Erythropoietin stimulating agents (ESAs) are commonly used adjuncts for the management of anaemia in select patient populations. Patients with head and neck squamous cell carcinoma (HNSCC) are particularly at risk of multi-factorial anaemia, with both local tumour and systemic effects contributing, which itself has been independently associated with poor prognosis and intrinsic resistance to adjunctive therapy.
In surgical patients with head and neck squamous cell carcinoma (HNSCC) undergoing curative intent therapy, the use of ESAs may be relatively contraindicated, with a significant trend towards increased locoregional failure and mortality demonstrated in several studies for patients undergoing primary radiotherapy. Several good quality randomised controlled trials have detected significant differences in rates of locoregional recurrence and overall survival, though data from surgical cohorts is lacking. In some studies, their use during curative-intent treatment was associated with a higher risk of death and locoregional recurrence than smoking.
The optimization of patient health pre-operatively includes the management of risk factors such as smoking and medications. Surgeons should be alert to the risks associated with the ongoing use of ESAs in patients receiving curative intent therapy prior to proceeding with surgery. These studies and the issuing of a black box warning by the FDA should alert clinicians to this risk. Despite a lack of research investigating surgical cohorts with HNSCC, the clear trend towards early locoregional failure and mortality amongst patients with advanced HNSCC receiving primary curative-intent radiotherapy on ESA therapy is suggestive of their contraindication.