers (gastric, colorectal, lung cancer and hepatocellular carcinoma), and biochemical features of anemia using ferritin, CRP, hepcidin and soluble transferrin receptor (sTfR) were assessed. Anemia was defined either by hemoglobin (Hb) ≤11 g/dL or a drop of Hb 2 g/dL or more during anticancer treatment. Results Among the 345 patients including 152 lung cancer, 101 gastric cancer, 69 colorectal cancer and 23 hepatocellular carcinoma, 49 patients (14.2%) had anemia at their initial diagnosis of cancer. During treatment, 129 (37.4%) experienced anemia, and 34 (26.4%) were treated mostly by transfusion. Biochemical feature of anemia was examined with 39 patients' samples. When comparing to the reference value from general population, cancer patients showed numerically higher ferritin, sTfR, CRP and hepcidin level. Among the cancer patients, anemic patients had significantly higher ferritin (p = 0.050) and sTfR (p = 0.009) level compared to non-anemic patients. Conclusion Anemia is a common issue in cancer patients and is largely undertreated with sub-optimal diagnoses of cause. The rates of anemia increase significantly during anti-cancer treatment and appear to be largely associated with iron deficiency.
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Abstract
Anemia is a frequent complication in cancer patients, both at diagnosis and during treatment, with a multifactorial etiology in most cases. Iron deficiency is among the most common causes of anemia in this setting and can develop in nearly half of patients with solid tumors and hematologic malignancies. Surprisingly, this fact is usually neglected by the attending physician in a way that proper and prompt investigation of the iron status is either not performed or postponed. In cancer patients, functional iron deficiency is the predominant mechanism, in which iron availability is reduced due to disease or the therapy-related inflammatory process. Hence, serum ferritin is not reliable in detecting iron deficiency in this setting, whereas transferrin saturation seems more appropriate for this purpose. Besides, lack of bioavailable iron can be further worsened by the use of erythropoiesis stimulating agents that increase iron utilization in the bone marrow. Iron deficiency can cause anemia or worsen pre-existing anemia, leading to a decline in performance status and adherence to treatment, with possible implications in clinical outcome. Due to its frequency and importance, treatment of this condition is already recommended in many specialty guidelines and should be performed preferably with intravenous iron. The evidences regarding the efficacy of this treatment are solid, with response gain when combined with erythropoiesis stimulating agents and significant increments in hemoglobin as monotherapy. Among intravenous iron formulations, slow release preparations present more favorable pharmacological characteristics and efficacy in cancer patients.
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[Iron deficiency, thrombocytosis and thromboembolism]. Wien Med Wochenschr 2016; 166:437-446. [PMID: 27682430 DOI: 10.1007/s10354-016-0514-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 08/05/2016] [Indexed: 12/16/2022]
Abstract
Iron deficiency, the most common nutritional deficiency worldwide, is often associated with reactive thrombocytosis. Although secondary thrombocytosis is commonly considered to be harmless, there is accumulating evidence that elevated platelet counts, especially in the setting of iron deficiency, can lead to an increased thromboembolic risk in both arterial and venous systems. Here we present the mechanisms of iron deficiency-induced thrombocytosis and summarize its clinical consequences especially in patients with inflammatory bowel diseases, chronic kidney disease or cancer. We hypothesize that iron deficiency is an underestimated thromboembolic risk factor, and that iron replacement therapy can become an effective preventive strategy in a variety of clinical settings.
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Varcher M, Zisimopoulou S, Braillard O, Favrat B, Junod Perron N. Iron deficiency intravenous substitution in a Swiss academic primary care division: analysis of practices. Int J Gen Med 2016; 9:221-7. [PMID: 27445502 PMCID: PMC4938240 DOI: 10.2147/ijgm.s107821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Iron deficiency is a common problem in primary care and is usually treated with oral iron substitution. With the recent simplification of intravenous (IV) iron administration (ferric carboxymaltose) and its approval in many countries for iron deficiency, physicians may be inclined to overutilize it as a first-line substitution. Objective The aim of this study was to evaluate iron deficiency management and substitution practices in an academic primary care division 5 years after ferric carboxymaltose was approved for treatment of iron deficiency in Switzerland. Methods All patients treated for iron deficiency during March and April 2012 at the Geneva University Division of Primary Care were identified. Their medical files were analyzed for information, including initial ferritin value, reasons for the investigation of iron levels, suspected etiology, type of treatment initiated, and clinical and biological follow-up. Findings were assessed using an algorithm for iron deficiency management based on a literature review. Results Out of 1,671 patients, 93 were treated for iron deficiency. Median patients’ age was 40 years and 92.5% (n=86) were female. The average ferritin value was 17.2 μg/L (standard deviation 13.3 μg/L). The reasons for the investigation of iron levels were documented in 82% and the suspected etiology for iron deficiency was reported in 67%. Seventy percent of the patients received oral treatment, 14% IV treatment, and 16% both. The reasons for IV treatment as first- and second-line treatment were reported in 57% and 95%, respectively. Clinical and biological follow-up was planned in less than two-thirds of the cases. Conclusion There was no clear overutilization of IV iron substitution. However, several steps of the iron deficiency management were not optimally documented, suggesting shortcuts in clinical reasoning.
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Affiliation(s)
- Monica Varcher
- Department of Community, Primary and Emergency Care, Division of Primary Care, Geneva University Hospitals, Geneva
| | - Sofia Zisimopoulou
- Department of Community, Primary and Emergency Care, Division of Primary Care, Geneva University Hospitals, Geneva
| | - Olivia Braillard
- Department of Community, Primary and Emergency Care, Division of Primary Care, Geneva University Hospitals, Geneva
| | - Bernard Favrat
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Noëlle Junod Perron
- Department of Community, Primary and Emergency Care, Division of Primary Care, Geneva University Hospitals, Geneva
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Shahid S. Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone. Crit Rev Oncol Hematol 2016; 105:145-55. [PMID: 27423975 DOI: 10.1016/j.critrevonc.2016.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/09/2016] [Accepted: 06/01/2016] [Indexed: 01/18/2023] Open
Abstract
We observed the outcomes of chemotherapy with radiotherapy (CR) or radiotherapy (RT) alone for cancer patients of larynx, breast, blood and brain origins through complete blood count (CBC). Following were more depressed in CR patients: mean corpuscular hemoglobin-MCH & lymphocytes-LYM, hematocrit, mean corpuscular hemoglobin concentration-MCHC, hemoglobin-HB and red blood cells-RBC. In RT patients, following were more depressed: LYM, MCH and MCHC. Overall, in all cancer patients, the lymphocytes were depressed 52%. There existed a significant difference between white blood cells and RBC in both CR and RT patients. A significant moderate negative correlation is found in HB with the dose range 30-78 (Gray) given to the CR cancer patients. More number of CBC parameters affected in patients treated with CR and RT; but in less percentage as compared to patients who treated with RT alone. The cancer patients suffered from anemia along with immune modulations from the treatments.
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Affiliation(s)
- Saman Shahid
- Department of Sciences and Humanities, National University of Computer and Emerging Sciences (NUCES)-Foundation for Advancement of Science and Technology (FAST), Lahore, Pakistan.
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Dingermann T, Scotte F. Biosimilar epoetin zeta: extrapolation of indications and real world utilization experience. Expert Opin Biol Ther 2016; 16:967-74. [DOI: 10.1080/14712598.2016.1194822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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47
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Current trends in the management of anaemia in solid tumours and haematological malignancies. Curr Opin Support Palliat Care 2016; 10:189-94. [DOI: 10.1097/spc.0000000000000209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clevenger B, Gurusamy K, Klein AA, Murphy GJ, Anker SD, Richards T. Systematic review and meta-analysis of iron therapy in anaemic adults without chronic kidney disease: updated and abridged Cochrane review. Eur J Heart Fail 2016; 18:774-85. [PMID: 27121474 DOI: 10.1002/ejhf.514] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/29/2015] [Accepted: 01/03/2016] [Indexed: 12/16/2022] Open
Abstract
AIMS Anaemia is increasingly recognized as having an independent impact upon patient outcomes in cardiac disease. The role of novel iron therapies to treat anaemia is increasing. This systematic review and meta-analysis assesses the efficacy and safety of iron therapies for the treatment of adults with anaemia. METHODS AND RESULTS Electronic databases and search engines were searched as per Cochrane methodology. Randomized controlled trials (RCTs) of iron vs. inactive control or placebo, as well as alternative formulations, doses, and routes in anaemic adults without chronic kidney disease or in the peri-partum period were eligible. The primary outcome of interest was mortality at 1 year. Secondary outcomes were blood transfusion, haemoglobin levels, quality of life, serious adverse events, and length of hospital stay. A total of 64 RCTs (including five studies of heart failure patients) comprising 9004 participants were included. None of the studies was at a low risk of bias. There were no statistically significant differences in mortality between iron and inactive control. Both oral and parenteral iron significantly reduced the proportion of patients requiring blood transfusion compared with inactive control [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.48-0.90; and RR 0.84, 95% CI 0.73-0.97, respectively]. Haemoglobin was increased more by both oral and parenteral iron compared with inactive control [mean difference (MD) 0.91 g/dL, 95% CI 0.48 to 1.35; and MD 1.04, 95% CI 0.52 to 1.57, respectively], and parenteral iron demonstrated a greater increase when compared with oral iron (MD 0.53 g/dL, 95% CI 0.31-0.75). In all comparisons, there were no differences in the results comparing patients with and without heart failure. CONCLUSION Both oral and parenteral iron are shown to decrease the proportion of people who require blood transfusion and increase haemoglobin levels, without any benefit on mortality. Further trials at a low risk of bias, powered to measure clinically significant endpoints, are still required.
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Affiliation(s)
- Ben Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, and Glenfield General Hospital, Leicester, UK
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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Birgegård G, Henry D, Glaspy J, Chopra R, Thomsen LL, Auerbach M. A Randomized Noninferiority Trial of Intravenous Iron Isomaltoside versus Oral Iron Sulfate in Patients with Nonmyeloid Malignancies and Anemia Receiving Chemotherapy: The PROFOUND Trial. Pharmacotherapy 2016; 36:402-14. [PMID: 26927900 PMCID: PMC5071650 DOI: 10.1002/phar.1729] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Study Objective A safe alternative to erythropoiesis‐stimulating agents to treat anemia is warranted in patients with cancer and anemia; thus the objective of this trial was to compare the efficacy and safety of intravenous (IV) iron isomaltoside with oral iron in patients with cancer and anemia by testing the noninferiority of IV versus oral iron. Design Phase III, prospective, open‐label, comparative, randomized, noninferiority, multicenter trial. Setting Forty‐seven hospitals or private cancer clinics in Asia, the United States, and Europe. Patients A total of 350 patients with cancer and anemia. Intervention Patients were randomized in a 2:1 ratio to either intravenous iron isomaltoside or oral iron sulfate. Patients in the iron isomaltoside group were then randomized into an infusion subgroup (single intravenous infusions of a maximum dose of 1000 mg over 15 min) or a bolus injection subgroup (bolus injections of 500 mg over 2 min). Measurements and Main Results The primary efficacy outcome was change in hemoglobin concentration from baseline to week 4. Changes in other relevant hematology variables, effect on quality of life, and safety outcomes were also assessed. The primary efficacy outcome was tested for noninferiority, whereas the remaining outcomes were tested for superiority. Iron isomaltoside was noninferior to oral iron in change in hemoglobin concentration from baseline to week 4 (difference estimate 0.016, 95% confidence interval –0.26 to 0.29, p<0.001). A faster onset of the hemoglobin response was observed with infusion of iron isomaltoside (superiority test: p=0.03 at week 1), and a sustained effect on hemoglobin level was shown in both the iron isomaltoside and oral iron treatment groups until week 24. A significant mean decrease in fatigue score was observed from baseline to week 12 in the iron isomaltoside group (p<0.001) but not in the oral iron group (p=0.057). A higher proportion of patients treated with oral iron experienced adverse drug reactions (18.8% vs 6.6%, p<0.001) and discontinued the trial due to intolerance (8.0% vs 0.9%, p=0.001). Transient hypophosphatemia (phosphate level less than 2 mg/dl) was reported at similar low frequencies among the groups: 7.1% in the iron isomaltoside infusion subgroup versus 8.5% in the iron isomaltoside bolus injection subgroup versus 5.4% in the oral iron group. Conclusion This trial demonstrated comparable sustained increases in hemoglobin concentration over time with both iron isomaltoside and oral iron. Iron isomaltoside was better tolerated than oral iron, and fatigue was significantly decreased with iron isomaltoside. Low rates of clinically insignificant hypophosphatemia were reported in patients receiving both treatments.
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Affiliation(s)
- Gunnar Birgegård
- Institute for Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - David Henry
- Joan Karnell Cancer Center, Pennsylvania Hospital, Philadelphia, PA
| | - John Glaspy
- Division of Hematology Oncology, Department of Medicine, UCLA School of Medicine, Los Angeles, CA
| | | | - Lars L Thomsen
- Department of Clinical and Non-Clinical Research, Pharmacosmos A/S, Holbaek, Denmark
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Mhaskar R, Wao H, Miladinovic B, Kumar A, Djulbegovic B. The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents. Cochrane Database Syst Rev 2016; 2:CD009624. [PMID: 26845108 PMCID: PMC8765740 DOI: 10.1002/14651858.cd009624.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are commonly used to treat chemotherapy-induced anemia (CIA). However, about half of patients do not benefit. OBJECTIVES To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. SEARCH METHODS We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. SELECTION CRITERIA All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high-quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response.The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate-quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient.We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low-quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response.Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low-quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI -0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI -0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02).We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI -0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high-quality evidence).We found no evidence for a difference in risk of grade III-IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate-quality evidence). The incidence of treatment-related mortality (TRM) was 0% (997 participants; four comparisons; high-quality evidence).Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms.Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow-up duration (up to 20 weeks), the long-term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. AUTHORS' CONCLUSIONS Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation.
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Affiliation(s)
- Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Hesborn Wao
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Branko Miladinovic
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Benjamin Djulbegovic
- Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
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