Blood Journal
Leading the way in experimental and clinical research in hematology

American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

  1. J. Douglas Rizzo1,*,
  2. Melissa Brouwers2,
  3. Patricia Hurley3,
  4. Jerome Seidenfeld3,
  5. Murat O. Arcasoy4,
  6. Jerry L. Spivak5,
  7. Charles L. Bennett6,
  8. Julia Bohlius7,
  9. Darren Evanchuk8,
  10. Matthew J. Goode9,
  11. Ann A. Jakubowski10,
  12. David H. Regan11, and
  13. Mark R. Somerfield3
  1. 1 Medical College of Wisconsin, Milwaukee, WI;
  2. 2 McMaster University, Hamilton, Ontario, Canada;
  3. 3 American Society of Clinical Oncology, Alexandria, VA;
  4. 4 Duke University School of Medicine, Durham, NC;
  5. 5 Johns Hopkins University School of Medicine, Baltimore, MD;
  6. 6 South Carolina College of Pharmacy, Columbia, SC;
  7. 7 Institute of Social and Preventive Medicine/University of Bern, Bern, Switzerland;
  8. 8 Commonwealth Hematology Oncology PC, Stoneham, MA;
  9. 9 Patient representative, Mesa, AZ;
  10. 10 Memorial Sloan-Kettering Cancer Center, New York, NY;
  11. 11 Northwest Cancer Specialists, Vancouver, OR
  1. * Corresponding author; email: cschwartz{at}


Objective: To update American Society of Hematology/American Society of Clinical Oncology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. Methods: An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched. Results: The literature search yielded one new individual patient data and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews. Recommendations: For patients undergoing myelosuppressive chemotherapy who have hemoglobin (Hb) less than 10 g/dL, the Update Committee recommends that clinicians discuss the potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs, and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should raise Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels ≥ 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration-approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.

  • Submitted August 4, 2010.
  • Accepted August 9, 2010.