Clinical Therapeutics/Volume 31, Theme Issue, 2009
Anemia and Thrombocytopenia in Patients Undergoing
Chemotherapy for Solid Tumors: A Descriptive Study of
a Large Outpatient Oncology Practice Database, 2000–2007
Ying Wu, PhD1; Suresh Aravind, MD, MBA1*; Gayatri Ranganathan, MS2;
Amber Martin, BS2; and Luba Nalysnyk, MD, MPH2
1Johnson & Johnson Pharmaceutical Services LLC, Malvern, Pennsylvania; and 2United BioSource
Corporation, Lexington, Massachusetts
ABSTRACT
Objective: This study was conducted to evaluate
data on chemotherapy-associated anemia and throm-
bocytopenia, and cycle delays in patients with cancer
in a community oncology practice.
Methods: Data on adult patients (age ≥18 years)
with cancer treated in outpatient oncology clinics
throughout the United States between 2000 and 2007
were obtained from a large electronic medical records
database. All types of cancer were included, although
the focus was on solid cancers (ie, lung, breast, ovari-
an, head and neck, and colorectal cancers). Chemo-
therapy regimens were grouped from most to least
toxic as follows: platinum-based, anthracycline-based,
gemcitabine-based, taxane-based, and all other regi-
mens. Anemia (defined as hemoglobin <11 g/dL), throm-
bocytopenia (defined as platelet count <150 × 109/L),
red blood cell (RBC) and platelet transfusions, and use
of erythropoietin-stimulating agents (ESAs) were exam-
ined by tumor and regimen type. Cycle delays (>7 days)
during chemotherapy were also evaluated.
Results: A total of 47,159 patients were included
in the study (58.4% female; mean [SD] age, 60.76
[13.9] years). The most common cancer was breast
cancer (19.5%), followed by non–small cell lung can-
cer (14.9%), colorectal cancer (11.9%), ovarian can-
cer (3.1%), and head and neck cancer (2.5%). At
baseline, 20.9% of patients had anemia and 11.1%
had thrombocytopenia. A total of 75,243 chemothera-
py regimens were administered. During the course of
chemotherapy, from 46.4% to 59.0% of patients de-
veloped anemia. The prevalence of thrombocytopenia
ranged from 21.9% in patients treated with taxane-
based regimens to 64.2% in patients treated with
gemcitabine-based regimens. In patients from a single
hospital-based outpatient center that had the most
complete transfusion data (representing 18.3% of the
2416
population), the use of RBC transfusion ranged from
4.5% in patients treated with anthracycline-based
regimens to 11.6% in patients treated with platinum-
based regimens. ESAs were received at some point dur-
ing chemotherapy by 49.1% of patients. For those with
complete dose information, dose delay occurred in 8.2%
of chemotherapy cycles; the mean delay was 17 days.
Conclusion: In this study of anemia and thrombo-
cytopenia in a large cohort of patients undergoing
chemotherapy for solid tumors in an outpatient on-
cology clinic in 2000–2007, the burden of anemia and
thrombocytopenia remained high. (Clin Ther. 2009;31
[Theme Issue]:2416–2432) © 2009 Excerpta Medica Inc.
Key words: cancer, chemotherapy, anemia, throm-
bocytopenia, dose delay.
INTRODUCTION
Myelosuppression, which commonly presents as ane-
mia, thrombocytopenia, or neutropenia, has a signifi-
cant effect on the treatment of cancer patients. Such
toxicity may lead to postponement of chemotherapy
cycles or dose reductions, as well as affecting patients’
well-being. The incidence and extent of cancer-related,
or primary, cytopenias depend on characteristics unique
to the patient and tumor type, and on the duration
and stage of disease. Treatment-related, or secondary,
cytopenia is a function of the modality of chemo-
The results of this study were presented in part as posters at the 12th
Annual ISPOR European Congress, held in Paris, France, on October
24–27, 2009.
*Current affiliation: Johnson & Johnson Pharmaceutical Services
LLC, Raritan, New Jersey.
Accepted for publication August 19, 2009.
doi:10.1016/j.clinthera.2009.11.020
0149-2918/$ - see front matter
© 2009 Excerpta Medica Inc. All rights reserved.
Volume 31 Theme Issue

therapy and/or radiation used. Consequently, the inci-
dence of anemia may range from 20% to 60% at the
time of the diagnosis of cancer and reach as high as
60% to 90% during treatment.1,2 The risk of anemia
generally increases with the duration and extent of
disease. Multiple cycles of chemotherapy can impair
erythropoiesis. The type, schedule, and intensity of
therapy, and whether the patient has received pre-
vious myelosuppressive therapy, are important factors
in the incidence and severity of chemotherapy-induced
anemia. The incidence of mild to moderate anemia
(hemoglobin [Hb] >8 and <11 g/dL, as defined by the
World Health Organization3) ranges from 50% to
80% with the most frequently used single-agent and
combination chemotherapy regimens.4
Anemia, whose most frequent symptoms are fa-
tigue, dyspnea, and depression, can have a nega-
tive impact on patients’ quality of life (QOL).2,5,6
Nearly 80% of patients experience fatigue during
treatment, and more than half consider the symptoms
debilitating.7 Before the 1990s, red blood cell (RBC)
transfusions were the primary treatment for severe or
life-threatening anemia. Since then, erythropoiesis-
stimulating agents (ESAs) have become available for
correcting mild to moderate anemia and preventing
severe anemia. The goals of anemia treatment include
correcting and maintaining Hb levels at ~12 g/dL, re-
ducing transfusion requirements, and improving QOL.
Even incremental corrections in Hb levels have been
associated with less fatigue and better QOL, as mea-
sured by anemia-specific instruments and global mea-
sures of QOL.1
Chemotherapy-induced thrombocytopenia is an-
other common hematologic toxicity associated with
myelosuppressive and ablative therapy. Treatment-
related thrombocytopenia is estimated to occur in
~10% to 36% of patients with solid tumors, and in
75% of those with hematologic cancers.8–10 The clini-
cal consequences of anemia and thrombocyto-
penia can vary widely, from asymptomatic labora-
tory abnormalities to dose-limiting and life-threatening
toxicities. Persistent and/or serious cytopenia may
necessitate a delay in subsequent chemotherapy cycles,
a reduction in dose, or discontinuation of therapy.
The objective of this study was to evaluate the in-
cidence, prevalence, and severity of anemia, thrombo-
cytopenia, and dose delays associated with chemo-
therapy in patients with cancer undergoing treatment
in community oncology practices in 2000–2007.
2009
Y. Wu et al.
PATIENTS AND METHODS
This was a retrospective, observational cohort study
that employed data from the electronic medical rec-
ords of adult cancer patients receiving care at com-
munity and hospital-affiliated clinical oncology prac-
tices throughout the United States from January 1,
2000, through December 31, 2007. The patient chart-
ing technology was installed in these practices and is
maintained by the Varian Medical Oncology database
(Varian Medical Systems, Inc., Palo Alto, California).
Deidentified electronic medical records from outpatient
medical oncology practices were searched for relevant
data elements prospectively defined in the study proto-
col. The protocol was approved by the New England
Institutional Review Board (Wellesley, Massachusetts),
which determined that the study was exempt from in-
stitutional review board oversight because of its retro-
spective design and the deidentified nature of the data.
Patient Selection and Data Extraction
Eligible patients had a diagnosis of cancer (Interna-
tional Classification of Diseases, Ninth Revision
[ICD-9] codes 140–165.9, 170–172.9, 174–195.8,
199–208.91, and 238.7–238.79); were aged ≥18 years;
had ≥1 visit to an outpatient oncology clinic in the
current Varian Medical Oncology system; and had
≥1 record of systemic antineoplastic treatment started
in 2000 or later. All cancer types were evaluated, al-
though the primary focus was on the most common
solid tumors: non–small cell lung cancer (ICD-9 codes
162–162.9), breast cancer (ICD-9 codes 174–174.9),
ovarian cancer (ICD-9 code 183), head and neck can-
cer (ICD-9 codes 140–149.9, 160–161.9, 165.0, and
195.0), and colorectal cancer (ICD-9 codes 153–154.8).
Patients with carcinoma in situ, skin cancer, or an
unspecified neoplasm were excluded.
The extracted patient information included age,
sex, cancer type, previous and current therapy, and
selected laboratory values. The treatment characteris-
tics retrieved included drug name, dose, start date, and
frequency of administration. Similar information was
collected for ESA treatment of anemia (erythropoietin
or darbepoetin).
Study Definitions and Analyses
The index date was the start date of the first-line
systemic antineoplastic regimen recorded in the data-
base after the diagnosis of cancer. Baseline was the
period within 30 days before or on the index date.
2417
 Clinical Therapeutics
To evaluate anemia outcomes, all Hb values were
collected at baseline and from the start of chemo-
therapy. Anemia was defined as a Hb value <11 g/dL
at any time during chemotherapy. Postchemotherapy
Hb was the lowest Hb value reached by a patient at
any time after the start of chemotherapy and before
receipt of ESA or a transfusion. Thrombocytopenia
was defined as platelet count (PC) <150 × 109/L at any
time during chemotherapy. Both anemia and throm-
bocytopenia were categorized by toxicity grade, ac-
cording to Common Terminology Criteria for Adverse
Events version 3.0.11 For anemia, grade 1 was an Hb
<11 to 10 g/dL; grade 2 an Hb <10 to 8 g/dL; grade 3
an Hb <8–6.5 g/dL; and grade 4 an Hb <6.5 g/dL. For
thrombocytopenia, grade 1 was a PC <150 to 75 ×
109/L; grade 2 a PC <75 to 50 × 109/L; grade 3 a PC
<50 to 25 × 109/L; and grade 4 a PC <25 × 109/L.
Information on RBC and platelet transfusions was
also obtained.
The incidence of anemia, thrombocytopenia, ESA
use, and RBC and platelet transfusions was examined
in all patients, stratified by tumor and chemotherapy
type. The analyses of RBC and platelet transfusions
were restricted to data from a single hospital-based
outpatient center that had the most complete transfu-
sion information, contributing data on 8607 patients
to the analyses.
A chemotherapy regimen was defined as ≥1 admin-
istration of chemotherapeutic drugs, with no more
than 45 days between any 2 consecutive administra-
tions. Because patients could be treated with >1 my-
elosuppressive regimen, double-counting was avoided
by grouping treatment regimens from most to least
toxic according to the following hierarchy: platinum-
based, anthracycline-based, gemcitabine-based, taxane-
based, and all other regimens. (For example, a patient
treated with a combination of cisplatin, cyclophospha-
mide, and doxorubicin would be counted as receiv-
ing only the platinum-based regimen). Individual
chemotherapy drugs administered outside a planned
treatment regimen were excluded; nonmyelosuppressive
cancer regimens, such as monoclonal antibodies in the
absence of cytotoxic chemotherapy, were also excluded.
Cycle delay was defined as >7 and <45 days’ delay
in the next planned cycle of chemotherapy. More than
7 days’ delay was chosen based on research indicating
that delays of ≤7 days are common, allow time for
resolution of cytopenia, and do not appear to affect
patient outcomes.12,13 To find delays in chemotherapy,
2418
all cycles after the initial cycle of a regimen were ex-
amined, and the planned cycle duration was compared
with the actual time from the start of one cycle to the
start of the next. The analysis of cycle delays was re-
stricted to cancer patients for whom complete infor-
mation on the chemotherapy treatment plan was en-
tered in the database. The cycle number specified in
the database was used to obtain the start and end
dates of each chemotherapy cycle.
Statistical Analysis
The collected data were summarized using descrip-
tive statistics and presented as means (SDs) or medians
(ranges) for continuous variables, and as counts and
percentages for categorical variables. Patient and out-
come data were stratified by cancer and chemotherapy
type. Analyses were performed using SPSS version 15.0
(SPSS Inc., Chicago, Illinois) and SAS version 9.1 (SAS
Institute Inc., Cary, North Carolina).
RESULTS
Patient Characteristics
The study sample included 47,159 patients who
met the protocol-specified inclusion criteria. Their base-
line characteristics are summarized in Table I. The
mean (SD) age of patients was 60.76 (13.9) years, and
the majority (60.7%) were aged ≤65 years. Of the
5 cancers of interest, breast cancer was the most fre-
quent diagnosis (19.5%), followed by non–small cell
lung cancer (14.9%), colorectal cancer (11.9%), ovarian
cancer (3.1%), and head and neck cancer (2.5%). The
remainder of patients had other solid tumors (20.7%),
hematologic cancers (16.3%), and mixed or unknown
cancers (11.1%). Overall, there were numerically
more female than male patients (58.4% vs 41.6%,
respectively). However, numerically more males had
head and neck cancer (75.1%), non–small cell lung
cancer (55.0%), and colorectal cancer (52.8%). Pa-
tients with breast cancer were numerically younger
(mean age, 55.12 years) compared with patients with
other types of cancer. Across all cancers, the majority
of patients with known cancer staging had metastatic
disease, except those with breast cancer, in whom
stage I–II cancers predominated.
Overall, the mean (SD) Hb at baseline was 12.41
(1.8) g/dL (median, 12.5 g/dL); it was >12 g/dL across
all cancer types except for ovarian cancer, in which it
was 11.8 (1.5) g/dL (Table I). At baseline, 20.9% of
patients were anemic, and 39.0% had an Hb <12 g/dL.
Volume 31 Theme Issue
2009

Table I. Patient characteristics at baseline.*

Non–Small Head and Mixed/

Cell Lung Breast Ovarian Neck Colorectal Other Solid Hematologic Unknown
Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
All Cancers (n = 7001 (n = 9197 (n = 1482 (n = 1166 (n = 5616 (n = 9769 (n = 7699 (n = 5229
Variable (N = 47,159) [14.9%]) [19.5%]) [3.1%]) [2.5%]) [11.9%]) [20.7%]) [16.3%]) [11.1%])

Sex, no. (%)

Female 27,561 (58.4) 3150 (45.0) 9197 (100) 1482 (100) 290 (24.9) 2650 (47.2) 4207 (43.1) 3541 (46.0) 3046 (58.3)
Male 19,598 (41.6) 3851 (55.0) – – 876 (75.1) 2966 (52.8) 5562 (56.9) 4158 (54.0) 2183 (41.7)
Age, mean 60.76 (13.9) 65.51 (10.4) 55.12 (11.9) 61.74 (13.3) 60.56 (12.0) 61.68 (12.6) 61.31 (14.0) 62.37 (15.9) 59.74 (16.1)
(SD), y
Stage (AJCC),
no. (%)
I–II 4945 (10.5) 398 (5.7) 2851 (31.0) 54 (3.6) 20 (1.7) 499 (8.9) 513 (5.3) 547 (7.1) 63 (1.2)
IIIA, IIIB 3346 (7.1) 715 (10.2) 697 (7.6) 160 (10.8) 47 (4.0) 920 (16.4) 409 (4.2) 353 (4.6) 45 (0.9)
IV 9862 (20.9) 1854 (26.5) 1840 (20.0) 230 (15.5) 267 (22.9) 1587 (28.3) 2767 (28.3) 763 (9.9) 554 (10.6)
Unknown 29,006 (61.5) 4034 (57.6) 3809 (41.4) 1038 (70.0) 832 (71.4) 2610 (46.5) 6080 (62.2) 6036 (78.4) 4567 (87.3)
No. of patients
with Hb values 42,923 6550 8231 1318 1082 5215 8909 7203 4415
Hb, mean (SD),
g/dL† 12.41 (1.8) 12.7 (1.8) 12.7 (1.5) 11.8 (1.5) 13.2 (1.8) 12.3 (1.7) 12.45 (1.9) 12.00 (2.0) 12.21 (2.1)

(continued)

Y. Wu et al.
2419
2420

Clinical Therapeutics
Table I (continued).

Non–Small Head and Mixed/

Cell Lung Breast Ovarian Neck Colorectal Other Solid Hematologic Unknown
Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
All Cancers (n = 7001 (n = 9197 (n = 1482 (n = 1166 (n = 5616 (n = 9769 (n = 7699 (n = 5229
Variable (N = 47,159) [14.9%]) [19.5%]) [3.1%]) [2.5%]) [11.9%]) [20.7%]) [16.3%]) [11.1%])

Hb category,
no. (%)
≥12 g/dL 26,191 (61.0) 4350 (66.4) 5886 (71.5) 621 (47.1) 797 (73.7) 3046 (58.4) 5381 (60.4) 3664 (50.9) 2446 (55.4)
≥11–<12 g/dL 7769 (18.1) 1149 (17.5) 1352 (16.4) 358 (27.2) 163 (15.1) 1033 (19.8) 1608 (18.0) 1333 (18.5) 773 (17.5)
≥10–<11 g/dL 4973 (11.6) 648 (9.9) 623 (7.6) 199 (15.1) 78 (7.2) 693 (13.3) 1126 (12.6) 1026 (14.2) 580 (13.1)
≥9–<10 g/dL 2570 (6.0) 285 (4.4) 254 (3.1) 106 (8.0) 33 (3.0) 314 (6.0) 531 (6.0) 705 (9.8) 342 (7.7)
≥8–<9 g/dL 1040 (2.4) 96 (1.5) 95 (1.2) 29 (2.2) 8 (0.7) 103 (2.0) 203 (2.3) 319 (4.4) 187 (4.2)
<8 g/dL 380 (0.9) 22 (0.3) 21 (0.3) 5 (0.4) 3 (0.3) 26 (0.5) 60 (0.7) 156 (2.2) 87 (2.0)
No. of patients
with platelet
counts 43,995 6657 8428 1368 1094 5326 9163 7376 4583
Platelet count, 296.01 322.0 286.2 335.3 290.6 289.3 286.52 245.16 296.01
mean (SD), × (212.6) (135.1) (95.8) (146.6) (113.5) (119.9) (130.3) (158.9) (212.6)
109/L†
(continued)
Volume 31 Theme Issue
2009

Table I (continued).

Non–Small Head and Mixed/

Cell Lung Breast Ovarian Neck Colorectal Other Solid Hematologic Unknown
Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
All Cancers (n = 7001 (n = 9197 (n = 1482 (n = 1166 (n = 5616 (n = 9769 (n = 7699 (n = 5229
Variable (N = 47,159) [14.9%]) [19.5%]) [3.1%]) [2.5%]) [11.9%]) [20.7%]) [16.3%]) [11.1%])

Platelet count
category, no. (%)
>400 t 109/L 6719 (15.3) 1520 (22.8) 848 (10.1) 377 (27.6) 136 (12.4) 751 (14.1) 1371 (15.0) 857 (11.6) 859 (18.7)
>150–400 t
109/L 32,387 (73.6) 4779 (71.8) 7220 (85.7) 902 (65.9) 892 (81.5) 4182 (78.5) 6895 (75.2) 4631 (62.8) 2886 (63.0)
>100–150 t
109/L 2903 (6.6) 290 (4.4) 235 (2.8) 78 (5.7) 56 (5.1) 296 (5.6) 684 (7.5) 901 (12.2) 363 (7.9)
>75–100 t
109/L 753 (1.7) 38 (0.6) 63 (0.7) 7 (0.5) 8 (0.7) 70 (1.3) 113 (1.2) 335 (4.5) 119 (2.6)
>50–75 t
109/L 496 (1.1) 19 (0.3) 34 (0.4) 2 (0.1) 1 (<0.1) 22 (0.4) 51 (0.6) 265 (3.6) 102 (2.2)
>25–50 t
109/L 410 (0.9) 6 (0.1) 20 (0.2) 1 (<0.1) – 3 (<0.1) 31 (0.3) 231 (3.1) 118 (2.6)

≤25 t 109/L 327 (0.7) 5 (<0.1) 8 (<0.1) 1 (<0.1) 1 (<0.1) 2 (<0.1) 18 (0.2) 156 (2.1) 136 (3.0)

AJCC = American Joint Commission on Cancer; Hb = hemoglobin.

*Percentages may not total 100 due to rounding.
†The measurement obtained within 30 days before and closest to the start of the first chemotherapy treatment.

Y. Wu et al.
2421
 Clinical Therapeutics
Hematologic cancers accounted for the largest pro-
portion of patients with anemia at baseline (30.6%).
At baseline, 11.1% of patients were thrombocytopen-
ic. The proportion was lower in patients with all solid
tumors combined (6.7%) and higher in those with
hematologic cancers (25.6%).
Chemotherapy Regimens
A total of 75,243 chemotherapy regimens were
administered to 47,159 cancer patients during the study
period. Platinum-based regimens accounted for 27.8%
of all chemotherapy regimens and were most common
in patients with head and neck cancer (76.8%), non–
small cell lung cancer (66.6%), ovarian cancer (60.2%),
and colorectal cancer (38.9%) (Table II). Anthracycline-
based regimens were most common in patients with
breast cancer (46.5%) and hematologic cancer (19.1%).
Gemcitabine-based regimens accounted for 4.8% of
all treatment regimens, with the largest proportions in
patients with other solid tumors (12.6%), ovarian
cancer (6.8%), non–small cell lung cancer (6.3%), and
breast cancer (5.3%). Taxane-based regimens consti-
tuted 6.2% of all chemotherapy regimens and were
most common in patients with breast cancer (15.3%),
ovarian cancer (7.7%), non–small cell lung cancer
(7.6%), and head and neck cancer (6.3%). Other che-
motherapy accounted for 45.6% of all regimens. A
similar distribution of treatment regimens was ob-
served when data were summarized by patient counts.
Anemia
The evaluation of anemia included a total of
42,923 patients and 61,005 chemotherapy regimens.
When only cancer types were considered, regardless of
chemotherapy type, patients with ovarian cancer had
the highest prevalence of anemia after the start of che-
motherapy (56.3%), followed by breast cancer (53.3%)
and non–small cell lung cancer (50.9%). The lowest
prevalence of anemia was in patients with colorectal
cancer (41.0%) and head and neck cancer (39.1%).
Grade 2 anemia was observed in 19.1% of patients
treated with all 4 chemotherapy regimens combined,
grade 3 anemia in 1.5%, and grade 4 anemia in 0.1%.
Patients receiving gemcitabine-based regimens had the
highest proportion of patients with grade 2–3 anemia
(26.5%).
Overall, anemia occurred at some point during
chemotherapy in 50.7%, 50.8%, and 46.4% of patients
treated with platinum-, anthracycline-, and taxane-
2422
based regimens, respectively, and in 59.0% of patients
treated with a gemcitabine-based regimen (Table III).
Of these, 29.9% had Hb levels between 10 and 11 g/dL
across all treatment regimens, ranging from 27.7% of
patients treated with taxane-based regimens to 32.3%
of those treated with gemcitabine-based regimens. Small-
er proportions had Hb levels between 9 and 10 g/dL,
with the lowest proportion (12.2%) in patients on
taxane-based regimens and the highest (18.1%) in
patients on gemcitabine-based regimens. Hb values
between 8 and 9 g/dL occurred in 5.1% of patients
and values <8 g/dL in 1.7% of patients.
In those with breast cancer, the largest proportion
of patients with anemia (62.2%) was seen in those
treated with platinum-based regimens. In patients with
non–small cell lung cancer, the highest prevalence of
anemia (66.7%) was seen in patients treated with
anthracycline-based regimens (Table III). In patients
with ovarian and colorectal cancer, those treated with
gemcitabine-based regimens had the highest preva-
lence of anemia (65.1% and 75.1%, respectively).
Across all chemotherapy regimens, the lowest preva-
lence of anemia was in patients with head and neck
cancer, ranging from 16.7% of those treated with
anthracycline-based regimens to 52.9% of those re-
ceiving taxane-based regimens.
Thrombocytopenia
The evaluation of thrombocytopenia included a
total of 43,995 patients and 62,072 chemotherapy regi-
mens. The prevalence of thrombocytopenia after ini-
tiation of chemotherapy ranged from 21.9% in pa-
tients treated with taxane-based regimens to 64.2%
in patients treated with gemcitabine-based regimens
(Table IV). Across all 4 types of chemotherapy regi-
mens, the highest prevalence of thrombocytopenia by
cancer type was observed in patients with colorectal
cancer (61.7%), non–small cell lung cancer (50.5%),
and ovarian cancer (45.6%); the lowest prevalence
was seen in patients with breast cancer (37.6%). Most
patients (17.6%–41.0%) with thrombocytopenia
across all treatment regimens had grade 1 thrombocy-
topenia. Grade 3–4 thrombocytopenia occurred in
10.6% of patients on platinum- and gemcitabine-based
regimens, 5.2% of patients on anthracycline-based
regimens, and 1.9% of patients on taxane-based regi-
mens. Across the 4 chemotherapy regimens, patients
with non–small cell lung cancer had the highest preva-
lence of grade 3–4 thrombocytopenia (10.7%); the
Volume 31 Theme Issue
2009

Table II. Distribution of chemotherapy regimens by tumor type.

Non–Small Head and Other Mixed/

All Cell Lung Breast Ovarian Neck Colorectal Solid Hematologic Unknown
Variable Cancers Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
Chemotherapy,
no. (%) of regimens
Total 75,243 9914 12,947 2684 1480 9017 13,852 15,400 9949
Type
Platinum based 20,950 (27.8) 6606 (66.6) 905 (7.0) 1615 (60.2) 1137 (76.8) 3508 (38.9) 5263 (38.0) 249 (1.6) 1667 (16.8)
Anthracycline based 11,709 (15.6) 35 (0.4) 6019 (46.5) 362 (13.5) 8 (0.5) 6 (<0.1) 817 (5.9) 2949 (19.1) 1513 (15.2)
Gemcitabine based 3632 (4.8) 621 (6.3) 684 (5.3) 182 (6.8) 19 (1.3) 17 (0.2) 1747 (12.6) 98 (0.6) 264 (2.7)
Taxane based 4674 (6.2) 749 (7.6) 1978 (15.3) 207 (7.7) 93 (6.3) 17 (0.2) 1289 (9.3) 37 (0.2) 304 (3.1)
Other 34,278 (45.6) 1903 (19.2) 3361 (26.0) 318 (11.8) 223 (15.1) 5469 (60.7) 4736 (34.2) 12,067 (78.4) 6201 (62.3)
Patients, no. (%)
Total treated with any
type of chemotherapy
regimen* 47,159 (100) 7001 (14.9) 9197 (19.5) 1482 (2.5) 1166 (3.1) 5616 (11.9) 9769 (20.7) 7699 (16.3) 5229 (11.1)
Total treated with each
type of chemotherapy
regimen 55,556 8602 11,263 2063 1275 6715 11,144 8606 5888
Platinum based 17,825 (32.1) 5821 (67.7) 801 (7.1) 1173 (56.9) 974 (76.4) 3066 (45.7) 4442 (39.9) 222 (2.6) 1326 (22.5)
Anthracycline based 10,506 (18.9) 34 (0.4) 5849 (51.9) 319 (15.5) 8 (0.6) 6 (<0.1) 725 (6.5) 2726 (31.7) 839 (14.2)
Gemcitabine based 3276 (5.9) 576 (6.7) 621 (5.5) 166 (8.0) 18 (1.4) 17 (0.3) 1555 (14.0) 93 (1.1) 230 (3.9)
Taxane based 4132 (7.4) 717 (8.3) 1782 (15.8) 168 (8.1) 80 (6.3) 17 (0.3) 1070 (9.6) 36 (0.4) 262 (4.4)
Other 19,817 (35.7) 1454 (16.9) 2210 (19.6) 237 (11.5) 195 (15.3) 3609 (53.7) 3352 (30.1) 5529 (64.2) 3231 (54.9)

*Patients could have received multiple types of treatments.

Y. Wu et al.
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2424

Clinical Therapeutics
Table III. Prevalence of anemia after the start of chemotherapy. Values are percentages, unless otherwise stated.*

Non–Small Head and Other Mixed/

All Cell Lung Breast Ovarian Neck Colorectal Solid Hematologic Unknown
Chemotherapy Type Cancers Cancer Cancer Cancer Cancer Cancer Tumors Cancers Cancers
Platinum based
No. of regimens evaluated 18,076 5931 720 1305 1007 3245 4510 219 1139
Postchemotherapy Hb, g/dL†
≥12 22.9 22.2 11.3 13.5 33.0 30.8 21.0 12.8 22.8
≥11–<12 26.4 25.9 26.5 27.7 28.8 28.4 25.1 25.6 25.4
≥10–<11 29.9 31.7 40.0 33.0 23.7 26.1 29.1 27.4 29.9
≥9–<10 14.5 14.4 14.7 17.8 10.6 10.7 16.4 21.9 15.8
≥8–<9 4.7 4.6 4.9 5.5 2.8 3.1 6.0 8.2 4.7
<8 1.6 1.2 2.6 2.4 1.1 0.9 2.4 4.1 1.5
Anthracycline based
No. of regimens evaluated 10,203 30 5444 279 6 6 674 2672 1092
Postchemotherapy Hb, g/dL†
≥12 23.4 16.7 16.4 30.8 33.3 – 23.4 21.9 60.0
≥11–<12 25.9 16.7 29.5 24.4 50.0 50.0 20.9 24.3 15.7
≥10–<11 31.3 43.3 36.6 24.4 16.7 50.0 30.3 28.4 13.6
≥9–<10 13.6 10.0 13.7 13.6 – – 16.6 15.2 7.1
≥8–<9 4.3 6.7 3.0 4.7 – – 6.1 6.8 2.7
<8 1.6 6.7 0.7 2.2 – – 2.7 3.3 0.9
Gemcitabine based
No. of regimens evaluated 3217 576 615 143 18 16 1551 95 203
Postchemotherapy Hb, g/dL†
≥12 16.5 19.8 14.0 13.3 38.9 18.8 16.2 8.4 21.2
≥11–<12 24.5 28.6 26.3 21.7 33.3 6.3 23.0 26.3 20.7
Volume 31 Theme Issue

≥10–<11 32.3 29.7 37.1 32.9 16.7 12.5 33.0 23.2 27.1
≥9–<10 18.1 16.0 15.4 18.2 5.6 56.3 19.1 16.8 23.2
≥8–<9 6.4 4.7 5.4 11.9 – 6.3 6.4 14.7 6.4
<8 2.2 1.2 1.8 2.1 5.6 – 2.2 10.5 1.5
(continued)
2009

Table III (continued).

Non–Small Head and Other Mixed/

All Cell Lung Breast Ovarian Neck Colorectal Solid Hematologic Unknown
Chemotherapy Type Cancers Cancer Cancer Cancer Cancer Cancer Tumors Cancers Cancers
Taxane based
No. of regimens evaluated 3851 641 1646 158 85 14 1086 28 193
Postchemotherapy Hb, g/dL†
≥12 24.3 27.0 25.1 24.1 24.7 28.6 21.9 17.9 21.8
≥11–<12 29.4 32.1 30.6 27.8 22.4 21.4 27.6 25.0 24.9
≥10–<11 27.7 26.2 28.4 29.1 31.8 28.6 27.5 17.9 25.9
≥9–<10 12.2 10.1 11.0 10.8 12.9 – 14.4 10.7 18.7
≥8–<9 5.1 4.2 3.9 5.7 3.5 14.3 6.8 17.9 6.7
<8 1.4 0.3 1.0 2.5 4.7 7.1 1.8 10.7 2.1
All other chemotherapy regimens
No. of regimens evaluated 25,658 1368 2492 203 183 4568 3229 9568 4047
Postchemotherapy Hb, g/dL†
≥12 47.8 39.5 46.3 26.1 51.9 45.1 53.4 48.5 49.5
≥11–<12 19.8 24.4 25.9 17.7 18.6 23.5 19.0 17.6 16.3
≥10–<11 16.2 21.9 17.2 23.6 20.2 19.4 14.7 14.3 15.0
≥9–<10 8.8 9.5 6.9 18.2 4.4 8.2 7.7 9.3 9.7
≥8–<9 4.8 3.9 2.7 10.3 4.4 2.9 3.7 6.2 5.8
<8 2.6 0.8 0.9 3.9 0.5 0.8 1.4 4.0 3.6

Hb = hemoglobin.
* Percentages may not total 100 due to rounding.
† Postchemotherapy Hb values represent the lowest values reached at any time after the start of chemotherapy in a patient not receiving an erythropoietin-

stimulating agent or transfusion.

Y. Wu et al.
2425
 Clinical Therapeutics
lowest prevalence was in patients with head and neck
cancer (2.8%).
Thrombocytopenia was observed in 53.6% of pa-
tients with anemia, and anemia was observed in
55.4% of patients with thrombocytopenia. A total of
14,103 patients (32.9% of all patients included in the
evaluation of anemia; 29.9% of all evaluated patients)
had both anemia and thrombocytopenia in the course
of chemotherapy.
RBC and Platelet Transfusions
RBC transfusion after the start of chemotherapy
was evaluated in 8607 patients (18.3% of the total
sample) and 10,539 chemotherapy regimens; this sam-
ple was generally comparable to patients in the overall
data set. The incidence of RBC transfusions was low,
ranging from 4.5% and 7.5% among patients on
anthracycline- and taxane-based regimens, respectively,
to 10.7% and 11.6% in patients on gemcitabine- and
platinum-based regimens, respectively (Figure 1). The
rate of transfusion among patients receiving other
chemotherapy regimens was 8.3%. Across all 4 che-
motherapy regimens, transfusions occurred more fre-
quently in patients with an Hb <9 g/dL (ranging from
3.8% in those receiving anthracycline-based regimens
to 8.9% in those treated with gemcitabine-based regi-
mens) compared with those with an Hb >9 g/dL. The
incidence of RBC transfusions was highest among pa-
tients with hematologic cancer (14.5%), ovarian cancer
(13.3%), and non–small cell lung cancer (10.6%), and
lowest in patients with head and neck cancer (4.9%),
colorectal cancer (4.4%), and breast cancer (4.2%).
Platelet transfusion was evaluated in 10,582 che-
motherapy regimens. The prevalence of platelet trans-
fusion was 2.5% in all cancer patients treated with
any type of chemotherapy. The prevalence was 1.8% in
patients receiving gemcitabine-based regimens, 1.0% in
those receiving platinum-based regimens, 0.6% in
those receiving anthracycline-based regimens, and
0.3% in those receiving taxane-based regimens. The
greatest proportion of platelet transfusions was in
patients with hematologic cancers (9.6%).
ESA Use
Across all 4 types of chemotherapy regimens, 49.1%
of patients received ESAs at some point after the start
of chemotherapy (Figure 2). Slightly lower utilization
of ESAs was observed in patients on anthracycline-
and taxane-based regimens (45.1% and 44.4%, re-
2426
spectively). The greatest use of ESAs across all chemo-
therapy regimens was among patients with Hb levels
between 9 and 11 g/dL, with proportions ranging
from 25.2% for taxane-based regimens to 35.4% for
gemcitabine-based regimens.
Among all ESA users, nearly 30% had an Hb ≥11 g/dL
at the time of ESA initiation (data not shown). The
mean time from the first dose of chemotherapy to the
first administration of ESA ranged from 27 to 35 days,
and was shorter in patients on taxane- and gemcitabine-
based regimens (27 and 30 days, respectively).
Chemotherapy Delays
Chemotherapy cycle delay was examined in
26,317 cancer patients (113,175 cycles) with com-
plete chemotherapy dose information in the database
(55.8% of the entire data set). No substantial differ-
ences in baseline demographic and clinical character-
istics were noted between patients evaluated for cycle
delay and the entire study population. Delays oc-
curred in 5961 patients (22.7%) and 9293 chemo-
therapy cycles (8.2%). The mean duration of cycle
delay was 17 days (median, 14 days; interquartile
range, 12–21 days). Of the 5961 patients with cycle
delays, 20.3% had colorectal cancer, 18.6% had non–
small cell lung cancer, 15.2% had breast cancer, 4.4% had
ovarian cancer, and 2.9% had head and neck cancer.
Among patients with cycle delays, 3604 (60.5%)
had anemia at some point during chemotherapy, with
anemia occurring during 4826 delayed chemotherapy
cycles (51.9%). Platinum-based regimens accounted
for the largest proportion of these cycles (45.3%), fol-
lowed by anthracycline-based (13.9%), gemcitabine-
based (8.6%), and taxane-based regimens (7.6%).
DISCUSSION
Anemia and thrombocytopenia, as well as neutrope-
nia, are common hematologic complications of cancer
chemotherapy and are associated with increased mor-
bidity, mortality, and health care costs. These toxici-
ties may also lead to delays in chemotherapy, dose
reductions, and discontinuation of treatment. The
present retrospective study used data on adult patients
undergoing chemotherapy for solid tumors in a com-
munity oncology practice to assess the prevalence of
anemia, thrombocytopenia, treatment of these toxici-
ties (RBC and platelet transfusions and ESA use), and
delays in chemotherapy associated with several com-
monly used chemotherapy regimens.
Volume 31 Theme Issue
2009

Table IV. Prevalence of thrombocytopenia after the start of chemotherapy.* Values are percentages, unless otherwise stated.

Non–Small Head and Other Mixed/

Chemotherapy All Cell Lung Breast Ovarian Neck Colorectal Solid Hematologic Unknown
Type Cancers Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
Platinum based
No. of patients evaluated 18,595 6059 742 1393 1027 3301 4640 227 1206
Postchemotherapy platelet
count, × 109/L†
>400 2.3 2.8 0.4 3.2 2.5 1.1 2.4 0.9 2.3
>150–400 42.2 44.3 38.4 45.8 57.3 37.2 41.2 18.5 39.3
>100–150 24.4 22.8 22.9 21.3 24.1 29.5 24.6 13.2 24.5
>75–100 11.1 9.8 11.9 9.8 7.3 16.3 10.5 9.3 10.9
>50–75 9.3 8.5 10.6 9.4 5.7 10.8 9.8 12.8 9.2
>25–50 6.5 7.0 10.1 6.2 2.0 4.0 7.1 18.1 8.1
≤25 4.1 4.8 5.6 4.3 1.0 1.2 4.4 27.3 5.6
Anthracycline based
No. of patients evaluated 10,322 30 5474 282 6 6 689 2735 1100
Postchemotherapy platelet
count, × 109/L†
>400 2.2 – 1.6 5.0 16.7 – 3.6 2.3 3.2
>150–400 59.9 46.7 61.6 68.1 50.0 33.3 60.2 49.9 74.5
>100–150 20.9 13.3 24.2 13.8 16.7 16.7 17.4 20.1 10.6
>75–100 6.8 6.7 6.5 5.7 – 16.7 6.8 8.9 3.5
>50–75 4.9 6.7 3.7 5.3 16.7 33.3 5.1 7.9 2.9
>25–50 3.0 23.3 1.7 1.4 – – 3.3 5.5 2.9
≤25 2.2 3.3 0.7 0.8 – – 3.4 5.4 2.4
Gemcitabine based
No. of patients evaluated 3291 584 630 155 18 16 1584 95 209
Postchemotherapy platelet
count, × 109/L†
>400 2.9 4.5 1.1 5.2 11.1 – 2.6 – 5.3
>150–400 32.9 36.3 32.2 39.4 33.3 25.0 32.4 12.6 34.4
>100–150 27.3 29.5 28.3 27.1 22.2 31.3 27.5 16.8 22.0
>75–100 13.7 12.7 13.5 9.7 16.7 25.0 14.5 16.8 12.0
>50–75 12.0 8.7 14.0 9.7 11.1 18.8 12.6 14.7 11.0

Y. Wu et al.
>25–50 7.8 6.2 7.8 5.8 5.6 – 7.8 18.9 9.6
≤25 3.4 2.3 3.2 3.2 – – 2.6 20.0 5.8
2427

(continued)
2428

Clinical Therapeutics
Table IV (continued).

Non–Small Head and Other Mixed/

Chemotherapy All Cell Lung Breast Ovarian Neck Colorectal Solid Hematologic Unknown
Type Cancers Cancer Cancer Cancer Cancer Cancer Tumors Cancer Cancers
Taxane based
No. of patients evaluated 3941 662 1675 164 85 14 1114 31 196
Postchemotherapy platelet
count, × 109/L†
>400 4.3 6.8 2.6 6.1 9.4 7.1 4.6 6.5 4.1
>150–400 73.8 72.1 78.6 70.7 76.5 64.3 70.5 32.3 66.8
>100–150 14.4 12.7 13.1 16.5 9.4 14.3 17.3 6.5 16.3
>75–100 3.2 3.2 2.7 4.9 3.5 7.1 3.4 9.7 4.6
>50–75 2.4 3.8 1.7 0.6 1.2 7.1 2.2 19.4 3.1
>25–50 1.4 0.5 1.0 1.2 – – 1.5 22.6 4.1
≤25 0.5 1.2 0.4 – – – 0.5 3.2 1.0
All other chemotherapy regimens
No. of patients evaluated 25,923 1387 2501 212 184 4604 3263 9688 4084
Postchemotherapy platelet
count, × 109/L†
>400 6.2 9.6 3.5 5.7 6.5 4.0 4.9 3.5 16.3
>150–400 60.9 67.3 77.3 58.5 77.7 70.3 64.5 53.5 52.4
>100–150 16.4 12.7 12.7 16.0 10.3 17.4 18.6 18.2 12.7
>75–100 5.4 4.0 3.2 8.5 3.3 4.5 5.5 6.9 4.7
>50–75 4.2 3.5 1.6 6.1 0.5 2.4 3.3 6.3 4.0
>25–50 3.2 1.7 1.0 4.2 0.5 1.1 1.9 5.0 4.3
Volume 31 Theme Issue

≤25 3.7 1.1 0.7 1.0 1.0 0.3 1.3 6.5 5.8

* Percentages may not total 100 due to rounding.

† Postchemotherapy platelet counts represent the lowest counts reached at any time after the start of chemotherapy and before platelet transfusion.
 Y. Wu et al.

Hb <9 g/dL
Hb 9–11 g/dL
Hb >11 g/dL
10
8.9

8 7.4

6.2
% of Regimens

3.9 3.8
4

2 1.6
1.3

0.3 0.5
0.2 0.2 0
0
Platinum Based Anthracycline Based Gemcitabine Based Taxane Based
(N = 3270) (N = 1636) (N = 597) (N = 685)
Chemotherapy Regimen
Figure 1. Prevalence of chemotherapy regimens associated with red blood cell transfusions.

Hb <9 g/dL
Hb 9–11 g/dL
Hb >11 g/dL
40
35.4
35
32.0
30 29.3

25.2
% of Regimens

25

20
16.8
15.6
14.5
15 12.8

10
4.7
5 3.4 3.0 3.6

0
Platinum Based Anthracycline Based Gemcitabine Based Taxane Based
(N = 17,906) (N = 10,126) (N = 3196) (N = 3835)
Chemotherapy Regimen

Figure 2. Prevalence of chemotherapy regimens associated with the use of erythropoietin-stimulating agents.

2009 2429
 Clinical Therapeutics
The National Cancer Institute (NCI) defines ane-
mia as an Hb <12 g/dL,4 whereas the World Health
Organization defines it as an Hb <11 g/dL.3 The inci-
dence of anemia varies not only by patient character-
istics, but also by disease characteristics and therapy
type. A large, prospective European survey of cancer
patients reported that the rate of anemia (defined as
an Hb <12 g/dL) was 75% in patients treated with
chemotherapy, compared with 40% in those not un-
dergoing chemotherapy.14 In the present study, the rate
of anemia (defined as an Hb <11 g/dL) in all cancer
patients was 20.9% at baseline, increasing to 46.4%
to 59.0% across all 4 regimens after the initiation of
chemotherapy. Applying the NCI definition of ane-
mia, the rate of anemia in this study would be similar
to that in the European study.
In this study, platinum-based regimens, which are
known to cause anemia, were the primary treatment
modalities in patients with lung, ovarian, head and
neck, and colorectal cancers, whereas anthracycline-
based regimens were more common in patients with
breast cancer and hematologic cancers. The highest in-
cidence of anemia was observed among patients treated
with gemcitabine-based regimens (59.0%) and lowest
in those treated with taxane-based regimens (46.4%).
As with anemia, the highest incidence of thrombo-
cytopenia was seen in patients receiving gemcitabine-
based chemotherapy (64.2%), and the lowest inci-
dence was seen in patients receiving taxane-based
chemotherapy (21.9%). The prevalence of grade 3–4
thrombocytopenia was greater with gemcitabine- and
platinum-based regimens compared with anthracy-
cline and taxane-based regimens (10.6%, 10.6%, 5.2%,
and 1.9%, respectively). Among solid tumors, colorec-
tal and non–small cell lung cancer were associated
with the highest incidence of thrombocytopenia across
the 4 chemotherapy regimens (61.7% and 50.5%,
respectively); the incidence was 52.0% for all other
solid tumors.
Thrombocytopenia was observed in 53.6% of
patients with anemia, and anemia was observed in
55.4% of patients with thrombocytopenia. Both ane-
mia and thrombocytopenia developed during chemo-
therapy in 29.9% of all evaluated patients. Grade 3–4
thrombocytopenia was associated with a greater se-
verity of anemia (data not shown).
In the subset of patients with complete transfusion
data (n = 8607), the incidence of RBC transfusions
was relatively low, ranging from 4.5% to 11.6%, with
2430
the highest incidence occurring among patients treated
with platinum-based regimens. Patients with an Hb
<9.0 g/dL accounted for the largest proportion of
RBC transfusions (3.8%–8.9%). Platelet transfusion
was rare, occurring in 2.5% of all patients receiving
chemotherapy.
ESA treatment was received by 49.1% of patients
after the initiation of chemotherapy. Patients with
grade 1–2 anemia, particularly those with an Hb from
≥10 to 11 g/dL, accounted for the largest proportion
of ESA use (25.2%–35.4%). These findings were con-
sistent with anemia treatment guidelines issued up to
2006, which recommended that ESAs be initiated in
patients receiving chemotherapy who have an Hb from
9 to 11 g/dL, with the goal of avoiding the need for
RBC transfusions and improving QOL.15–17 It should
be noted that the time frame of the present study
(2000–2007) antedated major revisions to the clinical
practice guidelines for ESA use.18 The revised guide-
lines recommend use of ESAs (erythropoietin or dar-
bepoetin) in patients with chemotherapy-induced
anemia with an Hb ≤10 g/dL to increase Hb and de-
crease the risk of transfusions. Initiation of ESAs at
higher Hb concentrations should be based on the clini-
cal circumstances, with starting doses and dose modi-
fications made according to the approved labeling.
Although chemotherapy-related anemia and throm-
bocytopenia have been extensively studied, a litera-
ture search revealed little published research on delays
in chemotherapy associated with these common he-
matologic toxicities of chemotherapy using data from
usual community practice. The present study found
that ~1 in 5 patients had cycle delays. Overall, 8.2%
of chemotherapy cycles were delayed for >7 days, with
a mean delay of 17 days. In another observational
study that investigated, among other outcomes, the
incidence of chemotherapy dose modification in pa-
tients with solid cancer, dose delay occurred in 8% of
cycles.19 Although the reasons for such delays are usu-
ally multifactorial, including hematologic toxicities
(anemia, thrombocytopenia, and neutropenia) and non-
hematologic toxicities (nausea, vomiting, and mucosi-
tis), chemotherapy-induced anemia and thrombocy-
topenia may have played an important role. From
50% to 60% of patients in the present study had ane-
mia at some point in their course of therapy. Myelo-
toxicity increases the risk of infection in cancer pa-
tients and interferes with the delivery of full-dose
chemotherapy, which may result in compromised
Volume 31 Theme Issue

outcomes. It has been reported that ~50% of cancer
patients receive <85% of their planned dose of
chemotherapy.20,21 Delays in chemotherapy have also
been reported to negatively affect patients’ well-being22
and to be associated with higher health care resource
use.19 The present study, however, could not assess
whether delays in chemotherapy were associated with
poorer clinical outcomes. More research is needed to
study the clinical and economic consequences of chemo-
therapy cycle delays.
This retrospective study had several limitations
that should be mentioned. First, the data were ex-
tracted from electronic medical records rather than
being prospectively collected. The accuracy and com-
pleteness of the patient information cannot be con-
firmed, as there is always the potential for incorrect
data entry and incomplete or missing data. The study
analyses focused primarily on the incidence and
prevalence of anemia and thrombocytopenia associ-
ated with different types of chemotherapy in patients
with solid tumors; however, it did not take into ac-
count disease severity, coexisting illnesses, treatment
history, or duration of chemotherapy, which may have
had an impact on the outcomes assessed. Further-
more, it did not evaluate neutropenia, which may be
among the main factors leading to cycle delays. Infor-
mation on tumor stage was not available for >60%
of patients in the data set. No distinction was made
between single and combination chemotherapy regi-
mens, and a hierarchy of chemotherapy agents was
used to define the treatment regimens. For instance, if
a patient was treated with a combination gemcitabine–
cisplatin regimen, this patient was included in platinum-
based regimens and excluded from gemcitabine-based
regimens. Therefore, the incidence of anemia and
thrombocytopenia may have been underestimated for
some regimens. The analyses of RBC and platelet
transfusions were based on patient records from a
single site (although the largest) in the database and
limited to 18.3% of the total study population; there-
fore, the study findings may not represent the true
incidence of transfusions. In addition, delays in che-
motherapy cycles were examined in only 55.8% of
patients in the data set for whom complete treatment
information was available.
CONCLUSIONS
This retrospective study of 2000–2007 data from a
community oncology practice database examined the
2009
Y. Wu et al.
incidence and prevalence of anemia, thrombocytope-
nia, RBC and platelet transfusions, and ESA use in
patients undergoing chemotherapy for solid tumors.
The burden of anemia and thrombocytopenia in these
patients remained high.
ACKNOWLEDGMENTS
This study was sponsored by Johnson & Johnson LLP.
Drs. Wu and Aravind are employees of Johnson &
Johnson LLP. The authors have indicated that they
have no other conflicts of interest with regard to the
content of this article.
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2432 Volume 31 Theme Issue