Patterns of Care in Patients with Chemotherapy Receiving Erythropoiesis Stimulating Agents (ESAs).
Authors: Naeim Arash , Friedman Lyssa , Elkin Eric , Adams Sara , Viswanathan Hema , Kallich Joel , Glaspy John 
Published: October 2019

Abstract
Background: Hemoglobin (Hb) levels at ESA treatment initiation have undergone recent policy debate. This retrospective chart review used baseline data prior to an educational intervention on anemia guidelines in community-based oncology practices to understand ESA patterns of care among cancer patients receiving chemotherapy. National guidelines at the time of data collection recommended treatment when Hb was <11 g/dL or when Hb was 11–12 g/dL in the presence of anemia symptoms or risk factors for development of symptomatic anemia. The objectives of this analysis were to examine Hb levels and presence of symptoms or risk factors at ESA treatment initiation and proportion of patients receiving at least one transfusion after initial ESA treatment.
Methods: Medical charts of patients ≥18 years receiving chemotherapy (June 2005 – August 2006) for lung, ovarian, multiple myeloma, Hodgkin’s and non-Hodgkin’s lymphoma, colorectal, breast, head and neck, bladder or testicular cancer from 47 sites were abstracted. Hb level at initial ESA administration was defined as the value recorded within 7 days prior to or on the day of treatment initiation. Anemia symptoms (chest pain, peripheral edema, sustained tachycardia, severe fatigue, dizziness) and risk factors for the development of symptomatic anemia (prior transfusion, radiation or chemotherapy; chronic obstructive pulmonary disease, cerebrovascular disease or cardiac disease; age ≥ 65 years) were identified using national guidelines.
Results: Of 2844 patients on chemotherapy, mean age was 62 years; 66% were female; most common malignancies were breast (36%), non-small cell lung cancer (19%) and colorectal (18%). A total of 1268 patients (44%) received at least one administration of an ESA and of these 1165 (92%) had Hb levels recorded at treatment initiation. A total of 238 patients (20%) had Hb levels ≤10g/dL at ESA initiation, 419 (36%) had Hb levels from 10.1–11.0 g/dL, 358 (31%) had Hb levels from 11.1–12.0 g/dL and 150 (13%) had Hb levels >12g/dL at treatment initiation. Of the 1268 patients who received initial treatment with an ESA, 102 (8%) required at least one transfusion during chemotherapy. Anemia symptoms or risk factors were present in 206 patients (87%) with Hb ≤10g/dL, 335 (80%) with Hb 10.1–11.0 g/dL and 287 (80%) with Hb 11.1–12.0 g/dL at ESA treatment initiation. Of the 1616 patients (56%) who did not receive an ESA during chemotherapy, the majority had a lowest recorded Hb level >12g/dL (647 patients, 40%) and 68% of such patients had anemia symptoms or risk factors. In comparison, 83% of patients receiving an initial ESA administration at Hb >12 g/dL had anemia symptoms or risk factors.
Conclusions: Initiation of ESAs occurred most commonly between Hb levels of 10.1–11.0 g/dL. A majority of patients had symptoms or risk factors at ESA treatment initiation across Hb levels. Evaluation of specific symptoms and the role of ESAs in symptom alleviation is needed. Future studies should investigate the impact of new polices for ESA use on utilization patterns.
Hb Levels at ESA Treatment Initiation and Presence of Symptoms or Risk Factors (N=1165)* ESA Treatment Presence of Symptoms or Risk Factors Hb at ESA Treatment Initiation N % N % *n=102 with no Hb in week prior to initial ESA treatment ≤10 238 20.4 206 86.6 >10–11 419 36.0 335 80.0 >11–12 358 30.7 287 80.2 >12 150 12.9 125 83.3