Anemia

Anemia is an abnormally low number of red blood cells in your bloodstream. The low number of these cells means that there is not enough hemoglobin (an iron protein). Hemoglobin is the part of the red blood cell that carries oxygen. With moderate to severe anemia, the body tissues do not get enough oxygen. Anemia can cause many symptoms; the one that bothers people the most is fatigue and weakness.

Other signs of anemia may include:

• Fast heart beat
• Shortness of breath
• Dizziness
• Feeling chilled
• Chest pain
• Swelling in the hands and/or feet
• Pale skin

These symptoms usually occur gradually and get worse as the hemoglobin level gets lower. The hemoglobin level is measured in a blood sample, and the level will be measured periodically during cancer treatment; if the level is too low, treatment may be delayed until the level increases. Among people with cancer, anemia is usually defined as a hemoglobin level of 10.0 gm/dL (mild anemia); lower levels are considered to be moderate or severe anemia.

Anemia is most likely to occur in people who receive chemotherapy that includes a platinum drug such as cisplatin (Platinol) or carboplatin (Paraplatin). Radiation therapy also increases the risk of anemia when it’s directed at certain bones rich in bone marrow (such as the pelvis and sternum). People who receive both types of treatment are at greater risk. The hemoglobin may decrease in people who have had extensive surgery, especially if severe bleeding occurred.

Red blood cells divide and grow rapidly (as do cancer cells) and thus may be damaged by chemotherapy and radiation therapy. Also, some chemotherapy drugs and radiation therapy can disrupt processes in the bone marrow, where new red blood cells are made. Chemotherapy drugs with platinum may cause damage to tissues in the kidneys that help produce erythropoietin, a hormone that helps new red blood cells to grow. Lastly, bleeding that occurs during surgery may cause anemia if red blood cells were lost more quickly than they could be made.

Anemia related to blood loss during surgery occurs within hours to days of the surgery. Anemia related to chemotherapy or radiation therapy can occur any time during treatment. Anemia is usually corrected within 1-2 weeks after treatment ends.

Anemia may be managed in several ways and depends on the cause. The goal is to increase the hemoglobin level, and this will alleviate symptoms. Management may include increasing the iron and folic acid in your body; blood transfusions; and growth factors, drugs that stimulate the production of new red blood cells. Managing anemia also includes ways to deal with fatigue (see page 8 for tips on this).

Increasing the amount of iron in your body may help correct your anemia. Iron can be increased by iron supplements or by eating foods high in iron, which include green, leafy vegetables; dried fruit; seafood, chicken, and beef; eggs; and nuts. Your doctor may tell you to take an iron supplement. This supplement is available over-the-counter, but you should not take it unless your doctor tells you to.

Blood transfusions are usually done when the hemoglobin is very low (usually around 8 g/dL), but your doctor will decide what level is most appropriate to treat in your individual case. Transfusions increase the hemoglobin level quickly, but there are some risks. The most common risk is transfusion reaction, which is usually minor but can be more serious. Better screening of donated blood has made it very uncommon for infection with hepatitis B or human immunodeficiency virus (HIV) to occur after a blood transfusion.

Red blood cell growth factors include epoetin (Epogen or Procrit) and darbepoetin (Arenesp). These drugs can reduce the need for blood transfusions, but there are risks involved and they are not appropriate for everyone. Your doctor will determine if a growth factor is right for you. Growth factors work much more slowly than blood transfusions and it is usually at least 2 weeks before they start working.

Talk to your doctor about the risk of anemia when discussing treatment options; ask about the likelihood of anemia with the types of chemotherapy your doctor plans to prescribe, or the risks of severe bleeding during a planned surgical procedure. You should call your doctor’s office if you feel extremely tired and weak, even after following suggestions on how to conserve energy.

Call your doctor immediately if you have one or more of these signs of anemia:

• Dizziness
• Shortness of breath or difficulty breathing
• Rapid heartbeat, heart palpitations, or chest pain

• American Cancer Society: www.cancer.org, Anemia in People with Cancer
• American Society of Clinical Oncology's patient Web site: www.cancer.net
  What to Know: ASCO's Guideline on Epoetin and Darbepoetin Treatment
• Oncology Nursing Society: www.cancersymptoms.org
  Cancer and Chemotherapy-Induced Anemia and Fatigue
• National Cancer Institute: www.cancer.gov