David Cella, PhD

Anemia raises special concerns in older cancer patients. This review addresses the prevalence, causes, and mechanisms of anemia in older individuals, the complications of anemia in this population (including its impact on cancer treatment), and the appropriate management of anemia in the elderly.

Fatigue is common in cancer patients treated with chemotherapy, and it has detrimental effects on their quality of life. Chemotherapy-induced anemia, however, is often under-recognized and under-treated. There is a clear association between hemoglobin (Hgb) levels and fatigue, with fatigue being greater in patients with lower Hgb levels. Managing fatigue requires that its causes be determined and corrected, and it is important that patients report their fatigue. Patients, however, are unlikely to mention such adverse events unless they are asked about them. In addition, busy practitioners generally have very little time to discuss anemia-related fatigue with their patients. Many studies have used the validated quality-of-life instrument Functional Assessment of Cancer Therapy-Fatigue (FACT-F) to assess fatigue and quality of life in patients treated with chemotherapy; these studies have shown a relationship between chemotherapy-induced anemia, fatigue, and quality of life. Studies of erythropoiesis-stimulating proteins to treat chemotherapy-induced anemia have shown increases in patients' hemoglobin levels, improvement in their FACT-F and FACT-General scores, and improvements in their quality of life.

In today's regulatory review environment, how do we keep the patient at center stage?

Fatigue, the most common symptomreported by people withcancer, is associated with functionalimpairments and decrements inquality of life. As Drs. Lipman andLawrence have pointed out, researchon the etiology of cancer-related fatigueis scant. Morrow et al[1] conducteda detailed review of theevidence to support four hypothesesfor cancer-related fatigue and highlightedindependent findings that implicatecytokines, 5-HT, and thehypothalamic-pituitary axis in the developmentof cancer-related fatigue.Additional research is needed in thisarea to articulate the pathophysiologyof fatigue and the associated clinicalimplications.

There is a growing recognition in oncology of the importance of maintaining or improving patients’ quality of life (QOL) throughout the disease course. With this goal in mind, many clinical trials in oncology now seek to evaluate QOL end points.

Anemia, common in people with cancer, can be due to the disease itself or to the associated therapy. Fatigue, the most prevalent of all symptoms experienced by cancer patients, is the primary symptom of anemia. Caused by many factors, fatigue, regardless of etiology, has an adverse impact on health-related quality of life.

The article by Drs. Lesage and Portenoy is an excellent overview of current knowledge regarding the etiology, diagnosis, and treatment of fatigue in the cancer patient. Although we still have much to learn about cancer-related fatigue, noteworthy progress has been made over the past 10 years in identifying the problem, describing its consequences, establishing it as a recognized diagnostic entity, understanding its causes, and offering treatments.

Low-grade non-Hodgkin’s lymphoma (NHL) is an indolent form of the disease with a generally slow course of progression. Although still usually incurable, low-grade disease has shown responsiveness to some of the newer