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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Blood Conservation and Chemotherapy-Induced Anemia: From Evidence-Based Guidelines to Clinical Practice


GOAL
To provide oncologists, hematologists, oncology surgeons, and hospital pharmacists with up-to-date information on blood conservation and chemotherapy-induced anemia.

TARGET AUDIENCE
This activity is designed for oncologists, hematologists, oncology surgeons, and hospital pharmacists. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Discuss current treatment strategies for managing patients with chemotherapy-induced anemia (CIA).
  • Identify patients with CIA at risk for blood transfusion.
  • Describe the benefits and risks of blood transfusion on patient outcomes.
  • Develop effective blood conservation strategies for patients with CIA.

The Johns Hopkins University School of Medicine and The University of Tennessee College of Pharmacy take responsibility for the content, quality, and scientific integrity of this CE activity.

ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The Johns Hopkins University School of Medicine and The University of Tennessee College of Pharmacy (UTCOP). The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The UTCOP is accredited by the Accreditation Council of Pharmacy Education (ACPE) to provide continuing education for pharmacists.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This knowledge-based program is sponsored by The University of Tennessee College of Pharmacy who is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Successful completion of this program will provide 2 contact hours credit (0.2 CEUs). A statement of CE credit will be available online immediately following successful completion of the program. ACPE program # 064-000-08-208-H01-P.

This continuing education activity was produced under the supervision of Glen E. Farr, PharmD, Associate Dean of Continuing Pharmacy Education, University of Tennessee College of Pharmacy.

The estimated time to complete this educational activity: 2 hours. After reading this monograph, participants may receive credit by completing the CE test, evaluation, and receiving a score of 70% or higher.

Release date: September 15, 2008. Expiration date: September 15, 2010.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine and The University of Tennessee College of Pharmacy names implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This activity is supported by an educational grant from Ortho Biotech.

Full Disclosure Policy Affecting CE Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education, it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Course Directors and Participating Faculty reported the following:

COURSE DIRECTORS

David S. Ettinger, MD, FACP, FCCP
Alex Grass Professor of Oncology
The Sidney Kimmel Comprehensive Cancer Center
The Johns Hopkins University
Baltimore, Maryland
Dr Ettinger reports having no financial or advisory relationships with corporate organizations related to this activity.

Edward J. Norris, MD, MBA, FAHA
Associate Professor
Department of Anesthesiology and Critical Care Medicine
Director, Vascular Anesthesia
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Norris reports having no financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Charles L. Bennett, MD, PhD, MPP
Professor
VA Chicago Healthcare System
VA Center for the Management of Complex Chronic Care
Department of Medicine
Division of Hematology/Oncology
The Robert H. Lurie Comprehensive Cancer Center
Northwestern University
Chicago, Illinois
Dr Bennett reports having no financial or advisory relationships with corporate organizations related to this activity.

Lawrence Tim Goodnough, MD
Professor of Pathology and Medicine
Department of Pathology
Stanford University School of Medicine
Stanford, California
Dr Goodnough reports serving as a consultant for, receiving honoraria from, and serving on the speakers’ bureau for American Regent, Inc, Amgen Inc, Ortho Biotech, and Watson Pharmaceuticals, Inc.

Stephen Y. Lai, MD, PhD
Assistant Professor
University of Texas MD Anderson Cancer Center
Departments of Head and Neck Cancer and Molecular and Cellular Oncology
Houston, Texas
Dr Lai reports having no financial or advisory relationships with corporate organizations related to this activity.

George M. Rodgers, III, MD, PhD
Professor, Divisions of Hematology and Oncology
Department of Internal Medicine
Huntsman Cancer Institute at the University of Utah
Salt Lake City, Utah
Dr Rodgers reports receiving grants/research support from, serving as a consultant for, and serving on the speakers’ bureau for Amgen Inc.

Athena T. Samaras, BA
Project Coordinator
VA Chicago Healthcare System
VA Center for the Management of Complex Chronic Care
Department of Medicine
Division of Hematology/Oncology
Northwestern University
Chicago, Illinois
Ms Samaras reports having no financial or advisory relationships with corporate organizations related to this activity.

Aryeh Shander, MD, FCCM, FCCP
Chief, Department of Anesthesiology, Critical Care and Hyperbaric Medicine
Englewood Hospital and Medical Center
Englewood, New Jersey
Clinical Professor of Anesthesiology, Medicine and Surgery
Mount Sinai School of Medicine
New York, New York
Dr Shander reports receiving grants/research support from Abbott Laboratories, AstraZeneca, Ortho Biotech, and Zymogenetics; serving as a consultant for Bayer, Biopure, HemoConcepts, Inc, Novo Nordisk, Ortho Biotech, and Zymogenetics; and receiving honoraria for serving on the speakers’ bureau for Bayer, Baxter, HemoConcepts, Inc, Novo Nordisk, Ortho Biotech, Pfizer Inc, and Zymogenetics.

This monograph was reviewed by Rowena N. Schwartz, PharmD, BCOP, for the Accreditation Council for Pharmacy Education accreditation purposes.

Notice: The audience is advised that articles in this CE activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Goodnough—iron sucrose injection, USP and sodium ferric gluconate complex in sucrose injection.
Dr Shander—Cell Saver, coagulation factor VIIa (recombinant), erythropoiesis-stimulating agents, and iron.

All other faculty have indicated that they have not referenced unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Blood Conservation and Chemotherapy-Induced Anemia: From Evidence-Based Guidelines to Clinical Practice
David S. Ettinger, MD, FACP, FCCP,* and Edward J. Norris, MD, MBA, FAHA

Quite different from cancer treatment of yesteryear that aimed to merely slow tumor growth, today’s chemotherapy is fortunately saving lives and extending survival in countless people living with cancer. But it is also important to acknowledge that these modern-day regimens are often more dose and schedule intense, employed more often frequently in patients who in the past would have been solely treated with surgery, and are often supplemented with newer biologic agents (eg, monoclonal antibodies, small molecules as targeted therapy, and immunomodulatory agents). As a result of this increasingly aggressive and complex approach to the management of many different types of cancer, the myelosuppressive consequences of treatment, particularly chemotherapy-induced anemia (CIA), have become a major focus of supportive care in oncology.

Anemia is a frequent complication of myelosuppressive chemotherapy, with an incidence that ranges between 70% and 90%, depending on factors, such as cancer type and the chemotherapy regimen used.1 Left untreated, anemia may lead to a multitude of symptoms (eg, fatigue, tachycardia, cognitive impairment, shortness of breath, depression, and dizziness), have an adverse impact on comorbid conditions (eg, cardiac and pulmonary disease) and mortality, and lead to chemotherapy dose reductions and administration delays. The economic burden of anemia is substantial, with costs of untreated anemia arising from lost wages, increased hospitalization stays, and increased morbidity and mortality. As a result of these consequences, timely diagnosis and correction of CIA is essential, and is addressed by regularly updated guidelines released by several organizations, such as the American Society of Clinical Oncology, the American Society of Hematology, and the National Comprehensive Cancer Network.

Although some of the basic guideline recommendations (eg, diagnosis and assessment) have not changed markedly over the last several years, many of the key therapeutic positions have been significantly revised, primarily as a result of emerging studies addressing the safety of erythropoiesis-stimulating agents (ESAs) and the accompanying regulatory/labeling changes. As a reflection of these events, there has been renewed interest in the risks and benefits of blood transfusions and the use of blood conservation strategies.

For clinicians involved in oncology supportive care services, it is critical to stay abreast of all the recent developments that have taken place in the management of CIA, and as such, this issue of Johns Hopkins Advanced Studies in Medicine is dedicated to providing the latest data and guideline recommendations pertaining to the various therapeutic options available for CIA. George M. Rodgers, III, MD, PhD, opens the discussion with a review of the prevalence and etiology of CIA, citing traditional cytotoxic drugs (eg, cisplatin, carboplatin, taxanes, vinorelbine, and topotecan), new biologic agents, and other factors (eg, radiation, repeated chemotherapy cycles, and dose intensity) that impact the incidence and severity of the condition. Dr Rodgers also explores the risks and benefits of current treatments (packed red blood cell transfusions, ESAs, and iron supplementation), in addition to therapeutic recommendations from several recently updated guidelines on the management of CIA.

Charles L. Bennett, MD, PhD, MPP, Athena T. Samaras, BA, and Stephen Y. Lai, MD, PhD, center their discussion on the impact of recent studies questioning the safety of ESA therapy on transfusion utilization patterns in the United States and abroad. Dr Bennett and colleagues explore various utilization studies (in Europe, Canada, and the United States) relating to the complex relationship between ESA regulatory and reimbursement actions, patterns of ESA use, and transfusion practices. They find that, generally, ESAs are used more frequently in the United States than in Europe, where the approach has been to administer ESAs or to transfuse patients with CIA who were symptomatic, rather than those who would potentially require a transfusion in the future. Also included in this article are factors to consider in identifying patients with CIA at risk for blood transfusion.

Lawrence Tim Goodnough, MD, and Aryeh Shander, MD, FCCM, FCCP, focus their discussion on risks and complications of allogenic blood transfusions, acknowledging that although today’s blood supply is safer than ever from various pathogens, infectious risks have not been completely eliminated because of limitations in current detection methods and the potential risk of emerging pathogens. Dr Goodnough and Dr Shander offer a considerable review of both infectious and noninfectious risks of transfusion, in addition to strategies used to ensure the safe and appropriate use of blood and blood products.

Aryeh Shander, MD, FCCM, FCCP, also authors an article on blood conservation strategies, which include various pharmacologic agents (ESAs, antifibrinolytics, and recombinant activated factor VII), as well as numerous devices and techniques (eg, acute normovolemic hemodiluton) used to minimize or avoid the use of allogenic blood transfusion. Dr Shander explores the current supporting evidence, which comes primarily from studies examining these treatments perioperatively, in critical care and trauma settings, and in those with congenital bleeding disorders. Also included is a discussion on areas of controversy related to blood conservation and examples of successful institution-based blood management programs.

For clinicians who manage patients with CIA, it is perhaps an uncertain time and, therefore, it is vital to stay informed on all the emerging studies and the resultant changes to guideline ecommendations when making clinical decisions.

REFERENCE

1.    Groopman JE, Itri LM. Chemotherapy-induced anemia in adults: incidence and treatment. J Natl Cancer Inst. 1999;91:1616-1634.

*Alex Grass Professor of Oncology, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland.

Associate Professor, Department of Anesthesiology and Critical Care Medicine, Director, Vascular Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: David S. Ettinger, MD, FACP, FCCP, Alex Grass Professor of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Bunting-Blaustein Cancer Research Building, G88, 1650 Orleans Street, Baltimore, MD 21231. E-mail: ettinda@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his or her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.