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Clinicians Report on Changes in Use of ESAs, Outpatient Blood Transfusions, and Supplemental Iron as Interventions for Anemia

By Jennifer Hinkel, NCCN e-Bulletin Editor-in-Chief

An NCCN Trends™ survey conducted in September 2009 queried clinicians regarding changes in the use of various interventions for cancer- and chemotherapy-induced anemia at their institutions. Of the 1,589 clinicians who responded, nearly half (47%) reported that their ESA use had decreased over the past two years, while 26% did not see a change and 27% saw an increase in ESA use for cancer patients with anemia. Of those who saw a decline in ESA use, half reported a decrease of greater than 50%. Results were segmented heavily among geographic lines, with United States clinicians reporting significant decreases and international clinicians primarily reporting increases or no change in the use of ESAs. Approximately 70% of United States oncology clinicians reported a decrease in ESA use over the past two years, while only 16% of international oncology clinicians reported the same. These respondents' observations are congruent with anecdotal reports and expectations of decreased use of ESAs in the U.S. subsequent to events including the emergence of new safety data about the use of ESAs in patients with cancer, the Medicare National Coverage Determination (NCD) changing reimbursement for the use of these agents, and changes in clinical practice guidelines including those from NCCN.

 

 

 

In a separate survey limited to NCCN Member Institution cancer centers, 14 pharmacy directors at NCCN institutions were also asked about perceived changes in the use of these same approaches to treating anemia in patients with cancer. Results from that survey indicated that 13 of the 14 responding pharmacy directors reported a decrease in the use of ESAs over the past two years, with six of the pharmacy directors (42%) reporting a decrease of greater than 50% in ESA use and seven pharmacy directors (50%) reporting a decrease of 1% to 50% in ESA use. Overall, this data suggests that a consistent practice in the prescribing of ESAs remains somewhat elusive, with variations in practice patterns existing among various practice settings.

The NCCN Trends survey of 1,589 clinicians also queried respondents as to whether they had seen changes in the use of outpatient blood transfusions and supplemental iron as approaches to managing anemia in cancer patients. For supplemental iron, the majority of clinicians (56%) reported seeing no change and 37% reported an increase in iron use. Few clinicians (6%) reported a decrease in its use.

 

 

Nearly 40% of the 1,589 reporting clinicians indicated that they had seen an increase in the use of outpatient blood transfusions for cancer patients with anemia. However, 45% reported that the use of transfusions had not changed.

 

 

In the smaller survey of 14 NCCN pharmacy directors, eight (57.1%) reported an increase of 1% to 50% in the use of outpatient blood transfusions, and one reported an increase of greater than 50% in transfusions.

These survey results generate hypotheses surrounding the use of ESAs, supplemental iron, and outpatient blood transfusions as interventions used in the management and treatment of cancer- and chemotherapy-related anemia. Further analysis will seek insight into whether clinicians from particular practice settings, such as academic or community settings, or from particular geographic regions within and outside of the United States were more likely to report increases or decreases in the use of these three different interventions in the treatment of cancer patients with anemia.

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