Treatment patterns and outcomes in the management of anaemia in cancer patients in Europe: Findings from the Anaemia Cancer Treatment (ACT) study

https://doi.org/10.1016/j.ejca.2009.02.003Get rights and content

Abstract

Objectives

To examine anaemia management in cancer patients treated with erythropoiesis-stimulating agents (ESAs) in Europe.

Methods

Retrospective pharmacoepidemiologic study of 2192 patients from 307 centres. Minimum of 3 visits over 8–10 weeks with ESA treatment initiated at visit 1.

Results

Most patients were treated per guidelines, except for low iron supplementation rates. Mean Hb rose from 9.54 ± 0.95 g/dl to 10.88 ± 1.49 g/dl at visit 3, without concomitant rise in WHO/ECOG score. Response rates were 65.0% (Hb increase ↑  1 g/dl); 54.3% (Hb increase ↑  1 g/dl in 8 weeks); 38.9% (haematopoietic response); 33.7% (Hb increase ↑  2 g/dl) and 18.8% (Hb between12.0 and 12.9 g/dl)

Conclusions

Treatment patterns were guideline congruent, except for (intravenous) iron supplementation. Hb increased by 1.34 g/dl. A net erythropoiesis boost of Hb  1 g/dl is attainable in two-thirds of patients and should be condensed to 8 weeks on an individual patient basis. Anaemia management in Europe has improved significantly. The general effectiveness and relative safety of judicious ESA treatment are evident.

Introduction

Anaemia is among the most prevalent side-effects of cancer and cancer treatment,1, 2 is associated with poor prognosis and outcomes3, 4, 5 and significantly impacts quality of life.6 According to the European Cancer Anaemia Survey (ECAS),2 in 2001 67.9% of cancer patients had haemoglobin [Hb] levels  12 g/dl during a 6-month period. Only 38.9% of them were treated: 17.4% received an erythropoiesis-stimulating agent (ESA) (either alone or in combination with blood transfusion or iron supplementation), 14.9% were given blood transfusion (alone or in combination with iron) and 6.5% were treated with iron alone. In a recent French survey, physicians reported to treat 64% of patients with Hb  12 g/dl with ESAs, yet 22% of patients did not receive any anaemia treatment at all.7

Given the benefits of ESAs but also the variability in treatment and outcomes, evidence-based guidelines have been proposed.8, 9, 10, 11, 12 These guidelines and the ECAS findings may explain the recent attention to anaemia in cancer patients. Whether this has translated into improved outcomes remains unknown.

ECAS was an epidemiological study of the epidemiology and treatment of anaemia in cancer patients. The Anaemia Cancer and Treatment (ACT) study13 focused on anaemic cancer patients treated with any ESA, treatment patterns, outcomes and response rates. ACT used the EORTC-recommended definition of anaemia of <11 g/dl, whereas in ECAS the threshold was <12 g/dl.

Section snippets

Methods

The background and methodology of ACT have been described in a separate background and methodology paper.13 Key points and deviations from the original methodology are reviewed below.

Patients

A total of 2807 patients were enrolled in the study and constituted the enrolment sample. To be considered evaluable, patients had to be of age 18 or older, with a type of cancer specified in the inclusion criteria, and ESA initiation at Hb  11 g/dl. Only those with valid Hb values at visits 1 through 3 were retained in the analysis sample (see Fig. 1). Data reported here are for the European analysis subsample (N = 2192).

Table 1 presents patient demographics and clinical status at enrolment. The

Discussion

ECAS2 raised awareness about the issue of anaemia in cancer patients. Coupled with the subsequent publication of evidence-based guidelines8, 9, 10, 11, 12, there seems to have been an impact on ‘real world’ clinical practice in cancer in Europe. The low ESA treatment rate in 2001 (17.4%) increased almost fourfold (62.2%) over 4–6 years; though with the caveat that these rates were calculated at the patient level in ECAS but at the centre level in ACT. This article is the first report of

Contributions

Study design: H. Ludwig, M. Aapro, K. MacDonald, P. Soubeyran, M. Turner, I. Abraham.

Study implementation: K. MacDonald, M. Turner, T. Albrecht, I. Abraham.

Data management: K. MacDonald, T. Albrecht, I. Abraham.

Statistical analysis: H. Ludwig, M. Aapro, C. Bokemeyer, K. MacDonald, I. Abraham.

Interpretation of results: H. Ludwig, M. Aapro, C. Bokemeyer, K. MacDonald, P. Soubeyran, M. Turner, T. Albrecht, I. Abraham.

Critical review of manuscript: C. Bokemeyer, P. Soubeyran, M. Turner.

Writing

Conflict of interest statement

H.L., M.A., C.B., and P.S. have received compensation from F. Hoffmann-La Roche AG for professional and scientific services. M.T. is an employee of F. Hoffmann-La Roche AG. I.A., K.M., and T.A. are employees of Matrix45. By company policy, they are prohibited from owning equity in client organisations and performing independent duties for client companies. Matrix45 received consulting and research contracts from F. Hoffmann-La Roche AG to conduct the study. Matrix45 provides similar services to

Acknowledgements

This study was supported by research funding from F. Hoffmann-La Roche. We thank physicians, nurses and other staff for implementing the study; and Matthew Abraham and Kevin Jones for editorial, proofreading and manuscript preparation support.

References (22)

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    Prise en charge de l’anémie chez les patients présentant une pathologie maligne: résultats de l’étude F-ACT (French Anaemia Cancer Treatment) [Managment of anaemia with cancer: results of the F-ACT study (French Anaemia Cancer Treatment)]

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      Third, among geriatric patients with cancer, the proportions of variance in Hb outcomes attributable to the center where patients receive cancer treatment tended to be lower than those for younger patients with cancer. Center effects are an indication of the relative homogeneity of patient management within a given center, which in turn is related to the internal adoption of guidelines and protocols for anemia management.6 The lower variance proportions in the older patient cohort may indicate that clinicians may deviate from guidelines and protocols when treating anemia in elderly patients with cancer and thus individualize anemia management in these patients.

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    Support: The ACT study was supported by F. Hoffmann-La Roche AG (Basel, Switzerland).

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