2. “In anemia of chronic disease, hemoglobin levels are usually 8 grams or greater and are not associated with any symptoms unless there is significant underlying lung or heart disease. Therefore, no treatment is necessary. The main importance of the anemia of chronic disease is as a clue to the existence of that underlying disease. Treatment of the secondary anemia does not alter that disease” -Medical School Classnotes, 1976

3. Toxicity Grading Systems for Anemia GradeWHO NCI ECOG SWOG CALGB GOG 0  11 WNL WNL WNLWNL WNL 1 9.5–10.9  10.0  10.0  10.0  10.0  10.0 2 8.0–9.4 8.0–10.08.0–10.0 8.0–9.9 8.0–10.0 8.0–10.0 3 6.5–7.9 6.5–7.96.5–7.96.5–7.96.5–7.9 6.5–7.9 4 <6.5<6.5<6.5<6.5<6.5<6.5 Values are hemoglobin in g/dL WHO = World Heatlh Organization; NCI = National Cancer Institute; ECOG = Eastern Co-operative Oncology Group; SWOG = Southwest Oncology Group; CALGB = Cancer and Leukemia Group B; GOG = Gynecologic Oncology Group; WNL = within normal limits

4. Incidence of Anemia in Cancer Patients Cancer 37.5 39.5 43.9 40.0 41.1 25.9 39.5 16.3 8.4 14.1 14.0 4.9 8.3 12.4 0 5 10 15 20 25 30 35 40 45 50 Lung Cancer Metastatic Breast Cancer Advanced Ovarian Cancer LymphomasAdvanced Colorectal Advanced Head and Neck Total Anemia Grade 1 or 2Anemia Grade 3 or 4 Patients (%) Source: Groopman JE, Itri LM. J Natl Cancer Inst. 1999;91:1616–1634.

5. Treatmentn Anemia Grade 1–2 (%) Anemia Grade 3–4 (%) Docetaxel34 37 97 NR 0 14 (grade 3) Paclitaxel30937 (grade 3) Vinorelbine59 143 67 71 14 5 Groopman. J Natl Cancer Inst. 1999;91:1616. Incidence and Severity of Anemia in Previously Untreated Patients With Breast Cancer NR = not reported Single-Agent Chemotherapy

6. Treatmentn Anemia Grade 1–2 (%) Anemia Grade 3–4 (%) Cyclophosphamide + Doxorubicin + 5-Fluorouracil + Methotrexate 266271 (grade 3) Paclitaxel + Doxorubicin 9 25 78 84 11 8 Cisplatin + Epirubicin + Paclitaxel 63NR25 Groopman. J Natl Cancer Inst. 1999;91:1616. Frasci. Breast Cancer Res Treat. 1999;56:239. Incidence and Severity of Anemia in Previously Untreated Patients With Breast Cancer Combination Chemotherapy

7. Lawless. Blood. 2000;96(11 suppl 2):(abstr 5447). Incidence of Anemia in Patients With Breast Cancer Cumulative Anemia in Patients With Breast Cancer Receiving AC AC = doxorubicin + cyclophosphamide Hb = Hemoglobulin Cyclen Hb  10 g/dL Prechemotherapy (% patients) Hb  10 g/dL Postchemotherapy (% patients) 15362.7 4.2 25303.69.3 35285.816.1 45186.5 24.2 Combination Chemotherapy

8. Anemia in Oncology: A Historical Perspective  1901-1990 –Focus on severe anemia (Hb < 8.5 gm/dl) –Red cell transfusion therapy  1991-1997 –rHuEPO to decrease transfusions –Focus on severe anemia  1997-2002 –Mild and moderate anemia recognized as QOL drivers –rHuEPO to improve QOL  Future –New insights (schedule, cost savings, Fe) –New endpoints (cognition, survival, cost-effectiveness)

9. Anemia Rx and QOL During Cancer Chemotherapy Glaspy Open-label YesLASA (1997) Demetri Open-label YesLASA, FACT-An (1998) Gabrilove Open-label YesLASA, FACT-An (2001) LittlewoodRandomised,YesLASA, FACT-An, (2001)placebo-controlled FACT-F, SF-36 Österborg Randomised,YesFACT-G, FACT-F, (2002)placebo-controlled FACT-An Boogaerts RandomisedYesFACT-G, FACT-F, (2002) FACT-An, SF-36 PirkerRandomised,YesFACT-F (2002)Placebo-conrolled QOL impactTrial typeStudyQOL tool(s)

10. Cross-Sectional Community Study 1and 2

11. Cross-Sectional Cut by Gender Community Study 2

12. Cancer Patients are Human

13. Critical Issues for BCIRG - 2002 Is there a biological basis for questioning the role of anemia in the progression of chronic diseases? Are there appropriate mechanistic models suggesting that anemia may impact the survival of cancer treated with: Radiotherapy? Chemotherapy? Observation/Palliation? Is it time for clinical trials?

14. Etiology of the Anemia of Cancer (Anemia of Chronic Disease) AIS = anemia-inducing substance; BFU-e = erythroid burst-forming unit; CFU-e = erythroid colony-forming unit; EPO = erythropoietin; IFN = interferon; IL-1 = interleukin-1; RBCs = red blood cells; TNF = tumor necrosis factor. Nowrousian M, et al. In: Smyth J, Boogaerts M, Ehmer B. rhErythropoietin in Cancer Supportive Treatment. New York, NY: Marcel Dekker Inc.;1996:13–34. ANEMIA Shortened survival AIS RBCs Reduced EPO production Impaired iron utilization Suppressed BFU-e CFU-e TNF Erythrophagocytosis Dyserythropoiesis IFN-  IL-1 TNF  1 -antitrypsin IFN-  IL-1 TNF IL-1 ,  TNF Activated immune system Macrophages Tumor cells

15. Anemia of Chronic Disease: Traditional Model Disease AnemiaDiseaseProgression InflammatoryFactors

16. Anemia of Chronic Disease: Novel Model Disease Anemia DiseaseProgression InflammatoryFactors

17. Median survival times for anemic and non-anemic patients Caro et al. Cancer 2001; 91: 2214-21 0 25 50 75 100 125 150 0255075100125150 Non-anemic (months) Anemic (months) Lung Ovarian Head & neck Prostate Lymphoma Leukaemia Other Multiple myeloma Colorectal Ampulla vater Mesothelioma Renal Metastatic transitional Cervix

18. Possible Mechanisms of Decreased Survival by Anemia Effects on the tumor –Increased angiogenesis –Decreased p53 –Resistance to apoptosis Effects on the treatment –Radiation therapy - oxygen radicals –Chemotherapy - oxygen radicals and resistance mutations Efffects on the host –Reduced tolerance of therapy –Reduced QOL –Reduced immune function

19. Relative Radiosensitivity Oxygen Tension (mm Hg at 37°C) 10 1.0 1.5 2.0 2.5 3.0 203040506070155760 Air 100% Oxygen Relative Radiosensitivity Versus Oxygen Tension Hall. Radiobiology for the Radiologist. 4th ed. 1994:133. 3 mm Hg Or About 1/2% Venous End Arterial End 70µ < 70µ Normoxic Hypoxic Viable Anoxic Cells

20. Frequency (%) Oxygen Partial Pressure (mm Hg) Tumorous CervixNormal Cervix Kallinowski et al. Int J Radiat Oncol Biol Phys. 1990;19:953. Oxygenation Of Tumorous And Normal Cervical Tissue

21. P=.02 Median pO 2  5 mm Hg (N = 35) Median pO 2 <5 mm Hg (N = 39) Oxygenation Associated With Disease-Free Survival After Radiation: Cervical Cancer Fyles et al. Radiother Oncol. 1998;48:149.

22. Hemoglobin Level Associated With Oxygenation And Disease Control: Cervical Cancer Hemoglobin (g/dL) <13  13 P Value Number of patients3319— Mean pO 2 (mm Hg)12.4 ± 10.728.1 ± 24.8.003 1-year treatment failure56%22%.046 Strauss et al. Int J Radiat Oncol Biol Phys. 1999;45(3S):364.

23. Importance Of Hemoglobin Level During Radiotherapy For Cervical Cancer 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0123456 Survival (%) Year Grogan et al. Cancer. 1999;86:1528. B: L  H D: H  H A: L  L C: H  L L: Hb <120 g/L H: Hb  120 g/L P<.0002

24. Median pO 2 (mm Hg) P <.0001 Tumor Oxygenation Associated With Hemoglobin Level: Head And Neck Cancer Hb <11.0 g/dL (N = 20) Hb  11.0 g/dL (N = 113) Becker et al. Int J Radiat Oncol Biol Phys. 2000;46:459.

25. Anemia Is Associated With Decreased Survival: Head And Neck Cancer Hb >13 g/dLHb <13 g/dLP Value Median pO 2 >10 mm Hg16/383/25.04 3-year locoregional control73%30%.01 3-year disease-free survival73%26%.005 3-year survival83%35%.02 Brizel et al. Radiother Oncol. 1999;53:113. pO 2 >10 mm Hg pO 2 <10 mm Hg P Value

26. Months After Treatment Overall Survival (%) Hb  14.5 g/dL Hb <14.5 g/dL + rHuEPO Hb <14.5 g/dL No rHuEPO Hb  14.5 g/dL vs Hb <14.5 g/dL No rHuEPO.04 Hb <14.5 g/dL No rHuEPO vs Hb <14.5 g/dL + rHuEPO.001 Hb  14.5 g/dL vs Hb <14.5 g/dL + rHuEPO.7 Effect Of Chemoradiotherapy And rHuEPO On Survival: Head And Neck Cancer Glaser et al. Int J Radiat Oncol Biol Phys. 2001;50:705. Comparison GroupsP Value

27. For Many Chemotherapy Drugs, the Effects of Hypoxia are as Profound as for Radiotherapy Treatment Oxygen enhancement ratio Teicher et al. Cancer Res 1990; 50: 3339–44 Cyclophosphamide BCNU Carboplatin Melphalan Antibiotics Alkylating agents Adriamycin Mitomycin C Antimetabolite5-Fluorouracil X-rays 6.3 3.2 2.4 2.2 0.3 2.3 2.8

28. 2.5 0 0 * p<0.05, **p<0.01 Anemic versus non-anemic animals Adapted from Thews et al. Cancer Res 2001; 61: 1358–61 Tumour volume (mL) 2.0 1.5 1.0 0.5 211512963 Days Cyclo- phosphamide 60 mg/kg i.p. Non-anaemic Anaemic Non-anaemic control (untreated) Anaemic + rhEPO * ** * Anemia and Chemotherapy: Murine Fibrosacoma Model 18 *

29. Anemia/Hypoxia Interacts with the Heregulin/HER2 Pathway in VEGF Induction Laughner E et al. Mol Cell Biol. 2001;21;3995-4004. Hypoxia Ubiquitination and degradation VEGF gene expression VHL p53/MDM2 32 X Akt S6KBad PI(3)K HIF-1  protein HIF-1  mRNA PTEN HIF-1  protein Anemia

30. Source: Ania et al. J AM Ger Soc. 1997;45:825. 0 0 Survival (%) Expected Observed Time Period (yrs) 100 80 60 40 20 1234576 Observed and expected survival among Olmstead County, Minnesota, 618 residents (  65 YOA) with anemia first recognized in 1986. Anemia and Survival in Geriatrics

31. Higher Hct Associated with Lower Mortality in ESRD Patients 1.33 1.12 1.00 0.96 1.25 1.11 1.00 0.97 0 0.2 0.4 0.6 0.8 1 1.2 1.4 <2727 to <3030 to <3333 to <36 Hct (%) *Relative Risk (RR) All-cause death Cardiac-related death N = 75,283 *After adjustment for medical diseases. Source: Ma JZ et al. J Am Soc Nephrol. 1999;10:610–619.

32. Anemia, rHu-EPO and Survival in a Murine Myeloma Model: Interaction of Anemia and Host Defense 20 30 40 50 60 70 80 Survival % control rhEPO 100806040200100806040200 Days post tumor challenge Anti-CD8mAb + rhEPO Normal + rhEPO Mittelman et al. PNAS 2001; 98: 5181–6 Anti-CD4mAb + rhEPO 100806040200100806040200 20 30 40 50 60 70 80 Days post tumor challenge

33. Years Dancey et al. Qual Life Res 1997; 6: 151–8 0 20 40 60 80 100 0.00.51.52.02.53.03.54.0 Global QoL score <60 1.0 Patients (%) Global QoL score  60 QoL and survival of cancer patients

34. MDS = myelodysplastic syndrome. Ludwig et al. Ann Oncol. 1993;4:161. The Old Responder’s Analysis Patients with advanced stages of selected hematologic malignancies and solid tumors (N = 42); Hb <11 g/dL Criteria –rHuEPO 150 IU/kg TIW in all patients; increased to 300 IU/kg at week 6 if no response –response at least 2 g/dL from initial baseline level Response –77% multiple myeloma, 10% MDS, 44% breast, 40% colon Survival in nonresponders (9.2 months) significantly shorter than in responders (28 months) (P<.005)

35. Littlewood, et. al. JCO 19:2865, 2001. Randomized Placebo-Controlled QOL Trial

36. Littlewood, et. al. JCO 19:2865, 2001. Randomized Placebo-Controlled QOL Trial

37. Littlewood, et. al. JCO 19:2865, 2001. Randomized Placebo-Controlled QOL Trial

38. Effect Of Anemia Therapy On Disease Progression: Lung Cancer Cumulative % Cumulative % 100 80 60 40 20 0 16111621263136414651586166 100 80 60 40 20 0 16111621263136414651586166 Study Week Pirker et al. Presented at ASCO; May 12-15, 2001; San Francisco, CA. NOTE: The median length of follow-up was approximately 1 year, with a minimum length of follow-up of approximately 6 months from study day 1. Small-Cell Lung Cancer Non-Small-Cell Lung Cancer Placebo23.0 Weeks Darbepoetin34.0 Weeks Median Time To Disease Progression Placebo19.0 Weeks Darbepoetin20.5 Weeks Median Time To Disease Progression

39. Conclusions Anemia and tissue hypoxia may impact the progression of chronic diseases, including cancer. There are mechanistic models which suggest that treatment for anemia may improve survival outcomes in cancer treated with: –Existing “targeted” therapies such as anti-HER2 and anti-VEGF –Radiotherapy –Chemotherapy (including alkylators and antibiotics) –Immunotherapy –Observation

40. Conclusions Survival-focused clinical trials are ongoing in several cancer settings. Issues in survival-focused clinical trials include: –The need for intermediate markers of success –The control group: what hgb is ethical/feasible? –The duration of intervention –The tension between a need for a rapid answer and the most appropriate clinical setting Survival-focused non-radiotherapy studies should incorporate what has been learned in anti-angiogenesis studies