Cancer and anaemia

Written by Dr Dan Rutherford, GP and Dr Rachel Green, consultant haematologist and clinical director of the Glasgow and West of Scotland Transfusion Centre

Blood transfusion
Although the processes and organisation behind the Blood Transfusion Service are complex, the procedure itself has become an ordinary part of routine medical care. Thousands of blood transfusions are given every day in the UK without difficulty, for hosts of different reasons. Most people tolerate a blood transfusion easily - it can often be done as an outpatient procedure - and the obvious advantage is that an immediate improvement in someone's condition can be obtained. For many people with cancer-related anaemia a 'top-up' transfusion will be the most convenient and effective way to correct it. Unless someone's outlook is very poor it is likely that periodic transfusions will be required to maintain the blood haemoglobin level above an acceptable minimum.

It is true nonetheless that blood transfusion can have its problems. Transfusion reactions - a form of allergic response - may hamper the smooth running of a transfusion or cause it to be abandoned completely. There is the need for access to a reasonable sized vein for the drip to be set up and the inconvenience of needing to attend hospital for the transfusion to take place.

There is a small but present risk of transmission of infection from donor blood and the reality of falling numbers of blood donations despite increasing demand for blood products. Therefore the availability of a treatment that can reduce or eliminate the need for transfusion has always been much sought after. Such a treatment exists in the form of erythropoietin.

Erythropoietin
Erythropoietin is a hormone, produced naturally within the body that acts upon the bone marrow to stimulate the 'stem' cells of the marrow to divide and produce more red cells. The majority of erythropoietin is produced by specialised cells within the kidneys.

These cells are sensitive to the amount of oxygen circulating in the blood and when the oxygen level drops (as occurs in anaemia) then the cells produce extra erythropoietin, which in turn results in more red cells being produced. Not surprisingly, the first uses of erythropoietin after it was isolated and identified were in the treatment of anaemia secondary to kidney failure. Until then, anaemia was an inevitable problem for patients with significant long-standing kidney disease.

The uses of erythropoietin subsequently expanded to include the correction of drug-induced anaemia (such as with chemotherapy drugs) and other types of cancer-related anaemia. Erythropoietin is now manufactured by gene technology using genetically modified bacteria, (eg Eprex and NeoRecormon) but it remains an extremely expensive treatment and research is still in progress to define the best ways in which to use erythropoietin in cancer-related anaemia.

To date the main types of cancers in which it is most useful are lymphomas, multiple myeloma and some solid tumours such as lung cancer. It can also reduce the need for transfusion in patients receiving platinum-containing anti-cancer chemotherapy and in patients with a relatively good outlook for whom there is a regular need for top-up transfusion.

As always, the guiding principle in the use of such treatment should be the welfare and quality of life of the recipient. Individuals need a treatment specifically tailored to their needs - there is no single 'best' way to act. While erythropoietin remains so expensive the financial issues surrounding its use will, however, be bound up with the clinical ones.

Conclusions
Anaemia, for several different reasons, can complicate many types of cancer and should be looked for.

Fatigue is not an inevitable symptom that every cancer sufferer can expect - correctable causes such as anaemia should be precisely diagnosed and treated appropriately.

When anaemia cannot be directly treated then blood transfusion, erythropoietin treatment or a combination of both should be seriously considered.

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