Standards, Options:: Recommendations for the use of erythropoiesis-stimulating agents (ESA: epoetin alfa, epoetin beta, darbepoetin) in anaemic patients with cancer:: 2007 update

Introduction : Since 1998, a working group of specialists set up by the guidelines department (Standards, Options and Recommendations: SOR) from the National French Federation of Comprehensive Cancer Centres (FNCLCC) published then updated regularly recommendations relative to the use of ESA in anaemic patients with cancer. The systematic monitoring process realized in 2006 has permitted the identification of new data non concordant with the last actualization of 2003, conferring thus sufficient indices to consider modifications in the existing recommendations. This work was performed in collaboration with specialists from university or general hospitals and private clinics, and with the French National Cancer Institute. This article presents a short version of the updated 2007 recommendations. Methods:This updating process is based on the methodology developed and used in the "Standards, Options, Recommendations" programme. The methodological approach combines systematic review with multidisciplinary group of experts' judgement. On the basis of literature analysis, the conclusions and their level of evidence are established. The level of evidence is a function of the type and the quality of the studies available as well as agreement or not of their results; it is explicitly specified for each outcome-clinical question considered. A recommendation is a proposal of one or several clinical attitudes intended to improve cancer patient care. There are two levels of gradation for the recommendations: Standards and Options. Their setting takes into account the organisational context of care, the particular situation of the patient and the expression of his preferences. Before publication, the RPC-SOR are re-examined by independent reviewers selected according to the same principle as the group of experts' writers. Results: New data are sufficiently important to update the last recommendations validated in 2003. Thus, five clinical questions were updated: use of ESA in anaemia treatment among adult patients with cancer; use of ESA in anaemia prophylaxis among adult patients with cancer; use of ESA in cancer patients undergoing surgery; use of ESA in children with cancer; use of iron with ESA in cancer patients. The resulting modifications were either major (new options or new standards) or minor (increased level of evidence). It should be noted that for the clinical question - use of ESA in radiotherapy - new data are not sufficient to generate modifications in the initial recommendations, which remain valid. Conclusions : Because of the important new data published on the subject between 2003 and 2007, it appears relevant to re-examine these recommendations within a systematic monitoring process, which should be set up in 2009.