Supportive Care in Cancer

, Volume 25, Issue 4, pp 1209–1214 | Cite as

Estimating prevalence of functional iron deficiency anaemia in advanced cancer

  • Karen NeohEmail author
  • Simon Stanworth
  • Sant-Rayn Pasricha
  • Michael I Bennett
Original Article



Anaemia is a common complication of cancer causing symptoms including fatigue. It is also associated with shorter survival. Cancer causes systemic inflammation which interrupts iron metabolism leading to a functional iron deficiency (FID). There are few data on prevalence or aetiology of anaemia in those with advanced cancer. We aimed to establish the prevalence of anaemia and estimate extent of FID anaemia in patients with advanced cancer.


All patients with advanced cancer referred to two UK specialist palliative care services over 1 year were identified. Demographic and clinical data were linked with routinely collected haematological and biochemical profiles. We assessed the numbers of patients with abnormal values for haemoglobin, % hypochromic red cells (>5% indicates iron-restricted erythropoiesis) and CRP (>10 indicates systemic inflammation). We judged that FID anaemia was likely when patients had all three abnormalities and ferritin 30–800 ng/ml.


Out of 2416 patients, 1797 had a cancer diagnosis and laboratory data available. Mean haemoglobin was 116 g/l. Sixty-three percent of patients were anaemic, mild 25%, moderate 35% and severe 3%. Women had significantly higher mean haemoglobin than men, and there was wide variation in anaemia prevalence across tumour sites. Thirty-nine percent of patients who had all four parameters checked met our criteria for FID anaemia. There were significant relationships between haemoglobin, % hypochromic red cells and CRP (p = 0.0001).


Anaemia was common in this population, and we estimate this was caused by FID in 66% of anaemic patients. Further research is needed to validate our diagnostic criteria before this approach can be used in clinical practice.


Anaemia Functional iron deficiency Advanced cancer Palliative care 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Magnusson K, Möller A, Ekman T, Wallgren A (1999) A qualitative study to explore the experience of fatigue in cancer patients. European Journal of Cancer Care 8(4):224–232CrossRefGoogle Scholar
  2. 2.
    Ludwig H, Müldür E, Endler G, Hüb W (2013) Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia. Ann Oncol 24(7):1886–1892CrossRefGoogle Scholar
  3. 3.
    Ludwig H, Van Belle S, Barrett-Lee P, Birgegård G, Bokemeyer C, Gascón P, Kosmidis P, Krzakowski M, Nortier J, Olmi P, Schneider M, Schrijvers D (2004) The European Cancer Anaemia Survey (ECAS): a large, multinational, prospective survey defining the prevalence, incidence, and treatment of anaemia in cancer patients. Eur J Cancer Oct 40(15):2293–2306CrossRefGoogle Scholar
  4. 4.
    Dunn A, Carter J, Carter H (2003) Anemia at the end of life: prevalence, significance, and causes in patients receiving palliative care. J Pain Symptom Manag 26(6):1132–1139CrossRefGoogle Scholar
  5. 5.
    Young B, Zaritsky J (2009) Hepcidin for clinicians. Clin J Am Soc Nephrol 4:1384–1387CrossRefGoogle Scholar
  6. 6.
    Bergamaschi G, Villani L (2009) Serum hepcidin: a novel diagnostic tool in disorders of iron metabolism. Haematol 94(12):1631–1633 Scholar
  7. 7.
    Sun CC, Vaja V, Babitt JL, Lin HY (2012) Targeting the hepcidin-ferroportin axis to develop new treatment strategies for anemia of chronic disease and anemia of inflammation. Am J Hematol 87(4):392–400CrossRefGoogle Scholar
  8. 8.
    Thomas DW, Hinchliffe RF, Briggs C, Macdougall IC, Littlewood T, Cavill I, British Committee for Standards in Haematology (2013) Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol 161:639–648CrossRefGoogle Scholar
  9. 9.
    Gilreath JA, Stenehjem DD, Rodgers GM (2014) Diagnosis and treatment of cancer-related anemia. Am J Hematol 89(2):203–212CrossRefGoogle Scholar
  10. 10.
    Caro JJ, Salas M, Ward A, Goss G (2001) Anemia as an independent prognostic factor for survival in patients with cancer: a systemic, quantitative review. Cancer 91(12):2214–2221CrossRefGoogle Scholar
  11. 11.
    World Health Organisation (2011) Haemoglobin concentrations for the diagnosis and assessment of severity. [Online]. [Accessed 28 August 2013]. Available from:
  12. 12.
    Eklund CM (2009) Proinflammatory cytokines in CRP baseline regulation. Adv Clin Chem 48:111–136CrossRefGoogle Scholar
  13. 13.
    CRP [Online] [Accessed 23 March 2016] Available from:
  14. 14.
    Bovy C, Gothot A, Delanaye P, Warling X, Krzesinski JM, Beguin Y (2007) Mature erythrocyte parameters as new markers of functional iron deficiency in haemodialysis: sensitivity and specificity. Nephrol Dial Transplant 22(4):1156–1162CrossRefGoogle Scholar
  15. 15.
    Murphy PT, Quinn JP, O'Donghaile D, Swords R, O'Donnell JR (2006) Myelodysplastic patients with raised percentage of hypochromic red cells have evidence of functional iron deficiency. Ann Hematol 85(7):455–457CrossRefGoogle Scholar
  16. 16.
    Thomas C, Thomas L (2002) Biochemical markers and hematologic indices in the diagnosis of functional iron deficiency. Clin Chem 48(7):1066–1076PubMedGoogle Scholar
  17. 17.
    Robertson KA, Hutchinson SM (2009) Assessment of iron status and the role for iron replacement therapy in anaemic cancer patients under the care of a specialist palliative care unit. Palliat Med 23:406–409CrossRefGoogle Scholar
  18. 18.
    Hoffbrand AV, Hershko C, Camaschella C (2011) Iron metabolism, iron deficiency and disorders of haem synthesis. In: Hoffbrand AV, Catovsky D, Tuddenham EGD, Green AR (eds) Postgraduate haematology: 6th edition. Blackwell, London, pp. 26–46Google Scholar
  19. 19.
    Bach V, Schruckmayer G, Sam I, Kemmler G, Stauder R (2014) Prevalence and possible causes of anemia in the elderly: a cross-sectional analysis of a large European university hospital cohort. Clinical Interventions In Aging 9:1187–1196PubMedPubMedCentralGoogle Scholar
  20. 20.
    Ludwig H, Evstatiev R, Kornek G, Aapro M, Bauernhofer T, Buxhofer-Ausch V, Fridrik M, Geissler D, Geissler K, Gisslinger H, Koller E, Kopetzky G, Lang A, Rumpold H, Steurer M, Kamali H, Link H (2015) Iron metabolism and iron supplementation in cancer patients. Wien Klin Wochenschr 127:907–919CrossRefGoogle Scholar
  21. 21.
    Hedenus M, Karlsson T, Ludwig H, Rzychon B, Felder M, Roubert B, Birgegård G (2014) Intravenous iron alone resolves anemia in patients with functional iron deficiency and lymphoid malignancies undergoing chemotherapy. Med Oncol 31(12):302CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Karen Neoh
    • 1
    Email author
  • Simon Stanworth
    • 2
  • Sant-Rayn Pasricha
    • 3
  • Michael I Bennett
    • 1
  1. 1.Academic Unit of Palliative Care, Leeds Institute of Health Sciences, School of MedicineUniversity of LeedsLeedsUK
  2. 2.NHS Blood and TransplantJohn Radcliffe HospitalOxfordUK
  3. 3.MRC Human Immunology Unit, Weatherall Institute of Molecular MedicineUniversity of OxfordOxfordUK

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