A multicenter study of recombinant human erythropoietin (epoetin alpha) in the management of anemia in cancer patients receiving chemotherapy

Current evidence suggests that epoetin alpha administration is well tolerated and effective in the management of anemia of cancer and cancer chemotherapy. An open-label, multinational, non-comparative study was conducted in 215 cancer patients with anemia secondary to chemotherapy with platinum- or non-platinum-based combinations. Epoetin alpha was administered s.c. (150 IU/kg three times/week) for a planned period of 16 weeks. The response rate of epoetin alpha, defined as an increase in hemoglobin level of 2 g/dl or more from baseline, was 67%. The rate of response was not related to the chemotherapy regimen administered (platinum or non-platinum based). The percentage of patients transfused and the transfusion rate during epoetin alpha treatment were reduced. Transfusional need was eliminated in 64 (75%) of the 85 patients transfused before the study start, after 1 month of therapy. Quality of life, assessed using a visual analog scale, improved markedly in patients who experienced a hematological response. These patients also experienced a statistically significant (p < 0.0001) improvement in mean WHO performance score. These findings indicate that epoetin alpha is a well tolerated and effective agent which increases hemoglobin concentration and reduces transfusion requirements in anemic cancer patients receiving chemotherapy.

Clinicoepidemiological features of adult leukemias in Pakistan

A total of 113 patients of leukemia, over 15 years of age, were seen in three different institutions from July, 1992 to June, 1994. There was an almost equal distribution of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) (44 vs 43 cases respectively). Chronic lymphocytic leukemia (CLL) was the least common, accounting for 5% of all cases. Mean age in CLL was 59 years. Chronic myeloid leukemia (CML) was three times commoner than CLL with a younger age distribution (median age was 34 years). We conclude that the clinicoepidemiological features of adult leukemias differ considerably from that seen in the developed world. However, recruitment of patients needs to continue in order to define these features based on a larger patient population.

Modified BFM protocol for childhood acute lymphoblastic leukemia: a retrospective analysis

Childhood acute lymphoblastic leukemia (ALL) has a 5-year disease-free survival (DFS) of more than 70%. This fact is not reflected in developing countries due to the lack of proper supportive care. A modified version of the standard Berlin-Frankfurt-Munich (BFM) protocol for pediatric ALL was developed to achieve balance between toxicity and favorable response rates. Modification included a dose reduction of asparaginase and methotrexate during the consolidation and reinduction phase. Forty-two patients younger than 15 years of age were put on the modified BFM protocol between November 1990 and November 1993. Thirty-nine patients were 2-10 years of age and 3 were older than 10 years. Male to female ratio was 3.2:1. 71.4% had L1 and 28.6% had L2 morphology. Univariate analysis factors revealed central nervous system (CNS) involvement and late complete remission (CR) during induction as poor prognostic factors. In multivariate analysis, CNS disease (P < 0.0083) was the only prognostic variable for prolonged DFS. All patients went into CR. Eleven patients have relapsed. Life table analysis of these patients shows a 59.4% probability of overall survival (OS) and a 52.5% probability of DFS at 48 months.

Acute leukemias of childhood: a retrospective analysis of 62 cases

Acute leukemia is reported to be less common in developing countries compared to non-Hodgkins lymphomas which is the most common childhood malignancy. A retrospective analysis was performed to identify the clinicopathological features of acute leukemias of childhood at the Oncology Department of Allama Iqbal Medical College, Lahore. The commonest malignancy in the under 15 years age group was leukemias (54%) followed by non-Hodgkins lymphomas (16%). Acute lymphocytic leukemia (ALL) was the commonest subtype (82%) followed by acute myeloid leukemia (16%). Peak incidence occurred in the 2.5-5 years age. The median duration of symptoms prior to diagnosis was 5 months. We conclude from our study that the incidence and clinicopathologic paediatric ALL is similar to that reported in the Western literature, unlike reports from other developing countries. Various environmental, viral and dietary carcinogens may play a major role in the etiology of leukemias.

Clinicopathological features and management of immunoproliferative small intestinal disease and primary small intestinal lymphoma in Pakistan

This study was performed to confirm the existence of immunoproliferative small intestinal disease (IPSID) in Pakistan. Clinicopathological features of 12 patients with histologically confirmed disease were analysed. Patients were mostly young males with median age of 24.6 years. Two thirds belonged to poor socioeconomic class. Main presenting features were chronic diarrhoea and weight loss. Eleven patients had radiologic evidence of malabsorption syndrome. Endoscopic findings of mucosal thickening, edema, and flattened villi were present in the majority. Patients had both secretory and non-secretory types of disease. Six patients presented with stage A disease. Four responded to antibiotics or steroids, although mucosal abnormalities persisted in three. Two stage A patients evolved into stage C disease, one was lost to follow-up, the other is alive with disease. Three patients presented with stage B disease. Two responded completely to chemotherapy, the third refused treatment and expired after 16 months. Three patients had stage C disease at diagnosis. They received aggressive combination chemotherapy and remain in complete remission with a median follow-up of 2.2 years. This is the first series of patients with IPSID reported from Pakistan. Clinicopathological features and therapeutic results are consistent with the experience elsewhere. Increased awareness may result in early diagnosis and better management.

Feasibility of outpatient management of fever in cancer patients with low-risk neutropenia: results of a prospective randomized trial

PURPOSE

We recently demonstrated the efficacy of single-agent oral ofloxacin in the management of hospitalized neutropenic febrile patients. Ofloxacin was particularly effective in patients with short duration of neutropenia and fever of undetermined origin. These results prompted us to study the feasibility of outpatient management of neutropenic febrile patients who are otherwise at low risk of morbidity and mortality.

PATIENTS AND METHODS

This multi-institutional, prospective, randomized trial included 182 low-risk neutropenic febrile episodes. After an initial work-up for fever, patients were randomized to receive oral ofloxacin 400 mg immediately and twice daily thereafter in the hospital or as outpatients. Close monitoring and follow-up were carried out in all patients. Those who failed to respond and remained febrile were given parenteral antibiotics. Nonresponding outpatients were admitted to the hospital for parenteral therapy.

RESULTS

One hundred sixty-nine episodes were evaluable. The hospital and outpatient treatment groups had comparable clinical characteristics. Pyrexias of undetermined origin (PUO) comprised 69% of episodes managed in hospital and 73% of episodes treated outside. The success rate with PUO was similar with inpatient and outpatient management. Patients with clinical and microbiologic infections fared less well than those with PUO. Overall, 78% of inpatient and 77% of outpatient fevers resolved with no modification of the initial treatment. Twenty-one percent of patients originally assigned to outside management required hospitalization. Mortality was 2% among inpatients and 4% among outpatients. One early death in a nonhospitalized patient underscores the need for close monitoring and surveillance in these cases.

CONCLUSIONS

Outpatient management of low-risk neutropenic febrile patients with ofloxacin is as effective as inpatient management with the same agent. This approach should be limited to the subset of patients with low-risk factors who are not otherwise on quinolone prophylaxis.

Self-administered antibiotic therapy for chemotherapy-induced, low-risk febrile neutropenia in patients with nonhematologic neoplasms

A multicenter prospective nonrandomized trial was conducted to evaluate the efficacy of self-administered oral ofloxacin in the treatment of cancer patients with fever and neutropenia. Patients receiving chemotherapy who either resided far away and were unable to reach the oncology ward within 12 hours of the onset of fever or were unable to afford the expensive inpatient care were eligible for inclusion in the study. Requirements for enrollment included an absolute neutrophil count of < or = 0.5 x 10(9)/L, temperature of > 38 degrees C, and the ability to take oral medications. The patients were instructed to immediately self-administer oral ofloxacin on recognition of fever and to maintain daily telephonic contact with the oncology staff. One-hundred eleven such episodes were evaluable. Neutropenia was mostly of short duration (87% of episodes, < or = 1 week); 92 (83%) of the febrile episodes responded to ofloxacin with resolution of fever and neutropenia (hospitalization was not required). Two episodes resulted in death before the patients could be brought to the hospital; 17 (15%) did not respond to ofloxacin, and the patients required hospitalization. The conditions of all except one improved with parenteral combination antibiotic therapy. No toxicity was observed, and the cost of therapy was negligible. Treatment with oral ofloxacin may possibly serve as an alternative to hospitalization for those who are otherwise at low risk of morbidity and death.