1
|
Schirm S, Engel C, Loibl S, Loeffler M, Scholz M. Model-based optimization of G-CSF treatment during cytotoxic chemotherapy. J Cancer Res Clin Oncol 2018; 144:343-358. [PMID: 29103159 PMCID: PMC5794835 DOI: 10.1007/s00432-017-2540-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/24/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Although G-CSF is widely used to prevent or ameliorate leukopenia during cytotoxic chemotherapies, its optimal use is still under debate and depends on many therapy parameters such as dosing and timing of cytotoxic drugs and G-CSF, G-CSF pharmaceuticals used and individual risk factors of patients. METHODS We integrate available biological knowledge and clinical data regarding cell kinetics of bone marrow granulopoiesis, the cytotoxic effects of chemotherapy and pharmacokinetics and pharmacodynamics of G-CSF applications (filgrastim or pegfilgrastim) into a comprehensive model. The model explains leukocyte time courses of more than 70 therapy scenarios comprising 10 different cytotoxic drugs. It is applied to develop optimized G-CSF schedules for a variety of clinical scenarios. RESULTS Clinical trial results showed validity of model predictions regarding alternative G-CSF schedules. We propose modifications of G-CSF treatment for the chemotherapies 'BEACOPP escalated' (Hodgkin's disease), 'ETC' (breast cancer), and risk-adapted schedules for 'CHOP-14' (aggressive non-Hodgkin's lymphoma in elderly patients). CONCLUSIONS We conclude that we established a model of human granulopoiesis under chemotherapy which allows predictions of yet untested G-CSF schedules, comparisons between them, and optimization of filgrastim and pegfilgrastim treatment. As a general rule of thumb, G-CSF treatment should not be started too early and patients could profit from filgrastim treatment continued until the end of the chemotherapy cycle.
Collapse
Affiliation(s)
- Sibylle Schirm
- Medical Faculty, Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Christoph Engel
- Medical Faculty, Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Sibylle Loibl
- German Breast Group, c/o GBG Forschungs GmbH, Martin-Behaim-Straße 12, 63263 Neu-Isenburg, Germany
| | - Markus Loeffler
- Medical Faculty, Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Markus Scholz
- Medical Faculty, Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| |
Collapse
|
2
|
Takahara N, Isayama H, Nakai Y, Ishigami H, Satoi S, Mizuno S, Kogure H, Matsubara S, Yamamoto N, Yamaguchi H, Tada M, Kitayama J, Watanabe T, Koike K. Intravenous and intraperitoneal paclitaxel with S-1 for treatment of refractory pancreatic cancer with malignant ascites. Invest New Drugs 2016; 34:636-42. [PMID: 27339809 DOI: 10.1007/s10637-016-0369-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/14/2016] [Indexed: 12/27/2022]
Abstract
UNLABELLED Objectives The aim of this study was to evaluate the safety and efficacy of intravenous and intraperitoneal paclitaxel (PTX) combined with S-1 for treatment of gemcitabine-refractory pancreatic cancer with malignant ascites. Methods After the feasibility of this regimen was first confirmed in an interim analysis in 10 patients, a total of 35 patients were enrolled between April 2011 and December 2014. PTX was administered intravenously (50 mg/m(2)) and intraperitoneally (20 mg/m(2)) on days 1 and 8, and 80 mg/m(2) S-1 was administered on days 1-14 every 3 weeks. The primary endpoint was overall survival (OS). The secondary endpoints were progression-free survival (PFS), the objective tumor response, efficacy against malignant ascites, and safety. Result In all 35 patients, the median OS and PFS were 4.8 (95 % confidence interval [CI], 2.1-5.3) months and 2.8 (95 % CI, 0.9-4.1) months, respectively. The 26 patients who were evaluable for efficacy achieved a response rate of 8 % and a disease control rate of 69 %. Malignant ascites had disappeared or decreased in 18 (69 %) patients, including complete resolution in 4 (15 %), and a negative change in cytological status was achieved in 8 (31 %) patients. The major grade 3/4 adverse events included neutropenia (34 %), anemia (31 %), nausea (9 %), and catheter-related infections (6 %). Conclusion Combination chemotherapy consisting of intravenous and intraperitoneal PTX with S-1 showed acceptable toxicity and favorable efficacy in pancreatic cancer patients with malignant ascites. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000005306).
Collapse
Affiliation(s)
- Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | | | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hironori Yamaguchi
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Joji Kitayama
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| |
Collapse
|
3
|
Kahan BC, Forbes AB, Doré CJ, Morris TP. A re-randomisation design for clinical trials. BMC Med Res Methodol 2015; 15:96. [PMID: 26541982 PMCID: PMC4634916 DOI: 10.1186/s12874-015-0082-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022] Open
Abstract
Background Recruitment to clinical trials is often problematic, with many trials failing to recruit to their target sample size. As a result, patient care may be based on suboptimal evidence from underpowered trials or non-randomised studies. Methods For many conditions patients will require treatment on several occasions, for example, to treat symptoms of an underlying chronic condition (such as migraines, where treatment is required each time a new episode occurs), or until they achieve treatment success (such as fertility, where patients undergo treatment on multiple occasions until they become pregnant). We describe a re-randomisation design for these scenarios, which allows each patient to be independently randomised on multiple occasions. We discuss the circumstances in which this design can be used. Results The re-randomisation design will give asymptotically unbiased estimates of treatment effect and correct type I error rates under the following conditions: (a) patients are only re-randomised after the follow-up period from their previous randomisation is complete; (b) randomisations for the same patient are performed independently; and (c) the treatment effect is constant across all randomisations. Provided the analysis accounts for correlation between observations from the same patient, this design will typically have higher power than a parallel group trial with an equivalent number of observations. Conclusions If used appropriately, the re-randomisation design can increase the recruitment rate for clinical trials while still providing an unbiased estimate of treatment effect and correct type I error rates. In many situations, it can increase the power compared to a parallel group design with an equivalent number of observations. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0082-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, E1 2AB, UK.
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia.
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, WC1E 6BT, UK.
| | - Tim P Morris
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, London, WC2B 6NH, UK.
| |
Collapse
|
4
|
Ye SG, Ding YI, Li L, Yang M, Zhang WJ, Liang AB. Colony-stimulating factors for chemotherapy-related febrile neutropenia are associated with improved prognosis in adult acute lymphoblastic leukemia. Mol Clin Oncol 2015; 3:730-736. [PMID: 26161258 DOI: 10.3892/mco.2015.527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/20/2015] [Indexed: 11/05/2022] Open
Abstract
Colony-stimulating factors (CSF) have been widely used to prevent febrile neutropenia associated with chemotherapy. Due to the high intensity of chemotherapy in acute lymphoblastic leukemia (ALL), CSF as a crucial component of supportive care has played a significant role in the therapy. However, the effectiveness of CSF in treatment has not been identified by large clinical trials until now. The aim of the present study was to evaluate the effect of CSF on the long-term outcome of adult ALL patients. A comprehensive search strategy has been conducted, which covered the Cochrane Central Register of Controlled Trials, PubMed and Web of Science. The result includes seven randomized controlled trials containing a total of 753 patients. The administration of CSF significantly reduced the mortality at the end of the follow-up (RR, 0.85; 95% CI, 0.75-0.95), the mortality at day 30 (RR, 0.41; 95% CI, 0.23-0.74) and the number of patients with infection or severe infections (RR, 0.8; 95% CI, 0.7-0.9 and RR, 0.48; 95% CI, 0.3-0.75). The addition of CSF also marginally increased the number of patients achieving CR (RR, 1.14; 95% CI, 1.05-1.23). The use of CSF also shortened the duration of neutropenia (median days, 8-17 to 12.5-24). In conclusion, CSFs can be administered to ALL patients during myelosuppressive chemotherapy, particularly in the induction phase.
Collapse
Affiliation(s)
- Shi-Guang Ye
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| | - Y I Ding
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| | - Liang Li
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| | - Meng Yang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| | - Wen-Jun Zhang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| | - Ai-Bin Liang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, P.R. China
| |
Collapse
|
5
|
Pathak R, Giri S, Aryal MR, Karmacharya P, Bhatt VR, Martin MG. Mortality, length of stay, and health care costs of febrile neutropenia-related hospitalizations among patients with breast cancer in the United States. Support Care Cancer 2015; 23:615-7. [PMID: 25556610 DOI: 10.1007/s00520-014-2553-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Febrile neutropenia is a potentially life threatening complication of breast cancer chemotherapy associated with a significant amount of morbidity, mortality, and health care resource utilization. Recent data on the national estimates of mortality rate, length of stay, and health care costs among the subpopulation of febrile neutropenia admissions with breast cancer are lacking. METHODS We used the Nationwide Inpatient Sample database to identify patients with breast cancer hospitalized for febrile neutropenia from 2009 to 2011. We derived data on inhospital mortality rate, length of stay, and mean health care costs and compared it with previous studies. RESULTS The average inhospital mortality rate during 2009-2011 was 2.6 % (n = 685). Advanced age (≥ 65 years) was found to be significantly associated with a higher odds of mortality (4.4 vs 1.7 %, OR 2.7, 95 % CI 2.3-3.1, p < 0.01). The mean length of stay was 5.7 days (95 % CI 5.5-5.9 days), whereas the mean cost of hospitalization was $37,087 (95 % CI $34,009-$40,165). CONCLUSION Febrile neutropenia-related hospitalizations continue to account for significant morbidity, mortality, and health care resource utilization among patients with breast cancer. Further efforts should be focused on curtailing the rising health care costs without compromising the quality of care.
Collapse
Affiliation(s)
- Ranjan Pathak
- Department of Internal Medicine, Reading Health System, 6th Avenue and Spruce St, West Reading, PA, 19611, USA,
| | | | | | | | | | | |
Collapse
|
6
|
Barnes G, Pathak A, Schwartzberg L. G-CSF utilization rate and prescribing patterns in United States: associations between physician and patient factors and GCSF use. Cancer Med 2014; 3:1477-84. [PMID: 25410813 PMCID: PMC4298373 DOI: 10.1002/cam4.344] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/16/2014] [Accepted: 08/15/2014] [Indexed: 12/22/2022] Open
Abstract
Febrile neutropenia (FN) is a common complication among patients with chemotherapy-induced myelotoxicity and is associated with a number of negative outcomes including prolonged hospitalization, increased medical costs, increased risk of mortality, dose reductions, and delays. Granulocyte-colony-stimulating factor (G-CSF), granulocyte-macrophage-colony stimulating factor (GM-CSF), and pegylated G-CSF are effective at reducing risk and duration of neutropenia-related events. However, despite guidelines, the use of G-CSF and pegylated G-CSF in the United States has not been consistent and pattern of care studies have focused primarily on G-CSF. A number of studies found that G-CSF is underutilized in patients undergoing chemotherapy treatments associated with a high risk of FN, while being over utilized in patients with a low-risk FN. Wide variations in overuse, underuse, and misuse of G-CSF are associated with a number of physician and patient factors. Improved awareness of the guidelines, feedback to providers regarding proper usage, and understanding of chemotherapy regimens associated with very low risks as well as high risks (>20%) of FN is some of the approaches that could lead to improving care.
Collapse
Affiliation(s)
- Gisoo Barnes
- Teva Pharmaceuticals41 Moores Rd., Frazer, Pennsylvania, 19355
| | - Ashutosh Pathak
- Teva Pharmaceuticals41 Moores Rd., Frazer, Pennsylvania, 19355
| | - Lee Schwartzberg
- The West Clinic100 N. Humphreys Blvd., Memphis, Tennessee, 38120
| |
Collapse
|
7
|
Mhaskar R, Clark OAC, Lyman G, Engel Ayer Botrel T, Morganti Paladini L, Djulbegovic B. Colony-stimulating factors for chemotherapy-induced febrile neutropenia. Cochrane Database Syst Rev 2014; 2014:CD003039. [PMID: 25356786 PMCID: PMC7141179 DOI: 10.1002/14651858.cd003039.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Febrile neutropenia is a frequent adverse event experienced by people with cancer who are undergoing chemotherapy, and is a potentially life-threatening situation. The current treatment is supportive care plus antibiotics. Colony-stimulating factors (CSFs), such as granulocyte-CSF (G-CSF) and granulocyte-macrophage CSF (GM-CSF), are cytokines that stimulate and accelerate the production of one or more cell lines in the bone marrow. Clinical trials have addressed the question of whether the addition of a CSF to antibiotics could improve outcomes in individuals diagnosed with febrile neutropenia. However, the results of these trials are conflicting. OBJECTIVES To evaluate the safety and efficacy of adding G-CSF or GM-CSF to standard treatment (antibiotics) when treating chemotherapy-induced febrile neutropenia in individuals diagnosed with cancer. SEARCH METHODS We conducted the search in March 2014 and covered the major electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and SCI. We contacted experts in hematology and oncology and also scanned the citations from the relevant articles. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) that compared CSF plus antibiotics versus antibiotics alone for the treatment of chemotherapy-induced febrile neutropenia in adults and children. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. We performed meta-analysis of the selected studies using Review Manager 5 software. MAIN RESULTS Fourteen RCTs (15 comparisons) including a total of 1553 participants addressing the role of CSF plus antibiotics in febrile neutropenia were included. Overall mortality was not improved by the use of CSF plus antibiotics versus antibiotics alone (hazard ratio (HR) 0.74 (95% confidence interval (CI) 0.47 to 1.16) P = 0.19; 13 RCTs; 1335 participants; low quality evidence). A similar finding was seen for infection-related mortality (HR 0.75 (95% CI 0.47 to 1.20) P = 0.23; 10 RCTs; 897 participants; low quality evidence). Individuals who received CSF plus antibiotics were less likely to be hospitalized for more than 10 days (risk ratio (RR) 0.65 (95% CI 0.44 to 0.95) P = 0.03; 8 RCTs; 1221 participants; low quality evidence) and had more number of participants with a more faster neutrophil recovery (RR 0.52 (95% CI 0.34 to 0.81) P = 0.004; 5 RCTs; 794 participants; moderate quality evidence) than those treated with antibiotics alone. Similarly, participants receiving CSF plus antibiotics had shorter duration of neutropenia (standardized mean difference (SMD) -1.70 (95% CI -2.65 to -0.76) P = 0.0004; 9 RCTs; 1135 participants; moderate quality evidence), faster recovery from fever (SMD -0.49 (95% CI -0.90 to -0.09) P value = 0.02; 9 RCTs; 966 participants; moderate quality evidence) and shorter duration of antibiotics use (SMD -1.50 (95% CI -2.83 to -0.18) P = 0.03; 3 RCTs; 457 participants; low quality evidence) compared with participants receiving antibiotics alone. We found no significant difference in the incidence of deep venous thromboembolism (RR 1.68 (95% CI 0.72 to 3.93) P = 0.23; 4 RCTs; 389 participants; low quality evidence) in individuals treated with CSF plus antibiotics compared with those treated with antibiotics alone. We found higher incidence of bone or joint pain or flu-like symptoms (RR 1.59 (95% CI 1.04 to 2.42) P = 0.03; 6 RCTs; 622 participants; low quality evidence) in individuals treated with CSF plus antibiotics compared with those treated with antibiotics alone. Overall, the methodological quality of studies was moderate to low across different outcomes. The main reasons to downgrade the quality of evidence were inconsistency across the included studies and imprecision of results. AUTHORS' CONCLUSIONS The use of a CSF plus antibiotics in individuals with chemotherapy-induced febrile neutropenia had no effect on overall mortality, but reduced the amount of time participants spent in hospital and improved their ability to achieve neutrophil recovery. It was not clear whether CSF plus antibiotics had an effect on infection-related mortality. Participants receiving CSFs had shorter duration of neutropenia, faster recovery from fever and shorter duration of antibiotics use.
Collapse
Affiliation(s)
- Rahul Mhaskar
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, Florida, USA
| | | | | | | | | | | |
Collapse
|
8
|
Gurion R, Belnik‐Plitman Y, Gafter‐Gvili A, Paul M, Vidal L, Ben‐Bassat I, Shpilberg O, Raanani P. Colony-stimulating factors for prevention and treatment of infectious complications in patients with acute myelogenous leukemia. Cochrane Database Syst Rev 2012; 2012:CD008238. [PMID: 22696376 PMCID: PMC7390444 DOI: 10.1002/14651858.cd008238.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute myelogenous leukemia (AML) is a fatal bone marrow cancer. Colony-stimulating factors (CSFs) are frequently administered during and after chemotherapy to reduce complications. However, their safety with regard to disease-related outcomes and survival in AML is unclear. Therefore, we performed a systematic review and meta-analysis to evaluate the impact of CSFs on patient outcomes, including survival. OBJECTIVES To assess the safety/efficacy of CSFs with regard to disease-related outcomes and survival in patients with AML. SEARCH METHODS We conducted a comprehensive search strategy. We identified relevant randomized clinical trials by searching the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 7), MEDLINE (January 1966 to July 2010), LILACS (up to December 2009), databases of ongoing trials and relevant conference proceedings. SELECTION CRITERIA Randomized controlled trials that compared the addition of CSFs during and following chemotherapy to chemotherapy alone in patients with AML. We excluded trials evaluating the role of CSFs administered for the purpose of stem cell collection and/or priming (e.g. before and/or only for the duration of chemotherapy). DATA COLLECTION AND ANALYSIS Two review authors appraised the quality of trials and extracted data. For each trial, we expressed results as relative risk (RR) with 95% confidence intervals (CI) for dichotomous data. We analyzed time-to-event outcomes as hazard ratios (HRs). MAIN RESULTS The search yielded 19 trials including 5256 patients. The addition of CSFs to chemotherapy yielded no difference in all-cause mortality at 30 days and at the end of follow up (RR 0.97; 95% CI 0.80 to 1.18 and RR 1.01; 95% CI 0.98 to 1.05, respectively) or in overall survival (HR 1.00; 95% 0.93 to 1.08). There was no difference in complete remission rates (RR 1.03; 95% CI 0.99 to 1.07), relapse rates (RR 0.97; 95% CI 0.89 to 1.05) and disease-free survival (HR 1.00; 95% CI 0.90 to 1.13). CSFs did not decrease the occurrence of bacteremias (RR 0.96; 95% CI 0.82 to 1.12), nor the occurrence of invasive fungal infections (RR 1.40; 95% CI 0.90 to 2.19). CSFs marginally increased adverse events requiring discontinuation of CSFs as compared to the control arm (RR 1.33; 95% CI 1.00 to 1.56). AUTHORS' CONCLUSIONS In summary, colony-stimulating factors should not be given routinely to acute myelogenous leukemia patients post-chemotherapy since they do not affect overall survival or infectious parameters including the rate of bacteremias and invasive fungal infections.
Collapse
Affiliation(s)
- Ronit Gurion
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Yulia Belnik‐Plitman
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Anat Gafter‐Gvili
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Sackler Faculty of MedicineInfectious Diseases UnitTel Aviv UniversityTel AvivIsrael49100
| | - Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | | | - Ofer Shpilberg
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | - Pia Raanani
- Beilinson Hospital, Rabin Medical CenterInstitute of Hematology, Davidoff Center39 Jabotinski StreetPetah TikvaIsrael49100
| | | |
Collapse
|
9
|
Abstract
The development of an infection involves interplay between the host's immune system and the virulence of the infecting microorganism. The traditional treatment of an infection involves antimicrobial chemotherapy to kill the organism. The use of immunotherapies in infections includes treatment options that modulate the immune response and can lead to control of infections. These therapies are expected to become more important therapeutic options with the increase in infections due to multidrug-resistant organisms and the increasing number of immunocompromised patients.
Collapse
Affiliation(s)
- Vivek Kak
- Allegiance Health, 1100 East Michigan Avenue, #305, Jackson, MI 49201, USA.
| | | | | | | |
Collapse
|
10
|
Gurion R, Belnik-Plitman Y, Gafter-Gvili A, Paul M, Vidal L, Ben-Bassat I, Shpilberg O, Raanani P. Colony-stimulating factors for prevention and treatment of infectious complications in patients with acute myelogenous leukemia. Cochrane Database Syst Rev 2011:CD008238. [PMID: 21901718 DOI: 10.1002/14651858.cd008238.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute myelogenous leukemia (AML) is a fatal bone marrow cancer. Colony-stimulating factors (CSFs) are frequently administered during and after chemotherapy to reduce complications. However, their safety with regard to disease-related outcomes and survival in AML is unclear. Therefore, we performed a systematic review and meta-analysis to evaluate the impact of CSFs on patient outcomes, including survival. OBJECTIVES To assess the safety/efficacy of CSFs with regard to disease-related outcomes and survival in patients with AML. SEARCH STRATEGY We conducted a comprehensive search strategy. We identified relevant randomized clinical trials by searching the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 7), MEDLINE (January 1966 to July 2010), LILACS (up to December 2009), databases of ongoing trials and relevant conference proceedings. SELECTION CRITERIA Randomized controlled trials that compared the addition of CSFs during and following chemotherapy to chemotherapy alone in patients with AML. We excluded trials evaluating the role of CSFs administered for the purpose of stem cell collection and/or priming (e.g. before and/or only for the duration of chemotherapy). DATA COLLECTION AND ANALYSIS Two review authors appraised the quality of trials and extracted data. For each trial, we expressed results as relative risk (RR) with 95% confidence intervals (CI) for dichotomous data. We analyzed time-to-event outcomes as hazard ratios (HRs). MAIN RESULTS The search yielded 19 trials including 5256 patients. The addition of CSFs to chemotherapy yielded no difference in all-cause mortality at 30 days and at the end of follow up (RR 0.97; 95% CI 0.80 to 1.18 and RR 1.01; 95% CI 0.98 to 1.05, respectively) or in overall survival(HR 1.00; 95% 0.93 to 1.08). There was no difference in complete remission rates(RR 1.03; 95% CI 0.99 to 1.07), relapse rates(RR 0.97; 95% CI 0.89 to 1.05) and disease-free survival(HR 1.00; 95% CI 0.90 to 1.13). CSFs did not decrease the occurrence of bacteremias(RR 0.96; 95% CI 0.82 to 1.12), nor the occurrence of invasive fungal infections(RR 1.40; 95% CI 0.90 to 2.19). CSFs marginally increased adverse events requiring discontinuation of CSFs as compared to the control arm(RR 1.33; 95% CI 1.00 to 1.56). AUTHORS' CONCLUSIONS The addition of CSFs to chemotherapy does not adversely influence all-cause mortality, complete remission or relapse rates in patients with AML. Although the benefit of CSFs is limited to reduction of neutropenic and febrile days, they can be administered safely when necessary.
Collapse
Affiliation(s)
- Ronit Gurion
- Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, Petah Tikva, Israel, 49100
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Held TK, Hildebrandt MO, Ludwig WD. [Hematopoietic growth factors. Possibilities and limitations]. Internist (Berl) 2010; 51:863-71; quiz 872-3. [PMID: 20544173 DOI: 10.1007/s00108-010-2641-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The production of hematopoietic cells is under the tight control of distinct growth factors. As therapeutic agents, granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO), and thrombopoiesis-stimulating agents (TSA) are in routine clinical use. Granulocyte colony-stimulating factor is used to prevent febrile neutropenia or to increase dose-density in chemotherapy regimens. Despite a reduced duration of neutropenia, randomized controlled trials have documented only a modest clinical benefit. A clinical advantage of dose-dense chemotherapy has been shown only in specific chemotherapy regimens. Clinical practice guidelines recommend the use of G-CSF for patients with a high risk of adverse outcome of febrile neutropenia. Erythropoiesis-stimulating agents (ESAs) are used as an alternative to blood transfusion in patients with chemotherapy-induced anemia. However, recent meta-analyses of clinical studies suggest that their use was associated with an increased risk of all-cause mortality and serious adverse events. Thrombopoiesis-stimulating agents have been introduced recently into the market for patients with immune thrombocytopenic purpura. Prior to the use of TSA in other conditions such as chemotherapy-induced thrombocytopenia the lessons learned with G-CSF and ESAs should be taken into account.
Collapse
Affiliation(s)
- T K Held
- Klinik für Hämatologie, Onkologie und Tumorimmunologie, HELIOS Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin, Germany
| | | | | |
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- Alfredo Carrato
- Medical Oncology Department, Ramón y Cajal University Hospital, Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Hozo I, Djulbegovic B, Clark O, Lyman GH. Use of re-randomized data in meta-analysis. BMC Med Res Methodol 2005; 5:17. [PMID: 15882470 PMCID: PMC1145185 DOI: 10.1186/1471-2288-5-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2004] [Accepted: 05/10/2005] [Indexed: 12/01/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Iztok Hozo
- Indiana University Northwest, Department of Mathematics, Gary, IN, USA
| | - Benjamin Djulbegovic
- Interdisciplinary Oncology Program, H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Tampa, FL, USA
| | - Otavio Clark
- Instituto do Radium de Campinas, Av Heitor Penteado 1780, Campinas-SP, Brasil
| | - Gary H Lyman
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
14
|
Abstract
BACKGROUND Many medications have been used for stabilizing heroin users: Methadone, Buprenorphine and LAAM. The present review focus on the prescription of heroin to heroin dependents. OBJECTIVES To assess the efficacy and acceptability of heroin maintenance versus methadone or other substitution treatments for opioid dependence, in retaining patients in treatment; reducing the use of illicit substances and improving health and social functioning. SEARCH STRATEGY The Cochrane Central Register of Trials (CENTRAL) issue 1, 2005; MEDLINE 1966-2005, EMBASE 1980-2005 and CINAHL till 2005 (on OVID) were searched. There was no language or publication year restrictions. Many researchers were contacted for information. SELECTION CRITERIA Randomised controlled trials of heroin (alone or combined with methadone) maintenance treatment compared with any other pharmacological treatments for heroin dependents. DATA COLLECTION AND ANALYSIS The trials were independently assessed for inclusion and methodological quality by the reviewers. Data were extracted independently and double checked. Studies were not pooled together because of heterogeneity. MAIN RESULTS 2400 references were obtained and 20 studies were eligible, 4 met the inclusion criteria for a total of 577 patients. The studies could not be analysed cumulatively because of heterogeneity of interventions and outcomes. Retention in treatment: no groups difference was found in two studies; one study (N=96) found RR=2.82 (95% CI 1.70-4.68) favouring heroin; one study (N=235) found RR 0.79 (95%CI 0.68-0.90) favouring methadone. Relapse to illegal heroin use (self- reported): in one study people using heroin in treatment was 64% (heroin group)and 59% (methadone group); in the other study the RR of heroin use was 0.33 (95%CI 0.15-0.72) favouring heroin. Criminal offence: one study showed the potential of heroin prescription in reducing the risk of being charged RR 0.32 (95% CI 0.14-0.78). Social functioning: two studies did not show statistical difference between intervention groups, and two studies considered criminal offence and social functioning as part of a multidomain outcome measure showing improvements among those treated with heroin plus methadone over those on methadone only. AUTHORS' CONCLUSIONS No definitive conclusions about the overall effectiveness of heroin prescription is possible. Results favouring heroin treatment come from studies conducted in countries where easily accessible Methadone Maintenance Treatment at effective dosages is available. In those studies heroin prescription was addressed to patients who had failed previous methadone treatments. The present review contains information about ongoing trials which results will be integrated as soon as available.
Collapse
Affiliation(s)
- M Ferri
- Project Unit: EBM and Models of Health Assistance, Agency of Public Health, Via di Santa Costanza 53, Rome, Italy, 00198.
| | | | | |
Collapse
|
15
|
Abstract
Fever with neutropenia is a common clinical problem in patients receiving cancer treatment. Prevention and optimum management of infectious complications is critical to the overall success of cancer therapy. This article provides an overview of the current status of this evolving subject. While the basic principles of rapid institution of broad spectrum antibiotics, early intervention with empiric antifungal therapy and continuation of antimicrobials during period of risk are unlikely to change, there is increasing interest in titrating this aggressive approach based on the projected risk of the development of a serious invasive infection. Oral antibiotic therapy and outpatient management are currently being studied in pediatric oncology patients, but even when successful these alternatives to the traditional "in hospital, parenteral antibiotic therapy" approach are unlikely to be applicable in all patient populations and clinical settings. While there is no replacement for clinical acumen and careful monitoring, judicious use of diagnostic resources such as blood cultures and imaging studies is a key component of optimum care. Selection of empiric antibiotics based on ongoing monitoring of antimicrobial susceptibility patterns is emphasized.
Collapse
Affiliation(s)
- Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA.
| | | | | |
Collapse
|