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Bordbar M, Hosseini-Bensenjan M, Sayadi M, Zekavat O, Bordbar S, Nozari F, Haghpanah S. The Impact of Prophylactic Post-Chemotherapy G-CSF on the Relapse Rates in Patients with Acute Myeloid Leukemia: A Meta-Analysis. Cancer Invest 2024; 42:452-468. [PMID: 38922312 DOI: 10.1080/07357907.2024.2352454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 05/03/2024] [Indexed: 06/27/2024]
Abstract
This meta-analysis evaluated the impact of prophylactic post-chemotherapy granulocyte colony-stimulating factor (G-CSF) in patients with acute myeloid leukemia (AML). Overall, the relapse rate, overall survival, event-free survival, and mortality rate were similar in G-CSF (+) compared to G-CSF (-) patients. However, the relative risk (RR) of relapse was higher in children and in secondary AML patients who were treated with G-CSF compared to the G-CSF (-) group [RR, 95% confidence interval: 1.26, 1.04-1.52, and 1.12 (1.02-1.24)]. Treatment with post-chemotherapy G-CSF should be prescribed with caution in pediatric patients with AML and secondary AML as possibly increasing the relapse risk.
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Affiliation(s)
| | | | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omidreza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shayan Bordbar
- Student Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farnoosh Nozari
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Zhu X, Zhang W, Zhang Y, Wang Y, Hu H, Li J, Zhou Y, Han T, Huang D. Pegfilgrastim on febrile neutropenia in pediatric and adolescent cancer patients: a systematic review and meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2172292. [PMID: 36719297 DOI: 10.1080/16078454.2023.2172292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES There is no meta-analysis about the effects of pegfilgrastim on the occurrence of febrile neutropenia (FN) in pediatric/adolescent cancer patients. The study explored the efficacy of prophylactic pegfilgrastim in preventing FN in children/adolescents with cancer. METHODS PubMed, Embase, and the Cochrane Library were searched for studies published before April 7, 2020. The primary outcome was the rate of FN. Effect size (ES) and odds ratio (OR) with 95% confidence intervals (CIs) were used to evaluate the outcome. The ES represented the rate of FN, and the STATA 'metaprop' command was used to synthesize the rate. RESULTS Eight studies were included, comprising 167 patients and 550 courses of treatment. There was no difference between pegfilgrastim and filgrastim for the rate of FN in children receiving chemotherapy (OR = 0.68, 95% CI: 0.20-2.23, P = 0.520). In patients receiving pegfilgrastim, the rate of FN was 25.6% (95% CI: 14.9%-36.3%), the rate of grade 4 FN was 38.3% (95% CI: 19.2%-59.5%), the rate of severe neutropenia (SN) was 40.5% (95% CI: 35.1%-46.1%), and the rate of treatment delays due to FN was 4.8% (95% CI: 0.8%-11.3%). DISCUSSION The number of studies that could be included was small; therefore, a specific type of cancer or a specific treatment could be studied. Heterogeneity was high. CONCLUSION There was no difference between pegfilgrastim and filgrastim for the rate of FN. The use of pegfilgrastim was still associated with rates of FN, grade 4 FN, severe neutropenia, and treatment delays due to FN in pediatric cancer patients.
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Affiliation(s)
- Xia Zhu
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Weiling Zhang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yi Zhang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yizhuo Wang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Huimin Hu
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Jing Li
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yan Zhou
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Tao Han
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
| | - Dongsheng Huang
- Department of Pediatrics, Beijing Tongren Hospital Capital Medical University, Beijing, People's Republic of China
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Kaya Z, Alıcı N, Kırkız S, Koçak Ü. Identifying Risk Factors and Improving Preventive Strategies for Febrile Neutropenia in Children with Leukemia Receiving Ciprofloxacin Prophylaxis. Turk J Haematol 2023; 40:183-186. [PMID: 37314294 PMCID: PMC10476261 DOI: 10.4274/tjh.galenos.2023.2023.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/03/2023] [Indexed: 09/01/2023] Open
Abstract
The purpose of this study was to identify risk factors and improve preventive strategies for febrile neutropenia (FEN) in children with leukemia who were receiving ciprofloxacin prophylaxis. The study included 100 children with leukemia [n=80 with acute lymphoblastic leukemia and n=20 with acute myeloblastic leukemia (AML)]. Patients were divided into two groups based on whether they had three or fewer FEN episodes (Group 1) or more than three FEN episodes (Group 2). Group 1 contained 63 (63%) of the 100 patients, while Group 2 contained 37 (37%). Older age (≥7 years), leukemia type, prolonged neutropenia (>10 days), and the presence of neutropenia and hypogammaglobulinemia at diagnosis were all risk factors for having more than three FEN episodes. Our findings suggest that, in addition to ciprofloxacin prophylaxis, identifying risk factors and improving preventive strategies could help reduce FEN episodes in children with leukemia.
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Affiliation(s)
- Zühre Kaya
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Türkiye
| | - Nurettin Alıcı
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Türkiye
| | - Serap Kırkız
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Türkiye
| | - Ülker Koçak
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Türkiye
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Radiotherapy/Chemotherapy-Immunotherapy for Cancer Management: From Mechanisms to Clinical Implications. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:7530794. [PMID: 36778203 PMCID: PMC9911251 DOI: 10.1155/2023/7530794] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/03/2022] [Accepted: 11/24/2022] [Indexed: 02/05/2023]
Abstract
Cancer immunotherapy has drawn much attention because it can restart the recognition and killing function of the immune system to normalize the antitumor immune response. However, the role of radiotherapy and chemotherapy in cancer treatment cannot be ignored. Due to cancer heterogeneity, combined therapy has become a new trend, and its efficacy has been confirmed in many studies. This review discussed the clinical implications and the underlying mechanisms of cancer immunotherapy in combination with radiotherapy or chemotherapy, offering an outline for clinicians as well as inspiration for future research.
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Cho JS, Oh HJ, Jang YE, Kim HJ, Kim A, Song J, Lee EJ, Lee J. Synthetic pro-peptide design to enhance the secretion of heterologous proteins by Saccharomyces cerevisiae. Microbiologyopen 2022; 11:e1300. [PMID: 35765186 PMCID: PMC9178654 DOI: 10.1002/mbo3.1300] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 12/02/2022] Open
Abstract
Heterologous protein production in Saccharomyces cerevisiae is a useful and effective strategy with many advantages, including the secretion of proteins that require posttranslational processing. However, heterologous proteins in S. cerevisiae are often secreted at comparatively low levels. To improve the production of the heterologous protein, human granulocyte colony-stimulating factor (hG-CSF) in S. cerevisiae, a secretion-enhancing peptide cassette including an hIL-1β-derived pro-peptide, was added and used as a secretion enhancer to alleviate specific bottlenecks in the yeast secretory pathway. The effects of three key parameters-N-glycosylation, net negative charge balance, and glycine-rich flexible linker-were investigated in batch cultures of S. cerevisiae. Using a three-stage design involving screening, selection, and optimization, the production and secretion of hG-CSF by S. cerevisiae were significantly increased. The amount of extracellular mature hG-CSF produced by the optimized pro-peptide after the final stage increased by 190% compared to that of the original pro-peptide. Although hG-CSF was used as the model protein in the current study, this strategy is applicable to the enhanced production of other heterologous proteins, using S. cerevisiae as the host.
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Affiliation(s)
- Ji Sung Cho
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Hye Ji Oh
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Young Eun Jang
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Hyun Jin Kim
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Areum Kim
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Jong‐Am Song
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
| | - Eun Jung Lee
- Department of Chemical Engineering, School of Applied Chemical EngineeringKyungpook National UniversityDaeguKorea
| | - Jeewon Lee
- Department of Chemical and Biological Engineering, College of EngineeringKorea UniversitySeoulKorea
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Safety and Efficacy of Pegteograstim on Chemotherapy-induced Neutropenia in Children and Adolescents With Solid Tumors. J Pediatr Hematol Oncol 2022; 44:e362-e367. [PMID: 34010932 DOI: 10.1097/mph.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Pegteograstim (Neulapeg) is a recombinant human granulocyte colony-stimulating factor conjugated with methoxy-maleimide-polyethylene glycol. We conducted a single-arm study investigating its safety and noninferiority to conventional filgrastim in children and adolescents. MATERIALS AND METHODS Patients younger than 21 years with solid tumors were eligible for the study. Pegteograstim was administered on day 7 of the fourth chemotherapy cycle. Toxicities were monitored, and the change in absolute neutrophil count was compared with that of the historic control (conventional filgrastim). This trial was registered at ClinicalTrials.gov as NCT02787876. RESULTS Thirty-two patients were enrolled. Adverse events possibly related to pegteograstim were musculoskeletal pain (n=3), skin nodule (n=1), paroxysmal cough (n=1), urticaria (n=2), rash (n=1), and itching (n=1). These adverse events were all grade 1 or 2. Duration of neutropenia (ANC<500/µL) was shorter in the pegteograstim group compared with the historic control (median 6.5 vs. 10 d, P=0.004). The time from day 0 to neutrophil recovery (ANC>500/µL) was shorter in the pegteograstim group (median 15 vs. 18 d, P=0.003). CONCLUSIONS Pegteograstim is safe and shows comparable efficacy to conventional filgrastim in children and adolescents. Randomized controlled trials are needed to confirm its safety and efficacy.
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Postoperative Rather Than Preoperative Neutropenia Is Associated With Early Catheter-related Bloodstream Infections in Newly Diagnosed Pediatric Cancer Patients. Pediatr Infect Dis J 2022; 41:133-139. [PMID: 34596627 DOI: 10.1097/inf.0000000000003315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship of early catheter-related bloodstream infections (CRBSIs) with perioperative neutropenia and antibiotic prophylaxis is not well established. We sought to evaluate perioperative factors associated with early CRBSIs in newly diagnosed pediatric cancer patients, particularly hematologic indices and antibiotic use. METHODS We retrospectively reviewed national registry records of newly diagnosed pediatric cancer patients with port-a-caths inserted using standardized perioperative protocols where only antibiotic use was not regulated. Thirty-day postoperative CRBSI incidence was correlated with preoperative factors using logistic regression and with postoperative blood counts using linear trend analysis. RESULTS Among 243 patients, 17 CRBSIs (7.0%) occurred at median 14 (range, 8-28) postoperative days. Early CRBSIs were significantly associated with cancer type [acute myeloid leukemia and other leukemias (AML/OLs) vs. solid tumors and lymphomas (STLs): odds ratio (OR), 5.09; P = 0.0036; acute lymphoblastic leukemia vs. STL: OR 0.83; P = 0.0446] but not preoperative antibiotics, absolute neutrophil counts and white blood cell counts. Thirty-day postoperative absolute neutrophil counts and white blood cell trends differed significantly between patients with acute lymphoblastic leukemia and STLs (OR 0.83, P < 0.05) and between AML/OLs and STLs (OR 5.09, P < 0.005), with AML/OL patients having the most protracted neutropenia during this period. CONCLUSIONS Contrary to common belief, low preoperative absolute neutrophil counts and lack of preoperative antibiotics were not associated with higher early CRBSI rates. Instead, AML/OL patients, particularly those with prolonged neutropenia during the first 30 postoperative days, were at increased risk. Our findings do not support the use of empirical preoperative antibiotics and instead identify prolonged postoperative neutropenia as a major contributing factor for early CRBSI.
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Pulcini CD, Lentz S, Saladino RA, Bounds R, Herrington R, Michaels MG, Maurer SH. Emergency management of fever and neutropenia in children with cancer: A review. Am J Emerg Med 2021; 50:693-698. [PMID: 34879488 DOI: 10.1016/j.ajem.2021.09.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery and Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine and Critical Care, Department of Surgery and Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States of America
| | - Richard A Saladino
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Ramsey Herrington
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Marian G Michaels
- Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Scott H Maurer
- Division of Hematology/Oncology, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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Lee S, Hong KT, Moon SJ, Choi JY, Hong CR, Shin HY, Cho JY, Jang IJ, Yu KS, Oh J, Kang HJ. Pharmacokinetic and Pharmacodynamic Characteristics of Tripegfilgrastim, a Pegylated G-CSF, in Pediatric Patients with Solid Tumors. Clin Pharmacol Ther 2021; 111:293-301. [PMID: 34605552 DOI: 10.1002/cpt.2433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/14/2021] [Indexed: 11/07/2022]
Abstract
A long-acting granulocyte colony-stimulating factor, tripegfilgrastim, was approved in Korea for the prevention of chemotherapy-induced neutropenia in adult patients. In this study, we evaluated the pharmacokinetics, pharmacodynamics, and safety of tripegfilgrastim in pediatric patients. A phase I, open-label, single ascending-dose study was performed in pediatric patients with solid tumors or lymphoma (ClinicalTrials.gov, NCT02963389). The patients were stratified according to age groups (aged 6 to 12 or 12 to 19 years) and received a single subcutaneous dose of tripegfilgrastim 60 μg/kg or 100 μg/kg. Tripegfilgrastim was administered 24 hours after the end of the chemotherapy, and serial blood sampling and safety monitoring were conducted. Twenty-seven patients with solid tumors were enrolled in this study. Tripegfilgrastim was detectable in plasma for an extended period (terminal half-life > 40 hours), and plasma concentrations increased slightly less than dose proportionally. The mean duration of grade 4 neutropenia was reduced as the average tripegfilgrastim concentration during the initial neutrophil recovery process increased. No substantial differences in the pharmacokinetic and pharmacodynamic responses were observed between the two age groups. When stratified by body weight, weighing more than 45 kg has a higher risk of a prolonged neutropenia period when receiving the lower dose (60 μg/kg) of tripegfilgrastim. Tripegfilgrastim was generally safe and well-tolerated in the pediatric patients. These results justify further clinical investigations of tripegfilgrastim at 100 μg/kg dose in pediatric patients.
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Affiliation(s)
- Soyoung Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyung Taek Hong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
- Seoul National University Cancer Research Institute, Seoul, Korea
| | - Seol Ju Moon
- Center for Clinical Pharmacology and Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju, Korea
| | - Jung Yoon Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
- Seoul National University Cancer Research Institute, Seoul, Korea
| | - Che Ry Hong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
- Seoul National University Cancer Research Institute, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
- Seoul National University Cancer Research Institute, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
- Seoul National University Cancer Research Institute, Seoul, Korea
- Wide River Institute of Immunology, Hongcheon, Korea
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Schlenker L, Manworren RCB. Timing of Pegfilgrastim: Association with Febrile Neutropenia in a Pediatric Solid and CNS Tumor Population. J Pediatr Oncol Nurs 2021; 38:375-384. [PMID: 34402328 DOI: 10.1177/10434542211037729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: While recommended timing of pegfilgrastim administration is ≥24 h after chemotherapy, patient barriers to next day administration, available adult evidence, and pharmacokinetic data have led to earlier administration in some pediatric patients with solid and central nervous system tumors. The purpose of this study was to compare patient outcomes by timing of pegfilgrastim after chemotherapy. Methods: A retrospective chart review examined timing of 932 pegfilgrastim administrations to 182 patients, 0-29 years of age. The primary outcome was febrile neutropenia (FN); the secondary outcome was neutropenic delays (ND) ≥7 days to next chemotherapy cycle. To account for multiple pegfilgrastim administrations per patient, a generalized mixed model was used with a logit link for the dichotomous outcomes (FN & ND), timing as the dichotomous independent variable, and random effect for patient. Results: FN occurred in 196 of 916 cycles (21.4%); and ND in 19 of 805 cycles (2.4%). The fixed effect of pegfilgrastim administration < or ≥24 h after chemotherapy was not significant, p = .50; however, earlier or later than 20 h was significant, p = .005. FN odds were significantly higher when pegfilgrastim was given <20 h (OR 1.78, 95% CI: 1.19-2.65) after chemotherapy, which may be attributable to differences in chemotherapy toxicity regardless of pegfilgrastim timing. Discussion: While attempts should be made to administer pegfilgrastim ≥24 h after chemotherapy, if barriers exist, modified timing based on individual patient characteristics should be considered. Prospective randomized trials are needed to identify lower risk patients for early pegfilgrastim administration.
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Affiliation(s)
- Laura Schlenker
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Renee C B Manworren
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, 12244Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Yankelevich M, Hoogstra DJ, Abrams J, Chu R, Bhambhani K, Taub JW. Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol 2020; 37:665-675. [PMID: 32643500 DOI: 10.1080/08880018.2020.1779885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The use of G-CSF after myelotoxic chemotherapy accelerates neutrophil recovery reducing the risk of febrile neutropenia. Current guidelines recommend initiating G-CSF 24 hours after myelotoxic chemotherapy. However, the optimal timing of post-chemotherapy G-CSF administration has not been elucidated. Our previous work in murine models demonstrated that the reappearance of myeloid progenitors does not occur in bone marrow until 3-4 days after completion of chemotherapy suggesting that delayed G-CSF administration may be equally efficacious compared to current practice. We conducted a prospective, randomized, crossover study to compare the absolute neutrophil count (ANC) recovery after chemotherapy and a delayed G-CSF administration to a standard G-CSF administration schedule with early G-CSF start. A total of 21 children with solid tumors who received 2 identical cycles of myelotoxic chemotherapy were randomized to start receiving G-CSF either 24 hours after completion of chemotherapy or on the day that their ANC dropped below 1,000/mm3. There was no significant difference in the time to neutrophil recovery (ANC > 1,000/mm3 post nadir) between the two G-CSF administration schedules: 16.0 ± 0.5 days in the standard group compared to 16.7 ± 0.4 days in the delayed group (p = 0.36). The total number of G-CSF doses given, however, was significantly less in the delayed group: 6.7 ± 0.6 compared to 10.5 ± 0.6 doses in the standard group (p < 0.0001). Our data show that a delayed administration of post chemotherapy G-CSF resulted in a significant reduction in the number of G-CSF injections without compromising the G-CSF effects on neutrophil recovery.
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Affiliation(s)
- Maxim Yankelevich
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA.,Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - David J Hoogstra
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA.,Helen DeVos Children's Hospital, Division of Pediatric Hematology/Oncology, Grand Rapids, Michigan, USA
| | - Judith Abrams
- Biostatistics Core, Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Roland Chu
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kanta Bhambhani
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jeffrey W Taub
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA
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Morjaria S, Zhang A, Kaltsas Md A, Parameswaran R, Patel D, Zhou W, Predmore J, Perez Johnston R, Jee J, Perales M, Daniyan A, Taur Y, Mailankody S. The Effect of Neutropenia and Filgrastim (G-CSF) in Cancer Patients With COVID-19 Infection. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.08.13.20174565. [PMID: 32817981 PMCID: PMC7430626 DOI: 10.1101/2020.08.13.20174565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
BACKGROUND Neutropenia is commonly encountered in cancer patients, and recombinant human granulocyte colony-stimulating factor (G-CSF, filgrastim) is widely given to oncology patients to counteract neutropenia and prevent infection. G-CSF is both a growth factor and cytokine that initiates proliferation and differentiation of mature granulocytes. However, the clinical impact of neutropenia and G-CSF use in cancer patients, who are also afflicted with coronavirus disease 2019 (COVID-19), remains unknown. METHODS An observational cohort of 304 hospitalized patients with COVID-19 at Memorial Sloan Kettering Cancer Center was assembled to investigate links between concurrent neutropenia (N=55) and G-CSF administration (N=16) on COVID-19-associated respiratory failure and death. These factors were assessed as time-dependent predictors using an extended Cox model, controlling for age and underlying cancer diagnosis. To determine whether the degree of granulocyte response to G-CSF affected outcomes, a similar model was constructed with patients that received G-CSF, categorized into high- and low-response, based on the level of absolute neutrophil count (ANC) rise 24 hours after growth factor administration. RESULTS Neutropenia (ANC < 1 K/mcL) during COVID-19 course was not independently associated with severe respiratory failure or death (HR: 0.71, 95% Cl: 0.34-1.50, P value: 0.367) in hospitalized COVID-19 patients. When controlling for neutropenia, G-CSF administration was associated with increased need for high oxygen supplementation and death (HR: 2.97, 95% CI: 1.06-8.28, P value: 0.038). This effect was predominantly seen in patients that exhibited a high response to G-CSF based on their ANC increase post-G-CSF administration (HR: 5.18, 95% CI: 1.61-16.64, P value: 0.006). CONCLUSION Possible risks versus benefits of G-CSF administration should be weighed in neutropenic cancer patients with COVID-19 infection, as G-CSF may lead to worsening clinical and respiratory status in this setting.
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Youn JK, Jung K, Park T, Kim HY, Jung SE. The effect of Absolute Neutrophil Count (ANC) on early surgical site infection in Implanted Central Venous Catheter (ICVC). J Pediatr Surg 2020; 55:1344-1346. [PMID: 31753614 DOI: 10.1016/j.jpedsurg.2019.09.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate surgical site infection (SSI) rates related to implanted central venous catheters (ICVC) in pediatric hematology and oncology patients with respect to absolute neutrophil count (ANC) levels. PATIENTS AND METHODS From January 2004 to December 2015, pediatric patients with ICVC insertion were investigated retrospectively. Patients were divided into four groups according to preoperative ANC levels and Granulocyte-colony stimulating factor (G-CSF) usage. Immediate and early surgical site infections were evaluated 7 and 30 days following surgery. RESULTS In total, 1143 patients were enrolled. Patients were placed into 4 groups: 930 patients in group 1 with an ANC≥500/μL without G-CSF, 149 in group 2 with an ANC≥500/μL after G-CSF usage, 36 in group 3 with an ANC<500/μL without G-CSF, and 28 in group 4 with an ANC<500/μL even after G-CSF administration. Rates of immediate and early SSIs were not statistically different between groups. In the two-group analysis (group 1 and 2 vs. 3 and 4), the number of immediate and early SSIs were not also different, respectively. CONCLUSION There was no correlation between ANC levels and immediate and early SSI occurrence after ICVC placement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joong Kee Youn
- Department of Surgery, Jeju National University Hospital, Jeju, Korea
| | - Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Taejin Park
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea.
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A Phase 2, International, Multicenter, Open-label Clinical Trial of Subcutaneous Tbo-Filgrastim in Pediatric Patients With Solid Tumors Undergoing Myelosuppressive Chemotherapy. J Pediatr Hematol Oncol 2019; 41:525-531. [PMID: 31274668 DOI: 10.1097/mph.0000000000001542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This phase 2, multicenter, open-label trial investigated the safety and tolerability of tbo-filgrastim in pediatric patients receiving myelosuppressive chemotherapy. In total, 50 patients 1 month to below 16 years of age with solid tumors without bone marrow involvement were stratified into 3 age groups (2 infants, 30 children, 18 adolescents) and prophylactically administered tbo-filgrastim 5 µg/kg body weight once daily subcutaneously. The administration started after the last chemotherapy treatment in week 1 of the first cycle and continued until the expected neutrophil nadir had passed, and the neutrophil count had recovered to 2.0×10/L. The primary endpoint was safety and tolerability of tbo-filgrastim; secondary endpoints included efficacy. The mean (SD) number of doses administered was 9.2 (2.83) in children and 7.3 (1.88) in adolescents. Serious treatment-emergent adverse events were reported in 24% of patients; the most common were febrile neutropenia (FN) (12%), anemia (8%), and thrombocytopenia (8%). Nine patients (18%) experienced mild treatment-related treatment-emergent adverse events; the most common were musculoskeletal and connective tissue disorders (8%). No deaths or withdrawals occurred. The incidence of severe neutropenia (SN) was 52% and the mean (SD) duration of SN was 1.8 (2.21) days; FN incidence was 26%. A daily dose of tbo-filgrastim 5 μg/kg body weight administered to pediatric patients demonstrated a safety profile consistent with the safety profile in adult patients. The incidence of FN was on the lower end of the range reported in the literature and the SN results provide supportive data on the efficacy of tbo-filgrastim in pediatric patients.
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Egan G, Robinson PD, Martinez JPD, Alexander S, Ammann RA, Dupuis LL, Fisher BT, Lehrnbecher T, Phillips B, Cabral S, Tomlinson G, Sung L. Efficacy of antibiotic prophylaxis in patients with cancer and hematopoietic stem cell transplantation recipients: A systematic review of randomized trials. Cancer Med 2019; 8:4536-4546. [PMID: 31274245 PMCID: PMC6712447 DOI: 10.1002/cam4.2395] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/07/2019] [Accepted: 06/20/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine the efficacy and safety of different prophylactic systemic antibiotics in adult and pediatric patients receiving chemotherapy or undergoing hematopoietic stem cell transplantation (HSCT). METHODS We conducted a systematic review and performed searches of Ovid MEDLINE, MEDLINE in-process and Embase; and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were HSCT recipients with anticipated neutropenia, and the intervention was systemic antibacterial prophylaxis. Strategies synthesized included fluoroquinolone vs no antibiotic/nonabsorbable antibiotic; fluoroquinolone vs trimethoprim-sulfamethoxazole; trimethoprim-sulfamethoxazole vs no antibiotic; and cephalosporin vs. no antibiotic. Fluoroquinolone vs cephalosporin and levofloxacin vs ciprofloxacin were compared by network meta-analysis. Primary outcome was bacteremia. RESULTS Of 20 984 citations screened, 113 studies comparing prophylactic antibiotic to control were included. The following were effective in reducing bacteremia: fluoroquinolone vs no antibiotic/nonabsorbable antibiotic (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.41-0.76), trimethoprim-sulfamethoxazole vs no antibiotic (RR 0.59, 95% CI 0.41-0.85) and cephalosporin vs no antibiotic (RR 0.30, 95% CI 0.16-0.58). Fluoroquinolone was not significantly associated with increased Clostridium difficile infection (RR 0.62, 95% CI 0.31-1.24) or invasive fungal disease (RR 1.28, 95% CI 0.79-2.08) but did increase resistance to fluoroquinolone among bacteremia isolates (RR 3.35, 95% CI 1.12 to 10.03). Heterogeneity in fluoroquinolone effect on bacteremia was not explained by evaluated study, population, or methodological factors. Network meta-analysis revealed no direct comparisons for pre-specified analyses; superior regimens were not identified. CONCLUSIONS Fluoroquinolone, trimethoprim-sulfamethoxazole, and cephalosporin prophylaxis reduced bacteremia. A clinical practice guideline to facilitate prophylactic antibiotic decision-making is required.
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Affiliation(s)
- Grace Egan
- Division of Haematology/OncologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | - Sarah Alexander
- Division of Haematology/OncologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Roland A. Ammann
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - L. Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children, and Leslie Dan Faculty of PharmacyUniversity of Toronto, The Hospital for Sick ChildrenTorontoOntarioCanada
| | - Brian T. Fisher
- Division of Infectious DiseasesChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Thomas Lehrnbecher
- Pediatric Hematology and OncologyJohann Wolfgang Goethe UniversityFrankfurtGermany
| | - Bob Phillips
- Leeds Children's Hospital, Leeds General Infirmary, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom and Centre for Reviews and Dissemination, University of YorkLeeds West YorkshireUK
| | - Sandra Cabral
- Pediatric Oncology Group of OntarioTorontoOntarioCanada
| | - George Tomlinson
- Biostatistics Research UnitToronto General HospitalTorontoOntarioCanada
- Institute of Health Policy Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Lillian Sung
- Division of Haematology/OncologyThe Hospital for Sick ChildrenTorontoOntarioCanada
- Institute of Health Policy Management and EvaluationUniversity of TorontoTorontoOntarioCanada
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Chen XY, Ruan M, Zhao BB, Wang SC, Chen XJ, Zhang L, Guo Y, Yang WY, Zou Y, Chen YM, Zhu XF. [Mitoxantrone-cytarabine-etoposide induction therapy in children with acute myeloid leukemia: a single-center study of complications and clinical outcomes]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:24-28. [PMID: 30675859 PMCID: PMC7390179 DOI: 10.7499/j.issn.1008-8830.2019.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/20/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate the complications and clinical outcome of children with acute myeloid leukemia (AML) undergoing mitoxantrone-cytarabine-etoposide (MAE) induction therapy. METHODS A total of 170 children with AML were given MAE induction therapy, and the complications and remission rate were analyzed after treatment. RESULTS The male/female ratio was 1.33:1 and the mean age was 7.4 years (range 1-15 years). Leukocyte count at diagnosis was 29.52×109/L [range (0.77-351)×109/L]. Of all children, 2 had M0-AML, 24 had M2-AML, 2 had M4-AML, 48 had M5-AML, 3 had M6-AML, 7 had M7-AML, 69 had AML with t(8;21)(q22;q22), and 15 had AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22). The most common complication was infection (158/170, 92.9%). Among these 158 patients, 22 (13.9%) had agranulocytosis with pyrexia (with no definite focus of infection), and 136 (86.1%) had definite focus of infection (including bloodstream infection). Other complications included non-infectious diarrhea, bleeding, and drug-induced hepatitis. Treatment-related mortality was observed in 10 children, among whom 8 had severe infection, 1 had multiple organ failure, and 1 had respiratory failure. Remission rate was evaluated for 156 children and the results showed a complete remission rate of 85.3%, a partial remission rate of 4.5%, and a non-remission rate of 10.3%. CONCLUSIONS Induction therapy with the MAE regimen helps to achieve a good remission rate in children with AML after one course of treatment. Infection is the main complication and a major cause of treatment-related mortality.
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Affiliation(s)
- Xiao-Yan Chen
- Department of Pediatric Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China.
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Bryant CE, Sutherland S, Kong B, Papadimitrious MS, Fromm PD, Hart DNJ. Dendritic cells as cancer therapeutics. Semin Cell Dev Biol 2018; 86:77-88. [PMID: 29454038 DOI: 10.1016/j.semcdb.2018.02.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/14/2017] [Accepted: 02/10/2018] [Indexed: 02/06/2023]
Abstract
The ability of immune therapies to control cancer has recently generated intense interest. This therapeutic outcome is reliant on T cell recognition of tumour cells. The natural function of dendritic cells (DC) is to generate adaptive responses, by presenting antigen to T cells, hence they are a logical target to generate specific anti-tumour immunity. Our understanding of the biology of DC is expanding, and they are now known to be a family of related subsets with variable features and function. Most clinical experience to date with DC vaccination has been using monocyte-derived DC vaccines. There is now growing experience with alternative blood-derived DC derived vaccines, as well as with multiple forms of tumour antigen and its loading, a wide range of adjuvants and different modes of vaccine delivery. Key insights from pre-clinical studies, and lessons learned from early clinical testing drive progress towards improved vaccines. The potential to fortify responses with other modalities of immunotherapy makes clinically effective "second generation" DC vaccination strategies a priority for cancer immune therapists.
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Affiliation(s)
- Christian E Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW Australia; Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia.
| | - Sarah Sutherland
- Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia; Sydney Medical School, The University of Sydney, Sydney, NSW Australia
| | - Benjamin Kong
- Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia; Sydney Medical School, The University of Sydney, Sydney, NSW Australia
| | - Michael S Papadimitrious
- Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia; Sydney Medical School, The University of Sydney, Sydney, NSW Australia
| | - Phillip D Fromm
- Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia; Sydney Medical School, The University of Sydney, Sydney, NSW Australia
| | - Derek N J Hart
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW Australia; Dendritic Cell Research, ANZAC Research Institute, Concord, NSW Australia; Sydney Medical School, The University of Sydney, Sydney, NSW Australia.
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Antifungal Prophylaxis in Children Receiving Antineoplastic Chemotherapy. CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0311-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Skoetz N, Bohlius J, Engert A, Monsef I, Blank O, Vehreschild J. Prophylactic antibiotics or G(M)-CSF for the prevention of infections and improvement of survival in cancer patients receiving myelotoxic chemotherapy. Cochrane Database Syst Rev 2015; 2015:CD007107. [PMID: 26687844 PMCID: PMC7389519 DOI: 10.1002/14651858.cd007107.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) and other infectious complications are some of the most serious treatment-related toxicities of chemotherapy for cancer, with a mortality rate of 2% to 21%. The two main types of prophylactic regimens are granulocyte (macrophage) colony-stimulating factors (G(M)-CSF) and antibiotics, frequently quinolones or cotrimoxazole. Current guidelines recommend the use of colony-stimulating factors when the risk of febrile neutropenia is above 20%, but they do not mention the use of antibiotics. However, both regimens have been shown to reduce the incidence of infections. Since no systematic review has compared the two regimens, a systematic review was undertaken. OBJECTIVES To compare the efficacy and safety of G(M)-CSF compared to antibiotics in cancer patients receiving myelotoxic chemotherapy. SEARCH METHODS We searched The Cochrane Library, MEDLINE, EMBASE, databases of ongoing trials, and conference proceedings of the American Society of Clinical Oncology and the American Society of Hematology (1980 to December 2015). We planned to include both full-text and abstract publications. Two review authors independently screened search results. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing prophylaxis with G(M)-CSF versus antibiotics for the prevention of infection in cancer patients of all ages receiving chemotherapy. All study arms had to receive identical chemotherapy regimes and other supportive care. We included full-text, abstracts, and unpublished data if sufficient information on study design, participant characteristics, interventions and outcomes was available. We excluded cross-over trials, quasi-randomised trials and post-hoc retrospective trials. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the search strategies, extracted data, assessed risk of bias, and analysed data according to standard Cochrane methods. We did final interpretation together with an experienced clinician. MAIN RESULTS In this updated review, we included no new randomised controlled trials. We included two trials in the review, one with 40 breast cancer patients receiving high-dose chemotherapy and G-CSF compared to antibiotics, a second one evaluating 155 patients with small-cell lung cancer receiving GM-CSF or antibiotics.We judge the overall risk of bias as high in the G-CSF trial, as neither patients nor physicians were blinded and not all included patients were analysed as randomised (7 out of 40 patients). We considered the overall risk of bias in the GM-CSF to be moderate, because of the risk of performance bias (neither patients nor personnel were blinded), but low risk of selection and attrition bias.For the trial comparing G-CSF to antibiotics, all cause mortality was not reported. There was no evidence of a difference for infection-related mortality, with zero events in each arm. Microbiologically or clinically documented infections, severe infections, quality of life, and adverse events were not reported. There was no evidence of a difference in frequency of febrile neutropenia (risk ratio (RR) 1.22; 95% confidence interval (CI) 0.53 to 2.84). The quality of the evidence for the two reported outcomes, infection-related mortality and frequency of febrile neutropenia, was very low, due to the low number of patients evaluated (high imprecision) and the high risk of bias.There was no evidence of a difference in terms of median survival time in the trial comparing GM-CSF and antibiotics. Two-year survival times were 6% (0 to 12%) in both arms (high imprecision, low quality of evidence). There were four toxic deaths in the GM-CSF arm and three in the antibiotics arm (3.8%), without evidence of a difference (RR 1.32; 95% CI 0.30 to 5.69; P = 0.71; low quality of evidence). There were 28% grade III or IV infections in the GM-CSF arm and 18% in the antibiotics arm, without any evidence of a difference (RR 1.55; 95% CI 0.86 to 2.80; P = 0.15, low quality of evidence). There were 5 episodes out of 360 cycles of grade IV infections in the GM-CSF arm and 3 episodes out of 334 cycles in the cotrimoxazole arm (0.8%), with no evidence of a difference (RR 1.55; 95% CI 0.37 to 6.42; P = 0.55; low quality of evidence). There was no significant difference between the two arms for non-haematological toxicities like diarrhoea, stomatitis, infections, neurologic, respiratory, or cardiac adverse events. Grade III and IV thrombopenia occurred significantly more frequently in the GM-CSF arm (60.8%) compared to the antibiotics arm (28.9%); (RR 2.10; 95% CI 1.41 to 3.12; P = 0.0002; low quality of evidence). Neither infection-related mortality, incidence of febrile neutropenia, nor quality of life were reported in this trial. AUTHORS' CONCLUSIONS As we only found two small trials with 195 patients altogether, no conclusion for clinical practice is possible. More trials are necessary to assess the benefits and harms of G(M)-CSF compared to antibiotics for infection prevention in cancer patients receiving chemotherapy.
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Affiliation(s)
- Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Julia Bohlius
- University of BernInstitute of Social and Preventive MedicineFinkenhubelweg 11BernSwitzerland3012
| | - Andreas Engert
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Ina Monsef
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Oliver Blank
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Jörg‐Janne Vehreschild
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
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Marlow N, Morris T, Brocklehurst P, Carr R, Cowan F, Patel N, Petrou S, Redshaw M, Modi N, Doré CJ. A randomised trial of granulocyte-macrophage colony-stimulating factor for neonatal sepsis: childhood outcomes at 5 years. Arch Dis Child Fetal Neonatal Ed 2015; 100:F320-6. [PMID: 25922190 PMCID: PMC4484494 DOI: 10.1136/archdischild-2014-307410] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 03/15/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We performed a randomised trial in very preterm, small for gestational age (SGA) babies to determine if prophylaxis with granulocyte macrophage colony stimulating factor (GM-CSF) improves outcomes (the PROGRAMS trial). GM-CSF was associated with improved neonatal neutrophil counts, but no change in other neonatal or 2-year outcomes. As subtle benefits in outcome may not be ascertainable until school age we performed an outcome study at 5 years. PATIENTS AND METHODS 280 babies born at 31 weeks of gestation or less and SGA were entered into the trial. Outcomes were assessed at 5 years to determine neurodevelopmental and general health status and educational attainment. RESULTS We found no significant differences in cognitive, general health or educational outcomes between 83 of 106 (78%) surviving children in the GM-CSF arm compared with 81 of 110 (74%) in the control arm. Mean mental processing composite (equivalent to IQ) at 5 years were 94 (SD 16) compared with 95 (SD 15), respectively (difference in means -1 (95%CI -6 to 4), and similar proportions were in receipt of special educational needs support (41% vs 35%; risk ratio 1.2 (95% CI 0.8 to 1.9)). Performance on Kaufmann-ABC subscales and components of NEPSY were similar. The suggestion of worse respiratory outcomes in the GM-CSF group at 2 years was replicated at 5 years. CONCLUSIONS The administration of GM-CSF to very preterm SGA babies is not associated with improved or more adverse neurodevelopmental, general health or educational outcomes at 5 years. TRIAL REGISTRATION NUMBER ISRCTN42553489.
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Affiliation(s)
- Neil Marlow
- UCL Institute for Women's Health, University College London, London, UK
| | - Timothy Morris
- MRC Clinical Trials Unit, University College London, London, UK
| | | | - Robert Carr
- Department of Haematology, Guy's and St Thomas’ Hospital, King's College London, London, UK
| | - Frances Cowan
- Section of Neonatal Medicine, Department of Medicine, Chelsea & Westminster campus, Imperial College London, London, UK
| | - Nishma Patel
- Department of Applied Health Research, University College London, London, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Margaret Redshaw
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Chelsea & Westminster campus, Imperial College London, London, UK
| | - Caroline J Doré
- MRC Clinical Trials Unit, University College London, London, UK
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Ju HY, Hong CR, Shin HY. Advancements in the treatment of pediatric acute leukemia and brain tumor - continuous efforts for 100% cure. KOREAN JOURNAL OF PEDIATRICS 2014; 57:434-9. [PMID: 25379043 PMCID: PMC4219945 DOI: 10.3345/kjp.2014.57.10.434] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/14/2014] [Indexed: 02/08/2023]
Abstract
Treatment outcomes of pediatric cancers have improved greatly with the development of improved treatment protocols, new drugs, and better supportive measures, resulting in overall survival rates greater than 70%. Survival rates are highest in acute lymphoblastic leukemia, reaching more than 90%, owing to risk-based treatment through multicenter clinical trials and protocols developed to prevent central nervous system relapse and testicular relapse in boys. New drugs including clofarabine and nelarabine are currently being evaluated in clinical trials, and other targeted agents are continuously being developed. Chimeric antigen receptor-modified T cells are now attracting interest for the treatment of recurrent or refractory disease. Stem cell transplantation is still the most effective treatment for pediatric acute myeloid leukemia (AML). However, in order to reduce treatment-related death after stem cell transplantation, there is need for improved treatments. New drugs and targeted agents are also needed for improved outcome of AML. Surgery and radiation therapy have been the mainstay for brain tumor treatment. However, chemotherapy is becoming more important for patients who are not eligible for radiotherapy owing to age. Stem cell transplant as a means of high dose chemotherapy and stem cell rescue is a new treatment modality and is often repeated for improved survival. Drugs such as temozolomide are new chemotherapeutic options. In order to achieve 100% cure in children with pediatric cancer, every possible treatment modality and effort should be considered.
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Affiliation(s)
- Hee Young Ju
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Che Ry Hong
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Smyth RL, Peak M, Turner MA, Nunn AJ, Williamson PR, Young B, Arnott J, Bellis JR, Bird KA, Bracken LE, Conroy EJ, Cresswell L, Duncan JC, Gallagher RM, Gargon E, Hesselgreaves H, Kirkham JJ, Mannix H, Smyth RMD, Thiesen S, Pirmohamed M. ADRIC: Adverse Drug Reactions In Children – a programme of research using mixed methods. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AimsTo comprehensively investigate the incidence, nature and risk factors of adverse drug reactions (ADRs) in a hospital-based population of children, with rigorous assessment of causality, severity and avoidability, and to assess the consequent impact on children and families. We aimed to improve the assessment of ADRs by development of new tools to assess causality and avoidability, and to minimise the impact on families by developing better strategies for communication.Review methodsTwo prospective observational studies, each over 1 year, were conducted to assess ADRs in children associated with admission to hospital, and those occurring in children who were in hospital for longer than 48 hours. We conducted a comprehensive systematic review of ADRs in children. We used the findings from these studies to develop and validate tools to assess causality and avoidability of ADRs, and conducted interviews with parents and children who had experienced ADRs, using these findings to develop a leaflet for parents to inform a communication strategy about ADRs.ResultsThe estimated incidence of ADRs detected in children on admission to hospital was 2.9% [95% confidence interval (CI) 2.5% to 3.3%]. Of the reactions, 22.1% (95% CI 17% to 28%) were either definitely or possibly avoidable. Prescriptions originating in the community accounted for 44 out of 249 (17.7%) of ADRs, the remainder originating from hospital. A total of 120 out of 249 (48.2%) reactions resulted from treatment for malignancies. Off-label and/or unlicensed (OLUL) medicines were more likely to be implicated in an ADR than authorised medicines [relative risk (RR) 1.67, 95% CI 1.38 to 2.02;p < 0.001]. When medicines used for the treatment of oncology patients were excluded, OLUL medicines were not more likely to be implicated in an ADR than authorised medicines (RR 1.03, 95% CI 0.72 to 1.48;p = 0.830). For children who had been in hospital for > 48 hours, the overall incidence of definite and probable ADRs based on all admissions was 15.9% (95% CI 15.0 to 16.8). Opiate analgesic drugs and drugs used in general anaesthesia (GA) accounted for > 50% of all drugs implicated in ADRs. The odds ratio of an OLUL drug being implicated in an ADR compared with an authorised drug was 2.25 (95% CI 1.95 to 2.59;p < 0.001). Risk factors identified were exposure to a GA, age, oncology treatment and number of medicines. The systematic review estimated that the incidence rates for ADRs causing hospital admission ranged from 0.4% to 10.3% of all children [pooled estimate of 2.9% (95% CI 2.6% to 3.1%)] and from 0.6% to 16.8% of all children exposed to a drug during hospital stay. New tools to assess causality and avoidability of ADRs have been developed and validated. Many parents described being dissatisfied with clinician communication about ADRs, whereas parents of children with cancer emphasised confidence in clinician management of ADRs and the way clinicians communicated about medicines. The accounts of children and young people largely reflected parents’ accounts. Clinicians described using all of the features of communication that parents wanted to see, but made active decisions about when and what to communicate to families about suspected ADRs, which meant that communication may not always match families’ needs and expectations. We developed a leaflet to assist clinicians in communicating ADRs to parents.ConclusionThe Adverse Drug Reactions In Children (ADRIC) programme has provided the most comprehensive assessment, to date, of the size and nature of ADRs in children presenting to, and cared for in, hospital, and the outputs that have resulted will improve the management and understanding of ADRs in children and adults within the NHS. Recommendations for future research: assess the values that parents and children place on the use of different medicines and the risks that they will find acceptable within these contexts; focusing on high-risk drugs identified in ADRIC, determine the optimum drug dose for children through the development of a gold standard practice for the extrapolation of adult drug doses, alongside targeted pharmacokinetic/pharmacodynamic studies; assess the research and clinical applications of the Liverpool Causality Assessment Tool and the Liverpool Avoidability Assessment Tool; evaluate, in more detail, morbidities associated with anaesthesia and surgery in children, including follow-up in the community and in the home setting and an assessment of the most appropriate treatment regimens to prevent pain, vomiting and other postoperative complications; further evaluate strategies for communication with families, children and young people about ADRs; and quantify ADRs in other settings, for example critical care and neonatology.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Rosalind L Smyth
- Institute of Child Health, University of Liverpool, Liverpool, UK
- Institute of Child Health, University College London, London, UK
| | - Matthew Peak
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Mark A Turner
- Institute of Translational Medicine, Liverpool Women’s National Health Service Foundation Trust and University of Liverpool, Liverpool, UK
| | - Anthony J Nunn
- National Institute for Health Research Medicines for Children Research Network, University of Liverpool, Liverpool, UK
| | | | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Janine Arnott
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jennifer R Bellis
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Kim A Bird
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Louise E Bracken
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | | | - Lynne Cresswell
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Jennifer C Duncan
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | | | - Elizabeth Gargon
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Hannah Hesselgreaves
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jamie J Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Helena Mannix
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Rebecca MD Smyth
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Signe Thiesen
- Institute of Child Health, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Langerová P, Vrtal J, Urbánek K. Adverse drug reactions causing hospital admissions in childhood: a prospective, observational, single-centre study. Basic Clin Pharmacol Toxicol 2014; 115:560-4. [PMID: 24810357 DOI: 10.1111/bcpt.12264] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/22/2014] [Indexed: 01/04/2023]
Abstract
Adverse drug reactions (ADRs) are common problems in both paediatric and adult medicine. The aim of this study was to prospectively identify the ADRs causing hospital admission of children and identification of the risk factors and involved drugs. The study was performed at the University Hospital in Olomouc, Czech Republic. All patients aged 19 years or under admitted to hospital were included in the study, and all admissions for ADRs were prospectively screened for a period of 9 months. Suspected ADRs were subsequently evaluated in detail, and causality assessment was undertaken to determine whether each suspected reaction was possible, probable or definite. The assessment of ADR causality was performed using the Naranjo algorithm, the Liverpool ADR Causality Assessment Tool and the Edwards and Aronson causality assessment method. During the study period, 2903 admissions were identified; of these, there were 143 admissions of patients with an oncological disease. Sixty-four admissions (2.2%) were caused by an ADR. Anticancer chemotherapy accounted for 35% of the cases, followed by antibiotics (18%), immunosuppressants and vaccines (9% each). The use of different scoring systems does not lead to the differences in the numbers of ADR-diagnosed patient but may result in differences in the determination of the level of certainty. ADRs cause a substantial proportion of children's hospital admissions. The majority of the ADR-diagnosed patient affected the hematopoietic and gastrointestinal systems; the drugs most frequently involved were cytotoxic agents and antibiotics. The most important risk factors identified were female sex and oncological disease.
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Affiliation(s)
- Petra Langerová
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
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Hakim H, Shenep JL. Managing fungal and viral infections in pediatric leukemia. Expert Rev Hematol 2014; 3:603-24. [DOI: 10.1586/ehm.10.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Invasive yeast infections are a significant cause of morbidity and mortality in patients with defective immune response, such as those with cancer-related immunosuppression, organ transplantation or other immunodeficiencies, and neonates. Hospitalization in the intensive care unit may increase the risk for such infections. Despite the advent of new antifungal agents, the problem is escalating as the number of susceptible hosts increase and virulent, more resistant fungal strains emerge. Over the past few years, advances in immunology and molecular biology have greatly contributed to a better understanding of the pathogenesis of yeast infections. There is evidence that reconstitution of the host immune function is a major contributor to the resolution of yeast infections. Strategies aiming to increase the phagocyte number (e.g., granulocyte transfusions), to stimulate immune response (e.g., administration of hematopoietic growth factors and other proinflammatory cytokines) and to stimulate antigen-specific immunity (e.g., antibody therapy or vaccination) benefit patients at risk of, or suffering from, yeast infections. Further preclinical and clinical studies, as well as improving our understanding of immune system functions and dysfunctions, remain a future challenge.
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Affiliation(s)
- Jorge Garbino
- University Hospitals of Geneva, Infectious Diseases Division (Clinical Research), 24 Rue Micheli du Crest, 1211 Geneva 14, Switzerland.
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26
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Du XL, Zhang Y, Hardy D. Temporal and Geographic Variations in the Receipt of Colony-Stimulating Factors and Erythropoiesis-Stimulating Agents in a Large Retrospective Cohort of Older Women With Breast Cancer From 2000 to 2009. Am J Ther 2014; 23:e411-21. [PMID: 25756469 DOI: 10.1097/mjt.0000000000000182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to use the most recent national data for a large cohort of patients diagnosed with breast cancer to evaluate temporal trend of receiving hematopoietic growth factors from 2000 to 2009 and to examine significant factors associated with increasing trends and geographic variations. We identified 26,130 women aged 65-89 years who were diagnosed with breast cancer and received chemotherapy in 2000-2009 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Colony-stimulating factors (CSFs) were identified if there was a claim from the following procedure codes: filgrastim, pegfilgrastim, or sargramostim. Erythropoiesis-stimulating agents (ESAs) were identified if there was a claim from the following procedure codes: epoetin or darbepoetin. Overall, 51.7% of patients with breast cancer received CSFs, which increased from 21.7% in 2000 to 63.2% in 2009. The percentage of patients receiving pegfilgrastim increased from 2.7% in 2000 to 19.5% in 2003 and then continuously to 49.7% in 2009. The overall percentage of patients receiving ESAs was 39.3%, which increased from 26.4% in 2000 to 60.8% in 2006, and then decreased significantly from 40.7% in 2007 to 12.9% in 2009. The receipt of both CSFs and ESAs differed significantly across different geographic areas. The receipt of CSFs continued to increase from 2000 to 2009, and pegfilgrastim started to replace filgrastim since 2003. The receipt of ESAs increased until 2006 and then declined substantially due to the black box warning. There were substantial geographic variations in the use of these hematopoietic growth factors.
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Affiliation(s)
- Xianglin L Du
- 1Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas, Houston, TX; 2Center for Health Services Research, School of Public Health, University of Texas, Houston, TX; 3Department of Biostatistics, School of Public Health, University of Texas, Houston, TX; and 4Department of Clinical and Environmental Health Sciences, College of Allied Health Sciences, Georgia Regents University, Augusta, GA
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Abstract
PURPOSE Chemotherapy-induced febrile neutropenia (FEN), which causes treatment delays or chemotherapy dose reductions, is a serious side effect of cancer treatment. In Turkey, recombinant G-CSF (rG-CSF) has been used since 2000 to control neutropenia. The purpose of this prospective randomized study is to compare the effectiveness, toxicities and the cost of these two drugs in children. METHODS Between April and December 2008, 29 patients were administered 40 courses of chemotherapy in each arm. A randomized crossover study was designed. All patients were administered rG-CSF 24 hours after the last day of chemotherapy as a secondary prophylaxis. Complete blood counts as well as peripheral blood progenitor (CD34+) cell levels were measured before G-CSF treatment and on the fifth and the seventh day of treatment. RESULTS The median duration of neutropenia, FEN, the length of hospitalization, the incidence of FEN, and documented infection was not different between the two rG-CSF treatment groups. Erythrocyte and platelet transfusion rates were also similar. After 7 days, the mean leukocyte (WBC [white blood cell]) and neutrophil count (ANC [absolute neutrophil count]), hemoglobin and platelet levels were not significantly different. However, the CD34+ cell level was significantly higher in the lenograstim group. Lenograstim was also more expensive than filgrastim. No serious side effects were reported for either rG-CSF treatment. CONCLUSIONS There is no difference following the administration of either lenograstim or filgrastim for the duration of neutropenia, FEN or hospitalization for pediatric cancer patients. For stem cell mobilization, lenograstim was superior to filgrastim.
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Affiliation(s)
- Neriman Sarı
- 1Department of Pediatric Hematology and Oncology, Dr Abdurrahman Yurtaslan Ankara Oncology Hospital, Ankara, Turkey
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28
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Marlow N, Morris T, Brocklehurst P, Carr R, Cowan FM, Patel N, Petrou S, Redshaw ME, Modi N, Dore C. A randomised trial of granulocyte-macrophage colony-stimulating factor for neonatal sepsis: outcomes at 2 years. Arch Dis Child Fetal Neonatal Ed 2013; 98:F46-53. [PMID: 22542709 PMCID: PMC3533400 DOI: 10.1136/fetalneonatal-2011-301470] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The authors performed a randomised trial in very preterm small-for-gestational age (SGA) babies to determine if prophylaxis with granulocyte-macrophage colony-stimulating factor (GM-CSF) improves outcomes (the PROGRAMS trial). Despite increased neutrophil counts following GM-CSF, the authors reported no significant difference in neonatal sepsis-free survival. PATIENTS AND METHODS 280 babies born <31 weeks of gestation and SGA were entered into the trial. Outcome was determined at 2 years to determine neurodevelopmental and general health outcomes, including economic costs. RESULTS The authors found no significant differences in health outcomes or health and social care costs between the trial groups. In the GM-CSF arm, 87 of 134 (65%) babies survived to 2 years without severe disability compared with 87 of 131 (66%) controls (RR: 1·0, 95% CI 0·8 to 1·2). Marginally, more children receiving GM-CSF were reported to have cough (RR 1·7, 95% CI 1·1 to 2·6) and had signs of chronic respiratory disease (Harrison's sulcus; RR 2·0, 95% CI 1·0 to 3·9) though this was not reflected in bronchodilator use or need for hospitalisation for respiratory disease. Overall, the rate of neurologic abnormality (7%-9%) was similar but mean overall developmental scores were lower than expected for gestational age. CONCLUSIONS The administration of GM-CSF to very preterm SGA babies is not associated with improved or more adverse outcomes at 2 years of age. The apparent excess of developmental impairment in the entire PROGRAMS cohort, without corresponding increase in neurological abnormality, may represent diffuse brain injury attributable to intrauterine growth restriction.
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Affiliation(s)
- Neil Marlow
- Institute for Womens Health, 74 Huntley Street, University College London, WC1E 6AU, UK.
| | | | | | - Robert Carr
- Department of Haematology, Kings College London, London, UK
| | - Frances M Cowan
- Department of Paediatrics, Imperial College (Hammersmith Hospital), London, UK
| | - Nishma Patel
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Maggie E Redshaw
- Policy Research Unit in Maternal Health & Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Neena Modi
- Department of Neonatal Medicine, Imperial College London, London, UK
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Kim S, Baek J, Min H. Effects of prophylactic hematopoietic colony stimulating factors on stem cell transplantations: meta-analysis. Arch Pharm Res 2012; 35:2013-20. [PMID: 23212644 DOI: 10.1007/s12272-012-1119-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 10/07/2012] [Accepted: 10/10/2012] [Indexed: 12/29/2022]
Abstract
Hematopoietic growth factors are often given for prevention of febrile neutropenia (FN), infections, and other complications by hastening neutrophil recovery in the treatment of malignancies after high dose chemotherapy (HDCT). Although several meta-analyses have already demonstrated beneficial effects of prophylactic granulocyte colony-stimulating factors (G-CSF) administration, the effects of G-CSF have not been confirmed in cancer patients receiving stem cell transplantation (SCT) after HDCT. Therefore, we performed a statistical combination of controlled clinical trials to investigate the efficacy of prophylactic use of G-CSF in preventing the neutropenic complications associated with SCT following HDCT in cancer patients. We searched PubMed to identify potentially relevant references and finally selected seven randomized controlled trials that met all of the eligibility criteria. Our meta-analysis demonstrated that prophylactic G-CSF reduced the risk of documented infections and time to hematologic recovery manifested by days to absolute neutrophil count (ANC) ≥ 0.5 × 10(9)/L, days to ANC ≥ 1.0 × 10(9)/L, and days to platelets ≥ 20 × 10(9)/L in SCT patients with cancer following HDCT. The G-CSF treated group also showed a decrease in the length of hospital stay. However, there was no difference between G-CSF treatment group and placebo group in regard to all-cause mortality, infection-related mortality, grade 2∼4 acute graft-versus-host-disease, and episode of fever.
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Affiliation(s)
- Sunhwa Kim
- College of Pharmacy, Chung-Ang University, Seoul 156-756, Korea
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Gallagher RM, Mason JR, Bird KA, Kirkham JJ, Peak M, Williamson PR, Nunn AJ, Turner MA, Pirmohamed M, Smyth RL. Adverse drug reactions causing admission to a paediatric hospital. PLoS One 2012; 7:e50127. [PMID: 23226510 PMCID: PMC3514275 DOI: 10.1371/journal.pone.0050127] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Accepted: 10/15/2012] [Indexed: 12/31/2022] Open
Abstract
Objective(s) To obtain reliable information about the incidence of adverse drug reactions, and identify potential areas where intervention may reduce the burden of ill-health. Design Prospective observational study. Setting A large tertiary children’s hospital providing general and specialty care in the UK. Participants All acute paediatric admissions over a one year period. Main Exposure Any medication taken in the two weeks prior to admission. Outcome Measures Occurrence of adverse drug reaction. Results 240/8345 admissions in 178/6821 patients admitted acutely to a paediatric hospital were thought to be related to an adverse drug reaction, giving an estimated incidence of 2.9% (95% CI 2.5, 3.3), with the reaction directly causing, or contributing to the cause, of admission in 97.1% of cases. No deaths were attributable to an adverse drug reaction. 22.1% (95% CI 17%, 28%) of the reactions were either definitely or possibly avoidable. Prescriptions originating in the community accounted for 44/249 (17.7%) of adverse drug reactions, the remainder originating from hospital. 120/249 (48.2%) reactions resulted from treatment for malignancies. The drugs most commonly implicated in causing admissions were cytotoxic agents, corticosteroids, non-steroidal anti-inflammatory drugs, vaccines and immunosuppressants. The most common reactions were neutropenia, immunosuppression and thrombocytopenia. Conclusions Adverse drug reactions in children are an important public health problem. Most of those serious enough to require hospital admission are due to hospital-based prescribing, of which just over a fifth may be avoidable. Strategies to reduce the burden of ill-health from adverse drug reactions causing admission are needed.
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Affiliation(s)
- Ruairi M Gallagher
- Department of Women's and Children's Health, University of Liverpool, Liverpool, United Kingdom.
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Lüthi F, Leibundgut K, Niggli FK, Nadal D, Aebi C, Bodmer N, Ammann RA. Serious medical complications in children with cancer and fever in chemotherapy-induced neutropenia: results of the prospective multicenter SPOG 2003 FN study. Pediatr Blood Cancer 2012; 59:90-5. [PMID: 21837771 DOI: 10.1002/pbc.23277] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/21/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fever and chemotherapy-induced neutropenia (FN) is the most frequent potentially lethal complication of therapy in children with cancer. This study aimed to describe serious medical complications (SMC) in children with FN regarding incidence, clinical spectrum, and associated characteristics. PROCEDURE Pediatric patients presenting with FN induced by non-myeloablative chemotherapy were observed in a prospective multicenter study. SMC was defined as potentially life-threatening complication (PLTC), transfer to the pediatric intensive care unit (PICU), or death. RESULTS A total of 443 FN episodes were reported from 8 centers. Of these, 411 episodes were reported from 4 centers recruiting consecutively and without bias regarding the risk of complications. They were used for calculation of proportions. An SMC was reported in 23 episodes [5.6%; 95% confidence interval (CI): 3.7-8.1], usually defined by more than one criterion. These were PLTC in 13 episodes, PICU in 22, and death in 3 (mortality, 0.7%; 95% CI: 0.2-2.1). Both a delayed onset of SMC (14 of 23 episodes, 61%) and a biphasic clinical course (11 of 23, 48%) were frequently observed. In a multivariate logistic regression analysis, 4 characteristics were significantly and independently associated with the risk of SMC: diagnosis of acute myeloid leukemia, interval since chemotherapy ≤7 days, severely reduced general condition, and hemoglobin ≥9.0 g/dl at presentation. CONCLUSIONS In children with FN, SMC were rare, and mortality was very low. Those with SMC often had a delayed onset and biphasic clinical course with secondary deterioration.
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Affiliation(s)
- Fabienne Lüthi
- Department of Pediatrics, University of Bern, Bern, Switzerland
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Gurion R, Belnik‐Plitman Y, Gafter‐Gvili A, Paul M, Vidal L, Ben‐Bassat I, Shpilberg O, Raanani P. Colony-stimulating factors for prevention and treatment of infectious complications in patients with acute myelogenous leukemia. Cochrane Database Syst Rev 2012; 2012:CD008238. [PMID: 22696376 PMCID: PMC7390444 DOI: 10.1002/14651858.cd008238.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute myelogenous leukemia (AML) is a fatal bone marrow cancer. Colony-stimulating factors (CSFs) are frequently administered during and after chemotherapy to reduce complications. However, their safety with regard to disease-related outcomes and survival in AML is unclear. Therefore, we performed a systematic review and meta-analysis to evaluate the impact of CSFs on patient outcomes, including survival. OBJECTIVES To assess the safety/efficacy of CSFs with regard to disease-related outcomes and survival in patients with AML. SEARCH METHODS We conducted a comprehensive search strategy. We identified relevant randomized clinical trials by searching the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 7), MEDLINE (January 1966 to July 2010), LILACS (up to December 2009), databases of ongoing trials and relevant conference proceedings. SELECTION CRITERIA Randomized controlled trials that compared the addition of CSFs during and following chemotherapy to chemotherapy alone in patients with AML. We excluded trials evaluating the role of CSFs administered for the purpose of stem cell collection and/or priming (e.g. before and/or only for the duration of chemotherapy). DATA COLLECTION AND ANALYSIS Two review authors appraised the quality of trials and extracted data. For each trial, we expressed results as relative risk (RR) with 95% confidence intervals (CI) for dichotomous data. We analyzed time-to-event outcomes as hazard ratios (HRs). MAIN RESULTS The search yielded 19 trials including 5256 patients. The addition of CSFs to chemotherapy yielded no difference in all-cause mortality at 30 days and at the end of follow up (RR 0.97; 95% CI 0.80 to 1.18 and RR 1.01; 95% CI 0.98 to 1.05, respectively) or in overall survival (HR 1.00; 95% 0.93 to 1.08). There was no difference in complete remission rates (RR 1.03; 95% CI 0.99 to 1.07), relapse rates (RR 0.97; 95% CI 0.89 to 1.05) and disease-free survival (HR 1.00; 95% CI 0.90 to 1.13). CSFs did not decrease the occurrence of bacteremias (RR 0.96; 95% CI 0.82 to 1.12), nor the occurrence of invasive fungal infections (RR 1.40; 95% CI 0.90 to 2.19). CSFs marginally increased adverse events requiring discontinuation of CSFs as compared to the control arm (RR 1.33; 95% CI 1.00 to 1.56). AUTHORS' CONCLUSIONS In summary, colony-stimulating factors should not be given routinely to acute myelogenous leukemia patients post-chemotherapy since they do not affect overall survival or infectious parameters including the rate of bacteremias and invasive fungal infections.
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Affiliation(s)
- Ronit Gurion
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Yulia Belnik‐Plitman
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Anat Gafter‐Gvili
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Sackler Faculty of MedicineInfectious Diseases UnitTel Aviv UniversityTel AvivIsrael49100
| | - Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | | | - Ofer Shpilberg
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Pia Raanani
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
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Reliability of 3 assessment tools used to evaluate randomized controlled trials for treatment of neck pain. Spine (Phila Pa 1976) 2012; 37:515-22. [PMID: 21673624 DOI: 10.1097/brs.0b013e31822671eb] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Pragmatic, cross-sectional study. OBJECTIVE To assess the interrater reliability of 3 tools used by the Cervical Overview Group (COG) for the assessment of the internal validity of randomized controlled trials (RCTs): Jadad, van Tulder, and risk of bias (RoB). SUMMARY OF BACKGROUND DATA For clinicians to implement evidence-based practice, they need to critically appraise health care literature. Checklists, scales, and domain-based criteria exist to evaluate the internal validity of RCTs for rehabilitation studies, but there is a lack of research reporting the reliability of existing assessment tools. METHODS Four members of the COG with multiprofessional and methodological background independently evaluated the internal validity of 54 RCTs using prepiloted Jadad and van Tulder reporting forms, and 18 RCTs using RoB, from June 2003 to May 2009. The κ statistic was calculated for each combination of raters and assessment tools. Standard agreement categorizations were used. RESULTS For Jadad, 4 of 7 items demonstrated mean κ statistic ranges from moderate to substantial agreement (mean values, 0.42-0.78), as did 8 of 11 items on the van Tulder tool (mean values, 0.44-0.77). The RoB demonstrated moderate to substantial (mean values, 0.56-0.76) agreement on 3 of 12 items. Consistent substantial agreement was found across all assessment tools for the domain "allocation concealment": Jadad 0.69 (mean range, 0.60-0.77); van Tulder 0.77 (mean range, 0.73-0.81); RoB 0.76 (mean range, 0.65-0.88); and moderate to substantial across 2 tools for the domain "sequence generation": van Tulder 0.53 (mean range, 0.37-0.66) and RoB 0.66 (mean range, 0.45-0.88). Other domains demonstrated slight or fair agreement. CONCLUSION Consistent interrater agreement was found across the 3 assessment tools for allocation concealment and for 2 tools for sequence generation. However, users should acknowledge that moderate variation exists within other items requiring more judgment. When evaluating rehabilitation RCTs, clinicians should consider limitations of rating certain items within the selected assessment tool.
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Lehrnbecher T, Aplenc R, Rivas Pereira F, Lassaletta A, Caselli D, Kowalczyk J, Chisholm J, Sung L. Variations in non-pharmacological anti-infective measures in childhood leukemia--results of an international survey. Haematologica 2012; 97:1548-52. [PMID: 22419572 DOI: 10.3324/haematol.2012.062885] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Standardization in clinical practice may lead to improved outcomes. Unfortunately, little is known about the variability of non-pharmacological anti-infective measures in children with cancer. DESIGN AND METHODS A web-based survey assessed institutional recommendations regarding restrictions of social contacts, pets and food and instructions on wearing face masks in public for children with standard- risk acute lymphoblastic leukemia and acute myeloid leukemia during intensive chemotherapy. RESULTS A total of 336 institutions in 27 countries responded to the survey (range, 1-76 institutions per country; overall response rate 61%). Most institutions recommend that patients with acute myeloid leukemia avoid indoor public places and daycare, kindergarten and school, whereas recommendations for patients with acute lymphoblastic leukemia differ considerably by institution. In terms of restrictions related to pets, there was a wide variability between institutions for both acute lymphoblastic and acute myeloid leukemia patients. Most, but not all institutions do not allow children with either acute lymphoblastic or acute myeloid leukemia to eat raw meat, raw seafood or unpasteurized milk. Whereas most institutions do not routinely recommend that patients with acute lymphoblastic leukemia wear face masks in public, advice on this matter varies for patients with acute myeloid leukemia. CONCLUSIONS The survey demonstrates that there is a wide variation in recommendations on non-pharmacological anti-infective measures between different institutions, countries and continents. This information may be used to encourage harmonization of supportive care practices and future clinical trials.
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Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, Macvittie TJ, Aleman BM, Edgar AB, Mabuchi K, Muirhead CR, Shore RE, Wallace WH. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012; 41:1-322. [PMID: 22925378 DOI: 10.1016/j.icrp.2012.02.001] [Citation(s) in RCA: 805] [Impact Index Per Article: 67.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.
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Gurion R, Belnik-Plitman Y, Gafter-Gvili A, Paul M, Vidal L, Ben-Bassat I, Shpilberg O, Raanani P. Colony-stimulating factors for prevention and treatment of infectious complications in patients with acute myelogenous leukemia. Cochrane Database Syst Rev 2011:CD008238. [PMID: 21901718 DOI: 10.1002/14651858.cd008238.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute myelogenous leukemia (AML) is a fatal bone marrow cancer. Colony-stimulating factors (CSFs) are frequently administered during and after chemotherapy to reduce complications. However, their safety with regard to disease-related outcomes and survival in AML is unclear. Therefore, we performed a systematic review and meta-analysis to evaluate the impact of CSFs on patient outcomes, including survival. OBJECTIVES To assess the safety/efficacy of CSFs with regard to disease-related outcomes and survival in patients with AML. SEARCH STRATEGY We conducted a comprehensive search strategy. We identified relevant randomized clinical trials by searching the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 7), MEDLINE (January 1966 to July 2010), LILACS (up to December 2009), databases of ongoing trials and relevant conference proceedings. SELECTION CRITERIA Randomized controlled trials that compared the addition of CSFs during and following chemotherapy to chemotherapy alone in patients with AML. We excluded trials evaluating the role of CSFs administered for the purpose of stem cell collection and/or priming (e.g. before and/or only for the duration of chemotherapy). DATA COLLECTION AND ANALYSIS Two review authors appraised the quality of trials and extracted data. For each trial, we expressed results as relative risk (RR) with 95% confidence intervals (CI) for dichotomous data. We analyzed time-to-event outcomes as hazard ratios (HRs). MAIN RESULTS The search yielded 19 trials including 5256 patients. The addition of CSFs to chemotherapy yielded no difference in all-cause mortality at 30 days and at the end of follow up (RR 0.97; 95% CI 0.80 to 1.18 and RR 1.01; 95% CI 0.98 to 1.05, respectively) or in overall survival(HR 1.00; 95% 0.93 to 1.08). There was no difference in complete remission rates(RR 1.03; 95% CI 0.99 to 1.07), relapse rates(RR 0.97; 95% CI 0.89 to 1.05) and disease-free survival(HR 1.00; 95% CI 0.90 to 1.13). CSFs did not decrease the occurrence of bacteremias(RR 0.96; 95% CI 0.82 to 1.12), nor the occurrence of invasive fungal infections(RR 1.40; 95% CI 0.90 to 2.19). CSFs marginally increased adverse events requiring discontinuation of CSFs as compared to the control arm(RR 1.33; 95% CI 1.00 to 1.56). AUTHORS' CONCLUSIONS The addition of CSFs to chemotherapy does not adversely influence all-cause mortality, complete remission or relapse rates in patients with AML. Although the benefit of CSFs is limited to reduction of neutropenic and febrile days, they can be administered safely when necessary.
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Affiliation(s)
- Ronit Gurion
- Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, Petah Tikva, Israel, 49100
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Sung L, Phillips R, Lehrnbecher T. Time for paediatric febrile neutropenia guidelines – children are not little adults. Eur J Cancer 2011; 47:811-3. [DOI: 10.1016/j.ejca.2011.01.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 01/28/2011] [Indexed: 10/18/2022]
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Myeloid growth factors in acute myeloid leukemia: systematic review of randomized controlled trials. Ann Hematol 2010; 90:273-81. [DOI: 10.1007/s00277-010-1069-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 08/22/2010] [Indexed: 10/19/2022]
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Ladenstein R, Valteau-Couanet D, Brock P, Yaniv I, Castel V, Laureys G, Malis J, Papadakis V, Lacerda A, Ruud E, Kogner P, Garami M, Balwierz W, Schroeder H, Beck-Popovic M, Schreier G, Machin D, Pötschger U, Pearson A. Randomized Trial of Prophylactic Granulocyte Colony-Stimulating Factor During Rapid COJEC Induction in Pediatric Patients With High-Risk Neuroblastoma: The European HR-NBL1/SIOPEN Study. J Clin Oncol 2010; 28:3516-24. [DOI: 10.1200/jco.2009.27.3524] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To reduce the incidence of febrile neutropenia during rapid COJEC (cisplatin, vincristine, carboplatin, etoposide, and cyclophosphamide given in a rapid delivery schedule) induction. In the High-Risk Neuroblastoma-1 (HR-NBL1) trial, the International Society of Paediatric Oncology European Neuroblastoma Group (SIOPEN) randomly assigned patients to primary prophylactic (PP) versus symptom-triggered granulocyte colony-stimulating factor (GCSF; filgrastim). Patients and Methods From May 2002 to November 2005, 239 patients in 16 countries were randomly assigned to receive or not receive PPGCSF. There were 144 boys with a median age of 3.1 years (range, 1 to 17 years) of whom 217 had International Neuroblastoma Staging System (INSS) stage 4 and 22 had stage 2 or 3 MYCN-amplified disease. The prophylactic arm received a single daily dose of 5 μg/kg GCSF, starting after each of the eight COJEC chemotherapy cycles and stopping 24 hours before the next cycle. Chemotherapy was administered every 10 days regardless of hematologic recovery, provided that infection was controlled. Results The PPGCSF arm had significantly fewer febrile neutropenic episodes (P = .002), days with fever (P = .004), hospital days (P = .017), and antibiotic days (P = .001). Reported Common Toxicity Criteria (CTC) graded toxicity was also significantly reduced: infections per cycle (P = .002), fever (P < .001), severe leucopenia (P < .001), neutropenia (P < .001), mucositis (P = .002), nausea/vomiting (P = .045), and constipation (P = .008). Severe weight loss was reduced significantly by 50% (P = .013). Protocol compliance with the rapid induction schedule was also significantly better in the PPGCSF arm shown by shorter time to completion (P = .005). PPGCSF did not adversely affect response rates or success of peripheral-blood stem-cell harvest. Conclusion Following these results, PPG-GSF was advised for all patients on rapid COJEC induction.
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Affiliation(s)
- Ruth Ladenstein
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Dominique Valteau-Couanet
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Penelope Brock
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Isaac Yaniv
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Victoria Castel
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Geneviève Laureys
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Josef Malis
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Vassilios Papadakis
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Ana Lacerda
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Ellen Ruud
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Per Kogner
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Miklos Garami
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Walentyna Balwierz
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Henrik Schroeder
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Maja Beck-Popovic
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Günter Schreier
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - David Machin
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Ulrike Pötschger
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
| | - Andrew Pearson
- From St. Anna Children's Hospital; Children's Cancer Research Institute; Austrian Institute of Technology, Vienna, Austria; Institut Gustave Roussy, Villejuif, France; Great Ormond Street Hospital, London; The Children's Cancer and Leukaemia Group, University of Leicester, Leicester; Royal Marsden Hospital, Sutton, United Kingdom; Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Hospital Universitario Infantil La Fe, Valencia, Spain; Ghent University Hospital, Ghent, Belgium
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Lyman GH, Rolston KVI. How we treat febrile neutropenia in patients receiving cancer chemotherapy. J Oncol Pract 2010; 6:149-52. [PMID: 20808559 PMCID: PMC2868641 DOI: 10.1200/jop.091092] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2010] [Indexed: 11/20/2022] Open
Abstract
Although improved supportive care has reduced mortality associated with febrile neutropenia, it continues to cause chemotherapy limitations, morbidity, mortality, and cost among patients with cancer.
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Affiliation(s)
- Gary H. Lyman
- Department of Medicine, Duke University School of Medicine and Duke Comprehensive Cancer Center, Durham, NC, and Department of Infectious Diseases, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Kenneth V. I. Rolston
- Department of Medicine, Duke University School of Medicine and Duke Comprehensive Cancer Center, Durham, NC, and Department of Infectious Diseases, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Fox E, Widemann BC, Hawkins DS, Jayaprakash N, Dagher R, Aikin AA, Bernstein D, Long L, Mackall C, Helman L, Steinberg SM, Balis FM. Randomized trial and pharmacokinetic study of pegfilgrastim versus filgrastim after dose-intensive chemotherapy in young adults and children with sarcomas. Clin Cancer Res 2009; 15:7361-7. [PMID: 19920107 DOI: 10.1158/1078-0432.ccr-09-0761] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare the effectiveness, tolerance, and pharmacokinetics of a single dose of pegfilgrastim to daily filgrastim in children and young adults with sarcomas treated with dose-intensive combination chemotherapy. EXPERIMENTAL DESIGN Patients were randomized to receive a single dose of 100 mcg/kg of pegfilgrastim s.c. or 5 mcg/kg/day of filgrastim s.c., daily until neutrophil recovery after two treatment cycles with vincristine, doxorubicin, and cyclophosphamide (VDC) and two cycles of etoposide and ifosfamide (IE). The duration of severe neutropenia (absolute neutrophil count, < or =500/mcL) during cycles 1 to 4 and cycle duration for all cycles were compared. Pharmacokinetics of pegfilgrastim and filgrastim and CD34+ stem cell mobilization were studied on cycle 1. Growth factor-related toxicity, transfusions, and episodes of fever and neutropenia and infections were collected for cycles 1 to 4. RESULTS Thirty-four patients (median age, 20 years; range 3.8-25.8) were enrolled, and 32 completed cycles 1 to 4. The median (range) duration of absolute neutrophil count of <500/mcL was 5.5 (3-8) days for pegfilgrastim and 6 (0-9) days for filgrastim (P = 0.76) after VDC, and 1.5 (0-4) days for pegfilgrastim and 3.75 (0-6.5) days for filgrastim (P = 0.11) after IE. More episodes of febrile neutropenia and documented infections occurred on the filgrastim arm. Serum pegfilgrastim concentrations were highly variable. Pegfilgrastim apparent clearance (11 mL/h/kg) was similar to that reported in adults. CONCLUSION A single dose per cycle of pegfilgrastim was well tolerated and may be as effective as daily filgrastim based on the duration of severe neutropenia and number of episodes of febrile neutropenia and documented infections after dose-intensive treatment with VDC and IE.
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Affiliation(s)
- Elizabeth Fox
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland 20892, USA.
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Borinstein SC, Pollard J, Winter L, Hawkins DS. Pegfilgrastim for prevention of chemotherapy-associated neutropenia in pediatric patients with solid tumors. Pediatr Blood Cancer 2009; 53:375-8. [PMID: 19484756 DOI: 10.1002/pbc.22086] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pegfilgrastim has similar efficacy to filgrastim in adults, but studies in pediatrics are limited. We report our institutional experience with pegfilgrastim following dose intensive chemotherapy for solid tumors. PROCEDURE We evaluated the initial four courses of myelosuppressive chemotherapy for 47 patients (total 176 courses) diagnosed between 1/1/07 and 2/6/08 who received chemotherapy with pegfilgrastim support (100 mcg/kg; 6 mg maximum dose) in this retrospective review. We collected demographic data, treatment characteristics, frequency of severe neutropenia (absolute neutrophil count (ANC) <200/mm(3)), duration of neutropenia, and frequency of neutropenic fever. RESULTS The median age of treated patients was 13 years (range 0.17-23 years) and the median weight was 50.8 kg (range 4-107 kg), including 16 (34%) <20 kg, and 22 (47%) <45 kg. Primary diagnoses included osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, soft tissue sarcoma, neuroblastoma, Hodgkin disease, and other solid tumors. No significant adverse events secondary to pegfilgrastim were noted. Severe neutropenia occurred in 57% of courses. The median duration of severe neutropenia was 1 day (range 0-11 days). Febrile neutropenia occurred in 28% of courses. Eight patients were treated with interval-compressed (every 14 days) sarcoma chemotherapy. Of the 30-interval compressed courses, the median duration per course was 14 days (range 14-18 days). CONCLUSIONS Pegfilgrastim following dose intensive chemotherapy for solid tumors is feasible in children, including those <45 kg. The frequency and duration of severe neutropenia, as well as incidence of febrile neutropenia, were similar to filgrastim historic data.
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Meckler G, Lindemulder S. Fever and Neutropenia in Pediatric Patients with Cancer. Emerg Med Clin North Am 2009; 27:525-44. [DOI: 10.1016/j.emc.2009.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Renwick W, Pettengell R, Green M. Use of Filgrastim and Pegfilgrastim to Support Delivery of Chemotherapy. BioDrugs 2009; 23:175-86. [PMID: 19627169 DOI: 10.2165/00063030-200923030-00004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- William Renwick
- Department of Haematology and Medical Oncology, Western Hospital, Footscray, Melbourne, Victoria, Australia.
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Lehrnbecher T, Creutzig U. Myeloid growth factors as anti-infective measures in children with leukemia and lymphoma. Expert Rev Hematol 2009; 2:159-72. [DOI: 10.1586/ehm.09.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Herbst C, Naumann F, Kruse EB, Monsef I, Bohlius J, Schulz H, Engert A. Prophylactic antibiotics or G-CSF for the prevention of infections and improvement of survival in cancer patients undergoing chemotherapy. Cochrane Database Syst Rev 2009:CD007107. [PMID: 19160320 DOI: 10.1002/14651858.cd007107.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Febrile neutropenia (FN) and other infectious complications are some of the most serious treatment-related toxicities of chemotherapy for cancer, with a mortality rate of 2% to 21%. The two main types of prophylactic regimens are granulocyte (G-CSF) or granulocyte-macrophage colony stimulating factors (GM-CSF); and antibiotics, frequently quinolones or cotrimoxazole. Important current guidelines recommend the use of colony stimulating factors when the risk of febrile neutropenia is above 20% but they do not mention the use of antibiotics. However, both regimens have been shown to reduce the incidence of infections. Since no systematic review has compared the two regimens, a systematic review was undertaken. OBJECTIVES To compare the effectiveness of G-CSF or GM-CSF with antibiotics in cancer patients receiving myeloablative chemotherapy with respect to preventing fever, febrile neutropenia, infection, infection-related mortality, early mortality and improving quality of life. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, databases of ongoing trials, and conference proceedings of the American Society of Clinical Oncology and the American Society of Hematology (1980 to 2007). We planned to include both full-text and abstract publications. SELECTION CRITERIA Randomised controlled trials comparing prophylaxis with G-CSF or GM-CSF versus antibiotics in cancer patients of all ages receiving chemotherapy or bone marrow or stem cell transplantation were included for review. Both study arms had to receive identical chemotherapy regimes and other supportive care. DATA COLLECTION AND ANALYSIS Trial eligibility and quality assessment, data extraction and analysis were done in duplicate. Authors were contacted to obtain missing data. MAIN RESULTS We included two eligible randomised controlled trials with 195 patients. Due to differences in the outcomes reported, the trials could not be pooled for meta-analysis. Both trials showed non-significant results favouring antibiotics for the prevention of fever or hospitalisation for febrile neutropenia. AUTHORS' CONCLUSIONS There is no evidence for or against antibiotics compared to G(M)-CSFs for the prevention of infections in cancer patients.
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Affiliation(s)
- Christine Herbst
- Cochrane Haematological Malignancies Group, Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, Cologne, Germany, 50924.
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Carr R, Brocklehurst P, Doré CJ, Modi N. Granulocyte-macrophage colony stimulating factor administered as prophylaxis for reduction of sepsis in extremely preterm, small for gestational age neonates (the PROGRAMS trial): a single-blind, multicentre, randomised controlled trial. Lancet 2009; 373:226-33. [PMID: 19150703 DOI: 10.1016/s0140-6736(09)60071-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Systemic sepsis is a major cause of death in preterm neonates. There are compelling theoretical reasons why treatment with haemopoietic colony-stimulating factors might reduce sepsis and improve outcomes, and as a consequence these agents have entered into use in neonatal medicine without adequate evidence. We assessed whether granulocyte-macrophage colony stimulating factor (GM-CSF) administered as prophylaxis to preterm neonates at high risk of neutropenia would reduce sepsis, mortality, and morbidity. METHODS We undertook a single-blind, multicentre, randomised controlled trial in 26 centres between June, 2000, and June, 2006. 280 neonates of below or equal to 31 weeks' gestation and below the 10th centile for birthweight were randomised within 72 h of birth to receive GM-CSF 10 microg/kg per day subcutaneously for 5 days or standard management. From recruitment to day 28 a detailed daily clinical record form was completed by the treating clinicians. Primary outcome was sepsis-free survival to 14 days from trial entry. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN42553489. FINDINGS Neutrophil counts after trial entry rose significantly more rapidly in infants treated with GM-CSF than in control infants during the first 11 days (difference between neutrophil count slopes 0.34 x 10(9)/L/day; 95% CI 0.12-0.56). There was no significant difference in sepsis-free survival for all infants (93 of 139 treated infants, 105 of 141 control infants; difference -8%, 95% CI -18 to 3). A meta-analysis of this trial and previous published prophylactic trials showed no survival benefit. INTERPRETATION Early postnatal prophylactic GM-CSF corrects neutropenia but does not reduce sepsis or improve survival and short-term outcomes in extremely preterm neonates.
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Affiliation(s)
- Robert Carr
- Department of Haematology, Guy's and St Thomas' Hospital, King's College, London, UK
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Wicki S, Keisker A, Aebi C, Leibundgut K, Hirt A, Ammann RA. Risk prediction of fever in neutropenia in children with cancer: a step towards individually tailored supportive therapy? Pediatr Blood Cancer 2008; 51:778-83. [PMID: 18726920 DOI: 10.1002/pbc.21726] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fever in severe chemotherapy-induced neutropenia (FN) is the most frequent manifestation of a potentially lethal complication of current intensive chemotherapy regimens. This study aimed at establishing models predicting the risk of FN, and of FN with bacteremia, in pediatric cancer patients. METHODS In a single-centre cohort study, characteristics potentially associated with FN and episodes of FN were retrospectively extracted from charts. Poisson regression accounting for chemotherapy exposure time was used for analysis. Prediction models were constructed based on a derivation set of two thirds of observations, and validated based on the remaining third of observations. RESULTS In 360 pediatric cancer patients diagnosed and treated for a cumulative chemotherapy exposure time of 424 years, 629 FN were recorded (1.48 FN per patient per year, 95% confidence interval (CI), 1.37-1.61), 145 of them with bacteremia (23% of FN; 0.34; 0.29-0.40). More intensive chemotherapy, shorter time since diagnosis, bone marrow involvement, central venous access device (CVAD), and prior FN were significantly and independently associated with a higher risk to develop both FN and FN with bacteremia. The prediction models explained more than 30% of the respective risks. CONCLUSIONS The two models predicting FN and FN with bacteremia were based on five easily accessible clinical variables. Before clinical application, they need to be validated by prospective studies.
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Affiliation(s)
- Silvia Wicki
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Bern, Bern, Switzerland
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