The Cancer Burden and Patterns of Erythropoiesis-stimulating Agent Use Among End-stage Renal Disease Patients on Hemodialysis Public Deposited

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  • March 19, 2019
  • Butler, Anne
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
  • Patients with end-stage renal disease (ESRD) receiving dialysis have been reported to have increased risk of cancer. Yet, contemporary cancer burden estimates in this population are sparse, and estimates that account for the high competing risk of death in this population are non-existent. In addition, erythropoiesis-stimulating agents (ESAs) and blood transfusion are commonly used to treat anemia in both ESRD and cancer, however, anemia treatment patterns have not been described among ESRD patients undergoing hemodialysis with concurrent cancer, especially in the recent era of ESA-related safety concerns. Using data from Medicare's ESRD program, we conducted a retrospective cohort study of hemodialysis patients to describe trends in overall and site-specific cancer incidence rates (1996-2009). We estimated the 5-year cumulative incidence of cancer since dialysis initiation, using competing risk methods. Among hemodialysis patients with incident cancer, we used multivariable generalized linear models to estimate temporal trends in ESA use, epoetin alfa (EPO) dose, transfusion use, and resulting hemoglobin levels (2000-2010). We observed a constant rate of incident cancers for all sites combined, but identified increasing and decreasing rates for some common site-specific cancers. The 5-year cumulative incidence of any cancer was substantially lower in the analysis that did not censor deaths compared to the analysis that censored deaths (9.48% vs. 13.86%). Accounting for case-mix characteristics and the competing risk of death, the 5-year cumulative incidence of any cancer varied by demographic and clinical characteristics. Among hemodialysis patients with incident cancer, ESA use was extremely high and constant whereas transfusion use became increasingly frequent. EPO dose and hemoglobin values increased and then declined. Patients with hematological malignancies or patients who received chemotherapy had higher ESA use, EPO dose, and transfusion use as well as lower hemoglobin levels. Our results suggest a high burden of cancer in the dialysis population, with varying patterns of cancer incidence across subgroups. Despite ESA-related safety concerns, ESA use remained extremely common and remarkably constant among hemodialysis patients with cancer between 2000 and 2010. Transfusions have increased in frequency. These results warrant additional research to examine the risk-benefit profile of ESA use in the dialysis population with cancer.
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Rights statement
  • In Copyright
  • Kshirsagar, Abhijit
  • Nielsen, Matthew
  • Wheeler, Stephanie
  • Brookhart, M. Alan
  • Olshan, Andrew
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2014
Place of publication
  • Chapel Hill, NC
  • This item is restricted from public view for 1 year after publication.

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