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.Survey Findings and Clinical Practice Implications
The 308 questionnaires covered 28 provinces and cities, including 204 hospitals, all secondary or higher level, with 62% being tertiary grade A hospitals (53% in the 2022 survey). Among the surveyed clinicians, 23% were chief physicians, 25% associate chief physicians, and 40% attending physicians. Notably, 83% were from oncology-related departments (63% in 2022), with the remaining from non-oncology specialties. Thirty-six percent were senior clinicians with over 20 years of experience (29% in 2022), 48% had more than five years of clinical experience, and the rest had less than five years. This diversity ensures the survey’s representativeness and the inclusion of experienced clinicians, providing an accurate reflection of CIA management in China.
The survey found that in the past three months, the average number of chemotherapy patients prescribed per clinician was 57, with an average of 22 CIA cases. Only 14 received anemia treatment, and 10 experienced chemotherapy dose reduction or delay due to CIA. Data from tertiary hospitals were consistent with overall results. The average incidence of chemotherapy dose reduction or delay due to CIA was 22%, slightly lower than the 24% in 2022. Tertiary hospitals had a lower incidence (15% vs. 13%), likely due to a higher proportion of corrective anemia treatments.
Clinicians closely monitor Hb levels and take appropriate measures to manage CIA. Ten percent of doctors believe anemia should be corrected when Hb <120 g/L, 33% at Hb ≤100 g/L, 40% at Hb ≤80 g/L, and 17% at Hb ≤60 g/L. Compared to the 2022 survey (3% at Hb <120 g/L, 32% at Hb ≤100 g/L, 45% at Hb ≤80 g/L, 20% at Hb ≤60 g/L), awareness of anemia correction has increased but remains inconsistent. The 2024 CSCO guidelines emphasize the need to evaluate anemia when Hb ≤110 g/L or ≥20 g/L below baseline. ESA or roxadustat treatment should start at Hb ≤100 g/L, aiming to maintain Hb levels between 110-120 g/L to significantly improve QoL.
Survey Insights and Future Directions
The survey revealed that 71% of clinicians believe patients’ Hb levels during chemotherapy should be maintained between 90-110 g/L, and only 11% between 110-120 g/L. This indicates that many clinicians do not follow guideline recommendations for CIA correction, underscoring the need for enhanced education on CIA management.
Anemia is also a common side effect of other cancer treatments, including radiotherapy (29%), ADCs (28%), targeted therapy (22%), and immunotherapy (21%). The updated 2024 CSCO anemia guidelines note that ADCs, as a new class of anti-cancer drugs with both chemotherapy and targeted therapy characteristics, can cause anemia due to bone marrow suppression, with an incidence of about 33.1%. Common ADCs in China include T-DXd, with an overall anemia incidence of 32-41.5% and grade 3 or higher anemia incidence of 8-12.9%; SG, with overall anemia incidence of 40-52% and grade 3 or higher anemia incidence of 9-12%; and T-DM1, with overall anemia incidence of 10-14% and grade 3 or higher anemia incidence of 1.1-4.1%. Notably, T-DXd treatment duration is long, with about one-third of patients experiencing anemia, primarily during the initial treatment cycles, with most Hb levels around 8.1 g/dL, affecting QoL and treatment tolerance. This indicates that the anemia incidence of most ADC drugs in China is higher than clinicians’ awareness, highlighting the need to strengthen the management of anemia related to these drugs.
Currently, 42% of surveyed hospitals have access to ADCs, with a slightly higher rate of 50% in tertiary hospitals. A total of 125 clinicians had prescribed ADCs, with a median of six prescriptions in the past three months, resulting in a median of three anemia cases, two receiving corrective treatment, and one experiencing dose reduction or delay due to anemia.
When anemia occurs due to ADCs, 49% of clinicians believe anemia should be corrected when Hb ≤80 g/L, and 27% when Hb ≤100 g/L. Due to the lack of standardized guidelines for correcting ADC-induced anemia, expert recommendations based on existing evidence (rated from 1 to 7, with 1 being strongly against and 7 being strongly for) showed that over half of the clinicians strongly recommend following the “Chinese Expert Consensus on the Multidisciplinary Management of ADC Safety” and the “CSCO Clinical Practice Guidelines for Cancer-Related Anemia (2024)” for correction. International consensus suggests considering EPO or RBC transfusion for symptomatic anemia or Hb <10 g/dL when using T-DXd.
The main recommended correction methods for anemia include ESA, roxadustat, iron, and transfusion. ESA is the primary method for CIA treatment, reducing transfusion demand and being well-tolerated, but it is effective in only about two-thirds of patients and takes 2-4 weeks to act. Roxadustat, a new addition to the 2024 CSCO anemia guidelines, is the first oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) with a novel mechanism similar to ESA. Iron supplements are highly accessible, convenient, and safe, but oral iron has low absorption and gastrointestinal toxicity, while intravenous iron can effectively resolve these issues but with poor compliance and high risk of adverse reactions. Transfusions can rapidly increase Hb levels and are used for ESA-refractory patients, but due to the limited RBC production improvement, blood supply shortages, and potential disease transmission risks, transfusions are not widely used.
Conclusion
In summary, the management of CIA in China has seen significant improvement since the 2022 survey, with a growing awareness among clinicians. However, only 33% of clinicians follow the guidelines to correct anemia at Hb ≤100 g/L, while 40% use Hb ≤80 g/L as the threshold. Thus, continued promotion of guideline-standardized CIA management is crucial.
Previous studies indicated that 60% of chemotherapy DDR patients experienced anemia, higher than the incidence of chemotherapy-induced neutropenia (CIN), suggesting a potential relationship between anemia and DDR. Increased attention to CIA management has improved the clinical situation in China, reducing the DDR proportion from 24% to 22%. The CSCO guidelines recommend Hb ≥80 g/L as the lower limit for chemotherapy, urging clinicians to manage CIA to prevent disruptions in anti-cancer treatment.
As anti-cancer treatments evolve, bringing new adverse reaction profiles, the survey shows that clinicians primarily source CIA management information from professional journals, academic conferences, and clinical practice. Clinicians also prefer multidisciplinary exchanges, domestic and international conferences, and case interpretations to gain in-depth knowledge of CIA management. With the addition of roxadustat to anemia correction strategies, clinicians’ options for managing CIA have expanded, necessitating comprehensive considerations of effectiveness, safety, convenience, and accessibility to improve CIA management.
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
