2000 update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. American Society of Clinical Oncology Growth Factors Expert Panel

Phase I dose-escalating study of docetaxel in combination with 5-day continuous infusion of 5-fluorouracil in patients with advanced gastric cancer

BACKGROUND

Published data suggests that docetaxel combined with 5-fluorouracil (5-FU) may have synergistic activity in treating advanced gastric cancer. We performed a phase I study of docetaxel and 5-FU to determine the maximum tolerated dose (MTD), the recommended dose for phase II studies, and the safety of this combination.

METHODS

Eligible patients had recurrent and/or metastatic advanced gastric cancer with normal cardiac, renal and hepatic function. Traditional phase I methodology was employed in assessing dose-limiting toxicity (DLT) and MTD. On day 1 every 3 weeks, docetaxel 75 mg/m2 (fixed dose) was infused over 1-h, followed immediately by 5-FU as a 5-day continuous infusion.

RESULTS

Dose escalation schema was as follows: dose level (DL) 1 (5-FU 250 mg/m2/day), 2 (500), 3 (750), and 4 (1000). Three patients were enrolled on DL1, without DLT. On DL2, 1 DLT (grade 3 stomatitis) was developed in first 3 patients, and this cohort was expanded to 6 patients. Three patients had been enrolled on DL3. Because two out of 3 patients had DLTs, the MTD was reached at DL3.

CONCLUSION

The recommended phase II dose of this combination is 75 mg/m2 docetaxel on day 1 immediately followed by a 5-day continuous infusion of 5-FU 500 mg/m2/day.

Colony stimulating factors for prevention of myelosupressive therapy induced febrile neutropenia in children with acute lymphoblastic leukaemia

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common cancer in childhood and febrile neutropenia is a potentially life-threatening side effect of its treatment. Current treatment consists of supportive care plus antibiotics. Clinical trials have attempted to evaluate the use of colony-stimulating factors (CSF) as additional therapy to prevent febrile neutropenia in children with ALL. The individual trials do not show whether there is significant benefit or not. Systematic review provides the most reliable assessment and the best recommendations for practice.

OBJECTIVES

To evaluate the safety and effectiveness of the addition of G-CSF or GM-CSF to myelosuppressive chemotherapy in children with ALL, in an effort to prevent the development of febrile neutropenia. Evaluation of number of febrile neutropenia episodes, length to neutrophil count recovery, incidence and length of hospitalisation, number of infectious disease episodes, incidence and length of treatment delays, side effects (flu-like syndrome, bone pain and allergic reaction), relapse and overall mortality (death).

SEARCH STRATEGY

The search covered the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CANCERLIT, LILACS, and SciElo. We manually searched records of conference proceedings of ASCO and ASH from 1985 to 2003 as well as databases of ongoing trials. We consulted experts and scanned references from the relevant articles.

SELECTION CRITERIA

We looked for randomised controlled trials (RCTs) comparing CSF with placebo or no treatment as primary or secondary prophylaxis to prevent febrile neutropenia in children with ALL.

DATA COLLECTION AND ANALYSIS

Two authors independently selected, critically appraised studies and extracted relevant data. The end points of interest were:* Primary end points: number of febrile neutropenia episodes and overall mortality (death) * Secondary end points: time to neutrophil count recovery, incidence and length of hospitalisation, number of infectious diseases episodes, incidence and length of treatment delays, side effects (flu-like syndrome, bone pain and allergic reaction) and relapse. We conducted a meta-analysis of these end points and expressed the results as Peto odds ratios. For continuous outcomes we calculated a weighted mean difference and a standardised mean difference. For count data, meta-analysis of the logarithms of the rate ratios using generic inverse variance was employed.

MAIN RESULTS

We scanned more than 5500 citations and included six studies with a total of 332 participants in the analysis. There were insufficient data to assess the effect on survival. The use of CSF significantly reduced the number of episodes of febrile neutropenia episodes (Rate Ratio = 0.63; 95% confidence interval (CI) 0.46 to 0.85; p =0.003, with substantial heterogeneity), the length of hospitalisation (weighted mean difference (WMD) = -1.58; 95% CI -3.00 to -0.15; p = 0.03), and number of infectious diseases episodes (Rate Ratio=0.44; 95%CI 0.24 to 0.80; p=0.002). In spite of these results, CSF did not influence the length of episodes of neutropenia (WMD = -1.11; 95% CI -3.55 to 1.32; p = 0.4) or delays in chemotherapy courses (Rate Ratio=0.77; 95%CI 0.49 to 1,23; p=0.28) .

AUTHORS' CONCLUSIONS

Children with ALL treated with CSF benefit from shorter hospitalisation and fewer infections. However, there was no evidence for a shortened duration of neutropenia nor fewer treatment delays, and no useful information about survival. The role of CSF regarding febrile neutropenia episodes is still uncertain. Although current data shows statistical benefit for CSF use, substantial heterogeneity between included trials does not allow this conclusion.

Capecitabine plus Oxaliplatin (XelOx/CapOx) Regimen for Colorectal Cancer

The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.

Neutropenic enterocolitis in adults: systematic analysis of evidence quality

OBJECTIVE

Neutropenic enterocolitis is a life-threatening complication occurring most frequently after intensive chemotherapy in acute leukaemias. The literature is heterogeneous and a systematic review is lacking.

METHODS

Following a systematic search we categorised all relevant reports according to their quality and extracted evidence to answer the questions: Which diagnostic criteria are appropriate? What is the incidence of neutropenic enterocolitis? Are there good quality studies supporting specific interventions: Which empiric antimicrobial therapy is recommendable? Is neutropenic enterocolitis without surgical emergency complications an indication for bowel resection?

RESULTS

We found and analysed 145 articles of these reports: 64 were reports of single cases, 30 papers reported of two or three cases, 13 were narrative reviews, 34 were retrospective case series of more than three cases and four were prospective diagnostic studies. There were no prospective trials or case control studies on the therapy of neutropenic enterocolitis. There was no consensus on diagnostic criteria. We discuss the difficulty to define diagnostic criteria without having a disease definition. Histology is mostly not available in the living patients. We suggest applying a combination of clinical and radiological criteria: fever, abdominal pain and any bowel wall thickening >4 mm detected by ultrasonography (US) or computed tomography. We calculated a pooled incidence rate from 21 studies of 5.3% (266/5058; 95% CI: 4.7%-5.9%) in patients hospitalised for haematological malignancies, for high-dose chemotherapy in solid tumours or for aplastic anaemia.

CONCLUSIONS

This systematic review provides diagnostic criteria for neutropenic enterocolitis, presents a quantitative synthesis on its incidence and discusses its treatment recommendations. Prospective studies are clearly warranted.

Granulocyte colony-stimulating factor for poor graft function after allogeneic stem cell transplantation: 3 days of G-CSF identifies long-term responders

Poor graft function (PGF) is a frequent cause of morbidity after allogeneic hematopoietic stem cell transplantation (allo-HSCT). To study the value of granulocyte colony-stimulating factor (G-CSF) in PGF, we retrospectively analyzed 81 episodes of PGF in 66 patients transplanted from 01/94 to 01/99 from an HLA-identical sibling (n = 45) or an unrelated (n = 21) donor. Median age was 29 years, 55 patients had malignancies. A total of 11 patients received a CD34+ selected graft. Viral infections (25%), myelotoxic drug (33%), fungal/bacterial infections (14%), and GVHD (31%) were present before PGF diagnosis. Median time from allo-HSCT to PGF was 75 (25-474) days. All patients were treated with G-CSF. In 77/81 episodes, there was a response that was sustained in 57. A total of 27 patients presented an increase of white cell count (WBC) >0.1 x 10(9)/l after 3 days of G-CSF. The 5-year survival was 37% and was significantly better in patients with increased WBC > 0.1 x 10(9)/l after 3 days of G-CSF (65 vs 18%, P < 0.0001). In multivariate analysis, increased WBC > 0.1 x 10(9)/l after 3 days of G-CSF (P = 0.002) was associated with better survival, while BuCy-based conditioning (P = 0.02) and GVHD (P = 0.005) were associated with higher risk of death. In conclusion, hematological response after 3 days with G-CSF predicted a better survival for patients with PGF after allo-SCT.

Colony-Stimulating Factors for Chemotherapy-Induced Febrile Neutropenia: A Meta-Analysis of Randomized Controlled Trials

Purpose

Current treatment for febrile neutropenia (FN) includes hospitalization for evaluation, empiric broad-spectrum antibiotics, and other supportive care. Clinical trials have reported conflicting results when studying whether the colony-stimulating factors (CSFs) improve outcomes in patients with FN. This Cochrane Collaboration review was undertaken to further evaluate the safety and efficacy of the CSFs in patients with FN.

Methods

An exhaustive literature search was undertaken including major electronic databases (CANCERLIT, EMBASE, LILACS, MEDLINE, SCI, and the Cochrane Controlled Trials Register). All randomized controlled trials that compare CSFs plus antibiotics versus antibiotics alone for the treatment of established FN in adults and children were sought. A meta-analysis of the selected studies was performed.

Results

More than 8,000 references were screened, with 13 studies meeting eligibility criteria for inclusion. The overall mortality was not influenced significantly by the use of CSF (odds ratio [OR] = 0.68; 95% CI, 0.43 to 1.08; P = .1). A marginally significant result was obtained for the use of CSF in reducing infection-related mortality (OR = 0.51; 95% CI, 0.26 to 1.00; P = .05). Patients treated with CSFs had a shorter length of hospitalization (hazard ratio [HR] = 0.63; 95% CI, 0.49 to 0.82; P = .0006) and a shorter time to neutrophil recovery (HR = 0.32; 95% CI, 0.23 to 0.46; P < .00001).

Conclusion

The use of the CSFs in patients with established FN caused by cancer chemotherapy reduces the amount of time spent in hospital and the neutrophil recovery period. The possible influence of the CSFs on infection-related mortality requires further investigation.

Protocols for managing chemotherapy-induced neutropenia in clinical oncology practices

Chemotherapy-induced neutropenia is managed in different ways in clinical practice. Chemotherapy dose reductions and delays are used more often than proactive, first-cycle use of colony-stimulating factors, but such dose modifications can result in suboptimal treatment outcomes. This article reviews how 3 oncology practices have used practice pattern studies to assess and improve their quality of care, particularly in the management of neutropenia. These practices analyzed their records for the occurrence of neutropenia and for delays or reductions in chemotherapy doses. Once baseline measurements of quality of care were established, the practices developed guidelines to optimize their management of neutropenia. The practice patterns were assessed again after the guidelines had been implemented, to determine the effect of these guidelines on clinical outcomes. All 3 practices had fewer delays and reductions of chemotherapy doses after the guidelines were used. These differences were both clinically and statistically significant. Clinical experience shows that nurses are well positioned to assess which patients may be at the greatest risk for neutropenia and its complications and therefore should be treated with colony-stimulating factors. Practice guidelines for the use of colony-stimulating factors are being developed, but broader acceptance of these guidelines is needed to support nurses' recommendations.

Increasing chemotherapy dose density and intensity: phase I trials in non-small cell lung cancer and non-Hodgkin's lymphoma

Dose densification and dose escalation of cytotoxic chemotherapy may be important in improving the cure rates of chemotherapy-responsive cancers. We conducted two phase I studies, in non-small cell lung cancer (NSCLC) and in lymphoma, to explore the possibility of intensifying chemotherapy by compressing the delivery of and escalating the dose of standard combination chemotherapy. One study used etoposide and cisplatin chemotherapy in patients with unresectable stage III or IV NSCLC, intensifying chemotherapy by reducing the cycle length. The second study used cyclophosphamide, doxorubicin, vincristine, and prednisone, CHOP chemotherapy, in the treatment of stage II-IV intermediate or immunoblastic high-grade lymphoma, intensifying chemotherapy first by reducing the cycle length and then by escalating the dosages of cyclophosphamide and doxorubicin. Filgrastim support was used during dose intensification. Fifty-five patients with NSCLC and 49 with non-Hodgkin's lymphoma (NHL) were enrolled and treated in successive cohorts. At standard dosages and intervals of chemotherapy, filgrastim support resulted in incidences of grade 3 and 4 neutropenia that were between 62% and 77% lower than those in the no-filgrastim control; the mean duration of neutropenia was, likewise, more than 80% lower. Absolute neutrophil counts were >/=2 x 10(9)/l at day 14 in virtually 100% of patients receiving filgrastim. In the NSCLC trial, etoposide and cisplatin were intensified by >50%, and in the lymphoma trial, cyclophosphamide was intensified by 270% and doxorubicin was intensified by 87%. Chemotherapy reductions or delays for neutropenia were rare in the groups receiving filgrastim; but at higher chemotherapy intensities, dose-limiting thrombocytopenia was encountered. We conclude that the delivery of myelosuppressive chemotherapy in both a dose-intense and a dose-dense manner is feasible with filgrastim support.

Adjuvant docetaxel for node-positive breast cancer

BACKGROUND

We compared docetaxel plus doxorubicin and cyclophosphamide (TAC) with fluorouracil plus doxorubicin and cyclophosphamide (FAC) as adjuvant chemotherapy for operable node-positive breast cancer.

METHODS

We randomly assigned 1491 women with axillary node-positive breast cancer to six cycles of treatment with either TAC or FAC as adjuvant chemotherapy after surgery. The primary end point was disease-free survival.

RESULTS

At a median follow-up of 55 months, the estimated rates of disease-free survival at five years were 75 percent among the 745 patients randomly assigned to receive TAC and 68 percent among the 746 randomly assigned to receive FAC, representing a 28 percent reduction in the risk of relapse (P=0.001) in the TAC group. The estimated rates of overall survival at five years were 87 percent and 81 percent, respectively. Treatment with TAC resulted in a 30 percent reduction in the risk of death (P=0.008). The incidence of grade 3 or 4 neutropenia was 65.5 percent in the TAC group and 49.3 percent in the FAC group (P<0.001); rates of febrile neutropenia were 24.7 percent and 2.5 percent, respectively (P<0.001). Grade 3 or 4 infections occurred in 3.9 percent of the patients who received TAC and 2.2 percent of those who received FAC (P=0.05); no deaths occurred as a result of infection. Two patients in each group died during treatment. Congestive heart failure and acute myeloid leukemia occurred in less than 2 percent of the patients in each group. Quality-of-life scores decreased during chemotherapy but returned to baseline levels after treatment.

CONCLUSIONS

Adjuvant chemotherapy with TAC, as compared with FAC, significantly improves the rates of disease-free and overall survival among women with operable node-positive breast cancer.

Methotrexate, Cisplatin, and Fluorouracil (MPF Regimen) for Head and Neck Cancer

The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.

Chemotherapy for older women with early breast cancer

The incidence of breast cancer increases with age, reaching over 300 per 100,000 in women aged 70-75 years in the U.K., increasing to almost 400 per 100,000 in women aged over 85 years. As a healthy 70-year old woman can now expect to live for an average of 15 years, control of breast cancer is likely to significantly affect survival. Variations exist in surgical care, radiotherapy and chemotherapy, depending on age; however, virtually all elderly women with hormone-responsive disease are given adjuvant endocrine therapy, usually tamoxifen. For older women who do not have hormone-responsive cancer, and who have high-risk disease characteristics, questions remain over their best management. Overview data of adjuvant chemotherapy in clinical trials show a significant benefit of chemotherapy for women up to the age of 69 years but, for older women, there are too few data to draw any firm conclusions. When considering treatment options for older women, assessment is critical; functional status and comorbidity are some of the factors linked to shorter survival.

[New medications for treatment of systemic mycoses]

The past few years have seen the advent of several new antifungal agents. The echinocandin, caspofungin, has greatly expanded the antifungal armamentarium by providing a cell wall-active agent with candidacidal activity as well as demonstrated clinical efficacy in the therapy of aspergillosis refractory to available therapy. In addition, in clinical trials, caspofungin exhibited efficacy comparable to amphotericin B for invasive and/or fluconazole-resistant Candida infections. According to a randomised trial, voriconazole has added a significantly improved therapeutic option for primary therapy of invasive aspergillosis. Additionally, voriconazole may be used successfully as salvage therapy for other fungal infections, i.e. cryptococcosis. Despite the advances offered by each of these drugs, the morbidity and mortality associated with invasive fungal infections remains high. Considering the adverse effects of the available antifungal agents and the considerable costs for their application, meaningful clinical trials for a precise indication in different clinical situations are urgently needed.

Use of re-randomized data in meta-analysis

Background

Outcomes collected in randomized clinical trials are observations of random variables that should be independent and identically distributed. However, in some trials, the patients are randomized more than once thus violating both of these assumptions. The probability of an event is not always the same when a patient is re-randomized; there is probably a non-zero covariance coming from observations on the same patient. This is of particular importance to the meta-analysts.

Methods

We developed a method to estimate the relative error in the risk differences with and without re-randomization of the patients. The relative error can be estimated by an expression depending on the percentage of the patients who were re-randomized, multipliers (how many times more likely it is to repeat an event) for the probability of reoccurrences, and the ratio of the total events reported and the initial number of patients entering the trial.

Results

We illustrate our methods using two randomized trials testing growth factors in febrile neutropenia. We showed that under some circumstances the relative error of taking into account re-randomized patients was sufficiently small to allow using the results in the meta-analysis. Our findings indicate that if the study in question is of similar size to other studies included in the meta-analysis, the error introduced by re-randomization will only minimally affect meta-analytic summary point estimate.

We also show that in our model the risk ratio remains constant during the re-randomization, and therefore, if a meta-analyst is concerned about the effect of re-randomization on the meta-analysis, one way to sidestep the issue and still obtain reliable results is to use risk ratio as the measure of interest.

Conclusion

Our method should be helpful in the understanding of the results of clinical trials and particularly helpful to the meta-analysts to assess if re-randomized patient data can be used in their analyses.

Quality of Life and Chemotherapy-induced Neutropenia

This report summarizes recent data on neutropenia-related quality of life (QOL), including measures and interventions. Neutropenia is a common adverse effect of cytotoxic chemotherapy. The clinical significance of QOL in patients with chemotherapy-induced neutropenia (CIN) remains largely unexplored, although recent studies have shown a correlation between severe CIN and impaired QOL. Neutropenia typically occurs at the same time as other adverse effects. Data indicate that other toxicities are worse in the presence of febrile neutropenia and that these concurrent events may have a greater effect on QOL. Precautions that are taken to minimize the incidence of infection in patients with neutropenia may also affect their QOL. Future research should focus on accurately defining and measuring QOL in patients with CIN as well as on assessing ways to manage CIN more effectively and thus improve QOL. A number of interventions may have a positive influence on QOL in patients with cancer and neutropenia. Hematopoietic growth factor support, for example, reduces the incidence and sequelae of neutropenia and may provide a QOL benefit. To assess the effect of such interventions, neutropenia-specific QOL instruments, such as the Functional Assessment of Cancer Therapy-Neutropenia (FACT-N), may be valuable tools.

Estimating resource use and cost of prophylactic management of neutropenia with filgrastim

The study objective is to develop a methodology for the measurement of time, resource use and cost of the prophylactic management of neutropenia with filgrastim in different settings where the drug is routinely used: in-hospital care, outpatient care and home care. The activity-based costing method is used to analyse the cost of managing prophylactically neutropenia and comprises four steps. First, department heads in each of the chosen settings were selected and interviewed to obtain key elements in the workflow that involves the management of neutropenia, followed by the second step involving in-depth, structured interviews of key personnel. The third step was the measurement of the time required for frequently occurring activities in monitoring neutropenia and the administration of filgrastim by a study nurse. Finally, information on resource unit costs and personnel salaries were collected from the administration units to calculate an average cost. Sensitivity analyses were undertaken on estimated variables in the study. A list of eight to 14 consecutive activities linked to the prophylactic management of neutropenia was observed. The number and type of activities do not differ between an in-hospital oncology ward and an outpatient setting except for blood samplings. The difference is more pronounced between hospital and home care settings, as in the latter the patient performs many of the activities him/herself. The cost estimate per setting for prophylactic drug use is 6.30 Euros for in-hospital care, 3.67 Euros for outpatient care and 5.49 Euros for home care. Taking the two most frequently occurring scenarios per chemotherapy cycle (i.e. with or without febrile neutropenia), the following cost estimates are obtained: 60.41 Euros for a patient with febrile neutropenia and 56.77 Euros for a patient without febrile neutropenia, excluding drug costs. With the activity-based costing method it is possible to accurately demonstrate cost savings in the management of neutropenia using the newer drug therapies.

Fluorouracil, Leucovorin and Irinotecan (FOLFIRI) Regimen for Colorectal Cancer

The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.

Phase I study of oblimersen sodium, an antisense to Bcl-2, in untreated older patients with acute myeloid leukemia: pharmacokinetics, pharmacodynamics, and clinical activity

PURPOSES

Pharmacologic downregulation of Bcl-2, an antiapoptotic protein overexpressed in cancer, might increase chemosensitivity in acute myeloid leukemia (AML). Herein, we investigated the feasibility of this approach in untreated elderly AML patients by administering oblimersen sodium (G3139), an 18-mer phosphorothioate antisense to Bcl-2, during induction and consolidation treatments.

PATIENTS AND METHODS

Untreated patients with primary or secondary AML (stratified to cohort 1 or 2, respectively) who were > or = 60 years received induction with G3139, cytarabine, and daunorubicin at one of two different dose levels (45 and 60 mg/m2) and, on achievement of complete remission (CR), consolidation with G3139 and high-dose cytarabine. An enzyme-linked immunosorbent assay (ELISA)-based assay was used to measure plasma and intracellular concentrations (IC) of G3139. Bcl-2 mRNA and protein levels were quantified by real-time reverse transcriptase polymerase chain reaction and ELISA, respectively, in bone marrow samples collected before induction treatment and after 72 hours of G3139 infusion, prior to initiation of chemotherapy.

RESULTS

Of the 29 treated patients, 14 achieved CR. With a median follow-up of 12.6 months, seven patients had relapsed. Side effects of this combination were similar to those expected with chemotherapy alone and were not dose limiting at both dose levels. After 72-hour G3139 infusion, Bcl-2/ABL mRNA copies were decreased compared with baseline (P = .03) in CR patients and increased in nonresponders (NRs; P = .05). Changes in Bcl-2 protein showed a similar trend. Although plasma pharmacokinetics did not correlate with disease response, the median IC of the antisense was higher in the CR patients compared with NRs (17.0 v 4.4 pmol/mg protein, respectively; P = .05).

CONCLUSION

G3139 can be administered safely in combination with intensive chemotherapy, and the degree of Bcl-2 downmodulation may correlate with response to therapy.

Supportive Care in Lung Cancer

Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.

First and subsequent cycle use of pegfilgrastim prevents febrile neutropenia in patients with breast cancer: a multicenter, double-blind, placebo-controlled phase III study

PURPOSE

We evaluated the efficacy of pegfilgrastim to reduce the incidence of febrile neutropenia associated with docetaxel in breast cancer patients.

PATIENTS AND METHODS

Patients were randomly assigned to either placebo or pegfilgrastim 6 mg subcutaneously on day 2 of each 21-day chemotherapy cycle of 100 mg/m(2) docetaxel. The primary end point was the percentage of patients developing febrile neutropenia (defined as body temperature >/= 38.2 degrees C and neutrophil count < 0.5 x 10(9)/L on the same day of the fever or the day after). Secondary end points were incidence of hospitalizations associated with a diagnosis of febrile neutropenia, intravenous (IV) anti-infectives required for febrile neutropenia, and the ability to maintain planned chemotherapy dose on time. Patients with febrile neutropenia were converted to open-label pegfilgrastim in subsequent cycles.

RESULTS

Nine hundred twenty-eight patients received placebo (n = 465) or pegfilgrastim (n = 463). Patients receiving pegfilgrastim, compared with patients receiving placebo, had a lower incidence of febrile neutropenia (1% v 17%, respectively; P < .001), febrile neutropenia-related hospitalization (1% v 14%, respectively; P < .001), and use of IV anti-infectives (2% v 10%, respectively; P < .001). The percentage of patients receiving the planned dose on time was similar between patients receiving pegfilgrastim and patients who initially received placebo (80% and 78%, respectively), as would be expected of the study design. Pegfilgrastim was generally well tolerated and safe, and the adverse events reported were typical of this patient population.

CONCLUSION

First and subsequent cycle use of pegfilgrastim with a moderately myelosuppressive chemotherapy regimen markedly reduced febrile neutropenia, febrile neutropenia-related hospitalizations, and IV anti-infective use.

Leucovorin, Fluorouracil, and Oxaliplatin (FOLFOX 4) Regimen for Colorectal Cancer

The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the US Department of the Army or the Department of Defense.

The effect of peptide stimulation on haematopoietic stem cell mobilisation including engraftment characteristics and a note on donor side effects

Aplasia or irreversible bone marrow failure and a variety of haematologic malignancies, as well as an increasing number of solid tumours, currently include various forms of marrow or equivalent transplantation in routine management. In both allogeneic and autologous procedures stable recipient immunohaematopoietic reconstitution depends upon infusing the requisite population harvested at a precise time following commencement of a stimulatory peptide. In a first step this prospective study documented the safety of apheresis, defined side effects and enumerated mononuclear, CD34+ and CD3+ cells obtained. In the second stage delivery of the graft, characterised in this way and with the additional measurement of in vitro growth in clonogenic assay, to the suitably conditioned patient was correlated with recovery of neutrophil and platelet numbers appearing in the circulation. In a third and ongoing analysis the influence of passenger T-lymphocytes is being evaluated for impact on infection and a potential anti-tumour effect. The conclusion is that this technology is reliable, has a high degree of patient acceptability without untoward complications, and that local results correspond to international experience thereby providing an important and relevant measure of quality control.

Innovative sequence of docetaxel–gemcitabine based on preclinical data in the treatment of advanced non small cell lung cancer: a phase I study

Based on our previous preclinical data, a phase I study was designed to investigate the tolerability of a novel sequence, docetaxel (DOC)-gemcitabine (GEM), in the treatment of non small cell lung cancer (NSCLC). Preclinical study: We evaluated the cytotoxicity of DOC and GEM on NSCLC cell lines and assessed the type of interaction between drug activities following different treatment schemes. Clinical study: Fifteen patients with stage IIIB-IV NSCLC received DOC (day 1) and GEM (days 3 and 8) every 21 days. Dose escalation of both agents was used to identify the maximum tolerated dose. The study was closed at the fifth dose level due to the occurrence of three dose-limiting toxicities: grade 4 febrile neutropoenia, persistent grade 2 fever and grade 3 diarrhoea. The most frequent toxicity was neutropoenia. Non haematological toxicities were diarrhoea, nausea and vomiting, mucositis and alopoecia. Of the 14 evaluable patients, 1 complete response, 4 partial responses, 4 stable diseases and 5 disease progressions were observed. Based on the results of the present study, a phase II trial is ongoing using the fourth dose levels.

Management of infections in critically ill neutropenic cancer patients

Because of improving antineoplastic treatment options with increasing cure rates, prolonging survival, and improving quality of life, the reluctance to admit patients with malignant disease to an intensive care unit is not justified; thus, the number of patients with malignancies treated in intensive care units rises. The use of more aggressive anticancer regimens leads to an increase of attendant infections, which are the most frequent and often life-threatening complications in cancer patients. A multidisciplinary practical approach to evaluation and treatment is needed to optimize treatment results and to meet the various diagnostic and therapeutic challenges in this subset of patients on an intensive care unit.

Platinum-Etoposide Chemotherapy in Elderly Patients With Small-Cell Lung Cancer: Results of a Randomized Multicenter Phase II Study Assessing Attenuated-Dose or Full-Dose With Lenograstim Prophylaxis—A Forza Operativa Nazionale Italiana Carcinoma Polmonare and Gruppo Studio Tumori Polmonari Veneto (FONICAP-GSTPV) Study

Purpose

Small-cell lung cancer (SCLC) is increasingly diagnosed in elderly patients, who are at higher risk of treatment-related morbidity and mortality. We conducted a randomized two-stage phase II study to assess the therapeutic index of two different platinum/etoposide regimens, attenuated-dose (AD) and full-dose (FD) plus prophylactic lenograstim.

Patients and Methods

SCLC patients older than 70 years were randomized to receive four courses of cisplatin 25 mg/m2 on days 1 and 2, and etoposide 60 mg/m2 on days 1, 2, and 3 every 3 weeks (AD); or cisplatin 40 mg/m2 on days 1 and 2, and etoposide 100 mg/m2 on days 1, 2, and 3 every 3 weeks, plus lenograstim 5 mg/kg days 5 through 12, every 3 weeks (FD). A combined primary end point named therapeutic success (TS), which took into account activity, toxicity, and compliance, was used.

Results

Ninety-five patients were enrolled. Seventy-five percent and 72% of the patients in the AD and FD arms, respectively, completed the treatment as per protocol. Response rate was 39% and 69% in the AD and FD arms, respectively, and 1-year survival probability was 18% and 39%, respectively. Treatment was well tolerated in both groups, with no grade 3 to 4 myelotoxicity in the AD arm, and 12% myelotoxicity in the FD arm. Overall, the observed TSs were 10 (36%) of 28 patients and 42 (63%) of 67 patients for AD and FD treatments, respectively.

Conclusion

In elderly patients with SCLC a full-dose cisplatin/etoposide regimen combined with prophylactic lenograstim is active and feasible, while attenuated doses of the same regimen are associated with a poor therapeutic outcome.

Risk modeling: applying evidence-based risk assessment in oncology nursing practice

PURPOSE/OBJECTIVES

To introduce nurses to the concept of evidence-based risk models and their use in practice.

DATA SOURCES

Poster presentations at meetings and published articles and books.

DATA SYNTHESIS

Evidence-based risk models can be used in many clinical situations to identify patients at higher risk for a particular disease or clinical outcome, such as adverse events. These models may be based on molecular, epidemiologic, clinical, or family information obtained from patients. Risk models also may provide information about the cost-effectiveness of prevention, treatment, or support strategies for specific patients.

CONCLUSIONS

Determining the risks of disease- or therapy-related adverse events can help healthcare providers and patients. Risk assessment to identify patients who are most likely to benefit from supportive care can lead to the cost-effective use of these supportive care measures and improved clinical outcomes.

IMPLICATIONS FOR NURSING

Through awareness of relevant evidence-based risk models, nurses can become more effective in actively managing their patients care. Because of their close and ongoing contact with patients with cancer, oncology nurses are in an ideal position to assess risk factors for adverse events and to use appropriate supportive care for those patients who are at greatest risk.

Effective Treatment of Indolent Non-Hodgkin’s Lymphomas with Mitoxantrone, Chlorambucil and Prednisone

Since indolent non-Hodgkin's lymphomas (NHL) represent about 35% of all malignant lymphomas and mainly affect elderly patients, availability of a conventional chemotherapy regimen with high efficacy and low toxicity is of clinical importance.

PATIENTS AND METHODS

We retrospectively analysed 13 patients with advanced indolent NHL who were treated with 6-9 cycles of MCP: mitoxantrone 8 mg/m2 (days 1 and 2), chlorambucil 3 x 3 mg/m2 (days 1-5) and prednisone 25 mg (days 1-5) every 4 weeks.

RESULTS

The overall response was 84% (61% complete response, 23% partial response), 1 patient had stable disease and 1 patient experienced progressive disease. Median time to progression was 37 months (95% CI: 20-53) and the median survival has not yet been reached. The main toxicity (66%) was neutropenia (WHO grade III). There was no hair loss and no cardial or neurologic adverse event.

CONCLUSION

In summary, MCP is an effective and well tolerated chemotherapy regimen and is probably an alternative to the more toxic CHOP regimen, especially in older patients.

Sepsis associated with immunosuppressive medications: an evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for sepsis associated with immunosuppressive medications that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Immunosuppressed patients, by definition, are susceptible to a wider spectrum of infectious agents than immunologically normal patients and, thus, require a broader spectrum antimicrobial regimen when they present with sepsis or septic shock. Special expertise managing immunosuppressed patient populations is needed to predict and establish the correct diagnosis and to choose appropriate empiric and specific agents and maximize the likelihood that patients will survive these microbial challenges.

Neutropenia management with granulocyte colony-stimulating factors: From guidelines to nursing practice protocols

Neutropenia, a problem that oncology nurses face in daily practice, is the major dose-limiting toxicity in patients with cancer who are treated with myelosuppressive chemotherapy. The incidence of chemotherapy dose reductions or treatment delays, which can impact overall dose intensity and compromise treatment outcomes, may be reduced by the proactive use of granulocyte colony-stimulating factor (G-CSF). National and international guidelines have been developed to promote the cost-effective use of G-CSF. Nursing care protocols for the management of chemotherapy-induced neutropenia (CIN) can be developed based on the national guidelines and modified for use by individual clinical practices. Risk assessment for CIN, which considers the prescribed chemotherapy regimen, patient risk factors, and treatment intent, should be a key component of the practice guidelines. Because most neutropenic events occur in the first cycle of chemotherapy, risk assessments should be conducted before the initiation of chemotherapy. Patients identified as at high risk for neutropenic complications should be given G-CSF in the first and subsequent cycles to allow the delivery of chemotherapy at full dose and on schedule. Nurses are instrumental in the development and implementation of neutropenia management protocols, which have the potential to markedly improve the quality of care and outcomes for patients with cancer.

Change in Cycle 1 to Cycle 2 Haematological Counts Predicts Toxicity in Older Patients with Breast Cancer Receiving Adjuvant Chemotherapy

PURPOSE

To determine the association between changes in complete blood counts and grade 3 or 4 toxicities from cycle 1 to cycle 2 during adjuvant chemotherapy in women > or =65 years of age with breast cancer.

DESIGN AND METHODS

A retrospective review was performed on 1405 patients > or =65 years of age who were treated for primary invasive breast cancer at Memorial Sloan-Kettering Cancer Center between January 1998 and December 2000. From this cohort, we identified patients with stage I-III breast cancer who received adjuvant chemotherapy: cyclophosphamide, methotrexate and fluorouracil (CMF) or the anthracycline-based regimens doxorubicin and cyclophosphamide (AC) or AC followed by paclitaxel (AC-T). Patients were excluded from the analysis if they had a prior history of breast cancer or chemotherapy, or if they had no baseline blood counts available for review. Toxicities, dose modification and causality were recorded.

RESULTS

The 104 patients who met our criteria had received either CMF (n = 58; mean age 70.6 years, range 65-78) or an anthracycline-based regimen (n = 46; mean age 68.9 years, range 65-77). Of these patients, 50% experienced treatment delay or treatment-related grade 3 or 4 toxicity. A decrease in white blood cell count and absolute neutrophil count from cycle 1 to cycle 2 was associated with grade 3 or 4 haematological toxicity, febrile neutropenia, hospitalisation and initiation of filgrastim for secondary prophylaxis. A decrease in haemoglobin was associated with febrile neutropenia and hospitalisation. Advanced age was not associated with a significant change in complete blood counts, other than a decline in absolute neutrophil count in patients receiving CMF.

CONCLUSIONS

In this cohort of older patients who received chemotherapy for breast cancer, changes in blood counts from cycle 1 to cycle 2 were associated with increased risk of treatment-related grade 3 or 4 toxicity.

Effect of outpatient treatment of febrile neutropenia on the risk threshold for the use of CSF in patients with cancer treated with chemotherapy

OBJECTIVES

Febrile neutropenia (FN) in patients with cancer treated with chemotherapy has traditionally been managed with inpatient broad-spectrum antibiotics until the infection and neutropenia have resolved. A newer strategy is outpatient oral or intravenous antibiotics in selected patients after an initial hospitalization. We sought to determine these costs, both overall and relative to those of traditional management, and the optimal role of prophylactic colony-stimulating factor (CSF) in patients at greatest risk for FN.

METHODS

Existing economic decision models were modified by incorporating a treatment strategy for FN in which patients are classified as high- and low-risk according to criteria described by Talcott. Low-risk patients were assumed to be treated as outpatients. Overall costs with the revised economic model were assessed and sensitivity analyses were performed.

RESULTS

The costs of an episode of FN were estimated as 1) no CSF: dollar 13,355; 2) CSF with hospitalization for FN: dollar 8677; and 3) CSF with risk stratification and outpatient management in low-risk patients: dollar 8188. The risk threshold for the cost-effective use of CSF was only slightly lower with outpatient treatment. When all patients with FN are treated as inpatients and the cost of hospitalization is dollar 1750/day the risk threshold for FN at which prophylactic CSF becomes cost-effective is 16%. It is 15% when low-risk patients are treated as outpatients.

CONCLUSIONS

Outpatient treatment slightly decreases the risk threshold for FN at which prophylactic CSF becomes cost-effective. The limited economic effect of this strategy may be because the patients who were at greatest risk of complications had significantly longer lengths of stay and accounted for most of the hospitalization costs.

CD4 lymphopenia as a risk factor for febrile neutropenia and early death after cytotoxic chemotherapy in adult patients with cancer

BACKGROUND

Lymphopenia is frequently observed in patients with cancer and correlates with the risk of febrile neutropenia and early death after chemotherapy. The phenotype of the depleted lymphocyte populations was investigated in the current study.

METHODS

Peripheral blood lymphocyte subsets (CD3, CD4, CD8, CD19, CD56) were quantified on Day 1 using fluorescence-activated cell sorting in a prospective study of 213 patients with cancer treated with chemotherapy in a single oncology ward during 12 months. Correlations between lymphocyte phenotype, clinical characteristics, and the risk of febrile neutropenia and early death within 31 days after chemotherapy were investigated in univariate and multivariate analyses.

RESULTS

Total lymphocyte count and CD3, CD4, and CD8 lymphocyte subsets were significantly lower in patients who experienced febrile neutropenia. Total lymphocyte count and CD3, CD4, CD8, CD19, and CD56 lymphocyte subsets were significantly lower in patients who died within 31 days after chemotherapy. Using logistic regression, CD4 lymphopenia (< 450/muL; odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.5-5.9) and the dose of chemotherapy (OR = 3,9, 95% CI = 2.0-7.8) were both identified as independent risk factors for febrile neutropenia. Fifty-four percent of patients with both risk factors experienced febrile neutropenia. CD4 lymphocyte count < 450/muL was also an independent risk factor for early death (OR = 7.7, 95% CI = 1.7-35). Thirteen percent of patients with a CD4 lymphocyte count </= 450/muL died within 31 days after chemotherapy. Eighty-seven percent (14 of 16) of patients who died before Day 31 had a CD4 lymphocyte count < 450/muL.

CONCLUSIONS

A low CD4 count was an independent risk factor for febrile neutropenia and early death in patients receiving cytotoxic chemotherapy.

[Clinical pathway based on evidence-based medicine (EBM) for chemotherapy for lung cancer]

Recently, combination treatment with cisplatin has been recommended as chemotherapy for lung cancer. However, no clinical pathway for safe and efficient use of anticancer agents has been established. We devised a clinical pathway satisfying evidence-based medicine (EBM) criteria by analyzing case records and the relevant literature. We analyzed 73 case records of hospitalized patients who had undergone chemotherapy for lung cancer on the internal medicine ward of the Showa University Hospital. Grade 3 or higher toxicities of leukopenia, thrombocytopenia, anemia, vomiting, and diarrhea occurred in 30%, 51%, 14%, 5%, 8%, and 1% of patients, respectively. Therefore the checklists for these toxicities were included in the clinical pathway. The National Cancer Institute Common Toxicity Criteria were used for the evaluation of toxicities. According to the guidelines of the American Society of Clinical Oncology and the US Infection Society, the indicated agents and criteria for their use were chosen for supportive cancer treatment. Pharmacists, physicians, and nurses collaborated in making the clinical pathway safe and sufficiently easy for practical use. The final version of the clinical pathway is compatible with EBM and includes items required for safe chemotherapy, which could be helpful in risk management.

Regulation of hematopoietic stem cell growth

Hematopoietic stem cells (HSC) must balance self-renewal and differentiation to provide sufficient primitive cells to sustain hematopoiesis, while generating more mature cells with specialized capabilities. The enhanced self-renewal capacity of primitive HSCs enables their ability to sustain hematopoiesis throughout decades of life and their ability to repopulate a host when used therapeutically in bone marrow transplantation. However, hematopoietic cell perturbations resulting in unchecked self-renewal participate in leukemogenesis. While mechanisms governing self-renewal are still being uncovered, they are thought to bear relationship to the malignant process in a variety of tumor types and may therefore provide useful therapeutic targets in putative cancer stem cells. This review discusses molecular mechanisms recently defined to participate in HSC governance and highlights features of stem cell interactions with the microenvironment that may help guide therapies directed at HSCs.

Liposomal anthracycline administration and toxicity management: A nursing perspective

Nursing care of the patient receiving chemotherapy includes patient education and drug administration, as well as ongoing assessment, early identification, and intervention for side effects. Two liposomal anthracyclines are available in the United States, pegylated liposomal doxorubicin (Doxil/Caelyx [PLD]) and liposomal daunorubicin (DaunoXome [DNX]). Because of their unique liposomal formulations, the administration and toxicity profiles of these agents are different from those of conventional anthracyclines, as well as each other. Common severe toxicities of conventional anthracycline treatment such as nausea/vomiting, alopecia, and neutropenia are less frequent and less severe during liposomal anthracycline treatment, and cumulative-dose cardiotoxicity is rare, particularly with PLD therapy. Dose-related adverse events with liposomal anthracycline therapy include stomatitis and neutropenia, and more frequent doses of PLD are associated with hand-foot syndrome. Ongoing nursing assessment, patient education, and adjustments to the dose or dose-schedule can reduce the severity or frequency of these toxicities. Nurses must be aware of the unique characteristics of liposomal anthracycline therapy to provide optimal patient education and nursing care.

A prospective randomized study of clinical and economic consequences of using G-CSF following autologous peripheral blood progenitor cell (PBPC) transplantation in children

This prospective and randomized study was conducted to evaluate clinical and economic consequences of using granulocyte colony-stimulating factor (G-CSF) following autologous peripheral blood progenitor cell (PBPC) transplantation in children. Between January 1999 and December 2003, 117 patients underwent autologous PBPCT: 51 patients received G-CSF following PBPCT, while 66 patients did not receive G-CSF. Median time to absolute neutrophil count > 0.5 x 10(9)/l was 10 days in the treatment group and 11 days in the control group (P < 0.009). The median time to platelets >20 x 10(9)/l was 12 days in both groups (P = NS). The median time to platelets >50 x 10(9)/l was 15 days in the G-CSF group and 14 days in the control group (P<0.005). In patients who received <5 x 10(6)/kg CD34+ cells, the median time to platelets >20 x 10(9)/l and >50 x 10(9)/l was similar with or without G-CSF (12 and 15 days, respectively). Platelet transfusion requirements were lower in the control group (2 vs 3 U in G-CSF group). There was a trend towards higher total costs with G-CSF: 8146.82 Euros and 7873.34 Euros with and without G-CSF, respectively (P = 0.1). Our data suggest that there is no indication of the standard application of G-CSF in children following PBPC transplantation. The only possible indication is the group of patients with a lower yield of CD34+ cells.

Lenograstim after autologous peripheral blood progenitor cell transplantation: results of a double-blind, randomized trial

A phase III, randomized, double-blind, placebo-controlled, multi-center trial was conducted in order to compare the incidence of microbiologically defined infections occurring after high-dose chemotherapy (HDT) and ASCT in 98 patients given lenograstim (Granocyte) and 94 patients given placebo after transplantation. Hematopoietic recovery, the use of i.v. antibiotics, the numbers of red blood cell and platelet transfusions, the days spent in hospital, and the days on parenteral nutrition were also compared. The incidence of infections until neutrophil recovery was significantly less in patients who received lenograstim after HDT and ASCT as compared to patients who received placebo (66 of 98 vs 86 of 94 patients, P<0.001). Lenograstim also significantly reduced the use of i.v. antibiotics (P<0.001) and the median duration of i.v. antibiotic treatment (8 days vs 10 days, P=0.04), improved neutrophil recovery (absolute neutrophil count >0.5 x 10(9)/l: 11 days vs 15 days, P<0.001) and reduced the number of days spent in hospital (15 days vs 17 days, P<0.001). The administration of lenograstim after HDT and ASCT significantly reduces the incidence of microbiologically defined infections until neutrophil recovery. It also leads to less use of antibiotics and earlier discharge from hospital.

Prognostic factors of hematological recovery in life-threatening nonchemotherapy drug-induced agranulocytosis

OBJECTIVES

We studied clinical factors that may influence the duration of hematological recovery to reach neutrophil counts and thus, indirectly, the prognosis in patients with life-threatening drug-induced agranulocytosis (DIA).

METHODS

Using univariate and multivariate analyses with Cox's proportional hazard models, we determined the prognostic factors for hematological recovery, defined as neutrophil counts>0.5 and>1.5.10(9)/L, in 91 patients with established life-threatening DIA.

RESULTS

Multivariable analysis showed that neutrophil count<0.1.10(9)/L (at diagnosis) and infection profile: severe infections or septic shock, adversely influenced the neutrophil recovery (for the two neutrophil levels). Hematopoietic growth factors were significantly associated with rapid hematological recovery (for the two neutrophil levels). Documented microbial infections and antiplatelet DIA were also associated with rapid hematological recovery (for a neutrophil count>1.5.10(9)/L).

CONCLUSION

Our findings demonstrate that in life-threatening DIA, hematological recovery is mainly dependent of the neutrophil level, the type of infections and the utilization of hematopoietic growth factors.

Breast cancer with synchronous metastases: trends in survival during a 14-year period

PURPOSE

Although new drugs were approved during the 1990s for the treatment of metastatic breast cancer, it is not clear whether their use has changed the outcome of patients in daily practice. This study sought to determine whether survival has improved over time for breast cancer patients who had metastases at diagnosis.

PATIENTS AND METHODS

A total of 724 patients have been treated in three French cancer centers for an initially metastatic breast cancer between 1987 and 2000; 343 were diagnosed between 1987 and 1993, and 381 were diagnosed between 1994 and 2000. Tumor characteristics, treatments, and outcomes of these patients were compared by chi(2) test, log-rank test, and Cox regression analysis.

RESULTS

Characteristics were not different between the patients diagnosed from 1987 to 1993 and those diagnosed from 1994 to 2000. Ten percent of patients treated from 1987 to 1994 and 58% of patients treated from 1994 to 2000 have received either a taxane or a new aromatase inhibitor. The 3-year overall survival rates were 27% for patients treated from 1987 to 1993 and 44% for patients treated from 1994 to 2000 (P <.001). The treatment period (1994 to 2000 v 1987 to 1993) was a prognostic factor in multivariate analysis (relative risk, 0.6; P <.001).

CONCLUSION

The survival of breast cancer patients presenting with metastases at diagnosis has improved over time. This study strongly suggests that this improvement is related to treatment.

Methotrexate, Vinblastine, Doxorubicin, and Cisplatin (MVAC) Regimen for Urothelial Tract Tumors

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column focuses on the commercially available and investigational agents used to treat malignant diseases and reviews issues related to the preparation, dispensing, and administration of cancer chemotherapy.

Prophylactic Granulocyte Colony-Stimulating Factor and Granulocyte-Macrophage Colony-Stimulating Factor Decrease Febrile Neutropenia After Chemotherapy in Children With Cancer: A Meta-Analysis of Randomized Controlled Trials

Purpose

To determine whether prophylactic hematopoietic colony-stimulating factors (CSFs) used in children with cancer reduce the rate of febrile neutropenia, hospitalization duration, documented infection rate, parenteral antibiotic duration, amphotericin B use, or infection-related mortality.

Methods

We included studies in this meta-analysis if their populations consisted of children, if there was randomization between CSFs and placebo or no therapy, if CSFs were administered prophylactically (before neutropenia or febrile neutropenia), and if chemotherapy treatments preceding CSFs and placebo or no therapy were identical. From 971 reviewed study articles, 16 were included.

Results

The mean rate of febrile neutropenia in the control arms was 57% (range, 39% to 100%). Using a random effects model, CSFs were associated with a reduction in febrile neutropenia, with a rate ratio of 0.80 (95% CI, 0.67 to 0.95; P = .01), and a decrease in hospitalization length, with a weighted mean difference of −1.9 days (95% CI, −2.7 to −1.1 days; P < .00001). CSF use was also associated with reduction in documented infections (rate ratio, 0.78; 95% CI, 0.62 to 0.97; P = .02) and reduction in amphotericin B use (rate ratio, 0.50; 95% CI, 0.28 to 0.87; P = .02). There was no difference in duration of parenteral antibiotic therapy (weighted mean difference, −4.3; 95% CI, −10.6 to 2.0 days; P = .2) or infection-related mortality (rate ratio, 1.02; 95% CI, 0.34 to 3.06; P = .97).

Conclusion

CSFs were associated with a 20% reduction in febrile neutropenia and shorter duration of hospitalization; however, CSFs did not reduce infection-related mortality.

Neulasta (pegfilgrastim): a once-per-cycle option for the management of chemotherapy-induced neutropenia

Neutropenia is a significant hematologic complication induced by cytotoxic chemotherapy. The clinical consequences of chemotherapy-induced neutropenia are often severe and can be potentially life-threatening. Patients who develop febrile neutropenia often need to be hospitalized, reducing their quality of life and increasing costs. Neutropenia can also compromise the ability to deliver chemotherapy at the full dose and on schedule. To help prevent the occurrence of neutropenia, patients with a high risk of developing chemotherapy-related infections may be given prophylactic colony-stimulating factors. Filgrastim is a recombinant human granulocyte colony-stimulating factor that has been widely used (in over 3 million patients) for over 12 years in the management of neutropenia. Pegfilgrastim is an approved, long-acting, next generation of granulocyte colony-stimulating factor that has similar clinical benefits to filgrastim but has novel pharmacokinetic properties. Pegfilgrastim shows at least comparable safety and efficacy to filgrastim, with the added benefit of simplified once-per-chemotherapy-cycle dosing. In addition, two randomized, controlled pivotal trials have shown that a single dose of pegfilgrastim given once per cycle led to a lower observed incidence of febrile neutropenia following myelosuppressive chemotherapy, compared with daily injections of filgrastim. Clinical trials are currently expanding the clinical experience with pegfilgrastim in a variety of solid tumors and hematologic malignancies. In addition to prevention of chemotherapy-induced neutropenia in 21- and 28-day regimens, future studies are examining the suitability of pegfilgrastim in dose-dense therapy and other cancer settings.