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Severe Iron Deficiency Anemia Warns of Cancer: Presented at DDW

By Roberta Friedman

SAN FRANCISCO, CA -- May 21, 2002 -- Severe anemia defined by a ferritin level of 20 ng/mL or less, or a hemoglobin level of 12.5 or less, is a sign of cancer risk that should be investigated by endoscopy, suggest research findings.

These results were presented here on May 20 at the 103^rd annual meeting of the American Gastroenterological Association and Digestive Disease Week (DDW).

A policy in place at the Veterans Affairs (VA) Hospital in Portland, Oregon, has led to endoscopy for anyone with a ferritin level of 50 or less based on a prior study at that institution which showed an increased cancer risk with that threshold value. Dr. Jeff Douglass presented the results obtained as a result of that policy's implementation.

The researchers conducted a chart review of 308 patients who had colonoscopy (224 also had upper endoscopy). They defined severe iron deficiency anemia (IDA) as ferritin values 20 ng/mL or less, or ferritin between 21 and 50 ng/mL and hemoglobin 12.5 or less. Mild IDA was defined as ferritin values between 21 and 50 ng/mL and hemoglobin above 12.5. By this criteria, 208 patients had severe IDA and 100 had mild IDA.

Results showed that severe anemia incurred a cancer risk of 7.7 percent. Milder anemia had a 1 percent risk of cancer associated with it. Severe iron deficiency anemia had a positive predictive value for cancer of 9 percent, a negative predictive value of 99 percent, sensitivity of 94 percent, and specificity of 34 percent.

Mean age of the patients was 67 years; 94.2 percent were male and 95.5 percent were Caucasian. Of 324 consecutive patients, 16 had been disqualified from inclusion due to polyps that were not removed.

In a comparison with a study of healthy veterans published in the July 2000 New England Journal of Medicine, in which the Portland VA Hospital participated, cancer rates did not differ from the 1 percent rate found by the present study for mild anemia, Dr. Douglass said.

He concluded, therefore, that mild anemia carries no added risk for cancer and that patients with mild anemia should be evaluated and screened for cancer only as is appropriate for their age. "People with ferritin less than 50 should not get knee-jerk bidirectional endoscopy," Dr. Douglass said. All of the upper gastrointestinal (GI) cancers were in the group with severe iron deficiency anemia, he added.

The study had a low yield of asymptomatic patients with upper GI endoscopy, if the lower endoscopy had identify the cause of the anemia, Dr. Douglass said. Reasons for the anemias included esophagitis, gastritis, small ulcers, and AVMs. Anemia should trigger an evaluation for these problems, Dr. Douglass said. Three cases of celiac disease were also uncovered, he added.

Two thirds of the 100 study patients with mild anemia underwent fecal occult blood testing, but the study numbers were not adequate to judge if there was a correlation with the occult test, Douglass said.

The trigger for complete endoscopic evaluation should be either ferritin level of 20 ng/mL or lower, or hemoglobin of 12.5 or lower.

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