Should intravenous iron be the standard of care in oncology?

Before 1989, when epoetin was introduced for dialysisassociated anemia, the use of intravenous (IV) iron in the United States was typically avoided. Shortly thereafter, it was shown that responses to epoetin could be improved by IV iron supplementation. By 1998, IV iron had become standard of care in dialysis patients receiving epoetin,1and the use of erythropoiesis-stimulating agents (ESAs) in oncology patients was in its infancy. In the ensuing decade, we have witnessed improvements in quality of life and fewer transfusions among patients receiving ESAs for the anemia associated with cancer and cancer chemotherapy. Some studies have shown the maximumimprovement in energy, activity, and quality of life occurswhen the hemoglobin (Hb) increases from 11 to 13 g/dL.2 In August 2007, the Committee on Medicare and Medicaid Services issued a Decision Memo restricting ESA usage when patients’ Hb levels are
10 g/dL. These new regulations were recommended on the basis of data suggesting harm with ESAs when used outside of established guidelines. To date, no study has shown a negative impact on cancer outcomes or survival in patients when ESAs were used in accordance with previously established American Society of Hematology, American Society of Clinical Oncology, or National Comprehensive Cancer Network guidelines. Recent data in the renal literature suggest that it is not the Hb level, but ESA exposure, that is associated with negative outcomes.