MANHASSET, New York-
Current criteria for correcting anemia
in older cancer patients are not stringent
enough, recent findings suggest.
However, clinical trials will be needed
to show that using erythropoietic
agents to correct anemia beyond the
generally accepted hemoglobin (Hb)
threshold of 12 g/dL will provide an
added patient benefit, according to
Stuart Lichtman, MD.
"We have the means to correct these
measures," said Dr. Lichtman, associate
professor of clinical medicine, NYU
School of Medicine, Division of Oncology,
North Shore University Hospital,
Manhasset, New York. "The
question is, can we prove the benefit in
a prospective manner?" Dr. Lichtman
spoke at a satellite symposium sponsored
by Amgen and held in conjunction
with the first annual Geriatric
Oncology Consortium multidisciplinary
National Comprehensive Cancer
Network (NCCN) guidelines describe
how to minimize anemia toxicity in
elderly patients undergoing chemotherapy.
The guidelines recommend
using hematopoietic growth factors
prophylactically in patients aged 70
years or older undergoing chemother-apy that has a dose intensity comparable
with CHOP (cyclophosphamide
The guidelines also state that erythropoietic
agents should be used to maintain
Hb levels at greater than 12 g/dL.
Adhering to those guidelines will
ensure that chemotherapy effectiveness
and quality of life are maintained,
according to Dr. Lichtman. However,
emerging data suggest that the cutoffof ≤ 12 g/dL as criteria for defining
anemia in older people should be reevaluated.
In a recent study that raised this
question, investigators showed that
incremental rises in Hb above 12 g/dL
may decrease the incidence of functional
disability in older women (J AmGeriatr Soc 50:1257-1264, 2002).
The study was a cross-sectional
analysis of two population-based studies
(Women's Health and Aging Studies
I and II, Baltimore, Maryland) including
633 community dwellingwomen aged 70 to 80 years. Investigators
measured Hb levels and assessed
difficulty with mobility, as shown by
either walking one-quarter mile or
climbing 10 steps.
Investigators found that mobility
varied within the "normal" Hb range
of 12 to 16 g/dL. For example, an Hb
level of 12 g/dL was associated with
more mobility difficulty vs an Hb level
of 13.5 g/dL. Performance-based
scores improved with increasing Hb
categories, from less than 12, to 12-
13, to 13-14 g/dL.
Based on these findings, investigators
said Hb ≤ 12 g/dL "might be a
suboptimal criterion for defining anemia
in older women," because even
Hb levels considered "low normal" by
today's standards were associated with
an adverse effect on mobility.
"The maximum optimal hemoglobin
in this study was approximately 13
to 14 [g/dL]," Dr. Lichtman said. "A
hemoglobin of 11 is not good enough,
and a hemoglobin of 12 g/dL might
even be a suboptimal criterion for defining
anemia. These researchers have
shown that older patients with a hemoglobin
level of 14 had an improved
degree of function."
These hypotheses must be formally
tested, however, in clinical trials uti-lizing erythropoietic agents, ideally in
studies that specifically include elderly
individuals with cancer.
Erythropoietic growth factors that
are available to treat anemia include
epoetin alfa (Procrit) and darbepoetin
(Aranesp). Dr. Lichtman noted that
data on file with Amgen, the manufacturer
of Aranesp, show that this particularagent yields similar efficacy in
younger and older cancer patients.
Correcting anemia with erythropoietic
agents can alleviate fatigue,
tiredness, and other symptoms in older
cancer patients. More importantly,
however, correcting anemia may ensure
elderly patients receive the appropriate
chemotherapy dose and schedule.
"It's easy to minimize toxicity by
giving less-effective therapy, but if you
do have a responsive disease (such as
non-Hodgkin's lymphoma), you really
do have to stick to the dosing schedule
that we know can be effective," Dr.