A Population-Based Analysis of the Frequency of Anemia and Its Management before and during Chemotherapy in Patients with Malignant Lymphoma.
Authors: Truong Pauline T. , Hart Jason , Alexander Cheryl , Berthelet Eric , Kader Adam , Petersen Ross , Culp Matthew , Wai Elaine S. 
Published: October 2019

Abstract
In patients with hematologic malignancies, chemotherapy has the potential to further suppress bone marrow production. While measures to correct anemia including transfusion and growth factor support can improve patients’ function and quality of life, the intervention threshold and the methods of correcting anemia among clinicians managing patients with malignant lymphoma are not clear. The present study evaluates the frequency, severity and corrective interventions for anemia used before and during the delivery of the four most common chemotherapeutic regimens used at the BC Cancer Agency to treat patients with Hodgkin’s and Non-Hodgkin’s Lymphoma. A retrospective, electronic chart review was conducted of 316 patients who received cytotoxic chemotherapy for lymphoma at four BC Cancer Agency centers from June 1, 2004 to December 31, 2005. Initial hemoglobin (Hgb) and dates of first Hgb in the ranges, 110–119g/L, 100–109g/L, 90–99g/L and <90g/L were recorded. Review of medical records was performed to document the frequency of anemia-associated symptoms including fatigue and the frequency of any discussion or delivery of interventions for anemia (transfusion, epoetin [EPO] or both). In this study cohort, 23% of patients had Hodgkin’s and 77% had Non-Hodgkin’s disease. The proportions of male and female patients were 55% and 45%, respectively. The chemotherapy regimens delivered were: Doxorubicin, Cyclophosphamide, Vincristine and Prednisone (CHOP) in 24 patients, CHOP + Rituximab (CHOP-R) in 215 patients, Adriamycin, Bleomycin, Vinblastine, Dacarbazine (ABVD) in 73 patients, and Gemcitabine, Dexamethasone and Cisplatin (GDP) in 4 patients. Median age was 57 years (range 16–87 years). Prior to starting chemotherapy, 33% of subjects had a Hgb<120g/L and 7% subjects had a Hgb <100g/L. In patients with Hgb <100g/L prior to chemotherapy, fatigue was documented in 67% but intervention for Hgb <100g/L pre-chemotherapy occurred in only 10% of patients. Overall (before and during chemotherapy), the proportion of subjects with at least one Hgb<120g/L was 67%, <110g/L was 41%, <100g/L was 23% and <90g/L was 10%. Table 1 summarized anemia-related symptoms and interventions during chemotherapy delivery. Discussion and intervention rates increased as Hb declined, particularly at levels <90g/L. Among 32 patients with Hgb<90g/L, symptoms were documented in 23 patients. Transfusion was used in 23 patients and EPO was used in 1 patient. In conclusion, anemia was relatively common prior to and during chemotherapy for patients with malignant lymphoma. The threshold of anemia intervention during chemotherapy was Hgb <90g/L with transfusion as the predominant method used. Pre-chemotherapy intervention rates for anemia were low even in the presence of symptoms and at Hgb values where randomized trials have shown that intervention can improve fatigue and quality of life.
Anemia-related symptoms and interventions during chemotherapy for patients with malignant lymphoma Hgb Range (g/L) Number of cases Symptoms Present Interventions Discussed but Not Given Transfusion Only EPO only Both Transfusion and EPO 110–119 137 21 0 0 0 0 100–109 96 31 1 0 0 0 90–99 59 27 7 4 0 0 <90 32 23 0 23 1 0