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ated for an underlying cause for her ane-mia. Her history of menstrual blood losswas not impressive, and she denied mele-na. The oral iron exacerbated her constipa-tion, thus she was unable to obtain stoolsamples for fecal occult blood testing. Shewas changed to intramuscular iron dex-tran, given as 1 mL (50 mg) into each but-tock each week (via Z-track technique)and given stool softeners. Stool obtainedwas tested for occult blood and was report-ed as 1+ guaiac reaction. The patient was referred to the GastroenterologyDepartment for colonoscopy, which founda mass approximately 6 cm in size locatedin the ascending colon and 18 in (45.72cm) from the anal verge, which was biop-sied. An additional adenomatous mass wasremoved from the transverse colon.Pathology report indicated: 1) proximalascending colon, mass, biopsy: poorly dif-ferentiated invasive adenocarcinoma withulceration; and 2) transverse colon, biopsy:tubular adenoma.

An abdominal computed tomogra-phy (CT) scan revealed an “apple core”lesion in the same area of her colon as oncolonoscopy. No lesions were seen in herliver. Some adenopathy was appreciatedproximal to the lesion in ascendingcolon. Chest CT scan was negative.Carcinoembryonic antigen (CEA) drawnwas 6 ng/mL. The surgeon was reluctantto perform surgery with her hematocritat 28%. Her lack of response to irontherapy was thought to be a result of aninflammatory state causing suppressionof erythropoietin. Thus, her anemia wasunlikely to resolve with iron replacementtherapy until the underlying cause of theanemia was corrected. He ordered trans-fusion of 2 U of packed RBCs and sched-uled an exploratory laparotomy and righthemicolectomy when her hematocritreached 32%.

A right hemicolectomy was per-formed to remove the tumor. Althoughthe CT scan showed no lesions in theliver, the surgeon biopsied a suspicioussite. Pathology report indicated: 1)right colon: moderately differentiatedadenocarcinoma (6 x 3.5 cm mass), car-cinoma invades through the muscularispropria into pericolic fat, and all mar-gins negative; 2) 4 of 21 pericoliclymph nodes positive for metastatic car-cinoma; and 3) liver, biopsy: negativefor carcinoma.

CANCER THERAPY AND SUPPORTIVE CARE

52-YEAR-OLD WOMAN WITH COLON CANCERTheresa Wicklin Gillespie, PhD, MA, BSN

BACKGROUND

BD, a 52-year-old Caucasian female, presented to her primary care providerwith complaints of weakness and fatigue, although she continued to work. Sheattributed these changes to menopause; her menstrual periods have been irregularbut occasionally heavy. She experienced recent weight loss of 10 lbs over the past6 months not attributable to diet or exercise.

LABORATORY FINDINGS

Initial laboratory workup shows: white blood cell count, 5200 cells/mm3; hemoglobin(Hgb), 7.5 g/dL; hematocrit, 26%; red blood cell (RBC) count, 3.5 x 106/µL; plateletcount, 650 000/µL; mean corpuscular Hgb, 24.8 pg/cell; mean corpuscular Hgb concen-tration, 33.4 g/dL; mean corpuscular volume (MCV), 55 µm3; and reticulocyte count,1.5%. Serum chemistries were: creatinine, 1.1 mg/dL; bilirubin (total), 0.9 µmol/dL;blood urea nitrogen, 15 mg/dL; glucose, 124 mg/dL; sodium, 134 mEq/L; potassium, 4 mEq/L; magnesium, 1.8 mEq/L; and calcium (total), 9.2 mg/dL.

MEDICAL HISTORY

The patient reported chronic constipation and hemorrhoids, mild dyspnea on exer-tion, and chronic arthritis in her knees and hands. She has been monitored for hyperten-sion with current control using diuretics. Her last mammogram 8 months ago was normal;the patient has had no screening colonoscopy or sigmoidoscopy. Current medicationsinclude furosemide 100 mg orally and ibuprofen 400 mg orally as needed. She took oralcontraceptives for 10 years, but is currently not receiving hormonal therapy.

FAMILY HISTORY

Her mother, aged 83 years, has type 2 diabetes (treated for 35 years) and her father diedat age 60 of acute myocardial infarction. One brother is alive at age 61 with hypertension.

SOCIAL HISTORY

BD owns and manages an interior design firm. She is divorced with 2 grown childrenand lives alone. She has never smoked and rarely drinks alcohol. She is an avid tennis player.

PHYSICAL EXAMINATION

BD appeared as a pale, thin woman in no acute distress. She was 5’6” tall and weighed128 lbs. Vital signs were as follows: blood pressure, 132/86 mm Hg; pulse, 86beats/minute; respiratory rate, 22 breaths/minute; and temperature, 37°C. Karnofsky per-formance status was 90%. Sclerae were anicteric with pale conjunctiva. There was no pal-pable adenopathy, and the lungs were clear to auscultation bilaterally. Cardiac examinationwas normal. The abdomen was soft without distension or tenderness, and bowel soundswere normal and present in all quadrants. There was no hepatosplenomegaly and rectalexamination revealed no masses or hemorrhoids.

WORKUP

Based on the initial laboratory findings, an iron panel was drawn; serum ferritin was 8ng/mL. The patient’s history, physical examination, and laboratory data supported a diag-nosis of iron deficiency anemia. Oral iron therapy 325 mg 3 times/day was initiated andthe patient was advised to take the iron with vitamin C at mealtimes. She also was evalu-

CASE STUDY

(Continued at top of next column)

TREATMENT PLAN

The patient was staged as T3N2M0,or stage IIIC colon cancer. PostoperativeCEA was 0.2 ng/dL. Referral was madeto a medical oncologist and the FOL-FOX4 regimen1 was initiated as adjuvanttherapy for 6 months, consisting of oxali-platin 85 mg/m2 intravenously (IV) day1; leucovorin 200 mg/m2 IV days 1 and2; and 5-fluorouracil 400 mg/m2 IVbolus, then 600 mg/m2 IV over 22 hourscontinuous infusion days 1 and 2. Theregimen was repeated every 2 weeks onceBD was cleared by her surgeon. Based onher current Hgb (9.8 g/dL) her treatmentplan included darbepoetin 200 µg fixeddose as subcutaneous injection givenevery 2 weeks to coincide with herchemotherapy regimen.2 Erythropoietictherapy was initiated before cycle 1 ofchemotherapy. The oncology nurse prac-titioner also instructed BD regardingexercise, nutrition, and other interven-tions to assist with her recovery and toaddress her continuing fatigue.

TREATMENT COURSE

BD was treated in the outpatient set-ting. Her continuing weakness andfatigue caused her daughter to take leavefrom her job to stay with her motherduring chemotherapy. At the start ofchemotherapy, BD’s Hgb rose to 10.6g/dL and darbepoetin was continuedthroughout her course of treatment tomaintain target Hgb between 11 and 12g/dL.3 BD tolerated her therapy withoutserious adverse events until cycle 4 whenher absolute neutrophil count droppedto 480 neutrophils/µL, requiring a delayin the start of cycle 5. Consequently, peg-filgrastim 6 mg administered subcuta-neously was initiated on day 2 of cycle 5to prevent subsequent severe neutropeniafor the remainder of her chemotherapyregimen.4 The rest of BD’s treatment wascompleted without significant toxicities.

DISCUSSION

Iron deficiency is a common condi-tion with the majority of cases in theUnited States occurring in women sec-ondary to menstrual blood loss.5 Ifmenses are not the cause, then effortsmust be directed at determining theunderlying etiology, and the healthcareprovider needs to rule out gastrointesti-nal bleeding as the source of the iron loss.

A symptomatic patient may require consid-eration of erythropoietic therapy, in addi-tion to iron replacement.6 Generally, irondeficiency, a form of microcytic anemia, ismarked by a serum ferritin level of less than12 ng/mL and decreased MCV.Unfortunately, BD’s constipation, exacer-bated by the use of oral iron, caused a delayin obtaining stool for occult blood andreferral for definitive diagnosis withcolonoscopy. However, once the underly-ing reason for the presenting anemia—astage IIIC colon cancer—was identifiedand surgically removed, the patientremained anemic and at risk for moresevere anemia with the initiation of adju-vant chemotherapy with its potential forhematologic toxicity. The use of darbepoet-in alfa every 2 weeks was efficacious andconvenient for the patient in view of herevery-2-week chemotherapy regimen.Another option would have been toadminister epoetin alfa 40 000 U weeklysubcutaneously.7 Newer erythropoietic reg-imens include epoetin alfa with 60 000 U subcutaneously as a loading dosefollowed by 120 000 U every 3 weeks asmaintenance,8 which is currently underinvestigation, and an every-3-week dosingschedule for darbepoetin alfa,9 which theUS Food and Drug Administration recent-ly approved. The recommended startingdose for darbepoetin alfa administered onceevery 3 weeks is 500 µg as a subcutaneousinjection with the dose adjusted to main-tain a target Hgb not to exceed 12 g/dL.10

Oncology practitioners should bemindful that developing one hematologictoxicity does not preclude occurrence ofanother, which happened in this case whenBD experienced grade 4 (life-threatening)neutropenia and required ongoing neu-trophil support with a myeloid growth fac-tor as well as erythropoietin support.

REFERENCES

1. Andre T, Boni C, Mounedji-Boudiaf L,et al. Multicenter International Studyof Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatmentof Colon Cancer (MOSAIC)Investigators. Oxaliplatin, fluorouracil,and leucovorin as adjuvant treatmentfor colon cancer. N Engl J Med.2004;350:2343-2351.

2. Glaspy J. Phase III clinical trials withdarbepoetin: implications for clini-cians. Bailliere’s Best Pract Res ClinHaematol. 2005;18:407-416.

3. Berndt E, Kallich J, McDermott A, etal. Reductions in anemia and fatigueare associated with improvements inproductivity in cancer patients receivingchemotherapy. Pharmacoeconomics.2005;23:505-514.

4 Burnstein HJ, Parker LM, KeshaviahA, et al. Efficacy of pegfilgrastim anddarbepoetin alfa as hematopoieticsupport for dose-dense every twoweek adjuvant breast cancerchemotherapy. J Clin Oncol.2005;23:8340-8347.

5. Woodley M, Whelan A, eds.Manual of Medical Therapeutics.27th Edition. Boston, Mass: Little,Brown and Company; 1992.

6. National Comprehensive CancerNetwork (NCCN). NCCN ClinicalPractice Guidelines in Oncology:Cancer- and Treatment-RelatedAnemia. Version 1.2006. Availableat: http://www.nccn.org/profession-als/physician_gls/PDF/anemia.pdf.Accessed January 27, 2006.

7. Epoetin alfa [prescribing information].Thousand Oaks, Calif: Amgen Inc.;2005.

8. Steensma DP, Molina R, Sloan JA, etal. Phase III study of two differentdosing schedules of erythropoietin inanemic patients with cancer. J ClinOncol. 2006;24:1026-1028.

9. Canon JL, Vansteenkiste J, Bodoky G,et al. Randomized, double-blind,active-controlled trial of every-3-weekdarbepoetin alfa for the treatment ofchemotherapy-induced anemia. J NatCancer Inst. 2006;98:273-284.

10. Darbepoetin alfa [prescribing infor-mation]. Thousand Oaks, Calif:Amgen Inc.; 2001-2005. Availableat: http://www.aranesp.com/pdf/aranesp_PI.pdf. Accessed April25, 2006.

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