Randomized Study Evaluating Agents Stimulants Erythropoiesis (ASE) Associated With Ferric Carboxymaltose (Ferinject ®) in Concomitant or Sequential Patients Treated for Cancer and With Anemia Associated With Functional Iron Deficiency

Study Overview
=================
Brief Summary
-----------------
Anemia in patients with cancer is a common problem associated with an impaired quality of life. Treatment with erythropoiesis stimulating agents (ESA) allows an increase in hemoglobin levels in 40-70% of patients and decreased transfusion requirements. Absolute or functional iron deficiency is also common with about 30% of cancer patients with all histologies combined iron deficiency and anemia. Several studies have shown the benefits of the combination of intravenous iron to erythropoiesis-stimulating agents in improving hemoglobin. However, none of them, to the investigators knowledge, has not been specifically performed on a population of patients with functional iron deficiency. In addition, in clinical practice, this association is not carried out in particular because there is no dosage or consensus sequence for the administration of iron associated with ESAs.

Detailed Description
-----------------
- Iron Deficiency and Cancer The literature review therefore presents uncertainties do not allow the routine application of intravenous iron associated with ESAs. The SOR also conclude that IV iron is consider if iron deficiency. These uncertainties are the heterogeneity of the study populations, contradictory results and the use of patterns intravenous iron binding and non-standardized. The investigators focus in this study in patients with chemotherapy-induced anemia with functional iron deficiency is a cause of lack of response to ESA. Indeed, patients with true iron deficiency seems to justify a routine iron supplementation. In contrast, patients without iron deficiency do not warrant formal way of initiating such treatment (although the literature is contradictory). This study aims to evaluate, in patients with chemotherapy-induced anemia and functional iron deficiency, the efficacy and safety of the combination epoietin zeta + Iron in concomitant intravenous or sequential. Because data RCP (Summary of Product Characteristics), ease of use, its safety profile, the ability to achieve higher doses of iron with a lower frequency and with better adherence, the ferric carboxymaltose was chosen as an intravenous iron. One specialty is available, the Ferinject ® (Laboratoires VIFOR Pharma). The erythropoiesis-stimulating agent chosen in this study is epoietin zeta. - Hepcidin and iron Hepcidin is a peptide hormone of 25 amino acids produced by the liver and considered as the central regulator of iron homeostasis in the body. It works by controlling intestinal iron absorption and iron reuse by the reticuloendothelial system. Hepcidin acts by preventing the export of iron enterocytes, intestinal site of absorption of dietary iron, and macrophages, iron recycling site of hemoglobin, by binding to ferroportin present at the membrane these cells and by inducing its internalization and degradation. Accordingly, hepcidin can be considered a hyposidérémiante hormone. The hepcidin rate is increased by the iron thereby limiting its accumulation and tissue damage associated with iron overload. Inversely, the rate is reduced hepcidin during increased iron as anemia needs, hypoxia, pregnancy or other situations of iron deficiency. Moreover, hepcidin is strongly induced by inflammation. Thus, in pathological situations such as cancer, high levels of hepcidin explain well enough inflammatory anemia characterized by anemia, iron retention at storage proteins such as ferritin but also at the level of the reticuloendothelial system endothelial and a decrease in intestinal iron absorption. Despite its importance in the pathophysiology of anemia of inflammation and a fortiori with iron deficiency anemia functional hepcidin is not measured in clinical routine. There is not, to the investigators knowledge, prospective data on its blood levels in situations of iron deficiency anemia in cancer patients functional and data on changes in hepcidin levels induced by treatment with intravenous iron or with erythropoietin.

Official Title
-----------------
Phase IV Randomized Study Evaluating Agents Stimulants Erythropoiesis (ASE) Associated With Ferric Carboxymaltose (Ferinject ®) in Concomitant or Sequential Patients Treated for Cancer and With Anemia Associated With Functional Iron Deficiency

Conditions
-----------------
Solid Cancer Metastatic Disease, Lymphoid Disease

Intervention / Treatment
-----------------
* Drug: ARM A : IV iron + epoietin zeta
* Drug: ARM B: IV iron + epoietin zeta sequence
* Drug: ARM C : single epoietin zeta


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patient> 18 years; Metastatic or locally advanced non-curable undergoing chemotherapy or lymphoid disease for which chemotherapy is indicated solid cancerous disease; Patient for which there are at least 3 cycles or 3 months of chemotherapy; Haemoglobin between 8.5 and 11 g / dL; Functional martial deficiency defined by a coefficient of transferrin saturation and serum ferritin ≤ 20% between 100 and 800 mg / L; Life expectancy> 3 months; ECOG ≤ 2. Exclusion Criteria: Documented hemochromatosis ; AST and / or ALT> 2.5N; Renal impairment with Cockcroft clearance <30 mL / min; Vitamin B12 deficiency or folate; Hemolysis; Infectious disease being untreated; Haemorrhagic syndrome related or not with the tumor; Hypersensitivity to Ferinject ® or any of the excipients; Land atopic asthma or eczema known Contraindication to EPO; Taking a supplement to oral iron; Treatment with EPO within 6 months prior to study entry; No transfusion of packed red cells within 15 days before enrollment or randomization in the study; Participation in another clinical trial; Psychiatric pathology can disrupt the course of treatment or prevent the interpretation of results; Pregnant or lactating women; Persons deprived of liberty; Major subject to a measure of legal protection or unable to consent.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Concomitant iron and I.V. epoietin zeta<br> | Drug: ARM A : IV iron + epoietin zeta<br>* Epoietin zeta at a dose of 450 IU / kg per week subcutaneously Carboxymaltose ferric (Ferinject ®) at week 1; Intravenous infusion not exceeding 1000 mg (administered once if weight> 50 kg, 500 mg twice otherwise, with an interval of one week between each administration). Renewable with a minimum of 4 weeks depending on the iron status (if CST <20% and absence of serum ferritin> 800) in the same manner as week 1.<br>|
| Experimental: Iron and I.V. epoietin zeta sequential<br> | Drug: ARM B: IV iron + epoietin zeta sequence<br>* Epoietin zeta at a dose of 450 IU / kg per week subcutaneously started in week 7 carboxymaltose ferric (Ferinject ®) at week 1 Intravenous infusion not exceeding 1000 mg (administered once if weight> 50 kg, 500 mg twice otherwise, with an interval of one week between each administration). Renewable with a minimum of 4 weeks depending on the iron status (if CST <20% and absence of serum ferritin> 800) in the same manner as week 1.<br>|
| Active Comparator: Epoietin zeta<br> | Drug: ARM C : single epoietin zeta<br>* Epoietin zeta at a dose of 450 IU / kg per week subcutaneously begun in week 1<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with hematopoietic response at 10 weeks. | The primary objective is to evaluate the rate of hematopoietic response to 10 weeks in patients with anemia and functional iron deficiency treated epoietin zeta + carboxymaltose concomitant IV iron, by epoietin zeta + carboxymaltose IV ferric sequential or epoietin zeta alone | The rate of hematopoietic response will be evaluated 10 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of transfusion requirements | The secondary objective is to assess transfusion requirements will be evaluated throughout the study | The number of transfusions will be evaluated weekly Week 1-16 | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Functional iron deficiency, Metastatic