Editor's Note: Cancer-related anemia (CRA) encompasses anemia that occurs in cancer patients during disease progression or treatment, including non-chemotherapy-related CRA and chemotherapy-induced anemia (CIA). With the increase in chemotherapy treatments, the incidence of anemia is significant, with over 90% of patients not receiving any corrective treatment. To gain a comprehensive understanding of the current practices and perceptions of Chinese clinicians in managing CIA and to improve the management level of CIA in China, Oncology Frontier initiated a "Survey on Chemotherapy-Induced Anemia in Cancer Patients," collecting 308 questionnaires from 28 provinces and cities across the country. The survey revealed that although the current management concepts of CIA in China still differ from existing guidelines, Chinese clinicians' awareness of CIA management is continually strengthening, contributing to the standardization of management for anemia related to new anti-cancer therapies.

Types of Anemia in Cancer and Treatment-Related Complications

Anemia is one of the most common complications in cancer and its treatment, existing in two forms: 1) Chemotherapy-induced anemia (CIA), an adverse reaction during anti-cancer treatment; and 2) Cancer-related anemia (CRA), caused by the overall impact of cancer and immune system activation. The prevalence of CIA is high, with about 89.5% of cancer patients experiencing anemia during chemotherapy, leading to a decrease in quality of life (QoL) and reductions or delays in chemotherapy doses (DDR). A post-hoc analysis comparing anemic and non-anemic cancer patients indicated a negative impact on QoL in anemic patients (45.6 vs. 58; mean difference: -12.4, P<0.001). Another study on non-Hodgkin’s lymphoma (NHL) patients treated with the CHOP regimen demonstrated higher five-year survival rates for patients with relative dose intensity (RDI) >70% compared to those with RDI ≤70%. Hence, timely clinical management of CIA is crucial, as inadequate chemotherapy dosing can lead to poor prognosis and reduced overall survival in cancer patients.

Current Guidelines and Practices

Most international guidelines recommend red blood cell (RBC) transfusion for cancer patients with hemoglobin (Hb) <8 g/dL and consider erythropoiesis-stimulating agents (ESA) for Hb <10 g/dL. For patients with iron deficiency (ID), defined by transferrin saturation (TSAT) <20% or serum ferritin (SF) <100 ng/mL, iron supplementation is advised. However, the Chinese Clinical Oncology Society (CSCO) guidelines for 2024 recommend RBC transfusion for Hb <6 g/dL due to blood policy restrictions in China. RBC transfusion can rapidly improve Hb levels, restore QoL, and alleviate anemia symptoms, but it may lead to adverse reactions such as hemolysis, non-hemolytic reactions, fever, lung injury, transfusion-associated circulatory overload (TACO), and infections. While ESA therapy can reduce RBC transfusion rates, sustain anemia improvement, and enhance QoL, it also poses risks such as tumor growth promotion, reduced survival in cancer-related anemia patients, and increased thromboembolism risk. Intravenous iron monotherapy has shown efficacy and safety in absolute iron deficiency CIA patients, with third-generation iron agents presenting minimal adverse reactions. For functional iron deficiency CIA patients, intravenous iron combined with ESA treatment can improve Hb levels, QoL, and reduce transfusion requirements and ESA dosage. However, intravenous iron therapy can cause immune reactions, transfusion reactions, pain, allergic reactions, and infections. Oral iron supplements have not shown better efficacy than no supplementation according to ESMO guidelines, and most CIA patients do not respond to oral iron as per NCCN guidelines. The CSCO guidelines acknowledge the convenience of oral iron but highlight its poor efficacy compared to intravenous iron.

Challenges and Insights from Recent Surveys

CIA treatment faces numerous challenges. Patient-centered management, while effective, requires balancing risks and benefits. Anemia results from multiple factors, and the three recommended treatments each have their advantages and limitations. The European Cancer Anemia Survey (ECAS) in 2004 explored the incidence, prevalence, and clinical principles of CIA. A 2012 survey by Song Zhengbo et al. investigated the prevalence and treatment data of CRA in China. However, most patient-based surveys fail to reveal the clinical evaluation and decision-making process from the perspective of clinicians. Moreover, China’s CIA treatment standards differ from US and European guidelines, such as the Hb threshold for RBC transfusion, necessitating further exploration.

To clarify the current state of CIA management in China and promote the dissemination and implementation of targeted guidelines, Oncology Frontier conducted another “Survey on Chemotherapy-Induced Anemia in Cancer Patients” from January to April 2024, building on the 2022 survey. This survey provided a realistic reflection of Chinese clinicians’ perspectives on CIA management. According to the “China Health Statistics Yearbook 2022,” there are 28,800 practicing oncologists in China, covering various levels of hospitals. From January to May 2024, Oncology Frontier collected 308 online questionnaires to assess the impact of CIA on cancer treatment, clinical practice measures and goals for CIA, management of ADC-related CIA, and clinicians’ sources of information on CIA. Descriptive statistical analysis was conducted on the survey responses, frequencies, etc.

Dr. Yanxia Shi

• Professor, Chief Physician, and Doctoral Supervisor at Sun Yat-sen University Cancer Center
• Deputy Director of the Department of General Medicine at Sun Yat-sen University Affiliated Cancer Hospital
• Standing Member of the Youth Committee of the China Anti-Cancer Association
• Chairperson of the Breast Cancer Professional Committee of the China Geriatric Care Association
• Vice Chairperson of the Rare Disease and Primary Tumor Committee of the China Anti-Cancer Association
• Standing Member of the Clinical Chemotherapy Committee of the China Anti-Cancer Association, Vice Chairperson of the Youth Committee
• Council Member of the Chinese Society of Clinical Oncology (CSCO)
• Chairperson of the Oncology Branch of the Guangdong Medical Association
• Vice Chairperson of the Breast Cancer Branch of the Guangdong Thoracic Tumor Prevention and Treatment Research Association
• Vice Chairperson of the Breast Cancer Branch of the Guangdong Women Doctors Association