Compliance with the National Comprehensive Cancer Network guidelines for evaluation and treatment of anemia among patients with solid tumors.
Authors: Demetra Hufnagel, Lia Manfredi Bos, Alaina J. Brown, Lauren S. Prescott
Journal: Journal of Clinical Oncology (2021)

11 Background: Anemia is associated with increased morbidity, mortality and decreased quality of life among oncology patients. The National Comprehensive Cancer Network (NCCN) recommends evaluation and treatment of anemia in patients with cancer. There is a paucity of data investigating compliance with the NCCN guidelines. Methods: A retrospective study of patients diagnosed with any malignant solid tumor at our institution from 2008-2017 was performed. Tumor-registry-confirmed cancer cases were identified using International Classification of Disease-Oncology (ICD-O) codes in the Synthetic Derivative (SD) database, a de-identified copy of the electronic medical record. Patients were included if they were between the ages of 18 and 89 and had a hemoglobin (hgb) within 6 months of diagnosis. Patients were excluded if they had more than one tumor registry entry. Anemia was defined as hgb ≤11g/dL and graded using the CTCAE v.5.0. Absolute and possible functional iron deficiency were defined by NCCN guidelines. B12 and folate deficiency were defined by institutional reference values. Chi-squared tests were conducted in R (Version 3.4.4). P &lt;.05 was interpreted as statistically significant. Results: A total of 25,018 patients met inclusion criteria. The median age was 60 years, and the most common malignancies were respiratory tract, prostate, and urologic (11% each, respectively). Of the 25,018 patients, 1,484 (17%) were noted to be anemic at time of diagnosis and 11,019 (44%) were anemic within 6 months of diagnosis. Of these patients, a plurality (N = 4,686, 43%) had grade 2 anemia and a majority (N = 9,623, 87%) had normocytic anemia. Patients with retroperitoneal/peritoneal cancers had the highest prevalence of anemia (N = 83, 75%). A total of 4,125 (37%) underwent any evaluation of their anemia, of which 1,742 (16%) had iron studies performed and 1,528 (14%) had B12 or folate studies performed. Of those with iron studies performed, 197 (11%) patients had absolute iron deficiency and 103 (6%) had possible functional iron deficiency. Of those with B12 labs, 74 (5%) had B12 deficiency and of those with folate labs, 69 (12%) had folate deficiency. Less than half of anemic patients (N = 4,318, 39%) received treatment for anemia, including blood transfusion (N = 3,528, 32%), oral iron (N = 1,279, 12%), or IV iron (N = 97, 1%). However, treatment of anemia significantly increased as grade of anemia increased (any treatment among mild: 12%; moderate: 31%; severe: 77%; χ 2 [2, N = 11,019] = 3020.6; P &lt;.001). Patients with male reproductive tract cancers had the highest prevalence of anemia evaluation (N = 57, 79%). Conclusions: Anemia is common in patients with solid tumors, yet compliance with NCCN guidelines for evaluation and treatment of anemia remains low. There are opportunities to improve compliance with NCCN guidelines for management of anemia across the spectrum of cancer care.