CMAJ • May 26, 2009; 180 (11). First published April 30, 2009; doi:10.1503/cmaj.090470
© 2009 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Research

Benefits and harms of erythropoiesis-stimulating agents for anemia related to cancer: a meta-analysis

Marcello Tonelli, MD SM, Brenda Hemmelgarn, PhD MD, Tony Reiman, MD SM, Braden Manns, MD MSc, M. Neil Reaume, MD MSc, Anita Lloyd, MSc, Natasha Wiebe, MMath PStat and Scott Klarenbach, MD MSc

From the Department of Medicine (Tonelli, Lloyd, Wiebe, Klarenbach) University of Alberta, Edmonton, Alta.; the Department of Medicine (Hemmelgarn, Manns), University of Calgary, Calgary, Alta.; the Department of Medicine (Reiman), Dalhousie University, Halifax, NS; and the Department of Medicine (Reaume), University of Ottawa, Ottawa, Ont.

Correspondence to: Dr. Marcello Tonelli, University of Alberta, 7-129 Clinical Science Building, 8440–112 St., Edmonton AB T6B 2B7; fax 780 407-7878; mtonelli-admin{at}med.ualberta.ca

Background: Erythropoiesis-stimulating agents are used to treat anemia in patients with cancer. However, their safety and effectiveness is controversial. We did a systematic review of the clinical efficacy and harms of these agents in adults with anemia related to cancer or chemotherapy.

Methods: We conducted a systematic review of published and unpublished randomized controlled trials (RCTs) using accepted methods for literature searches, article selection, data extraction and quality assessment. We included RCTs involving anemic adults with cancer. We compared the use of erythropoiesis-stimulating agents with nonuse and assessed clinical outcomes (all-cause mortality, cardiovascular events and hypertension, health-related quality of life, blood transfusions and tumour response) and harms (serious adverse events) between groups.

Results: We identified 52 trials (n = 12 006) that met our selection criteria. The pooled all-cause mortality during treatment was significantly higher in the group receiving erythropoiesis-stimulating therapy than in the control group (relative risk [RR] 1.15, 95% confidence interval [CI] 1.03 to 1.29). Compared with no treatment, use of erythropoiesis-stimulating agents led to clinically detectable improvements in disease-specific measures of quality of life. It also reduced the use of blood transfusions (RR 0.64, 95% CI 0.56 to 0.73). However, it led to an increased risk of thrombotic events (RR 1.69, 95% CI 1.27 to 2.24) and serious adverse events (RR 1.16, 95% CI 1.08 to 1.25).

Interpretation: Use of erythropoiesis-stimulating agents in patients with cancer-related anemia improved some disease-specific measures of quality of life and decreased the use of blood transfusions. However, it increased the risk of death and serious adverse events. Our findings suggest that such therapy not be used routinely as an alternative to blood transfusion in patients with anemia related to cancer.


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Can. Med. Assoc. J. 2009 180: 1085. [Full Text] [PDF]

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Can. Med. Assoc. J. 2009 180: E58. [Full Text] [PDF]



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eLetters:

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Use of Erythropoiesis-Stimulating Agents for Anemia Related to Cancer
Megan Bettle
CMAJ, 27 May 2009 [Full text]
Do Erythropoiesis Stimulating Agents Improve Quality of Life in the Anemia of Cancer?
Nadine Shehata
CMAJ, 7 Jul 2009 [Full text]