1 of 29

Course: Oncology Nursing

Topic: Nursing Management of Cancer Treatment Related Anemia

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 29

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 29

Module Goals

Learners will be able to:

Identify the common side effects of chemotherapy and radiation cancer therapies.
Identify causes, signs/symptoms and diagnostic factors of anemia in cancer patients.
Describe management of anemia in cancer patients
Describe nurse’s role in management of anemia in cancer patients.

Contact info: info@nursesinternational.org

4 of 29

Side - Effects of Cancer Treatment

Side-effects are problems that occur when cancer treatment affects healthy tissues or organs.
Cancer treatments and cancer cause arrays of serious side-effects.
Proper assessment and timely management of side-effects important because:

It can debilitate patient
It can have negative psychological impact affecting quality of life
It can lead to under-dosing, ineffective treatment
It can lead to patient “dropping out” of treatment

Contact info: info@nursesinternational.org

5 of 29

Common Side - Effects of Cancer Treatment

Constipation
Diarrhea
Appetite loss
Sleep problems/insomnia
Urinary bladder problems
Sexual Health issues

We discuss nursing management of anemia and bleeding in this lesson

National Cancer Institute, n.d., Side Effects of Cancer Treatment

Anemia
Extravasation
Bleeding and Bruising
Infection and Neutropenia
Mouth and throat problem
Peripheral Neuropathy

Contact info: info@nursesinternational.org

6 of 29

Anemia

A disorder characterized by a reduction in the amount of hemoglobin (Hgb)¹.
Hemoglobin is a protein inside red blood cells that carries oxygen.
Cancer itself and/or cancer therapies can cause anemia by².

Decreased production of functional red blood cells (RBCs)
Increased destruction of RBCs
Blood loss

Anemia associated with fatigue, impaired physical function leading to reduced quality of life.

US Department of Health and Human Services (2010)
Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

7 of 29

Anemia: National Cancer Institute Severity Classification

US Department of Health and Human Services (2010)
WHO (2011)

Grade 1	Grade2	Grade 3	Grade 4	Grade 5
Hgb <LLN - 10.0 g/dL; <LLN - 6.2 mmol/L; <LLN - 100 g/L	Hgb <10.0 - 8.0 g/dL; <6.2 - 4.9 mmol/L; <100 - 80g/L	Hgb <8.0 g/dL; <4.9 mmol/L; <80 g/L; Transfusion indicated	Life-threatening consequences; urgent intervention indicated	Death
Hgb= Hemoglobin LLN= Lower level of normal ²WHO Normal Hgb levels: Female ≥ 12 g/dL; Male ≥ 13 g/dL

Contact info: info@nursesinternational.org

8 of 29

Anemia

Causes may also be attributed to underlying comorbidities such as¹:

Bleeding
Hemolysis
Hereditary disease
Renal insufficiency
Nutritional deficiencies
Anemia of chronic disease
Combinations of above

Signs and symptoms of anemia²:

Pallor skin, mucous membranes
Shortness of breath
Palpitations of the heart
Soft systolic murmurs
Lethargy
Fatigue

Rodgers et al. (2012). NCCN.
US Department of Health and Human Services (2010)

Contact info: info@nursesinternational.org

9 of 29

Anemia: Diagnosis and Evaluation of Causes

Assessments for diagnosis and evaluation of causes anemia:

Blood Hgb ( ≤ 11 g/dL or ≥ 2g/dL below baseline)
CBC with indices and blood smear morphology: Reticulocyte count, Mean corpuscular volume (MCV)
Hemorrhage: stool guaiac, endoscopy
Hemolysis: Coombs test, DIC panel, haptoglobin
Nutritional: iron, total iron binding capacity, ferritin, B12, folate
Inherited : prior history, family history
Renal: GFR < 60 mL/min/1.73 m , low erythropoietin
Radiation-induced myelosuppression
Anemia of inflammation or myelosuppressive chemotherapy

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

Glossary:

Stool Guiac test: A test that checks for occult (hidden) blood in the stool. Small samples of stool are placed on special cards coated with a chemical substance called guaiac and sent to a doctor or laboratory for testing (National Cancer Institute US)

Coombs test: A laboratory test to identify antibodies that can bind to the surface of red blood cells or platelets and destroy them. This test is used to diagnose certain blood disorders in which patients make antibodies to their own red blood cells or platelets. It is also used to determine blood type. Also called antiglobulin test. (National Cancer Institute US)

DIC panel: A test scoring system developed by the International Society on Thrombosis and Haemostasis to evaluate disseminated intravascular coagulation (DIC),. DIC is a serious, sometimes life-threatening condition in which the proteins in the blood involved in blood clotting become overactive. Blood clots form in small blood vessels throughout the body. This can disrupt normal blood flow to organs such as the kidneys and liver and can lead to organ failure. (Lab Tests Online)

Haptaglobin: A protein produced by the liver that the body uses to clear free hemoglobin (found outside of red blood cells) from circulation. This test measures the amount of haptoglobin in the blood. (Lab Tests Online)

GFR: Glomerular filtration rate (GFR) is a measure of how well your kidneys are working. Measuring glomerular filtration rate (GFR) directly is considered the most accurate way to detect changes in kidney function (Lab Tests Online)

10 of 29

Anemia: Management

Treating the underlying cause
Iron supplementation for absolute or functional iron deficiency
Transfusions with packed red blood cells (PRBC)
Administration of Erythropoiesis-stimulating agents (ESAs)

Rodgers et al. (2012), NCCN

Contact info: info@nursesinternational.org

11 of 29

Iron Supplementation

Aapro et al. (2018)
Rodgers et al. (2012). NCCN

Iron deficiency (ID) in cancer patient is

mainly due to bleeding¹.

Iron homeostasis in cancer patients is often impared through release of pro-inflammatory cytokines and upregulation of hepcidin¹.
Functional ID often arises after continued ESAs use.
Iron treatment for correction of ID before initiation of ESA therapy is recommended^1,2.
Intravenous Iron is recommended for treatment of absolute and functional ID¹.

Contact info: info@nursesinternational.org

12 of 29

Iron Supplementation

Rodgers et al. (2012). NCCN

Iron Supplementation Administration:

Iron supplementation can be given in oral or parenteral form
Intravenous iron found to be superior to oral iron
Iron products alone recommended to treat absolute ID
Should be combined with ESAs to treat chemotherapy-induced anemia and functional ID
Shown to enhance efficacy of ESAs and reduce transfusion need

Contact info: info@nursesinternational.org

13 of 29

What would the nurse do?

Which of following laboratory tests would the nurse expect the doctor to order to diagnose nutritional iron deficiency anemia in cancer patient? (Select all that apply)

Serum Ferritin
Total Iron Binding Capacity
Serum Iron
Increased ferritin level

Contact info: info@nursesinternational.org

14 of 29

Iron Supplementation

Iron status assessment:

Transferrin saturation
Serum Iron
Total Iron Binding Capacity (TIBC)
Serum ferritin

Iron Supplementation Indication:

Cancer patient with absolute ID i.e (ferritin < 30 ng/mL, transferrin saturation < 15%)
Chemotherapy-induced anemia and functional ID with ESAs
Not recommended for patient with active infection

IV iron possibly promote inflammation and bacterial growth

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

15 of 29

Iron Supplementation

Common adverse effects of parenteral iron:

hypotension
nausea,vomiting and/or diarrhea
pain
hypertension
dyspnea
pruritus
headache
dizziness

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

16 of 29

PRBC (packed red blood cell)Transfusion

Rodgers et al. (2012), NCCN

Preferred blood product for transfusion to correct anemia.
Goal: Treat or prevent deficit of oxygen carrying capacity in blood to improve oxygen delivery to body tissues.
Rapid increase in Hgb and hematocrit levels.
Only intervention option for patients receiving myelosuppressive chemotherapy requiring immediate correction of anemia.
In a patient, without simultaneous loss of blood, 1 unit of PRBC (300 mL) estimated to result in

an average increase in Hgb of 1g/dL
OR hematocrit by 3% in a normal sized adult

Contact info: info@nursesinternational.org

17 of 29

PRBC Transfusion

Risks/limitations:

Transfusion-related reactions
Congestive heart failure/Circulatory overload
Bacterial contamination and viral infections
Iron overload

Observed in patients requiring frequent transfusions over several years
Unlikely to occur in patients receiving transfusion restricted to corresponding chemotherapy treatment

Limited supply of blood could be a problem

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

18 of 29

PRBC Transfusion: Indication

Asymptomatic:

Hemodynamically stable chronic anemia without acute coronary syndrome

Transfuse to maintain Hgb 7-9 g/dL

Symptomatic:

Acute hemorrhage with evidence of hemodynamic instability or inadequate oxygen delivery

Transfuse to correct hemodynamic instability, maintain adequate oxygen delivery

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

19 of 29

PRBC Transfusion: Indication

Continued...

Symptomatic (including tachycardia, tachypnea, postural hypotension) anemia (Hgb < 10 g/dL):

Transfuse to maintain Hgb 8-10 g/dL as needed for prevention of symptom

Anemia in setting of acute coronary syndromes or acute myocardial infarction:

Transfuse to maintain Hgb ≥ 10 g/dL

Source: Rodgers et al. (2012). NCCN.

Contact info: info@nursesinternational.org

20 of 29

PRBC Transfusion : Basic Principles of Transfusion

Limit exposure to allogeneic blood.
Before transfusion, PRBCs must be cross- matched to confirm compatibility with ABO and other antibodies in the recipient.
Leukocyte-reducing blood and use of premedication (acetaminophen or antihistamine) can minimize adverse reactions in long-term transfusion.
To be transfused by the unit and reassessment conducted after each transfusion.

Monitoring patient for signs of anaphylactic reaction and prompt management is vital!

Source: Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

21 of 29

Erythropoiesis Stimulating Agents (ESAs)

Rodgers et al. (2012). NCCN

Erythropoietin, a cytokine produced in kidneys, control RBC production in the body.
ESAs are synthetic, recombinant human erythropoietin .
ESAs takes weeks to initiate Hgb response.
ESAs are effective in maintaining a target Hgb level with repeated administration.
Benefits of ESAs therapy:

Decreases PRBC transfusion requirements in cancer patient undergoing chemotherapy
Gradual improvement in fatigue

Contact info: info@nursesinternational.org

22 of 29

ESAs

Risks/limitations of ESAs therapy:

Increase in thrombotic events
Pure Red Cell Aplasia (PRCA) in rare case

characterized by low reticulocyte count, loss of bone marrow erythroblasts, neutralizing antibodies against erythropoietin, and resistance to ESA therapy.

Increased mortality in cancer patients not receiving cancer therapy or only Radiotherapy.
Only effective in 60% of the patients.
Induction of functional ID and decreasing response over time.

Aapro et al. (2018)

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

23 of 29

ESAs Therapy Indications

Only used to treat chemotherapy-induced anemia

To be stopped once the chemotherapy course is complete
Only patient under myelosuppressive chemotherapy are eligible

Not recommended in myelosuppressive chemotherapy with curative intent.
In palliative treatment, it is considered preferential to transfusion.
In patients with anemia on myelosuppressive chemotherapy without other identifiable cause of anemia.

Aapro et al. (2018)

Rodgers et al. (2012). NCCN

Contact info: info@nursesinternational.org

24 of 29

Nurse’s Role in Management of Anemia

Carry out thorough nursing assessment to identify cause of anemia
Ensure informed consent is taken before administering therapies

Informed of risks/benefit of ESAs use, PRBCs, and Iron supplementation therapy
Informed of how these therapies will be administered

Follow protocol for safe administration of these therapies
Closely assess for side-effects related to these therapies
Assist with self-care activities
Minimize disturbances during sleep

Contact info: info@nursesinternational.org

25 of 29

Nurse’s Role in Management of Anemia

Provide patient education/counselling:

Recognizing signs/symptoms
Immediately reporting sign/symptoms to healthcare professional
Self-care practices:

Save energy by choosing important things to do everyday
When people offer help, let them do so
Balance rest with activity

take short naps during the day
take short walks or exercise little every day

Eat and drink well, foods high in protein or iron might be required

National Cancer Institute, 2018 Anemia and

Cancer Treatment

Contact info: info@nursesinternational.org

26 of 29

What Would the Nurse Do?

Which of the following patient history is the most significant in diagnosing anemia?

Nausea for 2 months
Blood in stool for three weeks
Frequent urination for three weeks
Vegetarian diet

Contact info: info@nursesinternational.org

27 of 29

Reference:

Aapro, M., Beguin, Y,, Bokemeyer, C., Dicato, M., Gasco, P., Glaspy, J., Hofmann A. , Link, H., Littlewood, T., Ludwig, H., O¨ sterborg, A., Pronzato, P., Santini, V., Schrijvers, D., Stauder, R., Jordan, K., & Herrstedt, J. (2018). Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Annals of Oncology 29 (Supplement 4): iv96–iv110. Accessed from: https://www.annalsofoncology.org/article/S0923-7534(19)31688-6/fulltext

National Cancer Institute (n.d.). Side Effects of Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects

National Cancer Institute (2018). Anemia and Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/anemia

Contact info: info@nursesinternational.org

28 of 29

Reference:

Rodgers, G. M. III, Becker, P.S., Blinder, M., Cella, D., Chanan-Khan, A., Cleeland, C., Coccia, P.F., Djulbegovic, B., Gilreath, J.A., et al. (2012). Cancer- and Chemotherapy-Induced Anemia. JNCCN, 10 (5). Available at: https://jnccn.org/view/journals/jnccn/10/5/article-p628.xml?ArticleBodyColorStyles=fullHtml-5594

US Department of Health and Human Services (2010). Common Terminology Criteria for Adverse Events (CTCAE), Version 4.03. National Institute of Health, National Cancer Institute. Accessed from: https://nciterms.nci.nih.gov/ncitbrowser/pages/multiple_search.jsf?nav_type=terminologies

WHO (2011). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization(WHO/NMH/NHD/MNM/11.1) (https://apps.who.int/iris/handle/10665/85841 pdf, accessed [21 April 2021])

Contact info: info@nursesinternational.org

29 of 29

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org