Is Retacrit (epoetin alfa) beneficial in patients with a history of breast cancer?

Retacrit (Epoetin Alfa) in Patients with History of Breast Cancer

Retacrit (epoetin alfa) is not recommended for patients with a history of breast cancer due to increased mortality risk, particularly in those with curative treatment intent. 1, 2

Risk Assessment for ESA Use in Breast Cancer Patients

• ESAs like Retacrit (epoetin alfa) have been associated with an increased risk of death in breast cancer patients (odds ratio 1.20; 95% CI 1.03-1.40) based on meta-analyses of randomized controlled trials 1

• The 2016 noninferiority trial by Leyland-Jones et al. specifically studying epoetin alfa in metastatic breast cancer patients concluded that "RBC transfusion should be the preferred approach for the management of anemia during first- or second-line chemotherapy for metastatic breast cancer" 1, 3

• FDA-approved labels contain boxed warnings indicating ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure 1, 2

Treatment Intent Considerations

• ESAs should not be offered to patients with chemotherapy-associated anemia whose cancer treatment is curative in intent (Strong recommendation with intermediate quality evidence) 1

• For patients with non-curative treatment intent who develop anemia:

  • RBC transfusion is the preferred approach for managing anemia in breast cancer patients 1, 3
  • If ESAs must be considered in advanced metastatic settings, they should be used with extreme caution after careful risk-benefit assessment 1

Specific Risks of ESAs in Breast Cancer

• ESAs increase the risk of thromboembolic events in cancer patients 1, 2

• In a randomized placebo-controlled study of women with metastatic breast cancer, epoetin alfa was associated with:

  • Higher mortality at 4 months (8.7% vs 3.4%)
  • Higher rate of fatal thrombotic reactions (1.1% vs 0.2%)
  • Lower 12-month survival (70% vs 76%; HR 1.37,95% CI: 1.07-1.75) 2

• Decision models suggest that while ESAs may increase quality-adjusted life years, they decrease overall life years in both curative and non-curative settings 1

Potential Limited Benefits

• ESAs do reduce the need for RBC transfusions in cancer patients 1

• Meta-analyses show statistically significant reductions in fatigue with ESA use, but the effect sizes were small and unlikely to be clinically important 1

• Some studies have shown improvements in hemoglobin levels and quality of life measures with epoetin alfa in breast cancer patients receiving chemotherapy 4, 5, 6, but these benefits are outweighed by mortality risks

Clinical Approach to Anemia in Breast Cancer Patients

• For patients with history of breast cancer requiring anemia management:

  • Prioritize RBC transfusions over ESAs, especially during first- or second-line chemotherapy 1, 3
  • Consider underlying causes of anemia (iron deficiency, tumor progression) before attributing to chemotherapy effects 1
  • If ESA must be considered (only in non-curative settings), initiate only when hemoglobin has declined to <10 g/dL 1

• Monitor for thromboembolic events if ESAs are used, particularly in patients with additional risk factors (history of thrombosis, surgery, immobilization) 1

Conclusion

The evidence strongly suggests that Retacrit (epoetin alfa) should be avoided in patients with a history of breast cancer due to increased mortality risk, particularly in those with curative treatment intent. RBC transfusion remains the preferred approach for managing anemia in these patients.