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

Neutropenia: occurrence and management in women with breast cancer receiving chemotherapy

OBJECTIVES

to identify the prevalence, and describe the management of, neutropenia throughout the chemotherapy treatment among women with breast cancer.

METHODS

observational study, cycles of chemotherapy. 116 neutropenic events were recorded, and 63.3% of the patients presented neutropenia at some point of their treatment, 46.5% of these presenting grade II. The management used was temporary suspension between the cycles and the mean number of delays was 6 days. The study was prospective and longitudinal, where the evaluation of the hematological toxicities was undertaken at each cycle of chemotherapy, whether neoadjuvant or adjuvant.

RESULTS

79 women were included, who received 572 cycles. However, the reasons for the suspensions were the lack of a space in the chemotherapy center, followed by neutropenia.

CONCLUSION

neutropenia is one of the most common and serious adverse events observed during the chemotherapy. Nursing must invest in research regarding this adverse event and in management strategies for organizing the public health system, so as to offer quality care.

A semiquinone glucoside derivative isolated from Bacillus sp. INM-1 provides protection against 5-fluorouracil-induced immunotoxicity

5-Fluorouracil (5-FU) is a widely used anti-cancer agent; however, it induces immunosuppression in patients undergoing a chemotherapy regime. The mode of action by which 5-FU induces immunosuppression is primarily via inhibition of hematopoietic growth factors. In the present study, immunoprotective effects of a semiquinone glucoside derivative (SQGD), a bacterial metabolite isolated from Bacillus sp. INM-1, were evaluated in a model of 5-FU-induced immunotoxicity in C57Bl/6 male mice. The evaluation was done by analyzing G-CSF, GM-CSF, and M-CSF expression in the serum, spleen, and bone marrow cells of the mice at different timepoints after 5-FU treatment. Mice received a single intraperitoneal injection of either 5-FU (75 mg/kg) alone, SQGD (50 mg/kg) alone, or SQGD 2 h prior to the 5-FU treatment. Control mice received saline vehicle only. The results demonstrated that 5-FU treatment significantly inhibited G-CSF, GM-CSF, and M-CSF expression in all three sites at all timepoints from 6-72 h post 5-FU. In SQGD treated mice, up-regulation of factor expression was observed in each compartment, and significantly so most often after 12 h. SQGD treatment prior to 5-FU administration to the mice significantly increased in all sites evaluated - relative to values in both control mice and 5-FU only-treated mice - G-CSF, M-CSF, and GM-CSF expression at almost every timepoint. The present findings suggest that SQGD provides protection against 5-FU-induced immunotoxicity in mice and could protect bone marrow progenitor cells against the effects of cytotoxic drugs used for treatment of cancer. The findings also suggested to us that SQGD is a potential immunomodulator and could protect hematopoiesis against toxic assault caused by anti-cancer drugs in the clinical setting.

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

PURPOSE

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

METHODS AND SAMPLE

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

KEY RESULTS

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

CONCLUSIONS

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

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

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

Risks and consequences of chemotherapy-induced neutropenia

Neutropenia represents a major dose-limiting toxicity of chemotherapy and is associated with an increased risk of infection, impaired patient quality of life, and interference with the delivery of full-dose chemotherapy. These complications increase not only morbidity and mortality associated with cancer treatment but also the overall cost of care for cancer patients. Conversely, chemotherapy-induced neutropenia as a surrogate for delivered dose intensity has been associated with improved cancer survival. Administration of myeloid growth factors, such as filgrastim and pegfilgrastim, reduces the risk for neutropenic complications and facilitates the delivery of full-dose chemotherapy. There is an ongoing effort to identify patients at increased risk for developing neutropenic complications who would likely benefit from preemptive myeloid growth factor therapy. Appropriate use of myeloid growth factors is associated with reduced neutropenic complications, improved patient quality of life, and potentially improved disease control and long-term survival.

An analysis of current neutropenia therapies, including pegfilgrastim

Currently, 2 granulocyte colony-stimulating factors are available in the United States--filgrastim and pegfilgrastim. In patients receiving chemotherapy for solid tumors, lymphoma, and acute myelogenous leukemia, these agents reduce the duration of severe neutropenia, decrease the incidence of febrile neutropenia, and facilitate on-time delivery of scheduled doses of chemotherapy. In addition, substantial data document the benefits of using these agents in patients undergoing peripheral blood progenitor cell mobilization and in patients who have undergone bone marrow transplantation or peripheral blood progenitor cell transplantation. Recent studies suggest that for all of these indications, the efficacy of pegfilgrastim, the newest agent, is comparable to or greater than that of filgrastim. Like filgrastim, pegfilgrastim is generally well tolerated. An important advantage of pegfilgrastim, however, is its once-per-cycle schedule of administration. Patients and health care providers are likely to prefer the administration schedule of pegfilgrastim to the daily administration schedule required with the use of filgrastim. Furthermore, the more convenient schedule of pegfilgrastim may be associated with greater treatment adherence and increased patient quality of life.