Hemoglobin (Hb) estimation is an important parameter in patients suffering from cancer. Cancer-induced anemia, mainly categorized as anemia of chronic disease, is often seen before or during the diagnosis of the underlying malignancy [1]. Up to 39% of cancer patients present with anemia at the time of diagnosis of which 40% have iron deficiency. Also, up to 53% of patients who do not present with anemia at diagnosis develop it during therapy like chemotherapy (CT) and/or radiotherapy (RT) treatment, so up to 67% of cancer patients will have anemia at some time during the evolution of their disease and therapy [2].
Anemia is associated with easy fatiguability, shortness of breath, weakness, lethargy, and reduced quality of life (QoL). Retrospective data analysis from patients with hematological malignancies and solid tumors indicates that a low baseline hemoglobin level is a prognostic marker that is associated with poor outcomes, though there is a dearth of prospective data [3]. Patients planned for surgery need to have an optimized level of hemoglobin to achieve adequate oxygen delivery to tissue due to increased demand, wound healing, and enhanced recovery after surgery.
The pathogenesis of anemia in cancer patients is complex and multifactorial, with iron deficiency (ID) often being a major and potentially treatable entity. ID in cancer patients can be due to multiple overlapping mechanisms, like bleeding (e.g., in gastrointestinal/hepato-pancreaticobiliary cancers or surgery), malnutrition, and medications [4].
However, not all causes are of equal importance in different cancers overt or occult bleeding and iron deficiency are often prominent in gastrointestinal, urogenital, and gynecological tumors, while bone marrow replacement by metastases is relatively frequent in breast and prostate cancer [5].
Given the significant impact of anemia on quality of life (QoL), disease progression, prognostication, and survival in cancer patients, adequate treatment strategies are of paramount importance. Several studies have shown that the treatment of cancer anemia determines a marked improvement in QoL, particularly among patients with mild-to-moderate anemia [6].
References:
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2. Escobar Álvarez Y, de las Peñas Bataller R, Perez Altozano J, Ros Martínez S, Sabino Álvarez A, Blasco Cordellat A, et al. SEOM clinical guidelines for anemia treatment in cancer patients (2020). Clinical and Translational Oncology. 2021 Mar 25;23(5):931–9.
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Anemia can be suspected and diagnosed from a thorough history taking and physical examination followed by blood tests. History of frank bleeding- per rectum or heavy menstruation, black stool, particular food habits, fatty stool with foul smell, recent abdominal surgeries, family history of disease like hemoglobinopathies, and any medication intake that can contribute to reduced hemoglobin production.
Mild anemia is generally asymptomatic; when upstaged to moderate or severe cases it can cause tiredness, lethargy, leg pains especially at night, shortness of breath to near syncope. More severe cases can present with chest pain and reduced exercise tolerance.
To diagnose anemia doctors generally suggest blood test for CBC which includes hemoglobin level measurement and hemoglobin lower than normal for age and sex confirms anemia. Other blood parameters like MCV, MCH, Reticulocyte count, serum ferritin, vitamin B12, or folate level help in further classification. The doctors or health care providers can also estimate hemoglobin levels from lower lid conjunctival examination, the color of the palm, nail, and tongue which is further corroborated by the blood tests.
In the case of management medicines along with proper dietary supplements are prescribed depending on the severity of anemia. A diet consisting of meat in regulated amounts and a vegetarian diet that includes legumes, fortified or whole grains, dried fruit, nuts, seeds, and green vegetables easily provides adequate iron that can improve hemoglobin levels. Vitamin C helps to increase dietary iron absorption and excessive consumption of tea or coffee, as these can decrease iron absorption. correction of anemia requires proper treatment and follow-up under strict supervision of doctors and healthcare providers. Organized collaboration among patients, family members, and healthcare providers including doctors and policymakers can provide promotive, protective, curative, and rehabilitative care for anemia affecting 1.8 billion people worldwide.
Reference:
1. https://www.ncbi.nlm.nih.gov/books/NBK499994/
2. Rizzo NS, Jaceldo-Siegl K, Sabate J, et al. Nutrient profiles of vegetarian and nonvegetarian dietary patterns. J Acad Nutr Diet. 2013;113(12):1610-9. [PMID:23988511]
4. https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(23)00171-0/fulltext
45-year-old MNC executive, Evelyn, fell asleep on the steering wheel on her way back home from work, just in time so that she could somehow stop the car avoiding any untoward accident. She felt lethargic for the last 1-2 months, which she felt was due to exertion at work. She was rescued and taken to the nearby hospital by local people. She was examined and advised for a complete blood count the next day by the attending physician. She was taken aback to find that her Hb was 7.0 gm /dl. All this while she had the notion that anemia is attributed to poor diet and is associated with low socioeconomic conditions or seen in only severely sick and debilitated persons. The burden of anemia is widespread, and most of the population can see only the iceberg of the problem. It’s about time that we get our facts right.
Global Prevalence of Anemia in Different Demography As per WHO Global Database on Anemia, globally, anemia affects 1.62 billion people, which corresponds to 24.8% of the population.
The highest prevalence is among preschool-age children. Worldwide, 47.4% of preschool children, 41.8% of pregnant women, and 30.2% of non-pregnant women are anemic. Anemia associated with pregnancy is the leading cause of morbidity and mortality of pregnant women in developing countries affecting both maternal and fetal health outcomes. For pregnant women, in over 80% of the countries, anemia poses a moderate to severe public health problem. Globally, anemia is estimated to cause more than 115,000 maternal and 591,000 perinatal deaths annually.
Common etiological factors of anemia include nutritional deficiencies, infections, inflammatory diseases, and hemoglobinopathies. Iron deficiency anemia was estimated to account for 22% of maternal deaths in 2019. The population groups at risk of developing anemia comprise children under 5 years of age, especially infants and children under 2 years of age, menstruating adolescent girls, and pregnant and postpartum women.
Global estimates state that anemia affects half a billion women between 15–49 years of age and 269 million children aged 6–59 months. In 2019, anemia was estimated to affect 30% (539 million) of non-pregnant women and 37% (32 million) of pregnant women 15–49 years of age. The most affected areas worldwide include WHO Regions of Africa and South-East Asia wherein 106 million women and 103 million children are anemic in Africa and 244 million women, and 83 million children affected in South-East Asia.
The prevalence of anemia in women 15–49 years of age, based on pregnancy status, is indicator numbered 2.2.3 of the UN Sustainable Development Goals, and the aim of reducing the anemia prevalence by half in women of reproductive age by 2030 is a continuation of the 2025 global nutrition targets endorsed by the World Health Assembly (WHA).
How to detect anemia: Early detection is indispensable to tackle this grave public health problem which affects populations in both developed and developing nations. Anemia can be suspected and diagnosed from a thorough clinical history and physical examination followed by blood tests. History of frank bleeding- per rectum or heavy menstruation, black stool, particular food habits, fatty stool with foul smell, recent abdominal surgeries, family history of diseases like hemoglobinopathies, and any medication intake that contributes to reduced hemoglobin production.
When to suspect: Mild anemia is generally asymptomatic; when upstaged to moderate or severe cases it can cause tiredness, lethargy, leg pains especially at night, shortness of breath to near syncope. More severe cases can present with chest pain and reduced exercise tolerance.
To diagnose anemia doctors generally suggest a Complete Blood Count (CBC) which includes hemoglobin level measurement and hemoglobin lower than normal for age and sex confirms anemia. Other blood parameters like MCV, MCH, Reticulocyte count, serum ferritin, vitamin B12, or folate level help in further classification. The doctors or health care providers can also estimate hemoglobin levels from lower lid conjunctival examination, the color of the palm, nails, and tongue which is further corroborated by the blood tests.
A novel smartphone-based application NiADA developed by Monere Corp. strives to employ Artificial Intelligence technology to detect anemia, by capturing inner eyelid images to give instant results on hemoglobin estimation. Early detection of anemia using a non-invasive technique promises to go a long way in reducing the burden of anemia prevalence among different age groups worldwide.
Management of anemia: Therapeutic interventions along with proper dietary supplements are prescribed depending on the severity of anemia. A diet that comprises meat, of course in regulated amounts, and a vegetarian diet that includes legumes, fortified or whole grains, dried fruit, nuts, seeds, and green vegetables easily provides adequate iron and thereby can improve hemoglobin levels. Vitamin C helps to increase dietary iron absorption while excessive consumption of tea or coffee can decrease iron absorption. Correction of anemia requires proper treatment and follow-up under strict supervision of doctors and healthcare providers. Organized collaboration among patients, family members, and healthcare providers including doctors and policymakers can provide promotive, protective, curative, and rehabilitative care for anemia which has affected 1.8 billion people worldwide.
REFERENCES:
[1] WHO/CDC. Worldwide Prevalence of Anemia 1993–2005: WHO Global Database on Anemia. Geneva, Switzerland: WHO Press; 2008.
[2] Akhtar M, Hassan I. Severe Anemia during late pregnancy. Case Reports in Obstetrics and Gynecology. 2012;2012:3 pages.485452
[3] Vivek RG, Halappanavar AB, Vivek PR, Halki SB, Maled VS, Deshpande PS. Prevalence of Anemia and its epidemiological. Determinants in Pregnant Women. 2012;5(3):216–223.
[4] Salhan S, Tripathi V, Singh R, Gaikwad HS. Evaluation of hematological parameters in partial exchange and packed cell transfusion in treatment of severe anemia in pregnancy. Anemia. 2012;2012:7 pages.608-658
[5] Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann NY Acad Sci. 2019;1450:15–31.
[6] Murray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223–1249.
[7]Anaemia [website]. Geneva: World Health Organization; 2023 (https://www.who.int/ healthtopics/anaemia).
[8] UNGA Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. March, 2020.
[9] https://www.ncbi.nlm.nih.gov/books/NBK499994/
[10] Rizzo NS, Jaceldo-Siegl K, Sabate J, et al. Nutrient profiles of vegetarian and nonvegetarian dietary patterns. J Acad Nutr Diet. 2013;113(12):1610-9. [PMID:2398851
[12] https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(23)00171-0/fulltext