The use of intravenous iron in patients with cancer related anaemia: don’t overlook iron deficiency anaemia in colorectal cancer – response to Fitzgerald et al

Abstract

We read with interest the comments by Fitzgerald and colleagues on our recent article regarding the use of intravenous iron in patients with cancer-related anaemia (Littlewood & Alikhan, 2008). Cancer-related anaemia is usually defined as a cytokine-mediated disorder resulting from complex interactions between tumour cells and the immune system. The pathological consequences include shortened survival of red blood cells, suppression of erythroid progenitor cells and impaired iron utilization. Most of these patients will have inadequate serum erythropoietin concentrations for the degree of anaemia. The main aim of our review was to discuss the recently published randomised studies which suggest that intravenous iron has a synergistic role in improving the haemoglobin response rates in patients with cancer-related anaemia who receive erythropoietic agents (ESAs). Indeed, since our review was published two further studies have been reported indicating the additional benefits of intravenous over oral iron in patients receiving ESAs. (Bastit et al, 2008; Pedrazzoli et al, 2008). A very large European survey of more than 15 000 patients with cancer (Ludwig et al, 2004) showed that cancer-related anaemia, exacerbated by the myelosuppressive effects of chemotherapy or radiotherapy, occurred in 67% of patients during their treatment. Of the 15 000 patients in this study, 17% had a gastrointestinal ‐ colorectal cancer, of whom 60% were anaemic at some point in the survey. There are no data specifically for the colorectal patients but overall just 6AE5% of patients were treated with iron alone. However, we absolutely agree with Fitzgerald et al on the importance of identifying patients whose anaemia can be attributed to iron deficiency and support the use of iron supplements in such patients. National guidelines suggest that blood transfusion should be avoided if possible (British Committee for Standards in Haematology, Blood Transfusion Task Force, 2001) and the Chief Medical Officer’s Health Service Circular ‘Better Blood Transfusion’ (Chief Medical Officer2002) states that for elective surgery, pre-operative assessment should permit the diagnosis and correction of anaemia in advance of surgery. Iron deficiency anaemia may be corrected pre-operatively by either oral iron, if time allows, or by the use of intravenous iron.