201
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Flores IQ, Ershler W. Managing neutropenia in older patients with cancer receiving chemotherapy in a community setting. Clin J Oncol Nurs 2011; 14:81-6. [PMID: 20118030 DOI: 10.1188/10.cjon.81-86] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Irene Q Flores
- Institute for Advanced Studies in Aging, Geriatric Oncology Consortium, Gaithersburg, MD, USA.
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202
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Gerlier L, Lamotte M, Awada A, Bosly A, Bries G, Cocquyt V, Focan C, Henry S, Lalami Y, Machiels JP, Mebis J, Straetmans N, Verhoeven D, Somers L. The use of chemotherapy regimens carrying a moderate or high risk of febrile neutropenia and the corresponding management of febrile neutropenia: an expert survey in breast cancer and non-Hodgkin's lymphoma. BMC Cancer 2010; 10:642. [PMID: 21092320 PMCID: PMC3006392 DOI: 10.1186/1471-2407-10-642] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 11/23/2010] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The use of chemotherapy regimens with moderate or high risk of febrile neutropenia (defined as having a FN incidence of 10% or more) and the respective incidence and clinical management of FN in breast cancer and NHL has not been studied in Belgium. The existence of a medical need for G-CSF primary and secondary prophylaxis with these regimens was investigated in a real-life setting. METHODS Nine oncologists and six hematologists from different Belgian general hospitals and university centers were surveyed to collect expert opinion and real-life data (year 2007) on the use of chemotherapy regimens with moderate or high risk of febrile neutropenia and the clinical management of FN in patients aged <65 years with breast cancer or NHL. Data were retrospectively obtained, over a 6-month observation period. RESULTS The most frequently used regimens in breast cancer patients (n = 161) were FEC (45%), FEC-T (37%) and docetaxel alone (6%). In NHL patients (n = 39), R-CHOP-21 (33%) and R-ACVBP-14 (15%) were mainly used. Without G-CSF primary prophylaxis (PP), FN occurred in 31% of breast cancer patients, and 13% had PSN. After G-CSF secondary prophylaxis (SP), 4% experienced further FN events. Only 1 breast cancer patient received PP, and did not experience a severe neutropenic event. Overall, 30% of chemotherapy cycles observed in breast cancer patients were protected by PP/SP. In 10 NHL patients receiving PP, 2 (20%) developed FN, whereas 13 (45%) of the 29 patients without PP developed FN and 3 (10%) PSN. Overall, 55% of chemotherapy cycles observed in NHL patients were protected by PP/SP. Impaired chemotherapy delivery (timing and/or dose) was reported in 40% (breast cancer) and 38% (NHL) of patients developing FN. Based on oncologist expert opinion, hospitalization rates for FN (average length of stay) without and with PP were, respectively, 48% (4.2 days) and 19% (1.5 days). Similar rates were obtained from hematologists. CONCLUSIONS Despite the studied chemotherapy regimens being known to be associated with a moderate or high risk of FN, upfront G-CSF prophylaxis was rarely used. The observed incidence of severe neutropenic events without G-CSF prophylaxis was higher than generally reported in the literature. The impact on medical resources used is sizeable.
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Affiliation(s)
- Laetitia Gerlier
- Health Economics and Outcomes Research Department, IMS Health Consulting, Medialaan 38, 1800 Vilvoorde, Belgium
| | - Mark Lamotte
- Health Economics and Outcomes Research Department, IMS Health Consulting, Medialaan 38, 1800 Vilvoorde, Belgium
| | - Ahmad Awada
- Medical Oncology Clinic, Jules Bordet Institute, boulevard de Waterloo, 121, B-1000 Brussels, Belgium
| | - André Bosly
- Department of Hematology, University Hospital of Mont-Godinne, Avenue Dr G. Therasse, 1, B-5530 Yvoir, Belgium
| | - Greet Bries
- Department of Hematology, Virga Jesse Hospital, Stadsomvaart, 11, B-3500 Hasselt, Belgium
| | - Véronique Cocquyt
- Medical Oncology, University Hospital Ghent, De Pintelaan, 185, B-9000 Gent, Belgium
| | - Christian Focan
- Department of Oncology, CHC-Saint-Joseph Clinic, rue de Hesbaye, 75, B-4000 Liège, Belgium
| | - Stéphanie Henry
- Department of Oncology, University Hospital of Mont-Godinne, Avenue Dr G. Therasse, 1, B-5530 Yvoir, Belgium
- Medical Oncology, Sainte-Elisabeth Clinic, place Louise Godin, 15, B-5000 Namur, Belgium
| | - Yassine Lalami
- Medical Oncology Clinic, Jules Bordet Institute, boulevard de Waterloo, 121, B-1000 Brussels, Belgium
| | - Jean-Pascal Machiels
- Medical Oncology, UCL Saint-Luc University Hospital, Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Jeroen Mebis
- Medical Oncology, Virga Jesse Hospital, Stadsomvaart, 11, B-3500 Hasselt, Belgium
| | - Nicole Straetmans
- Department of Hematology, Jolimont Hospital, rue Ferrer, 159, B-7100 Haine-Saint-Paul, Belgium
| | - Didier Verhoeven
- Medical Oncology, Iridiumkankernetwerk, AZ Klina, Augustijnslei 100, B-2930 Brasschaat, Belgium
| | - Luc Somers
- OncoLogX, Arthur Boelstraat 66, B-2990 Wuustwezel, Belgium
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203
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Carrato A, Guillén-Ponce C, Grande-Pulido E. [Antineoplastic drug-induced neutropenia: use of granulocyte colony stimulating factors]. FARMACIA HOSPITALARIA 2010; 34 Suppl 1:8-11. [PMID: 20920851 DOI: 10.1016/s1130-6343(10)70002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Neutropenia is a frequent adverse event of the pharmacologic treatment of cancer. Morbidity and mortality-associated neutropenia can be successfully treated and prevented with granulocyte-colony stimulating factors (G-CSF). European and American Guidelines recommend their prophylactic use when the expected percentage of febrile neutropenia exceeds 20% or there are concomitant risk factors. Afebrile neutropenia is not considered to benefit from G-CSF treatment. Other approved indications include stem cell mobilization, and an adequate delivery of dose-intense and dose-dense chemotherapy regimens.
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Affiliation(s)
- A Carrato
- Servicio de Oncología Médica, Hospital Universitario Ramón y Cajal, Madrid, España
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204
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Friese CR, Silber JH, Aiken LH. National Cancer Institute Cancer Center designation and 30-day mortality for hospitalized, immunocompromised cancer patients. Cancer Invest 2010; 28:751-7. [PMID: 20504224 DOI: 10.3109/07357901003735667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine 30-day mortality and National Cancer Institute (NCI) designation for cancer patients who are immunocompromised and hospitalized. METHOD Secondary analysis of 1998 and 1999 hospital claims, cancer registry, and vital statistics (n = 10,370) linked to survey and administrative data from 160 Pennsylvania hospitals. Logistic regression models estimated the effects of NCI designation on the likelihood of 30-day mortality. RESULTS NCI-designated centers were associated with a 33% reduction in the likelihood of death, after adjusting for patient, hospital, and nursing characteristics. CONCLUSIONS Immunocompromised cancer patients have lower mortality in NCI-designated hospitals. Identification and adoption of care processes from these institutions may improve mortality.
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205
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Jansen JP, O'Sullivan AK, Lugtenburg E, Span LFR, Janssen JJWM, Stam WB. Economic evaluation of posaconazole versus fluconazole prophylaxis in patients with graft-versus-host disease (GVHD) in the Netherlands. Ann Hematol 2010; 89:919-26. [PMID: 20383504 PMCID: PMC2908442 DOI: 10.1007/s00277-010-0939-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 03/04/2010] [Indexed: 11/25/2022]
Abstract
The objective of this study was to evaluate the cost-effectiveness of posaconazole versus fluconazole for the prevention of invasive fungal infections (IFI) in graft-versus-host disease (GVHD) patients in the Netherlands. A decision analytic model was developed based on a double-blind randomized trial that compared posaconazole with fluconazole antifungal prophylaxis in recipients of allogeneic HSCT with GVHD who were receiving immunosuppressive therapy (Ullmann et al., N Engl J Med 356:335–347, 2007). Clinical events were modeled with chance nodes reflecting probabilities of IFIs, IFI-related death, and death from other causes. Data on life expectancy, quality-of-life, medical resource consumption, and costs were obtained from the literature. The total cost with posaconazole amounted to €9,428 (95% uncertainty interval €7,743–11,388), which is €4,566 (€2,460–6,854) more than those with fluconazole. Posaconazole prophylaxis resulted in 0.17 (0.02–0.36) quality adjusted life year (QALY) gained compared to fluconazole prophylaxis, corresponding to an incremental cost effectiveness ratio (ICER) of €26,225 per QALY gained. A scenario analysis demonstrated that at an increased background IFI risk (from 9% to 15%) the ICER was €13,462 per QALY. Given the underlying data and assumptions, posaconazole prophylaxis is expected to be cost-effective relative to fluconazole in recipients of allogeneic HSCT developing GVHD in the Netherlands. The cost-effectiveness of posaconazole depends on the IFI risk, which can vary by hospital.
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206
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Aranda Aguilar E, Camps Herrero C, Carrato Mena A, Clopés Estela A, Cruz Hernández J, Delgado Sánchez O, Díaz-Rubio García E, Domínguez-Gil Hurlé A, Dorantes Calderón B, García Alfonso P, Herrero Ambrosio A. Documento de Consenso sobre el uso de factores estimuladores de colonias de granulocitos biosimilares para la corrección de la neutropenia asociada en pacientes con cáncer. FARMACIA HOSPITALARIA 2010; 34 Suppl 1:45-50. [DOI: 10.1016/s1130-6343(10)70008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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207
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Ibrahim AS, Edwards JE, Bryant R, Spellberg B. Economic burden of mucormycosis in the United States: can a vaccine be cost-effective? Med Mycol 2010; 47:592-600. [PMID: 18798118 DOI: 10.1080/13693780802326001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Mucormycosis is a life-threatening infection which causes unacceptably high morbidity and mortality despite treatment. Therefore, a vaccine to prevent mucormycosis is desirable. A major barrier to developing an anti-mucormycosis vaccine is the perception that such a vaccine would not be cost-effective to deploy because the disease is rare. We used data from a recent retrospective study to calculate the annual cost to the US healthcare system caused by mucormycosis infections. We created a model to estimate the cost-efficacy of a niche, anti-mucormycosis vaccine deployed in a targeted manner to high-risk patients. We found that each case of mucormycosis results in an average direct cost to the US healthcare system of $97,743, for an overall cost of mucormycosis of $50 million per year. In the base case scenario, targeted deployment of an anti-mucormycosis vaccine would result in a net cost per quality adjusted life year saved (QUALY) of $17,249. Variations in the price of the vaccine, its market penetration, or the cost of infection could dramatically decrease the net cost, and could even result in net savings per QUALY. In conclusion, mucormycosis causes considerable cost to the US health care system. Targeted deployment of a niche vaccine could decrease infection rates and mortality from mucormycosis in a cost-effective manner.
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Affiliation(s)
- Ashraf S Ibrahim
- Division of Infectious Diseases, Harbor-University of California at Los Angeles Medical Center, and the Los Angeles Biomedical Research Institute, Torrance, California 90502, USA.
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208
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Prophylaxis of chemotherapy-induced febrile neutropenia with granulocyte colony-stimulating factors: where are we now? Support Care Cancer 2010; 18:529-41. [PMID: 20191292 PMCID: PMC2846279 DOI: 10.1007/s00520-010-0816-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 01/07/2010] [Indexed: 11/23/2022]
Abstract
Updated international guidelines published in 2006 have broadened the scope for the use of granulocyte colony-stimulating factor (G-CSF) in supporting delivery of myelosuppressive chemotherapy. G-CSF prophylaxis is now recommended when the overall risk of febrile neutropenia (FN) due to regimen and individual patient factors is ≥20%, for supporting dose-dense and dose-intense chemotherapy and to help maintain dose density where dose reductions have been shown to compromise outcomes. Indeed, there is now a large body of evidence for the efficacy of G-CSFs in supporting dose-dense chemotherapy. Predictive tools that can help target those patients who are most at risk of FN are now becoming available. Recent analyses have shown that, by reducing the risk of FN and chemotherapy dose delays and reductions, G-CSF prophylaxis can potentially enhance survival benefits in patients receiving chemotherapy in curative settings. Accumulating data from ‘real-world’ clinical practice settings indicate that patients often receive abbreviated courses of daily G-CSF and consequently obtain a reduced level of FN protection. A single dose of PEGylated G-CSF (pegfilgrastim) may provide a more effective, as well as a more convenient, alternative to daily G-CSF. Prospective studies are needed to validate the importance of delivering the full dose intensity of standard chemotherapy regimens, with G-CSF support where appropriate, across a range of settings. These studies should also incorporate prospective evaluation of risk stratification for neutropenia and its complications.
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209
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Miller K. Using a computer-based risk assessment tool to identify risk for chemotherapy-induced febrile neutropenia. Clin J Oncol Nurs 2010; 14:87-91. [PMID: 20118031 DOI: 10.1188/10.cjon.87-91] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article evaluates the feasibility of developing and implementing a computer-based risk assessment tool (CBRAT) for febrile neutropenia and determines whether it could improve documentation of risk assessment in patients starting myelosuppressive chemotherapy regimens. The CBRAT was designed using a template creator in a commercial electronic medical records system. The effectiveness of the CBRAT was evaluated by comparing medical records data of patients with one or more risk factor for febrile neutropenia who were given prophylactic granulocyte-colony-stimulating factor before and after implementation. CBRAT usage significantly increased the likelihood of documented febrile neutropenia risk assessment from 13% before implementation to 100% after implementation (p < 0.001). No significant changes occurred in febrile neutropenia incidence rates, dose reductions, or dose delays. In addition, healthcare providers quickly learned how to operate the CBRAT and used it routinely, significantly improving the number of patients with documented febrile neutropenia risk assessment. Implementation of a computer-based tool can help nurses follow evidence-based guidelines that recommend routine febrile neutropenia risk assessment for patients initiating myelosuppressive chemotherapy.
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Affiliation(s)
- Kevin Miller
- Women's Health Center, Mount Carmel Health System, Columbus, OH, USA.
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210
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López-Pousa A, Rifà J, Casas de Tejerina A, González-Larriba JL, Iglesias C, Gasquet JA, Carrato A. Risk assessment model for first-cycle chemotherapy-induced neutropenia in patients with solid tumours. Eur J Cancer Care (Engl) 2010; 19:648-55. [PMID: 20088918 PMCID: PMC3082427 DOI: 10.1111/j.1365-2354.2009.01121.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
LÓPEZ-POUSA A., RIFÀ J., CASAS DE TEJERINA A., GONZÁLEZ-LARRIBA J.L., IGLESIAS C., GASQUET J.A. & CARRATO A. (2010) European Journal of Cancer CareRisk assessment model for first-cycle chemotherapy-induced neutropenia in patients with solid tumours Chemotherapy-induced neutropenia, the major dose-limiting toxicity of chemotherapy, is directly associated with concomitant morbidity, mortality and health-care costs. The use of prophylactic granulocyte colony-stimulating factors may reduce the incidence and duration of chemotherapy-induced neutropenia, and is recommended in high-risk patients. The objective of this study was to develop a model to predict first-cycle chemotherapy-induced neutropenia (defined as neutropenia grade ≥3, with or without body temperature ≥38°C) in patients with solid tumours. A total of 1194 patients [56% women; mean age 58 ± 12 years; 94% Eastern Cooperative Oncology Group (ECOG) status ≤1] with solid tumours were included in a multi-centre non-interventional prospective cohort study. A predictive logistic regression model was developed. Several factors were found to influence chemotherapy-induced neutropenia. Higher ECOG status values increased toxicity (ECOG 2 vs. 0, P= 0.003; odds ratio 3.12), whereas baseline lymphocyte (P= 0.011; odds ratio 0.67) and neutrophil counts (P= 0.026; odds ratio 0.90) were inversely related to neutropenia occurrence. Sex and treatment intention also significantly influenced chemotherapy-induced neutropenia (P= 0.012). The sensitivity and specificity of the model were 63% and 67% respectively, and the positive and negative predictive values were 17% and 94% respectively. Once validated, this model should be a useful tool for clinical decision making.
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Affiliation(s)
- A López-Pousa
- Medical Oncology Department, Santa Creu i Sant Pau Hospital, Barcelona, Spain.
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211
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Carrato A, Paz-Ares Rodríguez L, Rodríguez Lescure A, Casas Fernández de Tejerina AM, Díaz Rubio García E, Pérez Segura P, Constenla Figueiras M, García Carbonero R, Gómez Codina J, Lluch Hernández A, Maroto Rey JP, Martín Jiménez M, Mayordomo Cámara JI, Moreno Nogueira JA, Rueda Domínguez A. Spanish Society of Medical Oncology consensus for the use of haematopoietic colony-stimulating factors in cancer patients. Clin Transl Oncol 2009; 11:446-54. [PMID: 19574202 DOI: 10.1007/s12094-009-0383-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Neutropenia is a common complication of cancer chemotherapy. Colony-stimulating factors (CSF) may be used to avoid neutropenia-associated complications. The Spanish Society of Medical Oncology (SEOM) recently constituted a working group to review the main issues concerning the use of CSF and carried out a consensus process about the use of CSF in cancer patients, held in Madrid on 26 May 2006. The group concluded the following recommendations: prophylactic use of CSF is recommended when a rate of febrile neutropenia (FN) higher than 20% is expected without the use of CSF or when additional risk factors for neutropenia exist; therapeutic use of CSF is recommended in order to treat FN episodes but not to treat afebrile neutropenic episodes. In addition, the use of CSF is considered effective when used to mobilise stem cells before high-dose chemotherapy and when used for chemotherapy schedule optimisation in dose-dense and in dose-intense regimens.
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Affiliation(s)
- Alfredo Carrato
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain.
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212
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Heaney ML, Toy EL, Vekeman F, Laliberté F, Dority BL, Perlman D, Barghout V, Duh MS. Comparison of hospitalization risk and associated costs among patients receiving sargramostim, filgrastim, and pegfilgrastim for chemotherapy-induced neutropenia. Cancer 2009; 115:4839-48. [PMID: 19637341 DOI: 10.1002/cncr.24535] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Sargramostim is a granulocyte-macrophage-colony-stimulating factor (GM-CSF). Unlike filgrastim and pegfilgrastim, which are granulocyte-colony-stimulating factors (G-CSFs), sargramostim activates a broader range of myeloid lineage-derived cells. Therefore, GM-CSF might reduce infection risk more than the G-CSFs. This study compared real-world infection-related hospitalization rates and costs in patients using G/GM-CSF for chemotherapy-induced neutropenia. METHODS This retrospective matched-cohort study analyzed nationally representative health insurance claims in the United States from 2000 through 2007. The sample population included patients who received chemotherapy and G/GM-CSF. G/GM-CSF treatment episodes began with the first administration of G/GM-CSF and ended when a subsequent administration was >28 days after a prior administration. Sargramostim patients were matched 1:1 with filgrastim and pegfilgrastim patients based on gender and birth year. Outcomes included infection-related hospitalization rates and the associated costs. Hospitalization rates were analyzed using univariate and multivariate Poisson methods; covariates included myelosuppressive agents received, tumor type, anemia, and comorbidities. RESULTS A total of 990 sargramostim-filgrastim and 982 sargramostim-pegfilgrastim matched pairs were analyzed. Cohorts were similar with regard to age, gender, and comorbid conditions. Several differences were observed with regard to tumor type, anemia, and chemotherapy, but no systematic trends were apparent. Sargramostim patients experienced a 56% lower risk of infection-related hospitalizations compared with filgrastim and pegfilgrastim patients. Infection-related hospitalization costs were 84% and 62% lower for sargramostim patients compared with patients treated with filgrastim and pegfilgrastim, respectively. CONCLUSIONS Among patients with or at risk for chemotherapy-induced neutropenia, these data indicated that use of sargramostim was associated with a reduced risk of infection-related hospitalization and lower associated costs compared with filgrastim or pegfilgrastim.
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Affiliation(s)
- Mark L Heaney
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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213
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Repetto L. Incidence and clinical impact of chemotherapy induced myelotoxicity in cancer patients: An observational retrospective survey. Crit Rev Oncol Hematol 2009; 72:170-9. [DOI: 10.1016/j.critrevonc.2009.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Revised: 02/23/2009] [Accepted: 03/04/2009] [Indexed: 11/29/2022] Open
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214
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Lyman GH, Lalla A, Barron RL, Dubois RW. Cost-effectiveness of pegfilgrastim versus filgrastim primary prophylaxis in women with early-stage breast cancer receiving chemotherapy in the United States. Clin Ther 2009; 31:1092-104. [PMID: 19539110 DOI: 10.1016/j.clinthera.2009.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prophylaxis with granulocyte colony-stimulating factor reduces the risk for febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. OBJECTIVE We estimated the incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 of chemotherapy) with pegfilgrastim versus filgrastim in women with early-stage breast cancer receiving myelosuppressive chemotherapy in the United States. METHODS A decision-analytic model was constructed from a health payer's perspective with a lifetime study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality and on-time receipt of full-dose chemotherapy. Sensitivity analyses were conducted. RESULTS Pegfilgrastim was cost-saving and more effective (ie, dominant strategy) than 11-day filgrastim. The incremental cost-effectiveness ratio (ICER) for pegfilgrastim versus 6-day filgrastim was $12,904 per FN episode avoided. Adding the survival benefit due to reduced FN mortality and receipt of optimal chemotherapy dose yielded an ICER of $31,511 per quality-adjusted life year (QALY) gained and $14,415 per QALY gained, respectively. The most influential factors included inpatient FN case-fatality rate, cost of pegfilgrastim and filgrastim, baseline probability of FN, relative risk for FN between filgrastim and pegfil-grastim, and cost of administration of filgrastim. CONCLUSION Pegfilgrastim was cost-saving compared with 11-day filgrastim and cost-effective compared with 6-day filgrastim from a health payer's perspective for the primary prophylaxis of FN in these women with early-stage breast cancer receiving myelosuppressive chemotherapy.
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Affiliation(s)
- Gary H Lyman
- Division of Medical Oncology, Department of Medicine, Duke University School of Medicine and the Duke Comprehensive Cancer Center, Durham, North Carolina, USA
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215
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Weycker D, Malin J, Kim J, Barron R, Edelsberg J, Kartashov A, Oster G. Risk of hospitalization for neutropenic complications of chemotherapy in patients with primary solid tumors receiving pegfilgrastim or filgrastim prophylaxis: a retrospective cohort study. Clin Ther 2009; 31:1069-81. [PMID: 19539108 DOI: 10.1016/j.clinthera.2009.05.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND In a meta-analysis of data from randomized trials, the risk of febrile neutropenia during myelosuppressive chemotherapy was reported to be lower with pegfilgrastim prophylaxis than filgrastim prophylaxis. However, there is limited information on the comparative effectiveness of these agents in clinical practice. OBJECTIVE This study was undertaken to compare the risks of hospitalization for neutropenic complications of chemotherapy in US clinical practice in patients with primary solid tumors receiving pegfilgrastim or filgrastim prophylaxis. METHODS This was a retrospective cohort study employing a US health insurance database. The source population included all patients who received chemotherapy for a primary solid tumor between January 2003 and December 2005 and who received filgrastim or pegfilgrastim during their first course of chemotherapy. All unique chemotherapy cycles were identified for each patient, and cycles in which pegfilgrastim or filgrastim was administered by cycle day 5 (considered to represent prophylaxis) were selected and pooled for analysis. The risks of hospitalization for neutro-penic complications (using both narrow and broad criteria) and for any reason were then compared between cycles in which filgrastim or pegfilgrastim prophylaxis was administered. Generalized estimating equations were used to control for potential confounding variables. RESULTS Filgrastim prophylaxis was used in 1193 unique chemotherapy cycles (mean [SD] number of days per cycle, 4.5 [3.3]); for pegfilgrastim prophylaxis, the number of unique chemotherapy cycles was 14,570. First-cycle use represented 16% of all cycles analyzed. The mean ages of patients receiving filgrastim and pegfilgrastim prophylaxis were 61 and 60 years, respectively. Breast cancer was the most common tumor type (52% and 51%), followed by non-Hodgkin's lymphoma (21% and 18%) and lung cancer (11% and 15%). Hospitalization for neutropenic complications (narrow criterion) occurred during 2.1% of filgrastim cycles and 1.2% of pegfilgrastim cycles; hospitalization for neutropenic complications (broad criterion) occurred in a respective 4.8% and 3.1% of cycles; and hospitalization for all causes occurred in 8.7% and 6.3% of cycles (all, P < 0.01). The risks of hospitalization were consistently lower for chemotherapy cycles that involved pegfilgrastim prophylaxis compared with filgrastim prophylaxis (odds ratios = 0.64-0.73; P < 0.05). CONCLUSION The risk of hospitalization for neutro-penic complications during cancer chemotherapy in clinical practice was approximately one third higher among patients who received filgrastim prophylaxis than among those who received pegfilgrastim prophylaxis.
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Affiliation(s)
- Derek Weycker
- Policy Analysis Inc., Brookline, Massachusetts 02445, USA.
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Implementation of a pharmacist-initiated pharmaceutical handover for oncology and haematology patients being transferred to critical care units. Support Care Cancer 2009; 18:811-6. [PMID: 19662439 DOI: 10.1007/s00520-009-0713-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 07/23/2009] [Indexed: 10/20/2022]
Abstract
GOALS OF WORK An information gap with respect to specific therapies was identified when patients were transferred from the oncology and haematology unit (OHU) to the critical care units. The goal was to implement and evaluate the effectiveness of a pharmacist-initiated pharmaceutical handover (PIPH) for patients being transferred from the OHU to the critical care units at a major teaching hospital. PATIENTS AND METHODS A PIPH process for the specific therapies of mouthcare, chemotherapy regimen, growth factors and antibiotics was developed. The PIPH was delivered in written format or combined written and verbal format. The impact of the PIPH was by assessment of recorded clinical pharmacist interventions. Data were analysed to evaluate any difference in the number of interventions relating to and the time to administration of the specific therapies. MAIN RESULTS Data were available for 30 patient transfers in the pre-implementation group, with 22 transfers available in the post-implementation period. The number of interventions relating to the specific therapies was significantly reduced in the post-implementation group (144 vs 26; p < 0.0001). A significantly greater proportion of the specific therapies were administered on time in the post-implementation group (57% vs 96%; p < 0.0001). CONCLUSIONS Clinical pharmacists in the specialty area of oncology and haematology can improve the continuum of care when their patients are transferred to other units. By providing an accurate handover about specific therapies, there is an overall improvement in the prescribing and timely administration of these therapies.
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217
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Timmins NE, Nielsen LK. Blood cell manufacture: current methods and future challenges. Trends Biotechnol 2009; 27:415-22. [DOI: 10.1016/j.tibtech.2009.03.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 03/27/2009] [Accepted: 03/30/2009] [Indexed: 01/16/2023]
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Tan Sean P, Chouaid C, Hettler D, Baud M, Hejblum G, Tilleul P. Economic implications of using pegfilgrastim rather than conventional G-CSF to prevent neutropenia during small-cell lung cancer chemotherapy. Curr Med Res Opin 2009; 25:1455-60. [PMID: 19419340 DOI: 10.1185/03007990902918156] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For the prevention of chemotherapy-induced febrile aplasia, a single injection of pegfilgrastim per cycle has the same efficacy as six to ten injections of conventional granulocyte colony-stimulating factor (G-CSF). However, there are few data on the economic impact of pegfilgrastim use, especially in the context of small-cell lung cancer. METHODS This retrospective study involved 31 patients and 129 treatment cycles (32 with pegfilgrastim and 97 with granulocyte colony-stimulating factor (G-CSF)). We estimated the direct costs for preventing and managing febrile aplasia from the payer's perspective and also conducted a willingness-to-pay study with 100 healthy subjects, in order to estimate how highly a single-jab strategy was valued relative to multiple injections. RESULTS The costs per cycle were respectively 1743 euros+/- 837 euros and 1466 euros +/- 836 euros for the pegfilgrastim and G-CSF strategies (p < 0.001). The excess cost of the pegfilgrastim strategy was partly compensated for by the perceived value of the single-jab strategy: 88% of interviewees would prefer the pegfilgrastim strategy; 16% would be willing to pay all the excess cost (277 euros) and 67% would be willing to pay half the excess cost. CONCLUSION In this willingness-to-pay survey, the excess cost associated with pegfilgrastim relative to other G-CSF-based prophylactic strategies is partly offset by the perceived convenience of a single injection.
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Affiliation(s)
- P Tan Sean
- AP-HP, Hôpital Saint-Antoine, Service de Pharmacie, Paris, France
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219
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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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220
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Ramsey SD, Liu Z, Boer R, Sullivan SD, Malin J, Doan QV, Dubois RW, Lyman GH. Cost-effectiveness of primary versus secondary prophylaxis with pegfilgrastim in women with early-stage breast cancer receiving chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:217-225. [PMID: 18673353 DOI: 10.1111/j.1524-4733.2008.00434.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. We estimated the incremental cost-effectiveness of G-CSF pegfilgrastim primary (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) versus secondary (only after an FN event) prophylaxis in women with early-stage breast cancer receiving myelosuppressive chemotherapy with a >or=20% FN risk. METHODS A decision-analytic model was constructed from a health insurer's perspective with a lifetime study horizon. The model considers direct medical costs and outcomes related to reduced FN and potential survival benefits because of reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values. RESULTS The incremental cost-effectiveness ratio (ICER) of pegfilgrastim as primary versus secondary prophylaxis was $48,000/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $110,000/life-year gained (LYG) or $116,000/quality-adjusted life-year (QALY) gained. The most influential factors included FN case-fatality, FN relative risk reduction from primary prophylaxis, and age at diagnosis. CONCLUSIONS Compared with secondary prophylaxis, the cost-effectiveness of pegfilgrastim as primary prophylaxis may be equivalent or superior to other commonly used supportive care interventions for women with breast cancer. Further assessment of the direct impact of G-CSF on short- and long-term survival is needed to substantiate these findings.
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Affiliation(s)
- Scott D Ramsey
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center and University of Washington Department of Medicine, Seattle, WA 98109, USA.
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221
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Lyman G, Lalla A, Barron R, Dubois RW. Cost-effectiveness of pegfilgrastim versus 6-day filgrastim primary prophylaxis in patients with non-Hodgkin's lymphoma receiving CHOP-21 in United States. Curr Med Res Opin 2009; 25:401-11. [PMID: 19192985 DOI: 10.1185/03007990802636817] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Prophylaxis with granulocyte-colony stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. Randomized clinical trials have shown that pegfilgrastim, a 2nd-generation G-CSF, is at least as effective as the 1st-generation G-CSF filgrastim. In the meta-analysis of trials pegfilgrastim performed better than filgrastim with respect to FN risk. The incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) with pegfilgrastim versus filgrastim used for 6 days (as is often used in clinical practice) was estimated in patients with aggressive non-Hodgkin's lymphoma (NHL) receiving myelosuppressive chemotherapy in the United States. METHODS A decision-analytic model was constructed from a health insurer's perspective with a life-time study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values. RESULTS The incremental cost-effectiveness (ICER) of pegfilgrastim versus 6-day filgrastim primary prophylaxis was $2167/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $5532/LY gained or $6190/QALY gained. When the potential benefit of optimized chemotherapy was included, the ICER was $1494/LY gained or $1677/QALY gained. The most influential factors included cost of pegfilgrastim, relative risk of FN between pegfilgrastim and filgrastim, FN case-fatality rate, cost of filgrastim and baseline FN risk. CONCLUSIONS Pegfilgrastim is cost-effective in primary prophylaxis of FN compared to 6 days per cycle of filgrastim, in patients with NHL receiving myelosuppressive chemotherapy (e.g., cyclophosphamide + doxorubicin + vincristine + prednisolone [CHOP-21]) chemotherapy. Study limitations included lack of direct evidence linking G-CSF use with a reduction in FN-related mortality and limited data that show a relationship between relative dose intensity (RDI) and cancer-specific patient survival.
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Affiliation(s)
- Gary Lyman
- Duke University School of Medicine and the Duke Comprehensive Cancer Center, Chapel Hill, NC, USA
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Mortality in a heterogeneous population of low-risk febrile neutropenic patients treated initially with cefazolin and tobramycin. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2009; 20:e145-52. [PMID: 21119792 DOI: 10.1155/2009/631969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND At Sunnybrook Health Sciences Centre in Toronto, Ontario, the recommended empiric regimen for febrile neutropenia has been cefazolin and tobramycin for at least 25 years. However, we had no objective data to reassure us that patient mortality had not increased over the past five years. METHODS A retrospective chart review of 48 episodes occurring in 44 patients admitted for the treatment of febrile neutropenia secondary to chemotherapy in 2002, and initially managed with cefazolin and tobramycin was conducted. Prospective data from 48 episodes in 2007 had previously been collected. Patients who developed febrile neutropenia while in hospital were excluded. The primary objective of the present study was to compare the all-cause mortality in 2007 with that from 2002. RESULTS There were no statistically significant differences between the groups (P>0.05). All-cause mortality in 2007 was 8.3% (four of 48) compared with 10.4% (five of 48) in 2002 (P=1). All deaths occurred in patients considered to be at high risk according to the Talcott score. CONCLUSION Mortality has not increased in the past five years with the use of empiric cefazolin and tobramycin for the treatment of patients admitted with febrile neutropenia at Sunnybrook Health Sciences Centre. Rates are comparable with those reported in the literature for similar patients. The results of the present study provide reassurance that the regimen continues to be effective for lower-risk febrile neutropenic patients.
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223
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Timmins NE, Palfreyman E, Marturana F, Dietmair S, Luikenga S, Lopez G, Fung YL, Minchinton R, Nielsen LK. Clinical scale ex vivo manufacture of neutrophils from hematopoietic progenitor cells. Biotechnol Bioeng 2009; 104:832-40. [DOI: 10.1002/bit.22433] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Liu Z, Doan QV, Malin J, Leonard R. The economic value of primary prophylaxis using pegfilgrastim compared with filgrastim in patients with breast cancer in the UK. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2009; 7:193-205. [PMID: 19799473 DOI: 10.1007/bf03256152] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) is a serious adverse event associated with myelotoxic chemotherapy that predisposes patients to life-threatening bacterial infections. Prophylaxis with granulocyte colony-stimulating factors (G-CSFs) from the first cycle of chemotherapy is recommended by the 2006 American Society of Clinical Oncology, 2008 National Comprehensive Cancer Network and 2006 European Organisation for Research and Treatment of Cancer guidelines when the overall risk of FN is approximately 20% or higher. Once-per-cycle pegfilgrastim and daily filgrastim are two commonly used G-CSFs with different dosing schedules and associated costs. OBJECTIVE To evaluate the cost effectiveness of pegfilgrastim versus filgrastim primary prophylaxis in women with early-stage breast cancer receiving chemotherapy in the UK. METHODS A decision-analytic model was constructed from the UK NHS perspective with a lifetime study horizon. The model simulated three clinical scenarios: scenario 1 assumed that pegfilgrastim and filgrastim had differential impact on the risk of FN; scenario 2 assumed additional differential impact on FN-related mortality; and scenario 3 assumed additional differential impact on chemotherapy relative dose intensity (RDI) with long-term survival effects. The base-case population included 45-year-old women with stage II breast cancer receiving four chemotherapy cycles, with an FN risk of approximately 20% or higher. Model inputs, including FN risk, FN case-fatality, RDI, impact of RDI on survival and utility scores, were based on a review of the literature and expert panel validation. Using data from the literature, it was estimated that the absolute risk of FN associated with pegfilgrastim was 5.5% lower than with 11-day filgrastim (7% vs 12.5%), and 10.5% lower than with 6-day filgrastim (7% vs 17.5%). Costs were taken from official price lists or the literature and included drugs, drug administration, FN-related hospitalizations and subsequent medical costs. Breast cancer mortality and all-cause mortality were obtained from official statistics. The main outcome measures were the costs ( pound, year 2006 values) per percentage decrease in (absolute) FN risk, per FN event avoided, per life-year gained (LYG), and per QALY gained. Model robustness was tested using deterministic and probabilistic sensitivity analyses. RESULTS Pegfilgrastim was cost saving compared with 11-day filgrastim ( pound 3196 vs pound 4315). Compared with 6-day filgrastim, pegfilgrastim was associated with a cost of pound 4200 per FN event avoided, or pound 42 per 1% decrease in absolute risk of FN, in scenario 1. In scenario 2, pegfilgrastim provided 0.055 more LYGs or 0.052 more QALYs at a minimal cost increase of pound 441 ( pound 3196 vs pound 2754) per person, yielding an incremental cost-effectiveness ratio (ICER) of pound 8075/LYG or pound 8526/QALY. In scenario 3, when all potential benefits of G-CSF were considered, the ICER became pound 3955/LYG or pound 4161/QALY. Results were most sensitive to the relative risk of FN for 6-day filgrastim versus pegfilgrastim. CONCLUSION In this UK analysis, pegfilgrastim appears to dominate 11-day use of filgrastim. The value of pegfilgrastim versus 6-day filgrastim at pound 4161-8526/QALY was very favourable compared with the commonly used threshold in the UK. In this setting, primary prophylaxis with pegfilgrastim may be cost effective compared with filgrastim.
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Affiliation(s)
- Zhimei Liu
- Cerner LifeSciences, Beverly Hills, California, USA.
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225
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Stam WB, O’Sullivan AK, Rijnders B, Lugtenburg E, Span LFR, Janssen JJWM, Jansen JP. Economic evaluation of posaconazole vs. standard azole prophylaxis in high risk neutropenic patients in the Netherlands. Eur J Haematol 2008; 81:467-74. [DOI: 10.1111/j.1600-0609.2008.01141.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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226
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Identifying patients at high risk for neutropenic complications during chemotherapy for metastatic breast cancer with doxorubicin or pegylated liposomal doxorubicin: the development of a prediction model. Am J Clin Oncol 2008; 31:369-74. [PMID: 18845996 DOI: 10.1097/coc.0b013e318165c01d] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To develop a cycle-based risk prediction model for neutropenic complications (NC) during chemotherapy with doxorubicin (DOX) or a pegylated liposomal formulation (PLD) for patients with metastatic breast cancer (MBC). METHODS Data analyzed was from a phase III, randomized clinical trial of DOX (60 mg/m(2) every 3 weeks) or PLD (50 mg/m(2) every 4 weeks) for the first line therapy for MBC (n = 509) (O'Brien et al, Ann Oncol. 2004;15:440-449). NC were defined as an absolute neutrophil count < or =1.5 x 10(9) cells/L (ie, > or =grade II) before the next cycle, febrile neutropenia or neutropenia with a documented infection. Patient and hematologic factors potentially associated with NC were evaluated. Factors with a P value of < or =0.25 within a cycle were included in a generalized estimating equations regression model. Using backward elimination, we derived a risk scoring algorithm (range 0-63) from the final reduced model. RESULTS Risk factors retained in the model included poor performance status, absolute neutrophil count < or =2.0 x 10(9) cells/L in the previous cycle, the first cycle of chemotherapy, DOX versus PLD and advanced age. A precycle risk score from > or =25 to <40 for a given patient was identified as being the optimal threshold for sensitivity (58.0%) and specificity (78.7%). Patients with a score at or beyond this threshold would be considered at high risk for developing NC in later cycles. CONCLUSION The use of this model may enhance patient care by targeting preventative therapies (eg, granulocyte colony stimulating factor or PLD) to those MBC patients most likely to experience NC during anthracycline-based chemotherapy.
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227
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Tuffaha HW, Treish IM, Zaru L. The use and effectiveness of granulocyte colony-stimulating factor in primary prophylaxis for febrile neutropenia in the outpatient setting. J Oncol Pharm Pract 2008; 14:131-8. [DOI: 10.1177/1078155208091249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. To conduct a drug utilization review (DUR) on the use of granulocyte colony-stimulating factor (G-CSF) and to study the effectiveness of this agent in preventing the incidence of febrile neutropenia (FN). Methods. Outpatients to whom G-CSF was dispensed were identified and their actual medical records were reviewed to verify patients who received G-CSF for primary prophylaxis. Literature was reviewed to determine the expected incidence and risk of FN for chemotherapy regimens used, and the compliance of prescribers with the institutional guidelines was evaluated. After that, the proportion of patients who developed FN was identified and compared to the expected incidence from literature. Data analysis was performed on the outcome of patient-cycle. Results. Of the 99 patient-cycles, 53 (53%) were compliant with guidelines whereas 46 (47%) were not. FN developed in 12 (12.1%, 95% CI = 5.7, 18.5) while the expected average incidence of FN was 32.7%. Eleven (21%, 95% CI = 10.1, 32.2) of the 53 patient-cycles that were compliant with guidelines developed FN, whereas one patient among the non-compliant group developed FN (2%, 95% CI = 0.0, 6.2). The expected incidence of FN was 42.9 and 21.5%, in the compliant group, and noncompliant group, respectively. Based on expected FN rates, the respective reduction in the incidence of FN was 51, and 90%. Conclusions. Lack of adherence to institutional guidelines was noticed in G-CSF prescribing. Reasons behind poor compliance with the guidelines must be verified and resolved. Prophylactic G-CSF is effective in reducing the incidence of FN; however, further research in a larger population is warranted to confirm these findings. J Oncol Pharm Practice (2008) 14: 131—138.
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Affiliation(s)
- Haitham W Tuffaha
- Department of Pharmacy, King Hussein Cancer Center, P.O. Box 1269 Aljubeiha, Amman, 11941 Jordan
| | - Imad M Treish
- Department of Pharmacy, King Hussein Cancer Center, P.O. Box 1269 Aljubeiha, Amman, 11941 Jordan,
| | - Luna Zaru
- Department of Pharmacy, King Hussein Cancer Center, P.O. Box 1269 Aljubeiha, Amman, 11941 Jordan
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Iacovelli LM, Persson BL. Management of Chemotherapy-Induced Neutropenia: Opportunities for Pharmacist Involvement. Hosp Pharm 2008. [DOI: 10.1310/hpj4306-472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose This article highlights the clinical impact of chemotherapy-induced neutropenia (CIN) and reviews the clinical evidence supporting the updated guideline recommendations from leading scientific organizations that focus on cancer care regarding the use of myeloid growth factors to reduce the incidence of febrile neutropenia (FN) from chemotherapy. The aim is to provide insight for practicing pharmacists regarding how they can be more proactive in developing best-practice strategies for the management of CIN as well as the prevention of FN. Summary CIN, the primary dose-limiting toxicity of chemotherapy, is common in many tumor types that are treated with myelosuppressive chemotherapy and occurs with the greatest frequency in the first cycle of treatment. Treatment with myeloid growth factors, or colony-stimulating factors (CSFs), has shown to be effective in reducing the risk, severity, and duration of FN from chemotherapy. Despite recent revisions to various clinical guidelines that have resulted in alignment on the recommendation for prophylactic CSF use in patients with a greater than or equal to 20% risk of developing FN, a gap remains between actual clinical usage and best practice. Pharmacists are key members of multidisciplinary health care teams and are uniquely positioned to evaluate current practice and develop strategies that ensure appropriate CSF use. This paper summarizes the recent changes to CSF guidelines, reviews clinical data that support those changes, and discusses strategies for pharmacist involvement in the management of CIN and FN prevention using real-world examples of improvement initiatives. Conclusion Neutropenia is a dose-limiting toxicity of chemotherapy that has significant implications for effective cancer treatment and patient health outcomes. Pharmacists are uniquely positioned to perform various interventions, which help ensure appropriate CSF use and improve the management of CIN.
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Affiliation(s)
| | - Brandy L. Persson
- Moses Cone Health System Regional Cancer Center, Greensboro, North Carolina
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229
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Obradovic M, Mrhar A, Kos M. Cost–effectiveness of UGT1A1 genotyping in second-line, high-dose, once every 3 weeks irinotecan monotherapy treatment of colorectal cancer. Pharmacogenomics 2008; 9:539-49. [DOI: 10.2217/14622416.9.5.539] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The aim of the present study was to evaluate the cost–effectiveness of UGT1A1 genotyping in second-line, high-dose, once every 3 weeks irinotecan monotherapy treatment of colorectal cancer. Methods: Standard therapy was compared with alternative strategies based on UGT1A1 genotyping from the US healthcare payer perspective. Two alternative strategies (dose reduction and prophylactic use of G-CSF with prior genotyping) and standard therapy were evaluated in a decision analysis, whereas alternative regimens were considered in discussion. The effectiveness outcome was severe neutropenia occurrence and number of life-years gained. Results & Conclusion: Genotyping in combination with a subsequent reduction of initial irinotecan dose for UGT1A1 7/7 genotype patients was cost-saving for the population of African and Caucasian origin. By contrast, UGT1A1 genotyping was not cost effective for the population of Asian ancestry. Furthermore, the prophylactic use of G-CSFs in UGT1A1 7/7 genotype patients was not cost effective in any population group. Finally, the application of a 3-weekly high-dose treatment regimen with a 20% reduced dosage compared with the low-dose weekly irinotecan regimen in patients with UGT1A1 7/7 genotype was less expensive and is more convenient for the patient.
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Affiliation(s)
- Marko Obradovic
- University of Ljubljana, Faculty of Pharmacy, Askerceva 7,1000 Ljubljana, Slovenia
| | - Ales Mrhar
- University of Ljubljana, Faculty of Pharmacy, Askerceva 7,1000 Ljubljana, Slovenia
| | - Mitja Kos
- University of Ljubljana, Faculty of Pharmacy, Askerceva 7,1000 Ljubljana, Slovenia
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230
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Marino P. Measuring the cost of chemotherapy is important, but it is not enough. Ann Oncol 2008; 19:409-10. [DOI: 10.1093/annonc/mdn004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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231
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Eldar-Lissai A, Cosler LE, Culakova E, Lyman GH. Economic analysis of prophylactic pegfilgrastim in adult cancer patients receiving chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:172-179. [PMID: 18380630 DOI: 10.1111/j.1524-4733.2007.00242.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Neutropenia and its complications, including febrile neutropenia (FN), are a common side effect of cancer chemotherapy. Results of clinical trials showed that prophylactic use of granulocyte colony-stimulating factors (G-CSF) is effective in preventing FN. In this study, the cost effectiveness (measured as cost per quality-adjusted time [days]) of three treatment alternatives were evaluated: no G-CSF, filgrastim administered daily for 7-12 days after chemotherapy, and a pegylated form of G-CSF pegfilgrastim, administered once per cycle. METHODS A cost-utility model based on standard clinical practice of treating FN with immediate hospitalization or with ambulatory treatment, from a societal perspective was developed. Direct medical cost estimates for hospitalization were derived from claims data reported by 115 US academic medical centers. Indirect medical costs, productivity costs, probabilities, and utilities are based on published literature. Results were subjected to sensitivity analyses and 95% confidence intervals are based on a Monte Carlo simulation. RESULTS Mean estimated costs/day of hospitalization were $1984 (SD $1040, N = 24,687) for surviving patients and $3139 (SD $2014, N = 1437) for dying patients. Under baseline conditions, pegfilgrastim dominated both filgrastim and no G-CSF, with expected costs and effectiveness of $4203 and 12.361 quality adjusted life-days (QALDs) for no G-CSF, $3058 and 12.967 QALDs for pegfilgrastim, and $5264 and 12.698 QALDs for filgrastim. CONCLUSIONS This cost-utility analysis provides strong evidence that pegfilgrastim is not only cost-effective but also cost-saving in most common clinical and economic settings. There appear to be both clinical and economic benefits from prophylactic administration of pegfilgrastim.
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Affiliation(s)
- Adi Eldar-Lissai
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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232
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Balducci L, Al-Halawani H, Charu V, Tam J, Shahin S, Dreiling L, Ershler WB. Elderly cancer patients receiving chemotherapy benefit from first-cycle pegfilgrastim. Oncologist 2008; 12:1416-24. [PMID: 18165618 DOI: 10.1634/theoncologist.12-12-1416] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND There is a misconception that elderly cancer patients cannot tolerate standard doses of chemotherapy because of the frequency and severity of myelosuppressive complications. The reactive use of colony-stimulating factors (i.e., in response to severe neutropenia) commonly observed in this setting contributes to the frequency and severity of these complications. This study evaluated the incidence of febrile neutropenia and related events in elderly cancer patients receiving pegfilgrastim beginning with cycle 1 (proactive) in comparison with pegfilgrastim initiated after cycle 1 at the physician's discretion (reactive). METHODS Patients (> or = 65 years of age) with either solid tumors or non-Hodgkin's lymphoma (NHL) were randomly assigned to receive pegfilgrastim either proactively or reactively. The primary endpoint was the proportion of patients experiencing febrile neutropenia. RESULTS There were 852 patients enrolled (median age, 72 years). Proactive pegfilgrastim use resulted in a significantly lower incidence of febrile neutropenia for both solid tumor and NHL patients compared with reactive use. Proactive pegfilgrastim use also led to fewer hospitalizations resulting from neutropenia and febrile neutropenia by approximately 50%. Antibiotic use was lower for solid tumor patients receiving proactive pegfilgrastim and equivalent in the two NHL groups. CONCLUSIONS This is the largest, randomized, prospective trial evaluating growth factor support in typical elderly cancer patients. Proactive pegfilgrastim use effectively produced a lower incidence of febrile neutropenia and related events in elderly patients with either solid tumors or NHL receiving an array of mild to moderately neutropenic chemotherapy regimens. Pegfilgrastim should be used proactively in elderly cancer patients to support the optimal delivery of standard chemotherapy.
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Affiliation(s)
- Lodovico Balducci
- H Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA.
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Kearney N, Friese C. Clinical practice guidelines for the use of colony-stimulating factors in cancer treatment: Implications for oncology nurses. Eur J Oncol Nurs 2008; 12:14-25. [DOI: 10.1016/j.ejon.2007.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 10/21/2007] [Indexed: 10/22/2022]
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234
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Weycker D, Malin J, Edelsberg J, Glass A, Gokhale M, Oster G. Cost of neutropenic complications of chemotherapy. Ann Oncol 2007; 19:454-60. [PMID: 18083689 DOI: 10.1093/annonc/mdm525] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cost of neutropenic complications of myelosuppressive chemotherapy has been reported to be substantial. Prior research, however, has focused on initial hospitalization only and has failed to account for follow-on care. PATIENTS AND METHODS Using a US health-care claims database, all adult cancer patients who received a course of chemotherapy were identified. For each such patient, each unique cycle of chemotherapy within the course and each occurrence of neutropenic complications within these cycles were characterized. Patients developing neutropenic complications in a given cycle (neutropenia patients), starting with the first, were matched (1:1) to those who did not develop neutropenic complications in that cycle (comparison patients), and health-care costs (i.e. expenditures) were tallied for each matched pair. RESULTS Neutropenia patients (n = 373) and comparison patients were similar in terms of baseline characteristics. Costs of neutropenia-related care were $12,397 (95% confidence interval $10,274-$14,754) higher for neutropenia versus comparison patients [$14,407 ($12,357-$16,743) versus $2010 ($1490-$2553)]. Among neutropenia patients, mean cost of initial hospitalization for neutropenic complications was $7813 ($6537-$9379); cost of all subsequent neutropenia-related care averaged $6594 ($5217-$8272). CONCLUSIONS Neutropenic complications of myelosuppressive chemotherapy are costly. Prior research focusing on initial hospitalization only may have underestimated the cost of these complications by as much as 40%.
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Affiliation(s)
- D Weycker
- Policy Analysis Inc., Brookline, MA 02445, USA.
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235
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Zuckermann J, Moreira LB, Stoll P, Moreira LM, Kuchenbecker RS, Polanczyk CA. Compliance with a critical pathway for the management of febrile neutropenia and impact on clinical outcomes. Ann Hematol 2007; 87:139-45. [PMID: 17938926 DOI: 10.1007/s00277-007-0390-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 09/14/2007] [Indexed: 11/30/2022]
Abstract
Febrile neutropenia is associated with significant morbidity and mortality. Managing infectious in neutropenic patients remains a dynamic process, making necessary timely and efficient empirical antibiotic therapy. The implementation of critical pathways has been suggested as a strategy to improve clinical effectiveness. This study evaluated the compliance with an institutional critical pathway for the management of febrile neutropenia and the impact on clinical outcomes at Hospital de Clínicas de Porto Alegre, Brazil (HCPA). We performed a cohort study that prospectively included patients hospitalized from January 2004 to December 2005 and presented febrile neutropenia (190 episodes). Historical controls were selected from March 2001 to April 2003 (193 episodes) before the critical pathway was introduced. This study showed a low rate of full compliance (21.6%; 95% CI 15.7-27.5) with the critical pathway. In most cases, there was partial compliance (67.9%; 95% CI 61.3-74.5). Despite the moderate adherence observed, we recorded a decrease in in-hospital all-cause mortality in the sample studied after protocol implementation (from 24.4 to 14.4%; P = 0.017) and reduction in the length of use of cephalosporin and quinolones. In conclusion, implementation of a critical pathway seems to be an effective strategy to improve clinical outcomes in patients hospitalized with febrile neutropenia.
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Affiliation(s)
- J Zuckermann
- Postgraduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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236
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Liou SY, Stephens JM, Carpiuc KT, Feng W, Botteman MF, Hay JW. Economic burden of haematological adverse effects in cancer patients: a systematic review. Clin Drug Investig 2007; 27:381-96. [PMID: 17506589 DOI: 10.2165/00044011-200727060-00002] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patients receiving cancer treatments commonly experience haematological adverse effects (AEs) related to chemotherapy or molecularly targeted therapies, which may be associated with high healthcare costs. The objective of this review was to summarise the published literature on the economic burden of neutropenia, thrombocytopenia and anaemia as AEs of cancer treatment. METHODS A systematic search of the medical literature published between 1990 and 2006 was conducted using PubMed/MEDLINE, EMBASE, BIOSIS, related article links and supplemental searches. References selected for inclusion were prospective or retrospective studies specifically designed to examine the burden of illness, direct medical costs, indirect costs and/or cost drivers associated with neutropenia, thrombocytopenia and anaemia in adult cancer patients. All costs are reported as originally published and adjusted to 2006 US dollars. RESULTS In the US, the cost of neutropenia ranged from $US 1893 (2006 value $US 2632) per outpatient episode to $US 38,583 ($US 49,917) per febrile neutropenia hospitalisation. For countries outside the US, the cost of neutropenia appeared to be lower. The cost of thrombocytopenia ranged from $US 1035 ($US 1395) to $US 5328 ($US 7635) per cycle or episode in the US. Costs attributable to anaemia ranged from $US 18,418 ($US 22,775) to $US 69,478 ($US 93,454) per year in the US. The costs of AEs for patients with haematological malignancies appeared to be up to 2-3 times higher than those for patients with solid tumours. Economic studies of the cost of haematological AEs specific to new molecularly targeted treatments for haematological malignancy have not been published. CONCLUSIONS Chemotherapy-related haematological AEs result in a substantial economic burden on patients, payers, caregivers and society in general. Because of their burden, the frequency and severity of these toxicities should be one of the key factors in the selection of optimal treatments for patients with cancer, especially those with haematological malignancies. Future research is needed to assess the economic burden of AEs associated with new molecularly targeted treatments for haematological malignancies.
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Affiliation(s)
- S Y Liou
- Pharmerit North America LLC, Bethesda, Maryland 20814, USA
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237
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Abstract
Neutropenia represents a major dose-limiting toxicity of chemotherapy and is associated with an increased risk of infection, impaired patient quality of life, and interference with the delivery of full-dose chemotherapy. These complications increase not only morbidity and mortality associated with cancer treatment but also the overall cost of care for cancer patients. Conversely, chemotherapy-induced neutropenia as a surrogate for delivered dose intensity has been associated with improved cancer survival. Administration of myeloid growth factors, such as filgrastim and pegfilgrastim, reduces the risk for neutropenic complications and facilitates the delivery of full-dose chemotherapy. There is an ongoing effort to identify patients at increased risk for developing neutropenic complications who would likely benefit from preemptive myeloid growth factor therapy. Appropriate use of myeloid growth factors is associated with reduced neutropenic complications, improved patient quality of life, and potentially improved disease control and long-term survival.
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Affiliation(s)
- Gary H Lyman
- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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238
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Ricotta R, Cerea G, Schiavetto I, Maugeri MR, Pedrazzoli P, Siena S. Pegfilgrastim: current and future perspectives in the treatment of chemotherapy-induced neutropenia. Future Oncol 2007; 2:667-76. [PMID: 17155894 DOI: 10.2217/14796694.2.6.667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Myeloid colony-stimulating factors (granulocyte colony-stimulating factor [G-CSF] and granulocyte-macrophage colony-stimulating factor) are commonly used in clinical practice for the prevention of anticancer chemotherapy-induced neutropenia and its potentially life-threatening complications. Pegfilgrastim is a novel recombinant human G-CSF pharmaceutically developed by covalent binding of a polyethylene glycol molecule to the N-terminal sequence of filgrastim. Due to its unique neutrophil-mediated clearance, pegfilgrastim can be administered once per chemotherapy cycle. Clinical trials have demonstrated that a single, fixed, subcutaneous dose of pegfilgrastim is comparable in safety and efficacy to daily injections of filgrastim for decreasing the incidence of infection following myelosuppressive chemotherapy in patients with cancer. Recent trials have been conducted to evaluate the use of pegfilgrastim in different clinical settings, including support of dose-dense regimens, mobilization and transplantation of hematopoietic stem cells.
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Affiliation(s)
- Riccardo Ricotta
- Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy.
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239
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Abstract
PURPOSE OF REVIEW Febrile neutropenia causes significant morbidity and mortality in patients receiving cytotoxic chemotherapy. Antibiotic and granulocyte colony stimulating factor prophylaxis reduce the incidence of febrile neutropenia but uncertainty remains regarding their role in clinical practice. We review recent literature to clarify the issue. RECENT FINDINGS Recent research confirms that prophylactic antibiotics decrease febrile neutropenia and infection-related mortality in acute leukaemia patients and those receiving high dose chemotherapy. Fluoroquinolone prophylaxis also decreases the incidence of febrile neutropenia and all-cause mortality in the first cycle of moderately myelosuppressive chemotherapy for solid tumours. There is no convincing evidence that colonization of individuals with resistant organisms due to antibiotic prophylaxis increases febrile neutropenia or mortality. Granulocyte colony stimulating factor prophylaxis reduces infection-related mortality in patients with greater than 20% risk of febrile neutropenia. SUMMARY Antibiotic prophylaxis should be offered to patients receiving chemotherapy for acute leukaemia and high dose chemotherapy for solid tumours. It should also be offered to those receiving moderately myelosuppressive chemotherapy for solid tumours and lymphomas during the first cycle of chemotherapy. Prophylactic granulocyte colony stimulating factor is indicated for patients at greater than 20% risk of febrile neutropenia. Further research is indicated to determine whether combining granulocyte colony stimulating factor and antibiotic prophylaxis causes a further reduction in infection-related mortality.
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Affiliation(s)
- Jennifer Pascoe
- University Hospital Birmingham Cancer Centre, Birmingham, UK
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240
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Nirenberg A, Bush AP, Davis A, Friese CR, Gillespie TW, Rice RD. Neutropenia: state of the knowledge part I. Oncol Nurs Forum 2006; 33:1193-201. [PMID: 17149402 DOI: 10.1188/06.onf.1193-1201] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To review neutrophil physiology, consequences of chemotherapy-induced neutropenia (CIN), CIN risk assessment models, national practice guidelines, the impact of febrile neutropenia and infection, and what is known and unknown about CIN. DATA SOURCES Extensive review and summary of published neutropenia literature, guidelines, meta-analyses, currently funded National Institutes of Health and Oncology Nursing Society studies, and invited expert panel symposium presentations. DATA SYNTHESIS A comprehensive review of current literature regarding CIN risk assessment, practice guidelines, management, impact on dose-dense and dose-intense cancer treatment, complications, costs related to hospitalizations, and treatment strategies has been compiled. CONCLUSIONS CIN is the most common dose-limiting toxicity of cancer therapy. Medical practice guidelines and risk assessment models for appropriate use of myeloid growth factors and management of febrile neutropenia have been developed to assess patients for CIN complications prechemotherapy and during CIN episodes. CIN affects patients, families, practitioners, and the healthcare system. Although much is known about this common chemotherapy complication, a great deal remains to be learned. IMPLICATIONS FOR NURSING CIN is a serious and global problem in patients receiving cancer therapy. Oncology nurses need to critically analyze their own practices when assessing, managing, and educating patients and families about CIN.
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241
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Kuderer NM, Dale DC, Crawford J, Cosler LE, Lyman GH. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer 2006; 106:2258-66. [PMID: 16575919 DOI: 10.1002/cncr.21847] [Citation(s) in RCA: 779] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hospitalization for febrile neutropenia (FN) in cancer patients is associated with considerable morbidity, mortality, and cost. The study was undertaken to better define mortality, length of stay (LOS), cost, and risk factors associated with mortality and prolonged hospitalization in cancer patients with FN. METHODS The longitudinal discharge database derived from 115 US medical centers was used to study all adult cancer patients hospitalized with FN between 1995 and 2000, comprising a total of 41,779 patients. Primary outcomes included mortality, LOS, and cost per episode. RESULTS Overall, in-hospital mortality was 9.5%. Patients without any major comorbidities had a 2.6% risk of mortality, whereas 1 major comorbidity was associated with a 10.3% and more than 1 major comorbidity with a > or = 21.4% risk of mortality, respectively. Mean (median) length of stay was 11.5 (6) days, and the mean (median) cost was $19,110 ($8,376) per episode of FN. Patients hospitalized for > or = 10 days (35% of all patients) accounted for 78% of overall cost. Independent major risk factors for inpatient mortality included invasive fungal infections, Gram-negative sepsis, pneumonia and other lung disease, cerebrovascular, renal, and liver disease. Main predictors for LOS > or = 10 days included leukemia, invasive fungal infections, other types of infection, and several comorbid conditions. CONCLUSION Factors associated with increased mortality, LOS, and cost in hospitalized adult cancer patients with FN include patient characteristics, type of malignancy, comorbidities, and infectious complications. These factors may be useful in identifying patients at increased risk of serious medical complications and mortality for more aggressive supportive care measures.
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Affiliation(s)
- Nicole M Kuderer
- James P. Wilmot Cancer Center and Department of Medicine, University of Rochester, Rochester, New York 14642, USA
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242
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Adamson RT, Lew I, Mathis AS, Beyzarov E. Use of Filgrastim among Febrile Inpatients who Received Outpatient Filgrastim or Pegfilgrastim. Hosp Pharm 2006. [DOI: 10.1310/hpj4103-260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To characterize the inpatient use of filgrastim in cancer patients hospitalized for management of post-chemotherapy fever after receiving either outpatient filgrastim or pegfilgrastim. Method Retrospective review of chart records in a single-center, tertiary-care, teaching hospital and outpatient oncology center of cancer patients hospitalized for fever after outpatient chemotherapy and proactive administration of filgrastim or pegfilgrastim. Patients with the following tumor types were included: breast cancer, cervical cancer, colon cancer, Hodgkin disease, intermediate- or high-grade non-Hodgkin lymphoma, small cell or non-small cell lung cancer, and ovarian cancer. Result Billing data identified 1,438 outpatient chemotherapy patients treated with filgrastim or pegfilgrastim; 261 (18.2%) of whom were hospitalized for fever. All patients in the filgrastim groups, and 78% of those in the pegfilgrastim group, were given inpatient filgrastim. Duration of filgrastim administration in the inpatient setting was significantly shorter ( P < 0.001) for the pegfilgrastim group. Conclusions Filgrastim was frequently administered to cancer patients hospitalized for fever, even after outpatient pegfilgrastim was administered as an adjunct to chemotherapy. Patients treated with once-per-cycle pegfilgrastim in an outpatient setting do not require filgrastim if they are hospitalized for fever before neutrophil recovery. Thus, hospitals could realize immediate cost savings by not treating those patients with filgrastim. This study illustrates the need to develop operational procedures in institutions to rapidly identify prior outpatient pegfilgrastim administration as a patient is admitted for post-chemotherapy fever.
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Affiliation(s)
| | - Indu Lew
- Saint Barnabas Health Care System
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243
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Díaz-Mediavilla J, Lizasoain M. Epidemiología de las infecciones en el paciente neutropénico. Enferm Infecc Microbiol Clin 2005; 23 Suppl 5:7-13. [PMID: 16857150 DOI: 10.1157/13091240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Epidemiological data are useful to determine changes in forms of clinical expression and in the microbial agents causing infections. This allows empirical or preemptive treatments to be designed and can guide diagnostic tests. Empirical data also allow patients to be classified by risk group in order to decide on the need for hospitalization. The incidence of neutropenia is increasing as a result of the more aggressive antineoplastic treatments used and the broader age range of patients who receive them. It has been calculated that in the USA neutropenia causes approximately 60,000 hospitalizations per year and that a third of these occur in hematological patients. The most frequent foci of infection are: pneumonia (38%), bacteremia (35%) and urinary (11%). Of the bacteria causing infection, two thirds are Gram-positive and the remaining bacilli are Gram-negative. In the last few years, an increase of Gram-negative bacteria seems to have reemerged. The incidence of fungal isolates represents 2-10%, depending on the type of neutropenic patient analyzed. Fungal isolates are found preferentially in patients with prolonged neutropenia and/or other associated immunodeficiencies, as occurs in allogenic bone marrow transplantation or in patients who have received purine analogs. Viruses are very frequent. Respiratory viruses seem to be emerging pathogens in this group of patients.
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244
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Generali J. Recent Publications on Medications and Pharmacy. Hosp Pharm 2005. [DOI: 10.1177/001857870504000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hospital Pharmacy presents a new feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.
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Affiliation(s)
- Joyce Generali
- Drug Information Center, Kansas University Medical Center, Kansas City, KS
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