Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Hodgkin's lymphoma: a nationwide study

Treatment of diffuse large B-cell lymphoma in the elderly: regimens without anthracyclines are common and not futile

Anthracycline-containing regimens (ACRs) are recommended for patients with diffuse large B-cell lymphoma (DLBCL). However, over 40% of elderly patients do not receive ACRs, possibly due to expected toxicities. We characterized treatment choices and compared the 3-year overall survival (OS) rates of 8262 Medicare beneficiaries diagnosed with DLBCL in 2000-2006 identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Of the cohort, 45% had ACR with rituximab (ACR-R), 13% had ACR without R, 6% had non-ACR with R (non-ACR-R), 4% had R monotherapy, 3% had non-ACR and 29% had no systemic therapy. Patients not receiving ACR were older and/or had more comorbidities. The unadjusted OS was highest in ACR-R (65%), followed by ACR without R (55%) and non-ACR-R (44%). After adjusting patient covariates, ACR-R showed the best survival (63%). However, OS was comparable between non-ACR-R (52%) and ACR without R (52%). Non-ACR-R could be considered for patients who are poor candidates for ACR.

Prediction of adverse events during intensive induction chemotherapy for acute myeloid leukemia or high-grade myelodysplastic syndromes

Intensive chemotherapy for newly diagnosed acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS) is associated with significant treatment-related morbidity and mortality. Herein, we investigate how pretreatment characteristics relate to early adverse outcomes in such patients, studying 205 consecutive individuals receiving curative-intent induction chemotherapy with cytarabine and an anthracycline ("7 + 3"; n = 175) or a "7 + 3"-like regimen (n = 30). Among the entire cohort, baseline grade 4 neutropenia (i.e., absolute neutrophil count <500 cells/µL) was associated with development of fever (P = 0.04), documented infection (P < 0.0001), and bacteremia (P = 0.002) but not requirement for intensive care unit-level care; after exclusion of the 30 patients who received "7 + 3"-like induction, baseline grade 4 neutropenia remained associated with documented infection (P < 0.0001) and bacteremia (P = 0.0005). Among patients achieving a complete remission with the initial treatment cycle, grade 4 neutropenia was associated with delayed neutrophil count recovery (P < 0.0001). Low monocyte and lymphocyte counts at baseline were similarly associated with increased risk of documented infection or bacteremia. After adjustment for age, gender, disease type, cytogenetic/molecular risk, and performance status, the risk of fever, documented infection, or bacteremia was 1.87 (95% confidence interval: 1.04-3.34; P=0.04)-fold, 4.95 (2.20-11.16; P<0.001)-fold, and 3.14 (0.99-9.98; P=0.05)-fold higher in patients with initial grade 4 neutropenia. Together, our studies identify severe baseline neutropenia as a risk factor for infection-associated adverse events after induction chemotherapy and may provide the rationale for the risk-adapted testing of myeloid growth factor support in this high-risk AML/MDS patient subset.

What is the optimal treatment for obese patients with advanced ovarian carcinoma?

OBJECTIVE

The purpose of this study was to compare primary debulking surgery (PDS) vs neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among obese patients.

STUDY DESIGN

Medical records of patients with a body mass index (BMI) of ≥30 kg/m(2) with ovarian/fallopian tube/primary peritoneal carcinoma between January 2005 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures, and postoperative and oncologic outcomes were compared.

RESULTS

Of 117 patients, 95 women (81.2%) underwent PDS, and 22 women (18.8%) underwent NACT-IDS. Patients who underwent NACT-IDS were more likely to have stage IV disease (63.6% vs 26.3%; P = .001) and a low surgical complexity score (n = 14; 63.6%). There were no other differences between groups with respect to preoperative characteristics or postoperative morbidity. Compared with the NACT-IDS group, the PDS group had an improved progression-free survival (PFS; 15 vs 11 months; P = .006) and overall survival (OS; 53 vs 32 months; P = .036). Seventy-eight patients (66.7%) had a BMI of 30-34.9 kg/m(2). Within this subset of obese patients, the PDS group had an improved PFS (15 vs 10 months; P = .011) and OS (58 vs 32 months; P = .033), compared with the NACT-IDS group. Among patients with a BMI of ≥35 kg/m(2), there was no difference in PFS (14 vs 12 months; P = .316) or OS (38 vs 32 months; P = .640) when the PDS and NACT-IDS groups were compared.

CONCLUSION

Patients with a BMI of 30-34.9 kg/m(2) who undergo PDS have improved oncologic outcomes, compared with those women who undergo NACT-IDS. Patients with a BMI of ≥35 kg/m(2) who undergo PDS have similar oncologic outcomes to those who undergo NACT-IDS. Complication rates were similar at all BMIs, regardless of treatment approach.

R-split-CHOP chemotherapy for elderly patients with diffuse large B-cell lymphoma

OBJECTIVES

Chemoimmunotherapy with cyclophosphamide, doxorubicin, vincristine, prednisolone, and rituximab (R-CHOP) is the standard of care for patients with diffuse large B-cell lymphoma (DLBCL). However, management of elderly patients is challenging as critical comorbidities often account for increased number of treatment-related complications.

PATIENTS AND METHODS

In the past 8 yrs, we have treated elderly patients with a full-dose R-CHOP regimen by splitting the administration of cyclophosphamide and doxorubicin over 2 days (R-split-CHOP) to reduce peak plasma level. Here, we retrospectively analyzed the results of 30 patients with newly diagnosed DLBCL.

RESULTS

The overall response rate was found to be 87%, the overall survival probability after 3 yrs was 60.6% (95% CI, 42.1%-79.0%), and the progression-free survival probability was 49.7% (95% CI, 30.4%-68.9%). Grade 3/4 infectious complications were reported in 30% of patients, yet no treatment-related deaths occurred.

CONCLUSION

We suggest that R-split-CHOP could be a valuable option to safely administer full-dose-intensity R-CHOP to elderly patients at risk of treatment-related complications.

Patterns of chemotherapy-associated toxicity and supportive care in US oncology practice: a nationwide prospective cohort study

Neutropenic complications remain an important dose-limiting toxicity of cancer chemotherapy-associated with considerable morbidity, mortality, and cost. Risk of the initial neutropenic event is greatest during the first cycle. The purpose of this study was to better understand timing of neutropenic events in relation to delivered chemotherapy dose intensity and utilization of supportive care during cancer treatment. A prospective cohort study of adult patients with solid tumors or lymphoma initiating chemotherapy was conducted at 115 randomly selected US practice sites between 2002 and 2006. Chemotherapy-associated toxicities were captured in up to four treatment cycles including severe neutropenia, febrile neutropenia, and infection. Documented interventions included colony-stimulating factor (CSF), antibiotics use, and reductions in chemotherapy relative dose intensity (RDI). A total of 3638 patients with breast (39.7%), lung (23.7%), colorectal (13.6%), ovarian (8.3%) cancers, or lymphoma (14.7%) were eligible for this analysis. The majority of neutropenic and infection events occurred in the first cycle. A significant inverse relationship was observed between reductions in neutropenic and infectious events and increased utilization of measures to reduce these complications in subsequent cycles. More than 60% of patients with stage IV solid tumors underwent reductions in RDI. Patients with lymphoma and stage I–III solid tumors had less dose reductions while receiving more prophylactic CSFs. Approximately, 15% of patients received prophylactic antibiotics. While the risk of neutropenic complications remains greatest during the initial cycle of chemotherapy, subsequently instituted clinical measures in efforts to reduce the risk of these events vary with cancer type and stage.

What determines therapeutic choices for elderly patients with DLBCL? Clinical findings of a multicenter study in Portugal

BACKGROUND

Age is a negative prognostic factor in lymphomas, and elderly patients are often undertreated because of toxicity concerns. The pattern of treatment in elderly patients with diffuse large B-cell lymphoma (DLBCL) in Portugal has not been previously described.

PATIENTS AND METHODS

We conducted a multicenter retrospective study including 378 elderly patients with DLBCL receiving alkylating agent-containing regimens between 2003 and 2010. We compared the outcome of patients aged 60 to 79 years with patients > 79 years and analyzed the second group according to treatment.

RESULTS

R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisolone) was prescribed in only 60% of patients and was prescribed significantly less in patients > 79 years, despite no significant differences being found in comorbidities between the 2 age groups. Similarly, dose reductions frequently were instituted because of chronologic age and not always because of toxicity. When different regimens were compared, multivariate analysis showed an independent beneficial effect of R-CHOP in treatment outcomes. Additionally, treatment with anthracyclines and rituximab predicted a better progression-free survival (PFS) and time to progression (TTP) in patients > 79 years.

CONCLUSION

This was the first characterization of the clinical care of elderly Portuguese patients with DLBCL. We showed that R-CHOP is effective even in patients > 79 years, emphasizing that treatment decisions based on age alone can compromise treatment efficacy and outcome in fit patients.

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

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.

Febrile neutropenia risk assessment tool: improving clinical outcomes for oncology patients

PURPOSE

To develop, implement and evaluate the effectiveness of a nurse-led risk assessment tool to reduce the incidence of febrile neutropenia (FN) and evaluate the nurse's role in FN risk assessment in a hospital-based oncology unit.

METHODS AND SAMPLE

A FN risk assessment tool was developed, implemented and evaluated. A comparative prospective observational chart review was undertaken to evaluate the tool. Clinical data were collected from 459 patients' records from August 2008 through July 2009. Patients had no intervention during the first six months (n = 233). Patients in the following six months (n = 226) had the FN risk assessment completed and appropriate granulocyte-colony stimulating factor prescribed. A self-questionnaire was utilised to evaluate the nurses' role in FN risk assessment.

KEY RESULTS

The incidence of FN was reduced by 52% (p = 0.02). Hospital days, dose reductions and treatment delays were reduced. Nurses felt they were the most appropriate person to carry out the assessment.

CONCLUSIONS

Through consistent risk assessment, nurses could determine which patients were at high risk of developing FN leading to significant reduction in life-threatening infections, hospitalisations, dose reductions and delays. Nurses can be confident and competent in decision-making to reduce life-threatening infections through the use of an FN risk assessment tool.

Patterns of delivery of chemoimmunotherapy to patients with follicular lymphoma in the United States: results of the National LymphoCare Study

BACKGROUND

Drug choice and delivered dose of treatment potentially influence outcome in patients treated for follicular lymphoma (FL). Historically, observational studies have evaluated drug choice. The National LymphoCare Study (NLCS) is a prospective, observational study of patients with FL who were enrolled at academic and community practice sites in the United States between 2004 and 2007. In the current study, the authors report on measures of delivered dose and its impact on outcomes for the most common first-line regimens.

METHODS

All evaluable patients with FL who were treated with initial rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP); rituximab plus cyclophosphamide, vincristine, and prednisone (R-CVP); or rituximab plus a fludarabine-containing regimen (R-Flu) were included. Associations between baseline factors, choice of treatment, number of cycles received, completion of therapy, and patient outcomes were assessed.

RESULTS

A total of 646 patients received R-CHOP, 297 received R-CVP, and 222 received R-Flu. Characteristics were similar between the 3 groups with the following exceptions. Patients receiving R-CHOP were more often found to have grade 3 FL and patients receiving R-CVP were older and had higher Follicular Lymphoma International Prognostic Index scores. The majority of patients (80%) received ≥ 5 cycles of treatment. Toxicity, but not disease progression, was commonly cited as the reason for the early discontinuation of treatment (51% vs 6%). Time to retreatment was shorter for patients receiving ≤ 4 cycles, regardless of the treatment regimen used. The number of cycles was associated with overall survival, progression-free survival, and lymphoma-related mortality for patients receiving R-CVP.

CONCLUSIONS

The majority of patients with FL receiving chemoimmunotherapy in the NLCS completed ≥ 5 cycles of treatment. Strategies to improve dose delivery appear unlikely to impact outcomes, except possibly in patients receiving R-CVP. Although early treatment discontinuation appears to be associated with survival, this analysis does not implicate causality.

[Anticancer drug adherence]

A large number of anticancer drugs have been introduced during the two last decades with significant impact for survival, making cancer a chronic disease in a growing number of indications. However, these drugs are costly, induce adverse effects and their efficacy frequently depends on the dose. For all these reasons, adherence in cancer therapy is critical for an optimal benefit-risk ratio. Patient adherence remains virtually unexplored in many cancers, such as malignant blood diseases. When measured, adherence is poor, especially when the drug is administered as oral and prolonged therapy (hormonotherapy in breast cancer, imatinib). Physician nonadherence represents another form of drug misadministration; poorly documented, its mechanism remains obscure. Adherence may be measured by a panel of methods, each of them displaying limits and pitfalls, suggesting that several complementary methods should be used in the context of prospective studies. Risk factors are age, socio-educative profile, disease stage and physician profile. This review emphasizes some methods to prevent nonadherence. Finally, this review argues for prospective studies, which should integrate a social pharmacology approach, including medicine, psycho-sociology and economics.

Chemotherapy dosing in overweight and obese patients with cancer

Retrospective and prospective preclinical and clinical data have demonstrated an association between chemotherapy dose intensity and both clinical efficacy and toxicity. The optimum tolerable and effective dose and schedule of chemotherapeutic agents is based on data from dose-finding studies and early clinical trials. There is considerable evidence that reductions in the recommended dose intensity often occurs in actual clinical practice, particularly among overweight and obese patients with cancer. With increasing rates of obesity, and variation and uncertainty about appropriate dosing of chemotherapy in obese patients, ASCO has generated clinical practice guidelines for appropriate chemotherapy dosing for obese adult patients with cancer. Without evidence of any increase in treatment-related toxicity among obese patients receiving chemotherapy, the guidelines recommend that, after considering any accompanying comorbidities, chemotherapy dosing should be calculated based on body surface area using actual weight, rather than an estimate or idealization of weight. While further research is needed, pharmacokinetic studies support the use of actual body weight to calculate chemotherapy doses for most chemotherapy drugs in obese patients. We highlight the issue of chemotherapy dosing in this population, how a more personalized approach can be achieved, as well as discussing areas for further research.

Improving the relative dose intensity of systemic chemotherapy in a community-based outpatient cancer center

PURPOSE

This three-phase study was performed to improve the mean relative dose intensity (RDI) of chemotherapy administered to patients in a community-based outpatient cancer center.

METHODS

Medical records were reviewed for patients who began receiving systemic chemotherapy for lymphoma or cancer of the breast, lung, endometrium, ovary, or colon. During phase 1, records were reviewed and the mean RDI was determined through collection of demographic, diagnostic, chemotherapy, and laboratory data. Phase 2 involved implementation of quality improvement initiatives to improve the RDI: development of a febrile neutropenia risk assessment tool, revision of our dose cancellation policy, and interdisciplinary education. Finally, after implementation of these initiatives, the mean RDI was prospectively determined in phase 3, similar to phase 1.

RESULTS

The mean RDI was determined to be 83% during phase 1 compared with 91% during phase 3 (P=.0087). For adjuvant chemotherapy, the mean RDI was 85% and 95% for phases 1 and 3, respectively (P=.0035). Likewise, for metastatic disease, the mean RDI was 76% and 82% for phases 1 and 3, respectively (P=.3935). The proportion of regimens that met or exceeded the recommended minimum goal RDI of 85% was 54% for phase 1 and 80% for phase 3. Granulocyte colony-stimulating factor use increased from 69% preintervention to 81% postintervention.

CONCLUSION

The mean overall RDI improved above the threshold goal of 85%, with the RDI for adjuvant chemotherapy reaching 95%, after implementation of three quality-improvement initiatives. With continued education and following policies already in place, further improvements in RDI could be demonstrated.

Prognostic value of chemotherapy-induced leukopenia in small-cell lung cancer

OBJECTIVE

Chemotherapy is the standard treatment for small-cell lung cancer (SCLC), and leukopenia is a common side effect. This study assesses whether chemotherapy-induced leukopenia is a predictor of efficacy and whether it is associated with the survival of SCLC patients.

METHODS

A retrospective analysis was conducted on data from 445 patients with SCLC who received standard chemotherapy for 4 to 10 cycles. The World Health Organization grading system classifies leukopenia during chemotherapy as follows: absent (grade 0), mild (grades 1 and 2), or severe (grades 3 and 4). The primary endpoint is overall survival (OS).

RESULTS

The association between chemotherapy-induced leukopenia and OS was assessed. According to a multivariate Cox model with time-varying covariates, the hazard ratio of death was significantly lower among patients with mild leukopenia than among patients with severe leukopenia at 0.687 (0.506 to 0.943) and 1.414 (1.147 to 1.744), respectively. The median survival was 13 months (95% CI: 11 to 15 months) for patients who did not experience leukopenia, 17 months (95% CI: 14 to 18 months) for those with mild leukopenia, and 14 months (95% CI: 13 to 16 months) for those with severe leukopenia (absent vs. mild vs. severe leukopenia, P=0.047).

CONCLUSION

Leukopenia during chemotherapy is associated with the survival of SCLC patients. Mild leukopenia is strongly associated with longer survival time.

Risk factors for hematological toxicity of chemotherapy for bone and soft tissue sarcoma

The aim of this study was to assess chemotherapy treatment characteristics, neutropenic event occurrence and related risk factors in bone and soft tissue sarcoma patients in China. Knowledge of such risk factors aids healthcare providers in focusing resources on those who are at most risk and targeting prophylactic colony-stimulating factors (CSFs) for those patients. The study included 113 children and adults with different types of sarcoma who had been treated with neoadjuvant chemotherapy for bone and soft tissue sarcoma in order to identify risk factors for hematological toxicity of chemotherapy for bone and soft tissue sarcoma. Risk factors were determined using multivariate logistic regression analysis. Factors such as age <20 years, Karnofsky Performance Status Scale (KPS) score <60, malnutrition, number of previous chemotherapies >3 and combination therapy with >3 drugs were significantly associated with occurrence of grade III/IV neutropenia, suggestive of severe bone marrow suppression. Patients with such characteristics are at most risk of severe bone marrow suppression, and preventing discontinuation of treatment would be valuable for treating patients more effectively.

Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia.

METHODS

A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus.

RESULTS

Forty-seven articles from 43 studies met selection criteria.

RECOMMENDATIONS

Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.

Appropriate chemotherapy dosing for obese adult patients with cancer: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To provide recommendations for appropriate cytotoxic chemotherapy dosing for obese adult patients with cancer.

METHODS

The American Society of Clinical Oncology convened a Panel of experts in medical and gynecologic oncology, clinical pharmacology, pharmacokinetics and pharmacogenetics, and biostatistics and a patient representative. MEDLINE searches identified studies published in English between 1996 and 2010, and a systematic review of the literature was conducted. A majority of studies involved breast, ovarian, colon, and lung cancers. This guideline does not address dosing for novel targeted agents.

RESULTS

Practice pattern studies demonstrate that up to 40% of obese patients receive limited chemotherapy doses that are not based on actual body weight. Concerns about toxicity or overdosing in obese patients with cancer, based on the use of actual body weight, are unfounded.

RECOMMENDATIONS

The Panel recommends that full weight-based cytotoxic chemotherapy doses be used to treat obese patients with cancer, particularly when the goal of treatment is cure. There is no evidence that short- or long-term toxicity is increased among obese patients receiving full weight-based doses. Most data indicate that myelosuppression is the same or less pronounced among the obese than the non-obese who are administered full weight-based doses. Clinicians should respond to all treatment-related toxicities in obese patients in the same ways they do for non-obese patients. The use of fixed-dose chemotherapy is rarely justified, but the Panel does recommend fixed dosing for a few select agents. The Panel recommends further research into the role of pharmacokinetics and pharmacogenetics to guide appropriate dosing of obese patients with cancer.

HCV infection, B-cell non-Hodgkin’s lymphoma and immunochemotherapy: Evidence and open questions

There is plenty of data confirming that hepatitis C virus (HCV) infection is a predisposing factor for a B-cell non-Hodgkin’s lymphoma (B-NHL) outbreak, while relatively few reports have addressed the role of HCV in affecting B-NHL patients’ outcome. HCV infection may influence the short-term outcome of B-NHL because of the emergence of severe hepatic toxicity (HT) during immunochemotherapy. Furthermore, the long term outcome of HCV-related liver disease and patients’ quality of life will possibly be affected by Rituximab maintenance, multiple-lines of toxicity during chemotherapy and hematopoietic stem cell transplantation. In this review, data dealing with aggressive and low-grade B-NHL were separately analyzed. The few retrospective papers reporting on aggressive B-NHL patients showed that HCV infection is a risk factor for the outbreak of severe HT during treatment. This adverse event not infrequently leads to the reduction of treatment density and intensity. Existing papers report that low-grade B-NHL patients with HCV infection may have a more widespread disease, more frequent relapses or a lower ORR compared to HCV-negative patients. Notwithstanding, there is no statistical evidence that the prognosis of HCV-positive patients is inferior to that of HCV-negative subjects. HCV-positive prospective studies and longer follow-up are necessary to ascertain if HCV-positive B-NHL patients have inferior outcomes and if there are long term sequels of immunochemotherapies on the progression of liver disease.

Toxicities and outcomes among septuagenarians and octogenarians with diffuse large B-cell lymphoma treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone therapy

The diagnosis of non-Hodgkin lymphoma (NHL) is increasingly common among the elderly and it is well recognized that this patient population may benefit from therapy. No guidelines exist for chemotherapy dosing in the elderly population, and a clear assessment of treatment toxicity and benefits has not been previously reported. In this single-institution study, we report the toxicities and treatment outcomes of septuagenarians and octogenarians with large cell lymphoma treated with chemo-immunotherapy with or without radiation, as primary therapy with curative intent. We identified 37 patients over the age of 70 years diagnosed with large cell lymphoma treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) and compared their experience with 65 patients aged less than 70 years. Our retrospective analysis suggests that elderly patients are more susceptible to treatment-related toxicity despite more frequent chemotherapy dose reductions and greater utilization of supportive care. While our aged patients experienced greater frequency of hospitalization during R-CHOP treatment, the vast majority were able to receive relative chemotherapy dose-intensity greater than 70% and experienced similar rates of complete remission.

Importance of relative dose intensity in chemotherapy for diffuse large B-cell lymphoma

CHOP therapy combined with rituximab (R-CHOP) is currently a standard chemotherapy for diffuse large B-cell lymphoma (DLBCL). However, relapse is detected despite R-CHOP in approximately 30% of patients. Treatment results should be further improved. Previously, second- and third-generation therapies such as MACOP-B, m-BACOD, and ProMACE-CytaBOM were performed to improve the results of DLBCL treatment. However, dose intensity (DI) enhancement increased treatment-associated toxicity, and the treatment results did not improve. Recently, the entity of the relative dose intensity (RDI) was proposed as an index of the intensity of chemotherapy. In this method, the ratio of actual DI to the DI designed per specific period is numerically evaluated. The purpose of calculating the RDI is to achieve chemotherapy as scheduled while maintaining the DI, and not to improve the DI. Previous studies reported that the maintenance of the RDI during CHOP therapy improved the treatment results. In this paper, we review DI and RDI in studies of DLBCL, and revisit the significance of these indicators.

Prognostic value of chemotherapy-induced neutropenia in early-stage breast cancer

Neutropenia is one of the most important dose-limiting toxicities and often the reason for dose reduction. In this study we aimed to assess whether chemotherapy-induced neutropenia could be a marker of efficacy and associate with increased survival. Data from a retrospective survey for early breast cancer patients in our hospital were reviewed. Three hundred and thirty-five patients who had been treated with six cycles of cyclophosphamide, epirubicin, and fluorouracil (CEF) were studied. The association between chemotherapy-induced neutropenia and overall survival (OS) was assessed. According to a multivariate Cox model with time-varying covariates, hazard ratios of death were 0.434 (95% confidence interval (CI), 0.298-0.634; P < 0.001) for patients with mild neutropenia, and 0.640 (95% CI, 0.42-0.975; P = 0.038) for those with severe neutropenia. Neutropenia occurring in early breast cancer patients is an independent predictor of increased survival. These findings suggest that neutropenia in patients who receive chemotherapy is strongly associated with a better prognosis.

Systemic therapies for metastatic renal cell carcinoma in older adults

The introduction of targeted therapies has radically changed the treatment paradigm for metastatic renal cell carcinoma (mRCC). However, multiple clinical dilemmas have emerged. For instance, limited data are available to juxtapose the safety and efficacy profile of targeted therapies between older and younger adults. Herein, pivotal trials of vascular endothelial growth factor (VEGF)- and mammalian target of rapamycin (mTOR)-directed therapies are assessed in the context of their implications in treating older adults with mRCC. In general, subset analyses from these pivotal studies suggest similar efficacy of targeted therapies amongst older adults. Aging is accompanied by a multitude of physiological changes, as well as an increased prevalence of co-morbidities. The age-related toxicity profiles of targeted agents for mRCC are detailed to provide a framework for the risks and benefits of these therapies in older adults. Ultimately, tools such as the Comprehensive Geriatric Assessment (CGA) that account for physiological (as opposed to chronological) age may prove useful in the evaluation and treatment of older adults with mRCC.

A combined analysis of average relative dose intensity in the chemotherapy of solid tumors with pegfilgrastim or filgrastim support

A metaanalysis of 4 clinical studies that treated adult solid tumors with standard combination chemotherapy and growth factor support was conducted to study average relative dose intensity. All studies compared pegfilgrastim with filgrastim in a randomized, doubleblinded design. A total of 564 patients were included in the analyses: 291 who received pegfilgrastim and 273 who received filgrastim. For all cycles of treatment, the mean duration of filgrastim dosing was between 10 and 11 days, compared with 1 dose per cycle of pegfilgrastim. Median average dose intensities were between 99% and 100% of planned intensity in the pegfilgrastim and filgrastim groups. Across all studies, 96% of patients receiving pegfilgrastim and 95% of patients receiving filgrastim received an average relative dose intensity of >/= 85%. Less than 10% of patients in the pegfilgrastim and filgrastim groups experienced a dose delay, and < 5% of patients received a chemotherapy reduction. We conclude that the use of prophylactic growth factor support was associated with a high proportion of chemotherapy cycles that were delivered on schedule and at full dose.

Relative dose intensity delivered to patients with early breast cancer: Canadian experience

Adjuvant chemotherapy for early breast cancer improves disease-free and overall survival in pre- and postmenopausal women. The importance of maintaining relative dose intensity (rdi) is well-known; however, little information is available from routine clinical practice regarding how well dose intensity is maintained with modern chemotherapy regimens.

In a retrospective review of patients undergoing chemotherapy for early breast cancer at a single institution in Canada from January 2006 to November 2007, a total of 263 patients received one of the following regimens:

ac-t [doxorubicin (Adriamycin: Pharmacia, Kalamazoo, MI, U.S.A.)–cyclophosphamide, paclitaxel (Taxol: Bristol–Myers Squibb, Princeton, NJ, U.S.A.)]

fec-100 (5-fluorouracil–epirubicin–cyclophosphamide)

fec-d (5-fluorouracil–epirubicin–cyclophosphamide, docetaxel)

Overall, only 14.4% of patients had a rdi less than 85%. Dose delay or reduction (or both) occurred in 46%, 37%, and 20% of patients receiving fec-100, ac-t, and fec-d respectively. Optimal rdi was delivered to 96%, 95%, and 70.7% of patients for ac-t, fec-d and fec-100 regimens respectively. Patients over 65 years of age accounted for 14% of the total cohort and were more likely to receive a suboptimal rdi than were patients younger than 65 years of age (35% vs. 6.6%).

Optimal chemotherapy rdi (>85%) for early breast cancer can be achieved at an academic cancer centre. This goal is less often accomplished in elderly patients, and thus a proactive approach is required for managing toxicity in that population.

Summary and comparison of myeloid growth factor guidelines in patients receiving cancer chemotherapy

Chemotherapy-induced neutropenia and its complications are major dose-limiting toxicities of cancer chemotherapy. The myeloid growth factors have been shown to reduce the risk of neutropenic events across malignancies, regimens, and associated risk categories often enabling the delivery of greater chemotherapy dose intensity. Three different practice guidelines for the myeloid growth factors have recently been published by major professional organizations. A comprehensive review and comparison of the guidelines using a priori structured content criteria and a previously validated quality appraisal tool are reported. Consistency in the final recommendations from these guidelines is observed for primary prophylaxis with the colony-stimulating factors (CSFs) when the risk of febrile neutropenia is in the range of 20% or greater. There is also consistency in the recommendation that patients receiving regimens associated with lower risk should have CSF use guided by individual risk assessment. Critical quality appraisal indicates that the scope and purpose, stakeholder involvement, and applicability of the guidelines differ little. There is more emphasis on comprehensive literature reviews in the ASCO and EORTC guidelines while the NCCN guidelines are more current based on systematic annual updates. The clarity of presentation also favors the NCCN guidelines with recommendations generally presented as both text and algorithmic diagram. All three new or updated guidelines recommend prophylactic use of the myeloid growth factors in patients at greater than a 20% risk of febrile neutropenia and in those with important factors increasing individual risk of neutropenic complications.

Health resource consumption and costs attributable to chemotherapy-induced toxicity in German routine hospital care in lymphoproliferative disorder and NSCLC patients

BACKGROUND

Multidrug chemotherapy (CT) is still associated with relevant side-effects. We assessed, under current practice patterns, frequency and severity of CT-induced toxicity and its economic consequences.

PATIENTS AND METHODS

Prospective, multicentre, longitudinal, observational cohort study with lymphoproliferative disorder (LPD) and non-small-cell lung cancer (NSCLC) patients, receiving first- or second-line (immuno-) CT (excluding myeloablative CT). Data were collected from patient interviews and preplanned chart reviews. Costs in 2007 euros are presented from the provider perspective.

RESULTS

Two hundred and seventy-three patients (n = 153 LPD; n = 120 NSCLC) undergoing a total of 1004 CT cycles were assessable (age ≥65 years, 40%; female, 36%; Eastern Cooperative Oncology Group performance status ≥2, 11%; tumour stage ≥III, 56%; history of comorbidity, 80%). Fifty percent of cycles were associated with grade 3/4 toxicity and 37% (n = 371) with at least one hospital stay (outpatient/day care n = 154; intensive care n = 19). Mean (median) toxicity-related costs amounted to €1032 (€86) per cycle. Costs rose exponentially with the number of grade 3/4 adverse drug reactions (ADRs) and were highest in cycles affected by more than four ADRs, €10 881 (€5455); in cycles with intensive care, €14 121 (€8833); and in cycles affected by grade 3/4 infections and febrile neutropenia/leukopenia, €7093 (€4531) and €5170 (€2899), respectively. Five percent of CT cycles accounted for 56% of total expenses.

CONCLUSIONS

Individualised supportive care strategies are needed. Future research should focus on identifying toxicity clusters and patient characteristics predictive for high costs.

A prospective study of chemotherapy-induced febrile neutropenia in the South West London Cancer Network. Interpretation of study results in light of NCAG/NCEPOD findings

BACKGROUND

Chemotherapy-induced febrile neutropenia is a medical emergency complicating the treatment of many cancer patients. It is associated with considerable morbidity and mortality, as well as impacting on healthcare resources.

METHODS

A prospective study of all cases of chemotherapy-induced febrile neutropenia in the South West London Cancer Network was conducted over a 4-month period. Factors including demographics, treatment history, management of febrile neutropenia and outcome were recorded.

RESULTS AND CONCLUSION

Our results reflect those of the recent National Chemotherapy Advisory Group (NCEPOD, 2008)/National Confidential Enquiry into Patient Outcomes and Death reports (NCAG, 2009) and highlight the need for network-wide clinical care pathways to improve outcomes in this area.

Prophylactic and therapeutic strategies in chemotherapy-induced neutropenia

INTRODUCTION

Neutropenia poses a serious threat to patients on chemotherapy. It exposes them to the risk of infection--including potentially fatal infections--and also leads to delays in treatment and reductions in dose intensity, which can compromise the possibility of a favorable outcome.

AREAS COVERED

The use of granulocyte colony-stimulating factors (G-CSF) and antibiotics to prevent febrile neutropenia (FN) and to ameliorate cancer chemotherapy-induced myelosuppression is discussed, based on a systematic search of Pubmed for clinical trials, reviews and meta-analysis published in the last 20 years. We consider that the treatment of FN, with the emphasis on careful attention to the patient, prompts antibiotic therapy and good hospital care.

EXPERT OPINION

We would argue that antibiotic prophylaxis should be offered routinely to patients receiving cytotoxic chemotherapy for acute leukemia and for patients with solid tumors and lymphoma receiving high-dose chemotherapy. In patients undergoing cyclical standard-dose myelosuppressive chemotherapy, we believe that prophylaxis is indicated during the first cycle of chemotherapy in which there is an expectation of grade 4 neutropenia (< 500 neutrophils). However, although the use of antibiotics and haematopoietic growth factors may improve quality of life by reducing the risk and consequences of FN, further study of the magnitude of their effects is needed.

Managing neutropenia in older patients with cancer receiving chemotherapy in a community setting

Older patients with cancer who may be more susceptible than younger patients to the myelosuppressive effects of chemotherapy undergo dose delays and reductions that can compromise treatment outcomes. Incidence of neutropenic complications and suboptimal chemotherapy delivery can be reduced with prophylactic colony-stimulating factors; however, their use in older patients with cancer has not been well studied. A randomized, multicenter, community-based trial was designed to compare prophylactic pegfilgrastim use (all cycles of chemotherapy) versus its more common reactive use (at clinicians' discretion) in patients aged 65 years or older with various cancers. Pegfilgrastim use in all cycles reduced the incidence of febrile neutropenia by about 60% and hospitalizations caused by neutropenia and febrile neutropenia by about 50% versus reactive pegfilgrastim use in later cycles. The study showed that older patients with cancer can be treated safely with optimal doses of chemotherapy with appropriate supportive care. Nurses, key collaborators in providing supportive care, can take an active role in identifying older patients who may benefit from pegfilgrastim in all cycles of chemotherapy.

Charlson Comorbidity Index is an independent prognostic factor among elderly patients with diffuse large B-cell lymphoma

PURPOSE

The clinical outcome for elderly patients with diffuse large B-cell lymphoma (DLBCL) has improved. However, the management of elderly patients with cancer is frequently complicated by their coexisting disorders. The aim of this study was to evaluate the correlation between comorbid medical status and clinical outcome among elderly patients with DLBCL.

METHODS

We retrospectively analyzed all patients over 65 years old with newly diagnosed DLBCL from 2001 to 2008 in our institution. To assess their comorbid medical status, we calculated Charlson Comorbidity Index (CCI) of each patient without considering primary disease and then divided them into low CCI (0 or 1) or high CCI group (2 or more).

RESULTS

A total of 80 patients from age of 66-90 years (median 73 years) were analyzed. Seventy-two patients (90%) were treated with cyclophosphamide-, doxorubicin-, vincristine-, and prednisone (CHOP)-based chemotherapy, and 14 patients (18%) were assigned to high CCI. The overall survival (OS) rate at 3 years for all patients was 70%, with significant difference between good and poor risk patients in revised International Prognostic Index (IPI) (90 vs. 45%, P < 0.0001). Multivariate analysis revealed high CCI was associated with worse OS, while independent of other prognostic factors consisting IPI (hazard ratio 4.44, 95% confidence interval [1.63-11.3], P = 0.0045). In addition, high CCI group was significantly inferior to low CCI group for overall response rate (93 vs. 64% P = 0.0158) and 3-year OS (85 vs. 55% P = 0.0026), respectively.

CONCLUSIONS

Among elderly DLBCL, high CCI was independently associated with worse outcome. Novel discrete strategies for these deteriorated patients are therefore warranted.