Should Intravenous Iron Be the Standard of Care in Oncology?

Before 1989, when epoetin was introduced for dialysisassociated anemia, the use of intravenous (IV) iron in the United States was typically avoided.Shortly thereafter, it was shown that responses to epoetin could be improved by IV iron supplementation.By 1998, IV iron had become standard of care in dialysis patients receiving epoetin, 1 and the use of erythropoiesis-stimulating agents (ESAs) in oncology patients was in its infancy.In the ensuing decade, we have witnessed improvements in quality of life and fewer transfusions among patients receiving ESAs for the anemia associated with cancer and cancer chemotherapy.Some studies have shown the maximum improvement in energy, activity, and quality of life occurs when the hemoglobin (Hb) increases from 11 to 13 g/dL. 2In August 2007, the Committee on Medicare and Medicaid Services issued a Decision Memo restricting ESA usage when patients' Hb levels are Ն10 g/dL.These new regulations were recommended on the basis of data suggesting harm with ESAs when used outside of established guidelines.To date, no study has shown a negative impact on cancer outcomes or survival in patients when ESAs were used in accordance with previously established American Society of Hematology, American Society of Clinical Oncology, or National Comprehensive Cancer Network guidelines.Recent data in the renal literature suggest that it is not the Hb level, but ESA exposure, that is associated with negative outcomes. 3he success of IV iron supplementation in improving responses to ESAs in the anemia of end-stage renal disease has yet to be realized by the oncology community.Oncologists spend three times more on ESAs than nephrologists.A 50% reduction in transfusions has been accomplished in oncology patients, whereas transfusions have been virtually eliminated in the dialysis population. 4Is it possible that it is the suboptimal use of these expensive drugs that played a role in the restrictions recently imposed?Two articles in this issue of the Journal of Clinical Oncology represent the fourth and fifth of five recent publications showing that administration of IV iron to oncology patients receiving ESAs results in significantly greater increments in Hb and hematopoietic response rates compared with ESAs alone or with oral iron 5-9 (Table 1).In all five studies, the benefit was independent of baseline iron parameters.These two studies add unique and useful information to a rapidly growing body of data supporting the routine use of IV iron as an adjunct to ESA therapy in appropriately selected oncology patients.Bastit et al 5 studied 396 patients with nonmyeloid malignancies receiving chemotherapy, with Hb less than 10.5 g/dL and ferritin more than 10 ng/mL or transferrin saturation (TSAT) more than 15%.