By Heather Lindsey

Anemia, an often debilitating condition in which the body lacks a sufficient number of red blood cells (RBCs), may occur in up to 90% of patients with cancer, depending on the type of malignancy and treatment involved, according to the National Anemia Action Council.

Gail Crawford of Moorpark, California, knows just how difficult it can be to have anemia. “I went from busy career woman to being a couch potato practically overnight,” she says.

Crawford developed anemia after undergoing chemotherapy for stage IV breast cancer. Her chemotherapy not only killed tumor cells but also destroyed a substantial number of RBCs.

The effects of the anemia can “knock you on your back,” says the 46-year-old former vice president of an oil company. Because of the lethargy she was experiencing, Crawford’s mood became dark. “I was feeling lousy and depressed,” she says.

Crawford talked to her physician about how she was feeling, was promptly diagnosed, and started receiving treatment for her anemia. Despite her high risk for recurrence, she is feeling good. Keeping her anemia under control, she says, helps give her the energy to take care of herself and spend time with family.

What is Anemia?
Anemia results when the body has too few RBCs, which are made in the bone marrow and carry oxygen to the body’s tissues using the molecule hemoglobin. Oxygen binds to hemoglobin within RBCs while they circulate through the lungs. These RBCs travel throughout the body, delivering oxygen to tissues and picking up the waste product carbon dioxide, which is then carried back into the lungs and exhaled from the body.

The hormone erythropoietin (EPO), which is produced in the kidneys and tells the body when it needs to produce more RBCs, has become a key component in treating anemia.

When a person has anemia, the body does not have enough RBCs to successfully transport oxygen. Consequently, tissues cannot function normally, which can lead to symptoms such as fatigue and shortness of breath, symptoms that can greatly impact not only the quality of life but cancer treatment as well.

Physicians will determine if a patient has anemia by measuring the concentrations of hemoglobin in the blood, RBC volume, or RBC number.

Causes of Anemia in Cancer Patients
Why a patient with cancer may have anemia varies from person to person, says George Demetri, MD, co-director of the Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston. However, he says, cancer treatments are the primary cause of anemia. Chemotherapy and radiation therapy may make it harder for the body to produce more RBCs.

Chemotherapy can damage healthy cells, including RBCs, and prevent RBC production in the bone marrow, while radiation therapy can also damage bone marrow.

Although anemia can develop in patients with any form of cancer, people with lung and gynecologic malignancies are especially susceptible because of the nature of chemotherapy drugs such as Platinol® (cisplatin), which are used for these diseases, says Michael Schuster, MD, director of the Bone Marrow and Blood Stem Cell Transplant Program of New York, Weill Cornell Medical Center.

Patients with leukemia, lymphoma, or myeloma also have a higher risk of developing anemia, says Dr. Schuster, because in addition to decreases in RBCs due to treatment, leukemia, lymphoma, and myeloma can grow in the bone marrow and can suppress the production of RBCs.

In addition to cancer-related treatment, a person may develop anemia due to nutritional deficiencies of iron or vitamins such as B12 or folic acid. For example, patients with intestinal or colon cancers often have problems with their digestive system and can become malnourished, explains Dr. Demetri. Cancer can also suppress the patient’s appetite, making proper nutrition difficult. If patients do not get enough iron, folate, and vitamin B12, their body may not be able to adequately produce RBCs.

Another cause of cancer-related anemia is blood loss due to the malignancy itself. Tumors of the stomach and colon very often cause bleeding, although the patient may not notice it, says Dr. Demetri.

Not all cases of anemia in patients are due to cancer. Some patients may be prone to anemia before they are diagnosed with cancer, as is the case with many premenopausal women who have borderline or low iron levels due to menstrual blood loss, says Dr. Demetri.

Additionally, kidney disease may be a cause of anemia in patients since the kidney is the source of EPO, and disease may lower levels, inhibiting the signaling of RBC production.

Symptoms and Impact of Anemia
Whatever the cause, anemia can have a major impact on the way you feel. “Anemia has an insidious, draining effect on energy level, which in turn can lead to reduced activity and productivity, [and] a diminished sense of accomplishment and well-being,” says David Cella, PhD, professor of psychiatry and behavioral science at Northwestern University, Evanston, Illinois. When the condition is chronic, he adds, the patient has a risk of becoming depressed.

The impact of anemia on patients is tremendously variable, says Dr. Demetri. Fatigue is a common side effect. “It may also be harder for people to oxygenate, making breathing difficult,” he says.

Headaches, heart palpitations, an increased heart rate, and feeling faint when standing or sitting are other signs of anemia. Additionally, because the brain needs oxygen, cognition may be more difficult.

In addition to causing these symptoms, anemia may also interfere with your cancer treatment. Anemia can decrease the effectiveness of radiation treatment for cancer because oxygen helps make tissue—including cancerous tissue—sensitive to radiotherapy.

Treatment
Treatment for anemia includes maximizing the patient’s nutrition and iron status, says Dr. Demetri. Blood transfusions may be necessary if the patient’s RBC count is dangerously low, he adds.

The most common drug treatment for anemia is genetically engineered EPO, which compensates for the shortage of natural EPO in the body.
Allan J. Erslev, MD, a professor emeritus of medicine, Thomas Jefferson University, first demonstrated the existence of renal hormone EPO that stimulates RBC production in 1953 at Yale University. Scientists genetically engineered EPO in 1983, calling the compound epoetin alfa (Procrit®). Procrit was approved in 1989 by the U.S. Food and Drug Administration (FDA) for treating anemia in people undergoing dialysis for chronic kidney failure. In 1993, it was approved for cancer-related anemia. Procrit is injected to stimulate RBC production.

Another drug, Aranesp™ (darbepoetin alfa), also acts like natural EPO and was approved by the FDA in 2002 for patients with chemotherapy-induced anemia.
“Researchers changed the molecule slightly, so Aranesp lasts longer in the body,” explains Dr. Erslev, adding that for this reason, Aranesp may not need to be given as often, although studies have not shown one drug to be more effective than the other.

Both Procrit and Aranesp are remarkable breakthroughs in the care of patients with anemia, notes Dr. Schuster. However, blood pressure should be monitored in patients taking either drug. “Procrit has been used for many years and has proven to be very effective,” says Dr. Schuster.

Dr. Demetri agrees that both Procrit and Aranesp are very good treatment options, with patients generally feeling significant response in four to six weeks. While it’s possible Procrit may need to be given more often than Aranesp, says Dr. Demetri, a different dosing of Procrit could lead to administering the drug less often while maintaining blood cell counts. “Both drugs are good, safe, and effective,” he says. “We need to learn how to use them better.”

Knowledge and Communcation
Fortunately, doctors and nurses over the past decade have become more aware and knowledgeable about anemia, says Dr. Demetri. “It’s worth talking to the doctors and nurses about anemia,” he says. “They are adept at managing this condition.”

With it affecting such a large number, a patient’s healthcare team will routinely test his or her blood to determine if the body’s level of RBCs indicate anemia. There are several ways to monitor this level. The most accurate method used measures hemoglobin to determine the amount of the oxygen-carrying component in the blood.

Patients with cancer can take a number of steps to help prevent anemia. Proper nutrition can help, says Dr. Schuster. If patients are not eating a balanced diet, they may need to take vitamin and mineral supplements such as iron, folate, and B12.

Patients also need to report any bleeding to their doctors so they can correct the problem before anemia develops.

In cases where risk of anemia is high, EPO agents may be used to prevent the development of the condition, notes Dr. Cella.

Crawford’s advice to people with cancer who develop anemia is not to be afraid that their bodies are failing them. Patients need to understand that treatment for cancer commonly leads to anemia, she notes.

They also need to talk openly with their doctors about any anemic symptoms they may have so they can receive proper treatment and start feeling better.
“With renewed energy, you start thinking about life,” Crawford says.