A systematic scoping review of cancer-related anemia treatment: Comparative trial outcomes, current guidelines, and...

Cancer-related anemia (CRA) adversely affects quality of life and clinical outcomes. Despite extensive research, uncertainty remains regarding the optimal use of erythropoiesis-stimulating agents (ESAs), iron, and transfusions. This scoping review synthesizes efficacy and safety evidence and compares international management guidelines.

A systematic search of PubMed and Embase identified English-language studies on CRA published from 2000 up to November 30, 2024. Randomized controlled trials were reviewed to assess treatment efficacy and safety, and international guidelines were analyzed to compare management recommendations.

Fifty-six randomized controlled trials and 10 international guidelines were included. ESAs and iron supplementation were effective in improving hemoglobin concentration and reducing transfusion requirements, particularly in context-dependent settings. Combination therapy with ESAs and iron consistently demonstrated superior hematologic responses compared with ESA monotherapy without additional safety concerns. Both conventional and newer intravenous (IV) and oral iron formulations showed benefit across different clinical contexts, with faster responses generally favoring IV iron in some settings, while emerging evidence supports oral iron as a viable alternative in absolute iron deficiency. Emerging therapies, including sotatercept and selected adjunctive approaches, showed preliminary signals of efficacy in limited studies, warranting further investigation. Guidelines generally restrict ESAs to chemotherapy-induced anemia or high-risk patients. For iron therapy, discrepancies exist regarding indications and administration route; most guidelines prioritize IV over oral iron for both functional iron deficiency and absolute iron deficiency. Significant regional gaps in guideline availability were identified, particularly in Africa, South America, Asia-Pacific, and the Middle East.

CRA management relies on ESAs, iron supplementation, and transfusions, but guideline heterogeneity and regional discrepancies necessitate harmonization and individualized approaches. Updated, globally representative recommendations and further research in under-studied populations are essential.