The use of intravenous iron in patients with cancer related anaemia: don’t overlook iron deficiency anaemia in colorectal cancer

Abstract

We were interested to read the recent review regarding the ‘Use of intravenous iron in patients with cancer-related anaemia’ (Littlewood & Alikhan, 2008). The paper provides an excellent overview of an area that, in our experience, is frequently overlooked in the surgical care of cancer patients. However, this review largely addresses the use of intravenous iron preparations for treating anaemia of chronic disease (AoCD). Given the frequency with which gastrointestinal cancers are encountered in clinical practice, we were surprised that iron deficiency anaemia (IDA) received little attention. Previous studies have indicated IDA to be present in 38–75% of patients with colorectal cancer at the time of diagnosis, considerably more frequent than the figures quoted (Lidder et al, 2007). Colorectal adenocarcinoma is the third most common cancer in the UK, and IDA associated with this therefore represents a substantial burden of disease. Whilst concomitant systemic inflammatory processes may play a role in inhibiting erythrocyte production, the depleted iron stores resulting from occult or overt gastrointestinal bleeding merit specific consideration. For patients amenable to surgical intervention, IDA has traditionally been treated with peri-operative transfusion. The risks associated with homologous blood transfusion are well documented. However, the immunomodulatory consequences and their potential effects on outcomes are less well understood. The presence of IDA in this group has already been shown to have significant links with morbidity and long-term mortality (Houbiers et al, 1997). Controversy surrounds the longer term effects of transfusion on disease recurrence following potentially curative surgery. Several studies suggest a reduction in long term survival potentially mediated by posttransfusion immunosuppression (Amato & Pescatori, 1998). Given the improved safety profile of intravenous iron preparations, preoperative treatment with single-dose intravenous iron regimes offers the potential to significantly change practice in this area of cancer surgery. It may additionally deliver overall cost savings in comparison with homologous blood transfusion and the potential perioperative complications resulting from this. Further studies exploring the efficacy and outcomes of intravenous iron therapy in this setting are warranted.