Anemia has also been identified as an adverse prognostic factor
mild (10 g/dl—normal),
moderate (8–10 g/dl), severe (6.5–8 g/dl) and life threatening (<6.5 g/dl or unstable patient) anemia
anemia in cancer patients is often multifactorial.
Cancer itself can directly cause or exacerbate anemia either by suppressing hematopoiesis through bone marrow infiltration
or production of cytokines that lead to iron sequestration, or by reduced red blood cell production
in inflammatory anemia, iron deficiency should be defined by a low transferrin saturation
of <20%, ferritin levels of <100 ng/ml and a low reticulocyte hemoglobin concentration of <32 pg
anemia to thrombocytosis, as commonly
seen in cancer patients
TNF-α inhibits hemoglobin production
treatment
itself may be a major cause of anemia
Other cytokines, such as interleukin-6 (IL-6), IL-1 and interferon-γ, have also been shown to inhibit erythroid precursors
in vitro [9], albeit to a lesser extent
In inflammation, from whatever cause, IL-6 induces the liver to produce hepcidin. Hepcidin decreases iron absorption from
the bowel and blocks iron utilization in the bone marrow
Numerous in vitro studies have illustrated the central role of TNF-α in the pathogenesis of anemia
nephrotoxic effects of particular cytotoxic agents such as platinum salts can also lead to the persistence
of anemia through reduced Epo production by the kidney
Currently two options are at the disposal of the clinician for the treatment of anemia in cancer patients: transfusion of
packed red blood cells and the use of erythropoiesis-stimulating agents (ESAs)
The goal of the treatment is to relieve the
symptoms of anemia such as fatigue and dyspnea.
Transfusion of 1 unit of packed red blood cells has been estimated to result
in an increase in the hemoglobin level of 1 g/dl in a normal-sized adult
a higher mortality rate in patients receiving
ESA treatment
Recent concerns regarding the risk of thromboembolism in patients treated with ESA have been corroborated by the meta-analyses
conducted by Tonnelli and Bennett
Great review of anemia in Cancer:
1) blood loss
2) increased RBC loss
3) decreased RBC production
Cancer infiltration of marrow can reduce hematopoiesis. Inflammatory cytokines can reduce hematopoiesis. Inflammatory cytokines can block Fe absorption. Chemo and radiation can cause anemia--particularily platinum based therapies.
The authors are referencing the increase in the suggestions to use other testing techniques i.e. saliva.
Testosterone therapy can inhibit hepcidin transcription and is associated with increased iron incorporation into red blood cells and increased erythropoietin concentrations
Transdermal TRT has a more favorable adverse effect profile when compared to buccal testosterone formulations
Approximately 0.3% of testosterone is converted into estradiol by aromatase (CYP19A1)
the recommendation for injectable testosterone esters is to check the serum concentration midway between injections
it is recommended for serum testosterone to be evaluated 3 to 12 hours after application of the transdermal patch
testosterone concentrations should be checked 2–3 months after initiation of therapy and after adjusting the dose
a study from 1989 utilizing testosterone transdermally containing 5, 10, or 15 mg of testosterone showed that peak concentrations of testosterone were achieved 3 to 8 hours after scrotal application in hypogonadal men
It is used for many medications and has the advantage of high bioavailability, absence of hepatic first pass metabolism, increased therapeutic efficacy, and steadiness of plasma concentrations of the drug
evaluate serum testosterone at the end of the dosing interval for testosterone pellets
increased amount of fat leads to increased extragonadal aromatase activity, resulting in increased concentrations of estradiol. High circulating concentrations of estradiol down regulate the HPG axis and decrease the amount of circulating testosterone
Up to 80% of plasma estradiol originates from aromatization of testosterone and less than 20% of estradiol in the circulation is secreted by the testes
A PSA concentration, digital rectal examination, and hematocrit should be performed at baseline and at 3 months, 6 months, then yearly after TRT is initiated.
measure serum testosterone any time after the patient has been on treatment with gel for at least 1 week
If the hematocrit rises above 54%, treatment should be discontinued
elderly men having higher estradiol serum concentrations than postmenopausal women