Iron Deficiency Anemia in patients with cancer
Iron deficiency is a frequent complication associated with cancer. Gastrointestinal or colorectal cancer can cause internal bleeding,1 and some gynaecological cancers such as ovarian or cervical cancer cause blood loss, putting patients at higher risk of iron deficiency anaemia (IDA). Depending on the type of cancer, up to half of cancer patients may already present anaemia at diagnosis, and up to 3/4 of all cancer patients develop anaemia during radiotherapy or chemotherapy.2
Across all cancer types, approximately 30-45% of patients experience iron deficiency.1 In a single-centre study of 1,528 patients (1053 had solid tumors and 475 haematological malignancies), more than 40% had iron deficiency, defined as a transferrin saturation (TSAT) level of <20%2.
Multiple factors contribute to the development of iron deficiency anaemia (IDA) in cancer patients, depending on the type of cancer and the treatment that the patient receives. These factors include:
- Reduced intake of dietary iron: Patients with gastrointestinal or colorectal cancer may not be able to take up enough dietary iron, due to disease or treatment-related anorexia2
- Chronic bleeding: Many cancers cause blood loss through internal bleeding, particularly those in the gastrointestinal and genitourinary tracts2
- Chronic inflammation: Chronic inflammation may be linked to iron deficiency in patients with cancer.2 Inflammatory cytokines stimulate the release of hepcidin that inhibits the release of iron from iron stores, which can result in functional iron deficiency. Absorption of iron from the intestine is also blocked by hepcidin, preventing iron stores from being replenished and leading to absolute iron deficiency3
- Anti-cancer therapy , including chemotherapy and radiotherapy2
- Increased iron requirements during erythropoiesis-stimulating agent (ESA) therapy: Patients undergoing myelosuppressive chemotherapy may be given ESAs.4 ESAs reduce the pool of circulating iron by increasing erythropoiesis, and iron supplementation may be required concomitantly.5
The importance of treating IDA in cancer patients
The anaemia can have noticeable physical and psychological effects; It manifests itself, for example, in heavy exhaustion (fatigue), dizziness, shortness of breath, palpitations, depressive mood or sleep disorders. Above all, patients are affected by anemia in their quality of life and performance.
Studies in cancer patients with IDA have found a direct correlation between quality of life and haemoglobin levels in cancer patients receiving chemotherapy.6
Up to 96% of cancer patients experience fatigue, the impact of which can be profound.7,8 61% of cancer patients reported that fatigue had a greater impact on their daily lives than pain.8
Clinical evidence suggests that treatment of chemotherapy-related iron deficiency anaemia with intravenous iron and ESA therapy significantly increases haemoglobin levels, with resulting increases in energy level, activity, and overall quality of life9,10
Diagnosis and Treatment
Cancer patients should regularly have their blood and iron levels checked for iron deficiency (ID) or iron deficiency anemia (IDA). If there is inflammation in the body (high CRP value), in addition to the hemoglobin (Hb value) and the storage iron (ferritin), the load of the iron transporters (transferrin saturation) should be determined as well.
In inflammatory processes, the body not only absorbs less iron, but the mobilization from the iron stores is reduced as well. Unfortunately, the ferritin value under such conditions gives no reliable indication as to whether the iron stores are sufficiently filled, since ferritin is also increased due to inflammation.
Anemia can be so severe that patients with cancer need blood transfusions. In the contrary, iron deficiency anemia can be easily prevented if a systematic and thorough diagnosis is performed. In addition, in oncological surgery settings, it has been demonstrated that hospitalisation time is reduced when blood transfusions are avoided.
Anemia should undoubtedly be treated by the doctor to improve the quality of life of patients and to potentially avoid blood transfusions.
- Aapro M et al. Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of i.v. iron. Ann Oncol 2012; 23(8): 1954-1962.
- Ludwig H et al. Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia. Ann Oncol 2013; 24(7): 1886-1892.
- Ganz T. Nemeth E. Hepcidin and iron homeostasis.Biochim Biophys Acta 2012; 1823(9): 1434-1443
- Schrijvers D et al. Erythropoiesis-stimulating agents in the treatment of anaemia in cancer patients: ESMO Clinical Practice Guidelines for use. Ann Oncol. 2010; 21 (5): v244–7.
- Bokemeyer C, et al. EORTC guidelines for the use of erythropoietic proteins in anaemic patients with cancer: 2006 update.Eur J Cancer.2007; 43 (2): 258–70.
- Crawford J et al. Relationship between changes in hemoglobin level and quality of life during chemotherapy in anemic cancer patients receiving epoetin alfa therapy. Cancer 2002; 95(4): 888-895.
- Meyerowitz B et al. Adjuvant chemotherapy for breast carcinoma: psychosocial implications Cancer 1979; 43: 1613-1618.
- Vogelzang N et al. Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey. The Fatigue Coalition. Semin Hematol 1997; 34: 4-12.
- Auerbach M et al. Intravenous iron optimizes the response to recombinant human erythropoietin in cancer patients with chemotherapy-related anemia: a multicenter, open-label, randomized trial. J Clin Oncol 2004; 22(7): 1301-1307.
- Steinmetz T et al. Clinical experience with ferric carboxymaltose in the treatment of cancer- and chemotherapy-associated anaemia. Annals of Oncology 2013; 24(2): 475-482.
- Calleja JL et al. Ferric carboxymaltose reduces transfusions and hospital stay in patients with colon cancer and anemia Int J Colorectal Dis 2016;31:543–51.
- Aapro et al. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Annals of Oncology 0: 1–15, 2018 doi:10.1093/annonc/mdx758.