Guidelines clearly recommend endoscopic investigation for iron deficiency anemia but are ambiguous for iron deficiency without anemia. We aimed to compare gastrointestinal malignancy rates between patients with iron deficiency without anemia and iron deficiency anemia, and to identify factors associated with malignancy. We performed a retrospective cohort study of adult patients who underwent bidirectional endoscopic examination for iron deficiency (ferritin levels < 45 µg/l) at two major Jordanian hospitals over 1.5 years. The total cohort consisted of 480 patients and was divided into two groups: iron deficiency anemia (274 patients) and iron deficiency without anemia (206 patients). Patients with iron deficiency anemia were significantly older (mean age 56.0 vs. 52.2 years, p = 0.007) and included a higher proportion of females (68.2% vs. 57.8%, p = 0.018). There was no significant difference in the rate of gastrointestinal malignancy between patients with anemia (1.8%) and those without anemia (2.4%), with an overall prevalence of malignancy of 2.1%. Colorectal adenocarcinoma was the most common malignancy (7 out of 10 cases). Notably, all gastric malignancies (3 cases) occurred in patients without anemia. Increasing age emerged as the only significant predictor of malignancy. These preliminary findings suggest that endoscopic evaluation may be considered for all patients with iron deficiency, regardless of anemia status, particularly for older patients. Larger prospective studies are needed to clarify the true risk.
Ali et al. (2026) studied this question.