Anemia is a common, yet preventable condition in patients with cancer. The World Health Organization (WHO) describes anemia as an insufficient number of red blood cells (RBC) to meet oxygen-carrying requirements, often defined as a hemoglobin (Hb) concentration less than 120 g/L in females [1,2]. Patients undergoing major surgery have a higher anemia risk than the general population [3]. Large observational studies report a preoperative anemia prevalence of 25–40 % [[4], [5], [6], [7]]. In malignancy, anemia can result from blood loss, malnutrition, marrow suppression from chemotherapy, or immunologic responses [8,9].

Preoperative anemia is a well-established negative prognostic factor in patients with gynecologic cancers, especially when moderate or severe. It is linked to higher in-hospital mortality (OR 2.09), 30-day mortality (OR 1.42), intensive care admissions, perioperative complications, transfusions and longer hospital stays [[4], [5], [6],10]. According to a systematic review, anemia is associated with a reduction in median overall survival from 43 to 20 % in patients with cancer (aHRR 1.65) [11]. In patients with gynecologic malignancies, similar findings are noted, particularly in patients with cervical [12,13], endometrial [14,15] and ovarian cancer [16].

Iron-deficiency anemia, defined by ferritin <30 μg/L, is the most common and treatable type of anemia [17,18]. Inflammatory conditions increase ferritin, therefore cancer-related iron-deficiency subtypes include: absolute (ferritin <30 ng/mL), inflammatory (ferritin 30–100 ng/mL with transferrin saturation (TSAT) <20 %), and functional (ferritin 100–500 ng/mL with TSAT <50 %) iron-deficiency anemia [19,20].

Oral iron is less effective in cancer-related iron-deficiency anemia due to interference of absorption by hepcidin, therefore intravenous (IV) iron, administered at least 14 days prior to surgery, is preferred for short-term supplementation [19,20]. Multiple randomized control trials show that IV iron increases the nadir Hb and reduces transfusion needs in gynecologic malignancy patients prior to chemotherapy compared to oral iron [[21], [22], [23]]. In iron-deficiency anemia with inflammation or functional iron-deficiency anemia, erythropoiesis-stimulating agents (ESA) may be considered in addition to IV iron in selected circumstances [19,20,24].

Even though 48 % of patients with gynecologic cancers are anemic at their preoperative visit, only 40 % will be adequately treated prior to surgery [25]. Therefore, perioperative RBC transfusion rates in major gynecologic oncology surgeries range from 39 to 56 %, increasing the risk of perioperative complications and mortality [26]. Each year in the United States, approximately 6 million units of RBCs are transfused, which represents an estimated cost of US $1600–$2400 per transfusion event [[26], [27], [28]], of which 34 % are cancer-related [29].

To minimize the use of blood products as first-line treatment, strong literature supports the use of multidisciplinary and multimodal strategies within local Patient Blood Management (PBM) programs that focus on: early detection of preoperative anemia, individualize treatment strategies, optimize hemostasis and limit blood loss during surgery [20,[30], [31], [32], [33]]. Based on anemia type and target Hb, treatment algorithms usually include a combination of IV iron and ESA, depending on the institution and the products available. According to recent data, PBM clinics, such as the ONTraC program, have been successful in reducing the use of blood products and improve patient outcomes [34,35]. However, these multidisciplinary programs have not yet been utilized for preoperative anemia management in the gynecologic oncology setting.

Although strong evidence shows that preoperative anemia increases the rate of perioperative RBC transfusions and postoperative mortality, we currently lack information on how screening and referral to PBM programs should be implemented in the workflow prior to surgery in the gynecologic oncology population. This represents an important gap in the literature as this information is essential to investigate and treat preoperative anemia, reduce the need for perioperative transfusions and associated costs, and improve patient outcomes.

This quality-improvement initiative aimed to increase the treatment rate of preoperative anemia (IV iron or ESA) from 5 % to 50 % in gynecologic oncology patients undergoing surgery at Sunnybrook Health Sciences Centre by November 1, 2021. Secondary goals included increasing median preoperative Hb level by 10 g/L, reducing RBC transfusion rate to 10 % and shortening median hospital stays from 4 to 3 days.