A 48-year-old woman comes to the office to discuss ongoing treatment for her recent diagnosis of right-sided, locally advanced, triple-negative (estrogen/progesterone receptor/HER2) breast cancer. The patient completed a course of chemotherapy 2 weeks ago and is scheduled for surgery in 2 weeks. She has a distant history of right leg venous thrombosis treated with 6 months of anticoagulation. The patient now feels well but is tired by the end of the day. She occasionally takes a nap around noon. She has no fever, palpitations, shortness of breath, or chest discomfort.
Blood pressure is 122/70 mm Hg and pulse is 77/min. On examination, an irregular mass is palpated in the right breast. There are no other significant examination findings.
Laboratory results are as follows:
Serum folate and vitamin B₁₂ levels are within normal limits.
Which of the following is the most appropriate next step in management of this patient's anemia?

Question

A 48-year-old woman comes to the office to discuss ongoing treatment for her recent diagnosis of right-sided, locally advanced, triple-negative (estrogen/progesterone receptor/HER2) breast cancer. The patient completed a course of chemotherapy 2 weeks ago and is scheduled for surgery in 2 weeks. She has a distant history of right leg venous thrombosis treated with 6 months of anticoagulation. The patient now feels well but is tired by the end of the day. She occasionally takes a nap around noon. She has no fever, palpitations, shortness of breath, or chest discomfort.
Blood pressure is 122/70 mm Hg and pulse is 77/min. On examination, an irregular mass is palpated in the right breast. There are no other significant examination findings.
Laboratory results are as follows:

Serum folate and vitamin B₁₂ levels are within normal limits.
Which of the following is the most appropriate next step in management of this patient's anemia?

Quizplus · Accepted Answer

Anemia is a frequent complication of malignancy and can be due to a myriad of causes, including: Iron deficiency from internal or external bleeding or impaired iron absorptionMyelosuppression from antineoplastic treatment (eg, chemotherapy, radiotherapy), bone marrow infiltration, cytokine-induced suppression (eg, anemia of chronic disease), or amyloidosisIncreased red blood cell destruction due to tumor-induced hemolysis (autoimmune or microangiopathic) Iron deficiency from internal or external bleeding or impaired iron absorption Iron deficiency from internal or external bleeding or impaired iron absorption Myelosuppression from antineoplastic treatment (eg, chemotherapy, radiotherapy), bone marrow infiltration, cytokine-induced suppression (eg, anemia of chronic disease), or amyloidosis Myelosuppression from antineoplastic treatment (eg, chemotherapy, radiotherapy), bone marrow infiltration, cytokine-induced suppression (eg, anemia of chronic disease), or amyloidosis Increased red blood cell destruction due to tumor-induced hemolysis (autoimmune or microangiopathic) Increased red blood cell destruction due to tumor-induced hemolysis (autoimmune or microangiopathic) This patient recently received chemotherapy and now has moderate normocytic anemia with normal iron, ferritin, vitamin B₁₂, and folate levels, suggesting chemotherapy-induced myelosuppression. Anemia is generally treated when hemoglobin levels are <10 mg/dL and patients are symptomatic (eg, exertional fatigue, orthostasis, dyspnea, sustained tachycardia, chest pain). This patient's end-of-day fatigue is unlikely to represent symptomatic anemia; it is more likely multifactorial due to her underlying cancer or recent treatment. As a result, she should be observed for now and have blood work rechecked at her next office visit. ₁₂ Potential treatment options for symptomatic anemia include: Blood transfusion - rapidly improves hemoglobin but has transient effects and can lead to transfusion reactions, infections, and iron overload (if administered frequently); it is typically reserved for patients with severe, symptomatic anemia (Choice E).Erythropoietin-stimulating agents - indicated for patients with cancer who are undergoing chemotherapy, have a hemoglobin <10 mg/dL, and are symptomatic; these agents increase the risk of thromboembolism and cardiovascular complications and should not be used in asymptomatic patients (Choice C). Blood transfusion - rapidly improves hemoglobin but has transient effects and can lead to transfusion reactions, infections, and iron overload (if administered frequently); it is typically reserved for patients with severe, symptomatic anemia (Choice E). Blood transfusion - rapidly improves hemoglobin but has transient effects and can lead to transfusion reactions, infections, and iron overload (if administered frequently); it is typically reserved for patients with severe, symptomatic anemia (Choice E). Erythropoietin-stimulating agents - indicated for patients with cancer who are undergoing chemotherapy, have a hemoglobin <10 mg/dL, and are symptomatic; these agents increase the risk of thromboembolism and cardiovascular complications and should not be used in asymptomatic patients (Choice C). Erythropoietin-stimulating agents - indicated for patients with cancer who are undergoing chemotherapy, have a hemoglobin <10 mg/dL, and are symptomatic; these agents increase the risk of thromboembolism and cardiovascular complications and should not be used in asymptomatic patients (Choice C). (Choice A) A bone marrow biopsy would be indicated in patients with pancytopenia due to suspected bone marrow involvement from malignancy. Bone marrow infiltration is seen most often with leukemias, lymphomas, and plasma cell dyscrasias. This patient who had a decline in hemoglobin 2 weeks after chemotherapy is far more likely to have treatment-induced myelosuppression. (Choice D) This patient has a normocytic anemia with normal ferritin and iron levels; iron deficiency anemia is unlikely. Educational objective: Cancer-related anemia is common and can be due to a myriad of causes. Treatment should be considered for patients with hemoglobin levels <10 mg/dL who are symptomatic (eg, exertional fatigue, orthostasis, dyspnea, sustained tachycardia, chest pain). Asymptomatic patients do not usually require treatment and can be monitored with serial hemoglobins. __________ References: Cancer-related anemia and recombinant human erythropoietin--an updated overview. (http://www.ncbi.nlm.nih.gov/pubmed/16520805) Randomized, double-blind, placebo-controlled trial of erythropoietin in non-small-cell lung cancer with disease-related anemia. (http://www.ncbi.nlm.nih.gov/pubmed/17312332)

A 48-Year-Old Woman Comes to the Office to Discuss Ongoing