University of Bern, Bern, Switzerland.
American Society of Clinical Oncology, Alexandria, VA.
Blood Adv. 2019 Apr 23;3(8):1197-1210. doi: 10.1182/bloodadvances.2018030387.
To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.
PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed.
The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited.
ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines.
更新美国临床肿瘤学会（ASCO）/美国血液学会（ASH）关于癌症患者使用红细胞生成刺激剂（ESA）的建议。
检索 2010 年 1 月 31 日至 2018 年 5 月 14 日期间发表的癌症患者随机对照试验（RCT）和 RCT 荟萃分析的 PubMed 和 Cochrane 图书馆。对于生物类似 ESA，由于癌症环境中 RCT 证据有限，文献检索范围扩大到包括癌症或慢性肾脏病患者的荟萃分析和 RCT 以及癌症患者的队列研究。ASCO 和 ASH 召集专家小组审查证据并根据需要修订以前的建议。
主要文献综述包括 15 项 ESA 的 RCT 荟萃分析和 2 项 RCT。越来越多的证据表明，在 ESA 治疗中添加铁可能会改善血液反应并降低 RBC 输血的可能性。生物类似物文献综述表明，促红细胞生成素 α 的生物类似物与参比产品具有相似的疗效和安全性，尽管癌症方面的证据仍然有限。
对于化疗相关性贫血且癌症治疗无治愈意图且血红蛋白已降至<10 g/dL 的患者，可以提供 ESA（包括生物类似物）。RBC 输血也是一种选择。除了少数骨髓增生异常综合征患者外，大多数非化疗相关性贫血患者不应使用 ESA。在 ESA 治疗期间，血红蛋白可能会增加到避免输血所需的最低浓度。对于接受 ESA 治疗且有或没有缺铁的患者，可使用铁替代治疗来改善血红蛋白反应并减少 RBC 输血。更多信息可在 www.asco.org/supportive-care-guidelines 和 www.hematology.org/guidelines 上获得。
