Granulocyte colony-stimulating factor in severe chemotherapy-induced afebrile neutropenia

[Neutropenia - when is GCSF support indicated?]

Many systemic treatments used in genitourinary oncology negatively affect haematopoiesis, thus leading to neutropenia. Neutropenic patients are vulnerable to bacterial, and other infections. Often fever is the only symptom in these patients. Neutropenic fever is a major threat for these patients, as it may lead to life-threatening therapy complications that significantly impair the patient's quality of life, Moreover, it may also worsen the prognosis due to therapy delays or necessary dose modifications. Granulocyte colony stimulating factors (GCSF), which can improve neutrophil granulocyte formation, are used both for supportive treatment in febrile neutropenia and for its prophylaxis. The correct indication for such GCSF support depends on the general risk of febrile neutropenia of the therapy used, as well as on individual patient factors and the treatment intent (palliative vs. curative). Based on the current recommendations both of the German and international guidelines, this article aims to provide an up-to-date and practice-oriented overview of the use of GCSF in uro-oncology.

Myeloid cell-mediated drug delivery: from nanomedicine to cell therapy

In the presence of tissue inflammation, injury, or cancer, myeloid cells are recruited to disease regions through a multi-step process involving myelopoiesis, chemotaxis, cell migration, and diapedesis. As an emerging drug delivery approach, cell-mediated drug delivery takes advantage of the cell recruitment process to enhance the active transport of therapeutic cargo to disease regions. In the past few decades, a variety of nano-engineering methods have emerged to enhance interactions of nanoparticles with cells of interest, which can be adapted for cell-mediated drug delivery. Moreover, the drug delivery field can benefit from the recent clinical success of cell-based therapies, which created cell-engineering methods to engineer circulating leukocytes as 'living drug delivery vehicles' to target diseased tissues. In this review, we first provide an overview of myeloid cell recruitment and discuss how various factors within this process may affect cell-mediated delivery. In the second part of this review article, we summarize the status quo of nano-engineering and cell-engineering approaches and discuss how these engineering approaches can be adapted for cell-mediated delivery. Finally, we discuss future directions of this field, pointing out key challenges in the clinical translation of cell-mediated drug delivery.

Neutrophil trafficking to the site of infection requires Cpt1a-dependent fatty acid β-oxidation

Cellular metabolism influences immune cell function, with mitochondrial fatty acid β-oxidation and oxidative phosphorylation required for multiple immune cell phenotypes. Carnitine palmitoyltransferase 1a (Cpt1a) is considered the rate-limiting enzyme for mitochondrial metabolism of long-chain fatty acids, and Cpt1a deficiency is associated with infant mortality and infection risk. This study was undertaken to test the hypothesis that impairment in Cpt1a-dependent fatty acid oxidation results in increased susceptibility to infection. Screening the Cpt1a gene for common variants predicted to affect protein function revealed allele rs2229738_T, which was associated with pneumonia risk in a targeted human phenome association study. Pharmacologic inhibition of Cpt1a increases mortality and impairs control of the infection in a murine model of bacterial pneumonia. Susceptibility to pneumonia is associated with blunted neutrophilic responses in mice and humans that result from impaired neutrophil trafficking to the site of infection. Chemotaxis responsible for neutrophil trafficking requires Cpt1a-dependent mitochondrial fatty acid oxidation for amplification of chemoattractant signals. These findings identify Cpt1a as a potential host determinant of infection susceptibility and demonstrate a requirement for mitochondrial fatty acid oxidation in neutrophil biology.

Outcomes of granulocyte colony-stimulating factor use in pediatric kidney transplant recipients: A Pediatric Nephrology Research Consortium study

BACKGROUND

Neutropenia is common in the first year after pediatric kidney transplant and is associated with an increased risk of infection, allograft loss, and death. Granulocyte colony-stimulating factor (G-CSF) increases neutrophil production, but its use in pediatric solid organ transplant recipients remains largely undescribed.

METHODS

We performed a multicenter retrospective cohort study of children with neutropenia within the first 180 days after kidney transplant. Multivariable linear regression and Poisson regression were used to assess duration of neutropenia and incidence of hospitalization, infection, and rejection.

RESULTS

Of 341 neutropenic patients, 83 received G-CSF during their first episode of neutropenia. Median dose of G-CSF was 5 mcg/kg for 3 (IQR 2-7) doses. G-CSF use was associated with transplant center, induction immunosuppression, steroid-free maintenance immunosuppression, hospitalization, and decreases in mycophenolate mofetil, valganciclovir, and trimethoprim-sulfamethoxazole dosing. Absolute neutrophil count nadir was also significantly lower among those treated with G-CSF. G-CSF use was not associated with a shorter duration of neutropenia (p = .313) and was associated with a higher rate of neutropenia relapse (p = .002) in adjusted analysis. G-CSF use was associated with a decreased risk of hospitalization (aIRR 0.25 (95%CI 0.12-0.53) p < .001) but there was no association with incidence of bacterial infection or rejection within 90 days of neutropenic episode.

CONCLUSION

G-CSF use for neutropenia in pediatric kidney transplant recipients did not shorten the overall duration of neutropenia but was associated with lower risk of hospitalization. Prospective studies are needed to determine which patients may benefit from G-CSF treatment.

Usability evaluation of a non-invasive neutropenia screening device (PointCheck™) for cancer chemotherapy patients: Observational Study (Preprint)

Background

Patients with cancer undergoing cytotoxic chemotherapy face an elevated risk of developing serious infection as a consequence of their treatment, which lowers their white blood cell count and, more specifically, their absolute neutrophil count. This condition is known as neutropenia. Neutropenia accompanied by a fever is referred to as febrile neutropenia, a common side effect of chemotherapy with a high mortality rate. The timely detection of severe neutropenia (<500 absolute neutrophil count/μL) is critical in detecting and managing febrile neutropenia. Current methods rely on blood draws, which limit them to clinical settings and do not allow frequent or portable monitoring. In this study, we demonstrated the usability of PointCheck, a noninvasive device for neutropenia screening, in a simulated home environment without clinical supervision. PointCheck automatically performs microscopy through the skin of the finger to image the blood flowing through superficial microcapillaries and enables the remote monitoring of neutropenia status, without requiring venipuncture.

Objective

This study aimed to evaluate the usability of PointCheck, a noninvasive optical technology for screening severe neutropenia, with the goal of identifying potential user interface, functionality, and design issues from the perspective of untrained users.

Methods

We conducted a multicenter study using quantitative and qualitative approaches to evaluate the usability of PointCheck across 154 untrained participants. We used a mixed method approach to gather usability data through user testing observations, a short-answer qualitative questionnaire, and a standardized quantitative System Usability Scale (SUS) survey to assess perceived usability and satisfaction.

Results

Of the 154 participants, we found that 108 (70.1%) scored above 80.8 on the SUS across all sites, with a mean SUS score of 86.1 across all sites. Furthermore, the SUS results indicated that, out of the 151 users who completed the SUS survey, 145 (96%) found that they learned how to use PointCheck very quickly, and 141 (93.4%) felt very confident when using the device.

Conclusions

We have shown that PointCheck, a novel technology for noninvasive, home-based neutropenia detection, can be safely and effectively operated by first-time users. In a simulated home environment, these users found it easy to use, with a mean SUS score of 86.1, indicating an excellent perception of usability and placing this device within the top tenth percentile of systems evaluated for usability by the SUS.

Trial Registration

ClinicalTrials.gov NCT04448314; https://clinicaltrials.gov/ct2/show/NCT04448314 (Hospital Universitario 12 de Octubre registration) and NCT04448301; https://clinicaltrials.gov/ct2/show/NCT04448301 (Boston Medical Center registration)

Granulocyte Colony-Stimulating Factor is Safe and Well Tolerated following Allogeneic Transplantation in Patients with Sickle Cell Disease

Granulocyte colony-stimulating factor (G-CSF) used after hematopoietic stem cell transplantation (HSCT) can enhance neutrophil recovery in patients rendered neutropenic by the preparative regimen. G-CSF is contraindicated in patients with sickle cell disease (SCD) as life-threatening complications can ensue in the presence of sickle vasculopathy. However, the safety profile of G-CSF after HSCT for SCD has not been previously described. We report clinical outcomes in the first 100 days post-HSCT in patients supported with G-CSF until neutrophil recovery on a clinical trial of reduced intensity transplantation for SCD. Patients (n=62) received G-CSF for a median of 9 days (range, 5-33) following transplant from the best available stem cell source. Preparation for transplant included a target hemoglobin S level of ≤45%. Neutrophil engraftment (ANC >0.5 × 10³/mL) was achieved at a median of 13 days (range,10-34) and platelet engraftment (>50 × 10³/mL) at a median of 19 days (range, 12-71). The median duration of inpatient hospitalization following stem cell infusion (day 0) was 21.5 days (range 11-33). No patient developed SCD related complications following G-CSF use. The most common organ toxicities encountered between G-CSF commencement (on day +7) and day +100 were anorexia (14), hypertension (11) and electrolyte imbalance requiring correction (9). Central nervous system related events were noted in 5 patients, all with pre-existing cerebral vasculopathy/moyamoya disease and attributed to reversible posterior leukoencephalopathy syndrome (RPLS) in the presence of calcineurin inhibitor therapy and hypertension. We conclude that G-CSF does not adversely impact SCD transplant recipients and can be safely used post-HSCT to enhance neutrophil recovery.

Chemotherapy induced neutropenia and febrile neutropenia among breast cancer patients in a tertiary hospital in Nigeria

Purpose

This study assessed the incidence of chemotherapy-induced neutropenia and febrile neutropenia (FN) while identifying their associated factors.

Methods

A prospective cross-sectional study was conducted among 113 female chemotherapy-naïve breast cancer patients over a 2-year period. Socio-demographic, clinical and haematological data were obtained via semi-structured interviews and from medical case files. Blood samples for complete blood count parameters were collected 2 weeks after each course of chemotherapy. The National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 was used to assess FN, neutropenia and their severity.

Results

The incidence of neutropenia and FN among the patients was 31.9% and 5.3%, respectively. Throughout all courses of chemotherapy (n = 502), there were 57 (11.4%) neutropenic episodes with 6.6% mild, 3.4% moderate and 1.4% severe neutropenia. The incidence of neutropenia decreased with increasing chemotherapy courses, with a rate of 14.2% and 4.9% after the first and last course, respectively. Factors associated with the risk of developing neutropenia include increasing age (p = 0.014), Eastern Cooperative Oncology Group performance score ≥ 1 at presentation (p = 0.033) and presence of bone metastasis (p = 0.002).

Conclusion

One in three breast cancer patients in this study developed neutropenia while on chemotherapy but no independent risk factors were identified for FN among these patients. This study has, therefore, provided the preliminary data necessary for further independent validation of the identified risk factors for FN in a more robust and well-designed study within our clinical practice setting in Nigeria.

Management of chemotherapy-induced neutropenia in patients with cancer: 2019 guidelines of the Italian Medical Oncology Association (AIOM)

Neutropenia is the most frequent side effect of commercially available myelosuppressive drugs and its most significant complication is febrile neutropenia. It is associated with increased hospital admissions and higher probability of death. Prophylaxis with the administration of granulocyte colony-stimulating factor can prevent neutropenia caused by anticancer drugs. The correct administration of these drugs and the management of febrile neutropenia are extremely important in the treatment of patients with cancer.

Development of an improved murine model of necrotizing enterocolitis shows the importance of neutrophils in NEC pathogenesis

Various research models to induce necrotizing enterocolitis (NEC) in animals exist, yet significant differences in NEC severity between murine animal models and human patients persist. One possible explanation for the difference in severity may be the variance in neutrophil concentration among newborn humans (50-70%) in comparison to neonatal mice (10-25%). However, neutrophil activity has yet to be evaluated in NEC pathogenesis. Thus, the aim of the study was to evaluate the effects of altered neutrophil concentrations in neonatal mice while simultaneously undergoing a NEC induction. A total of 44 neonatal mice were included in this study and 40 were subjected to an established NEC induction paradigm and 4 were assigned a sham group. Of the 40 mice, 30 received granulocyte-colony stimulating factor (G-CSF) on a daily basis, while 10 were used as controls (receiving inactivated G-CSF). Mice undergoing G-CSF treatment were further divided into two subgroups: (1) wildtype and (2) ELANE-knockout (KO). ELANE - KO mice are incapable of producing neutrophil elastase (NE) and were used to evaluate the role of neutrophils in NEC. For each of the groups, the following metrics were evaluated: survival, NEC severity, tissue damage, neutrophil count and activation, and NETs formation. An improved murine model of NEC was developed using (1) Lipopolysaccharides and Neocate gavage feeding, (2) hypoxia, and (3) G-CSF administration. The results suggest that the addition of G-CSF resulted in significantly elevated NEC manifestation rates with consequent tissue damage and intestinal inflammation, without affecting overall mortality. Animals without functioning NE (ELANE-KO) appeared to have been protected from NEC development. This study supports the importance of neutrophils in NEC pathogenesis. The optimized NEC induction paradigm, using G-CSF administration, resulted in elevated neutrophil counts, resembling those of neonatal humans. Elevation of neutrophil levels significantly improved NEC disease manifestation by modeling human physiology more accurately than current NEC models. Thus, in the future, murine NEC experiments should include the elevation of neutrophil levels to improve the transition of research findings from mice to humans.

Clinical role of filgrastim in the management of patients at risk of prolonged severe neutropenia: An evidence-based review

BACKGROUND

Patients undergoing chemotherapy are at risk of toxicity, especially of haematological origin. Granulocyte depletion, although often underestimated, can lead to the occurrence of an event defined as febrile neutropenia (FN). Neutropenic fever syndromes are dangerous because they cause major complications in around 25%-30% of patients and have a mortality rate of up to 11%. Treatment for FN was limited to antibiotics and supportive therapies until filgrastim was approved for use in the 1990s.

OBJECTIVES

The present systematic review focuses on the efficacy and safety of this haematopoietic growth factor.

DATA SOURCES AND METHODS

For this review, a systematic literature search of electronic databases and references from recent reviews up to December 2018 was carried out to identify clinical trials, observational studies and case reports evaluating filgrastim efficacy and safety. English language was defined as a restriction. Published randomised controlled trials (RCTs), case reports and reviews analysing the effects of filgrastim on severe neutropenia and its limits were considered. Four review authors independently selected the studies, assessed the risk of bias and extracted study data.

RESULTS

As reported in ASCO guidelines, the efficacy of filgrastim with respect to placebo or no treatment in RCTs is based on its prevention of FN. A recent meta-analysis analysed nine RCTs with 2197 patients, revealing a reduction in the incidence of FN with filgrastim (risk ratio [RR] 0.63, 95% CI 0.53-0.75). These findings were further confirmed in two observational studies. Bone pain is the most commonly reported adverse event with filgrastim, while other toxicities are associated with filgrastim efficacy and with an increased neutrophil count.

KEY FINDINGS

In conclusion, our findings attest to the previous results on the efficacy and safety of filgrastim.

Strategies to generate functionally normal neutrophils to reduce infection and infection-related mortality in cancer chemotherapy

Neutrophils form an essential part of innate immunity against infection. Cancer chemotherapy-induced neutropenia (CCIN) is a condition in which the number of neutrophils in a patient's bloodstream is decreased, leading to increased susceptibility to infection. Granulocyte colony-stimulating factor (GCSF) has been the only approved treatment for CCIN over two decades. To date, CCIN-related infection and mortality remain a significant concern, as neutrophils generated in response to administered GCSF are functionally immature and cannot effectively fight infection. This review summarizes the molecular regulatory mechanisms of neutrophil granulocytic differentiation and innate immunity development, dissects the biology of GCSF in myeloid expansion, highlights the shortcomings of GCSF in CCIN treatment, updates the recent advance of a selective retinoid agonist that promotes neutrophil granulocytic differentiation, and evaluates the benefits of developing GCSF biosimilars to increase access to GCSF biologics versus seeking a new mode to fundamentally advance GCSF therapy for treatment of CCIN.

Increase in short-term risk of rejection in heart transplant patients receiving granulocyte colony-stimulating factor

BACKGROUND

Neutropenia is a significant adverse event after heart transplantation (HT) and increases infection risk. Granulocyte colony-stimulating factor (G-CSF) is commonly used in patients with neutropenia. In this work, we assessed the adverse effects of G-CSF treatment in the setting of a university hospital.

METHODS

Data on HT patients from January 2008 to July 2016 were reviewed. Patients who received G-CSF were identified and compared with patients without a history of therapy. Baseline characteristics, rejection episodes, and outcomes were collected. Data were analyzed by incidence rates, time to rejection and survival were analyzed using Kaplan-Meier curves, and odds ratios were generated using logistic regression analysis.

RESULTS

Two hundred twenty-two HT patients were studied and 40 (18%) received G-CSF for a total of 85 total neutropenic events (0.79 event/patient year). There were no differences in baseline characteristics between the groups. In the 3 months after G-CSF, the incidence rate of rejection was 0.067 event/month. In all other time periods considered free of G-CSF effect, the incidence rate was 0.011 event/month. This rate was similar to the overall incidence rate in the non-GCSF group, which was 0.010 event/month. There was a significant difference between the incidence rates in the G-CSF group at 0 to 3 months after G-CSF administration and the non-GCSF group (p = 0.04), but not for the other time periods (p = 0.5). Freedom from rejection in the 3 months after G-CSF administration was 87.5% compared with 97.5% in the non-GCSF group (p = 0.006).

CONCLUSIONS

G-CSF administration was found to be associated with significant short-term risk of rejection. This suggests the need for increased surveillance during this time period.

Adequate Neutrophil Responses and Non-Inferior Clinical Outcomes Can Be Achieved by a Two-Day Course of Low-Dose Filgrastim: A Retrospective Single Institution Experience

Background

Filgrastim is used in the setting of chemotherapy-induced neutropenia to stimulate recovery of bone marrow, which allows for further chemotherapy administration without delay. The recommended dose is 5 ug/kg. The commercially available vials of the drug come in two strengths; 300 ug and 480 ug. Due to these limitations in dosage formulations, it is a frequent occurrence to administer a lower dosage to patients weighing more than 60 kg, in whom the ideal dose would have been more than 300 ug but less than 480 ug. It is also a frequent practice to administer the drug for two consecutive days as it often leads to adequate response that will render patients eligible for their next cycle administration.

Objective

To determine whether a course of 300 ug of filgrastim administered daily for two consecutive days was as successful at reducing chemotherapy-induced neutropenia-related complications in patients with a higher weight (>60 kg) and hence receiving suboptimal dose as compared to those with weight less than 60 kg who are receiving the recommended dose.

Methods

We identified 91 patients from our facility with chemotherapy-induced neutropenia treated with 300 ug of filgrastim daily for two consecutive days, and we separated them into low, medium, and high weight groups. Multivariate logistic regression models examined correlations between outcomes (e.g., increases in absolute neutrophil count) and predictors (e.g., weight groups).

Results

The vast majority of encounters demonstrated rises in white blood cell (WBC) and absolute neutrophil count (ANC). Infection rates were not significantly different between low and medium weight groups (5% vs 0%; p = 0.1658), but the high weight group’s infection rate was significantly higher than the medium weight group (5% vs 33%; p = 0.001). The high weight group did have an increased rate of febrile neutropenia as compared to medium and low weight groups, but these differences were not significant. Incidences of chemotherapy delay and dose reduction were comparable across the three weight groups.

Limitations

Retrospective study, small sample size, heterogeneous cancer sites and different chemotherapy regimens administered limit generalizability of findings.

Conclusion

Patients with weights <85 kg receiving a two-day course of 300 ug of filgrastim have similar neutropenia-related complication rates with a potential percent cost-savings of roughly 43%.

Neutrophils in critical illness

During critical illness, dramatic alterations in neutrophil biology are observed including abnormalities of granulopoeisis and lifespan, cell trafficking and antimicrobial effector functions. As a result, neutrophils transition from powerful antimicrobial protectors into dangerous mediators of tissue injury and organ dysfunction. In this article, the role of neutrophils in the pathogenesis of critical illness (sepsis, trauma, burns and others) will be explored, including pathological changes to neutrophil function during critical illness and the utility of monitoring aspects of the neutrophil phenotype as biomarkers for diagnosis and prognostication. Lastly, we review findings from clinical trials of therapies that target the harmful effects of neutrophils, providing a bench-to-bedside perspective on neutrophils in critical illness.

Filgrastim (G-CSF) loaded liposomes: mathematical modeling and optimization of encapsulation efficiency and particle size

Introduction: Optimization of filgrastim (G-CSF) (granulocyte colony stimulating factor) liposomes formulation prepared by the method of film hydration was the aim of this research.

Methods: To study the independent variables effects in the development of filgrastim (G-CSF) liposomes, method of factorial design was applied. The molar ratio of dipalmitoyl phophatidylcholine (DPPC) per cholesterol (Chol.) and hydration time were chosen as two independent factors. The dependent variables were encapsulation efficiency percent (EE %) and particle size (PS). Ultrafiltration method was applied for separation of un-encapsulated protein. RP-HPLC method was employed for analysis of G-CSF.

Results: Application of response surface methodology (RSM) in formulation of filgrastim liposomes and the obtained results for responses including particle size and EE % showed that the main effective independent variable was DPPC/Chol molar ratio. Different impacts of influencing parameters including interaction and individual effects were checked employing a mathematical method for obtaining desired liposomes. Optimum liposomal formulations were established using this method for enhancing their characteristics. Average percent errors (APEs) were 3.86% and 3.27% for predicting EE % and PS, respectively which reflect high model ability in this regard.

Conclusion: It is concluded that observed and predicted values regarding PS and EE % were consistent and this model is efficient enough in prediction of the mentioned characteristics while preparing filgrastim (G-CSF) liposomes.

Am80-GCSF synergizes myeloid expansion and differentiation to generate functional neutrophils that reduce neutropenia-associated infection and mortality

Neutrophils generated by granulocyte colony‐stimulating factor (GCSF) are functionally immature and, consequently, cannot effectively reduce infection and infection‐related mortality in cancer chemotherapy‐induced neutropenia (CCIN). Am80, a retinoic acid (RA) agonist that enhances granulocytic differentiation by selectively activating transcription factor RA receptor alpha (RARα), alternatively promotes RA‐target gene expression. We found that in normal and malignant primary human hematopoietic specimens, Am80‐GCSF combination coordinated proliferation with differentiation to develop complement receptor‐3 (CR3)‐dependent neutrophil innate immunity, through altering transcription of RA‐target genes RARβ_2,C/EBPε, CD66,CD11b, and CD18. This led to generation of functional neutrophils capable of fighting infection, whereas neutralizing neutrophil innate immunity with anti‐CD18 antibody abolished neutrophil bactericidal activities induced by Am80‐GCSF. Further, Am80‐GCSF synergy was evaluated using six different dose‐schedule‐infection mouse CCIN models. The data demonstrated that during “emergency” granulopoiesis in CCIN mice undergoing transient systemic intravenous bacterial infection, Am80 effect on differentiating granulocytic precursors synergized with GCSF‐dependent myeloid expansion, resulting in large amounts of functional neutrophils that reduced infection. Importantly, extensive survival tests covering a full cycle of mouse CCIN with perpetual systemic intravenous bacterial infection proved that without causing myeloid overexpansion, Am80‐GCSF generated sufficient numbers of functional neutrophils that significantly reduced infection‐related mortality in CCIN mice. These findings reveal a differential mechanism for generating functional neutrophils to reduce CCIN‐associated infection and mortality, providing a rationale for future therapeutic approaches.

Is pegfilgrastim appropriate for the treatment of established febrile neutropenia?

Objective. To report a case where both pegfilgrastim and filgrastim were considered in the treatment of febrile neutropenia in a hospitalized patient and assess the most cost-effective option.

Case summary. A 77-year-old white female was diagnosed with squamous cell carcinoma of the anus and adjuvant chemotherapy was ordered. She subsequently developed Grade 4 neutropenia, a wound infection and her Eastern Cooperative Oncology Group (ECOG) performance status declined to 4. Antibiotics were started and growth factor therapy was considered as part of her treatment. Filgrastim 480 g subcutaneously every day was chosen and her absolute neutrophil count (ANC) recovered after seven days of therapy.

Discussion. This case illustrates the potential cost benefits of using filgrastim over pegfilgrastim in hospitalized patients. The choice of filgrastim in our patient resulted in only seven days of filgrastim therapy at a cost of $2205.70. A 6 mg dose of pegfilgrastim is priced similarly to 10 days of filgrastim 480 g, therefore a cost savings of $744.01 was realized in our patient.

Conclusions. Filgrastim is the most appropriate growth factor for the treatment of established high-risk febrile neutropenia given that the ANC can be monitored on a daily basis and therapy can be discontinued upon recovery.

Prophylactic antibiotics or G(M)-CSF for the prevention of infections and improvement of survival in cancer patients receiving myelotoxic chemotherapy

BACKGROUND

Febrile neutropenia (FN) and other infectious complications are some of the most serious treatment-related toxicities of chemotherapy for cancer, with a mortality rate of 2% to 21%. The two main types of prophylactic regimens are granulocyte (macrophage) colony-stimulating factors (G(M)-CSF) and antibiotics, frequently quinolones or cotrimoxazole. Current guidelines recommend the use of colony-stimulating factors when the risk of febrile neutropenia is above 20%, but they do not mention the use of antibiotics. However, both regimens have been shown to reduce the incidence of infections. Since no systematic review has compared the two regimens, a systematic review was undertaken.

OBJECTIVES

To compare the efficacy and safety of G(M)-CSF compared to antibiotics in cancer patients receiving myelotoxic chemotherapy.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, databases of ongoing trials, and conference proceedings of the American Society of Clinical Oncology and the American Society of Hematology (1980 to December 2015). We planned to include both full-text and abstract publications. Two review authors independently screened search results.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing prophylaxis with G(M)-CSF versus antibiotics for the prevention of infection in cancer patients of all ages receiving chemotherapy. All study arms had to receive identical chemotherapy regimes and other supportive care. We included full-text, abstracts, and unpublished data if sufficient information on study design, participant characteristics, interventions and outcomes was available. We excluded cross-over trials, quasi-randomised trials and post-hoc retrospective trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the search strategies, extracted data, assessed risk of bias, and analysed data according to standard Cochrane methods. We did final interpretation together with an experienced clinician.

MAIN RESULTS

In this updated review, we included no new randomised controlled trials. We included two trials in the review, one with 40 breast cancer patients receiving high-dose chemotherapy and G-CSF compared to antibiotics, a second one evaluating 155 patients with small-cell lung cancer receiving GM-CSF or antibiotics.We judge the overall risk of bias as high in the G-CSF trial, as neither patients nor physicians were blinded and not all included patients were analysed as randomised (7 out of 40 patients). We considered the overall risk of bias in the GM-CSF to be moderate, because of the risk of performance bias (neither patients nor personnel were blinded), but low risk of selection and attrition bias.For the trial comparing G-CSF to antibiotics, all cause mortality was not reported. There was no evidence of a difference for infection-related mortality, with zero events in each arm. Microbiologically or clinically documented infections, severe infections, quality of life, and adverse events were not reported. There was no evidence of a difference in frequency of febrile neutropenia (risk ratio (RR) 1.22; 95% confidence interval (CI) 0.53 to 2.84). The quality of the evidence for the two reported outcomes, infection-related mortality and frequency of febrile neutropenia, was very low, due to the low number of patients evaluated (high imprecision) and the high risk of bias.There was no evidence of a difference in terms of median survival time in the trial comparing GM-CSF and antibiotics. Two-year survival times were 6% (0 to 12%) in both arms (high imprecision, low quality of evidence). There were four toxic deaths in the GM-CSF arm and three in the antibiotics arm (3.8%), without evidence of a difference (RR 1.32; 95% CI 0.30 to 5.69; P = 0.71; low quality of evidence). There were 28% grade III or IV infections in the GM-CSF arm and 18% in the antibiotics arm, without any evidence of a difference (RR 1.55; 95% CI 0.86 to 2.80; P = 0.15, low quality of evidence). There were 5 episodes out of 360 cycles of grade IV infections in the GM-CSF arm and 3 episodes out of 334 cycles in the cotrimoxazole arm (0.8%), with no evidence of a difference (RR 1.55; 95% CI 0.37 to 6.42; P = 0.55; low quality of evidence). There was no significant difference between the two arms for non-haematological toxicities like diarrhoea, stomatitis, infections, neurologic, respiratory, or cardiac adverse events. Grade III and IV thrombopenia occurred significantly more frequently in the GM-CSF arm (60.8%) compared to the antibiotics arm (28.9%); (RR 2.10; 95% CI 1.41 to 3.12; P = 0.0002; low quality of evidence). Neither infection-related mortality, incidence of febrile neutropenia, nor quality of life were reported in this trial.

AUTHORS' CONCLUSIONS

As we only found two small trials with 195 patients altogether, no conclusion for clinical practice is possible. More trials are necessary to assess the benefits and harms of G(M)-CSF compared to antibiotics for infection prevention in cancer patients receiving chemotherapy.

[Granulocyte- colony stimulating factor (G-CSF) use in clinical practice in patients receiving chemotherapy for breast cancer: The Opaline Study]

OBJECTIVES

To describe the French routine use of G-CSF in patients treated for breast cancer as per the EORTC recommendations.

PATIENTS AND METHODS

A prospective multicenter observational study conducted between February 2008 and September 2009 in 869 breast cancer patients treated by chemotherapy (CT) and for whom G-CSF treatment will be delivered in primary (PP) or secondary prophylaxis.

RESULTS

The mean age was 55 years. A total of 80.3% of CT was in neoadjuvant/adjuvant setting (NAS). PP was delivered in 78.9% of the NAS patients and 67.5% in metastatic situation. Of the 702 evaluable patients, incidences of severe (SN) and febrile neutropenias (FN) in patients who received PP were 9.3% and 4.2%, respectively. In patients who did not received G-CSF at first cycle, SN and FN were 12.4% and 7.3%, respectively. The use of PP was mainly driven by the type of CT for patients treated in the NAS and by patient or disease related risk factors in the locally advanced/metastatic setting.

CONCLUSION

This study has shown that the use of G-CSF was in accordance with the 2010 updates of the EORTC recommendations. However, G-CSF appears more widely used in the routine practice.

Attitudes and practice patterns for maintaining relative dose intensity of chemotherapy in outpatient clinics: results of a Japanese web-based survey

Background

This analysis was undertaken to evaluate the practice patterns of Japanese physicians regarding curative-intent chemotherapy, especially in outpatient settings, and to define factors negatively affecting the maintenance of relative dose intensity (RDI).

Methods

We performed a web-based questionnaire survey of Japanese physicians involved in malignant lymphoma chemotherapy (Group ML) or in breast cancer chemotherapy (Group BC). The questionnaire inquired how they manage low-risk febrile neutropenia (FN) caused by initial chemotherapy for diffuse large B-cell lymphoma(DLBCL) or by adjuvant chemotherapy for breast cancer in an outpatient setting.

Results

Valid responses were obtained from 185 physicians in Group ML and 160 in Group BC. In Group ML, 76 % (n = 141) of the physicians were board-certified hematologists, while 82 % (n = 131) of the physicians in Group BC were board-certified surgeons. A significantly higher proportion of physicians in Group ML responded that “dose reduction is not required for the subsequent course of chemotherapy after the first episode of FN” than in Group BC (ML versus BC; 77 % versus 31 %; P < 0.001). Significantly higher proportions of physicians in Group ML were more likely to prophylactically administer antibiotics or granulocyte-colony stimulating factor (G-CSF; ML versus BC; antibiotics: 36 % versus 26 %, P = 0.049; G-CSF: 25 % versus 16 %, P = 0.047). Eighty six percent (n = 159) of Group ML and 70 % (n = 112) of Group BC responded that “emergency outpatient unit is open at all hours”.

Conclusions

Japanese physicians are more likely to administer reduced doses of chemotherapy to patients with breast cancer than to patients with malignant lymphoma. Supportive infrastructures should be improved to ensure the provision of adequate chemotherapy to all cancer patients.

Granulocyte colony-stimulating factors as prophylaxis against febrile neutropenia

Myelosuppression secondary to chemotherapy remains a serious adverse effect of cancer therapy that causes high morbidity and mortality. Several current European and American guidelines recommend consideration of primary prophylaxis with colony-stimulating factors (CSFs) when the risk of febrile neutropenia is higher than 20 %. The main factors associated with a high risk of febrile neutropenia include the chemotherapy regimen, tumor type, and patient-related factors such as old age and/or comorbidities. The purpose of this paper is to summarize the most relevant clinical trials and updated recommendations of the main guidelines on the role of granulocyte colony-stimulating factors (G-CSFs) in febrile neutropenia, examining whether the combination of G-CSF with chemotherapy improves overall survival. Future directions for G-CSF use are also discussed.

Comments on the mechanisms of action of radiation protective agents: basis components and their polyvalence

Purpose

These comments suggest a division of radiation protective agents on the grounds of their mechanism of action that increase the radio resistance of an organism.

Conclusion

Given below is the division of radiation protective agents on the basis of their mechanism of action into 3 groups: 1) Radiation protective agents, with the implementation of radiation protective action taking place at the cellular level in the course of rapidly proceeding radiation-chemical reactions. At the same time, when the ionizing radiation energy is absorbed, these agents partially neutralize the “oxygen effect” as a radiobiological phenomenon, especially in the radiolysis of DNA; 2) Radiation protective agents that exert their effect at the system level by accelerating the post-radiation recovery of radiosensitive tissues through activation of a number of pro-inflammatory signaling pathways and an increase in the secretion of hematopoietic growth factors, including their use as mitigators in the early period after irradiation prior to the clinical development of acute radiation syndrome (ARS). 3) Radiomodulators including drugs and nutritional supplements that can elevate the resistance of the organism to adverse environmental factors, including exposure to ionization by means of modulating the gene expression through a hormetic effect of small doses of stressors and a “substrate” maintenance of adaptive changes, resulting in an increased antioxidant protection of the organism. Radiation protective agents having polyvalence in implementation of their action may simultaneously induce radioprotective effect by various routes with a prevalence of basis mechanisms of the action.

Pharmacoeconomics of granulocyte colony-stimulating factor: a critical review

INTRODUCTION

In the USA, neutropenia-related hospitalization is estimated to occur in 34.2 cases per 1,000 chemotherapy-treated patients. The cost of hospitalization is significant with estimates ranging, on average, from $10,000 to $30,000 per neutropenia-related hospitalization. Prophylactic use of granulocyte colony-stimulating factor (G-CSF) significantly reduces the risk and duration of neutropenia-related negative events. However, the exact economic benefits of using G-CSF prophylactically are not completely known. The objective of this review is to examine the cost of G-CSF as primary prophylaxis (PP) as well as when used reactively to treat severe neutropenia (SN) or febrile neutropenia (FN).

METHODS

Electronic databases were searched for studies published up to January 2014.

RESULTS

The evidence supporting the cost-effectiveness of PP use of G-CSF is inconsistent. The cost savings of PP use of G-CSF associated with the reduction of neutropenia-related events are offset by the increased costs associated with improved chemotherapy administration. Cost savings due to the reduction in mortality and disease/symptoms and use of dose-dense regimens have not been adequately incorporated into previous cost-effectiveness studies. Available data suggest that using G-CSF in conjunction with antibiotics is more cost-effective than antibiotics alone when treating patients with SN/FN. Recent studies of biosimilars suggest that they are as effective as originator G-CSFs and, given their lower cost, could represent a cost-effective alternative. Finally, studies have not taken into consideration the indirect patient costs of experiencing a neutropenia-related event.

CONCLUSION

G-CSF use is effective in preventing SN/FN. Costs due to hospitalization and other neutropenia-related events are lower in patients treated with G-CSF as PP versus untreated patients. Despite this, many studies have not found solid evidence for the overall cost-effectiveness of PP use of G-CSF. One possibility for this is that patients receiving G-CSF prophylactically often receive more intense chemotherapy regimens, have better relative dose intensity, and fewer dose delays, and thereby have greater costs associated with chemotherapy administration than patients who do not receive G-CSF.

Febrile neutropenia in hematologic malignancies

Febrile neutropenia (FN) can occur at any time during the course of a malignancy, especially hematologic malignancies, from diagnosis to end-stage disease. The majority of FN episodes are typically confined to the period of initial diagnosis and active treatment. Because of suppressed inflammatory responses, fever is often the sole sign of infection. As FN is a true medical emergency, prompt identification of and intervention in FN can prolong survival and improve quality of life. This article reviews FN in the setting of hematologic malignancies, specifically myelodysplastic syndromes and acute leukemias, providing an overview of the definition of fever and neutropenia, diagnostic approach, categories of risk/risk assessment, management in patients at low and high risk, and prophylaxis of infections.

Granulocyte colony-stimulating factor receptor mutations in myeloid malignancy

Granulocyte colony-stimulating factor is a cytokine able to stimulate both myelopoiesis and hematopoietic stem cell mobilization, which has seen it used extensively in the clinic to aid hematopoietic recovery. It acts specifically via the homodimeric granulocyte colony-stimulating factor receptor (G-CSFR), which is principally expressed on the surface of myeloid and hematopoietic progenitor cells. A number of pathogenic mutations have now been identified in CSF3R, the gene encoding G-CSFR. These fall into distinct classes, each of which is associated with a particular spectrum of myeloid disorders, including malignancy. This review details the various CSF3R mutations, their mechanisms of action, and contribution to disease, as well as discussing the clinical implications of such mutations.

Use of colony-stimulating factor in patients with ovarian cancer receiving paclitaxel and carboplatin in Japan

OBJECTIVE

To assess the use of colony-stimulating factors (CSFs) in patients with ovarian cancer who receive adjuvant paclitaxel and carboplatin chemotherapy in clinical practice and to assess whether the frequency of CSF use differs among hospitals in Japan.

METHODS

CSF use in patients with ovarian cancer who received first-line paclitaxel and carboplatin was analyzed retrospectively using data from the Japanese hospitalization payment system.

RESULTS

A total of 1,050 patients at 104 hospitals were identified. The median age was 60 years (range, 22 to 88 years). Of these, 163 patients (15.5%) were diagnosed with neutropenia and 134 patients (12.8%) received CSFs. Among the patients who received CSFs, 125 (93%) received them for the treatment of neutropenia without fever and 1 received them for febrile neutropenia. In total, CSFs were administered for 272 cycles of chemotherapy. Among them, CSFs were used as treatment for neutropenia without fever in 259 cycles (95%), as prophylaxis (primary or secondary) in 12 cycles (4%), and as treatment for febrile neutropenia in 1 cycle. Among hospitals, a median of 4.0% of patients received CSFs with an interquartile range of 25% (Q1, 0%; Q3, 25%). A logistic random effects model showed that the variation in the proportion of patients receiving CSFs among the 104 hospitals was 2.0 (p<0.001), suggesting that the use of CSFs varied across hospitals.

CONCLUSION

Most patients received CSFs for neutropenia without fever. Standardized and evidence-based use of CSFs is critically required among hospitals in Japan.

Temporal and Geographic Variations in the Receipt of Colony-Stimulating Factors and Erythropoiesis-Stimulating Agents in a Large Retrospective Cohort of Older Women With Breast Cancer From 2000 to 2009

The purpose of this study was to use the most recent national data for a large cohort of patients diagnosed with breast cancer to evaluate temporal trend of receiving hematopoietic growth factors from 2000 to 2009 and to examine significant factors associated with increasing trends and geographic variations. We identified 26,130 women aged 65-89 years who were diagnosed with breast cancer and received chemotherapy in 2000-2009 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Colony-stimulating factors (CSFs) were identified if there was a claim from the following procedure codes: filgrastim, pegfilgrastim, or sargramostim. Erythropoiesis-stimulating agents (ESAs) were identified if there was a claim from the following procedure codes: epoetin or darbepoetin. Overall, 51.7% of patients with breast cancer received CSFs, which increased from 21.7% in 2000 to 63.2% in 2009. The percentage of patients receiving pegfilgrastim increased from 2.7% in 2000 to 19.5% in 2003 and then continuously to 49.7% in 2009. The overall percentage of patients receiving ESAs was 39.3%, which increased from 26.4% in 2000 to 60.8% in 2006, and then decreased significantly from 40.7% in 2007 to 12.9% in 2009. The receipt of both CSFs and ESAs differed significantly across different geographic areas. The receipt of CSFs continued to increase from 2000 to 2009, and pegfilgrastim started to replace filgrastim since 2003. The receipt of ESAs increased until 2006 and then declined substantially due to the black box warning. There were substantial geographic variations in the use of these hematopoietic growth factors.

Retinoid agonist Am80-enhanced neutrophil bactericidal activity arising from granulopoiesis in vitro and in a neutropenic mouse model

Despite advances in the therapeutic use of recombinant granulocyte colony-stimulating factor (G-CSF) to promote granulopoiesis of human hematopoietic stem cells (HSCs), neutropenia remains one of the most serious complications of cancer chemotherapy. We discovered that retinoid agonist Am80 (tamibarotene) is more potent than G-CSF in coordinating neutrophil differentiation and immunity development. Am80-induced neutrophils (AINs) either in vitro or in neutropenic mouse model displayed strong bactericidal activities, similar to those of human peripheral blood neutrophils (PBNs) or mouse peripheral blood neutrophils (MPBNs) but markedly greater than did G-CSF–induced neutrophils (GINs). In contrast to GINs but similar to PBNs, the enhanced bacterial killing by AINs accompanied both better granule maturation and greater coexpression of CD66 antigen with the integrin β2 subunit CD18. Consistently, anti-CD18 antibody neutralized Am80-induced bactericidal activities of AINs. These studies demonstrate that Am80 is more effective than G-CSF in promoting neutrophil differentiation and bactericidal activities, probably through coordinating the functional interaction of CD66 with CD18 to enhance the development of neutrophil immunity during granulopoiesis. Our findings herein suggest a molecular rationale for developing new therapy against neutropenia using Am80 as a cost-effective treatment option.

Prediction of docetaxel monotherapy-induced neutropenia based on the monocyte percentage

We retrospectively reviewed the medical records of 32 chemonaïve patients with either breast, lung or prostate cancer, who were treated with docetaxel (DOC) monotherapy, and evaluated whether the proportion of peripheral blood monocytes was capable of predicting the occurrence of neutropenia following chemotherapy. In the granulocyte-colony stimulating factor (G-CSF) non‑administration group, the monocyte percentage was inversely correlated with the decrease in neutrophils (P=0.01; corrected correlation coefficient, -0.71). The neutrophil count decreased by ≥30% in 7 of 8 patients with <5% monocytes, whereas it decreased by >30% in 1 of 6 patients with ≥5% monocytes (P=0.01). Three of 8 patients with <5% monocytes experienced grade 4 neutropenia, while in the group with ≥5% monocytes, 1 of 6 patients experienced grade 4 neutropenia. The frequency of grade 3 or 4 neutropenia was lower in patients with ≥5% monocytes than in patients with <5% monocytes, but the difference was not significant (P=0.41). Following G-CSF administration, grade 3 or 4 neutropenia had the tendency of lasting longer in patients with <5% monocytes than in those with ≥5% monocytes; however, the monocyte percentage was not correlated with the grade of neutropenia (P=0.34). The monocyte percentage following chemotherapy was inversely correlated with the decrease in neutrophils. The percentage of monocytes that are available in clinical practice may be predictive of neutropenia following chemotherapy. Our findings suggest that patients with <5% monocytes following DOC monotherapy are at risk of severe neutropenia and should be carefully monitored.

Evaluation of infection control advice for patients at risk of chemotherapy-induced neutropenia in 2 pediatric oncology centers: Cape Town, South Africa, and Newcastle-Upon-Tyne, UK

Childhood cancers are treated with myelotoxic chemotherapy. Resultant neutropenia can lead to life-threatening infections. There is no consistent guidance on infection control precautions for neutropenic patients who are not yet febrile or infected. Although it is not possible to eradicate infection risk, it is conceivable that the risk could be reduced by effective infection prevention. This study compared infection control measures advised to pediatric and adolescent oncology patients receiving chemotherapy in 2 centers (Cape Town, South Africa, and Newcastle, UK). Prospective, observational, cross-sectional surveys of staff and patients/parents were undertaken using standardized, study-specific questionnaires. Seventy-eight staff and 56 patients/parents participated. Precautions advised in Newcastle were significantly different to Cape Town (all P < .05), except both agreed inpatient isolation was unnecessary. Over 40% of patients/parents felt isolation was important (P < .01). In Cape Town, staff and patients had similar views. In Newcastle, patients/parents had stricter opinions on particular precautions than staff, for example, attending school, playing outside and avoiding busy places (P < .01). Patient/parent responses were similar between centers. Over 90% of staff felt advising patients/parents about hand washing was important. Currently infection prevention advice is inconsistent. Further research is needed to elucidate effective guidance for infection prevention in pediatric neutropenic patients.

Development and calibration of a standard for the protein content of granulocyte colony-stimulating factor products

This collaborative study characterizes a homogeneous standard for the protein content determination of granulocyte colony-stimulating factor (G-CSF) products with traceability of the measurement. The Kjeldahl method was used to determine the average protein content of G-CSF bulk as 2.505 mg/ml (95% C.I: 2.467-2.543 mg/ml, GCV 4.0%). Using G-CSF bulk as a traceability benchmark, the protein content of the final freeze-dried standard using reverse phase HPLC (RP-HPLC) was 215.4 μg protein per ampoule (95% C.I: 212.407-218.486 μg/ampoule, GCV 3.4%). A comparative study showed that there was no difference between using Filgrastim CRS (European Pharmacopeia G-CSF reference standard) and freeze-dried homogeneous standard when quantifying G-CSF protein content by RP-HPLC (P > 0.05). However, there were significant differences in the G-CSF protein content obtained using a serum albumin standard by Lowry assay and a G-CSF standard with RP-HPLC. Therefore, use of RP-HPLC with a freeze-dried homogeneous standard would eliminate the systematic errors introduced when using a serum albumin standard because of the differences in protein composition between the standard and the sample. It would also be helpful to use this method to compare the quality of G-CSF biosimilar products in situations where the protein content has been calibrated using various standards.

Optimal use of recombinant granulocyte colony-stimulating factor with chemotherapy for solid tumors

Neutropenia is a frequent complication of anticancer chemotherapy (CT) often associated with life-threatening infections, hospitalization, dose reduction and/or delay in the administration of CT. Administration of recombinant granulocyte colony-stimulating factor (rG-CSF) reduces the duration and the degree of CT-neutropenia. rG-CSF that stimulates both neutropoiesis and neutrophil function, has become an integral part of supportive care during cytotoxic CT, to prevent febrile neutropenia (FN), particularly in patients with a risk of FN ≥ 20%. International guidelines have standardized conditions for rG-CSF administration, however, some 'gray zones' still exist around optimal timing and tailoring of this therapy. We report here the results of a research project aimed to extend the consensus on the optimal use of rG-CSF in association with CT in patient with solid tumours. We also propose a recently developed pharmacodynamic model, based on the biological effects of CT and rG -CSF on bone marrow compartments that clearly indicates within the prophylactic rather than therapeutic setting the better way of rG-CSF administration.

Retracted: Modulation of p53 /Akt / phosphatase and tensin homolog expression by esculetin potentiates the anticancer activity of cisplatin and prevents its nephrotoxicity

This article has been retracted at the request of Editor‐in‐Chief and Authors, and is available online only.

The following article from Cancer Science , ‘Modulation of p53/Akt/phosphatase and tensin homolog expression by esculetin potentiates the anticancer activity of cisplatin and prevents its nephrotoxicity’ (doi: 10.1111/j.1349‐7006.2011.02091.x), by Kulbhushan Tikoo, Abhijit Babaji Shinde, Chanchal Gupta and Gopabandhu Jena, published online on 18 October 2011 in Wiley Online Library (http://onlinelibrary.wiley.com ), has been retracted by agreement between the authors, the journal Editor in Chief, Yusuke Nakamura, and Blackwell Publishing Asia Pty Ltd. The retraction has been agreed due to inappropriate image utilization in relation to Figure 2.

Yusuke Nakamura 
Editor‐in‐Chief 
Cancer Science

Effect of primary prophylactic granulocyte-colony stimulating factor use on incidence of neutropenia hospitalizations for elderly early-stage breast cancer patients receiving chemotherapy

OBJECTIVE

Chemotherapy is vital for breast cancer management, but early-onset toxicities like neutropenia hinder its administration, especially in the elderly. Primary prophylactic (PP) use of granulocyte-colony stimulating factors (G-CSF) helps prevent neutropenia and its complications while receiving chemotherapy. Nevertheless, evidence supporting the effectiveness of PPG-CSF in the elderly is limited. Thus, the American Society of Clinical Oncology (ASCO) guidelines for PPG-CSF use in the elderly are not explicit. This study analyzed the effects of administration of PPG-CSF and duration of administration on the occurrence of chemotherapy-induced neutropenia hospitalizations in elderly breast cancer patients.

METHODS

This retrospective observational study of newly diagnosed breast cancer patients receiving chemotherapy used Surveillance, Epidemiology, and End Results-Medicare data from 1994 to 2003. To account for the nonrandom nature of the observational data, a nonparametric matching technique was used to preprocess the data before parametrically estimating the treatment effects.

RESULTS

Administration of PPG-CSF during the first course chemotherapy reduced neutropenia hospitalizations by 16% within the first 3 months and 17% within the first 6 months of chemotherapy initiation (P < 0.05). Hospitalization rates within the first 3 months of chemotherapy initiation were 3 times higher in women receiving less than 5 consecutive days of PPG-CSF compared with women receiving PPG-CSF for 5 or more days (P < 0.05). Hospitalization rates within the first 1 and 6 months were also lower with longer PPG-CSF duration (≥5 d) (P < 0.10).

CONCLUSIONS

PPG-CSF use is associated with reductions in in-patient healthcare utilization. These findings have implications for ASCO guidelines and Medicare coverage policies for PPG-CSF administration in elderly breast cancer patients.

Granulocyte colony-stimulating factor (filgrastim) in chemotherapy-induced febrile neutropenia

Background:

The use of granulocyte colony-stimulating factors to treat patients with chemotherapy-induced neutropenia is well accepted. To assess whether administration of filgrastim along with standard empiric antibiotic therapy is beneficial for patients with chemotherapy-induced febrile neutropenia (FN), we conducted an open, non-randomized clinical trial.

Materials and Methods:

This was a prospective, open, Phase IV clinical trial in patients receiving chemotherapy for histologically confirmed cancer, with an oral temperature of >38.2°C and absolute neutrophil count (ANC) of <500/mm ³. Filgrastim was administered subcutaneously in a dose of 5 mcg/kg/day, 24 hours after administration of cytotoxic therapy, for up to two weeks or until the ANC reached 10,000 cells/mm ³. The parameters of assessment included duration of neutropenia, fever, hospitalization and antibiotic usage.

Results:

All 24 evaluable patients recovered from neutropenia, fever and FN in a median duration of two days. This result is similar to that reported in earlier studies with filgrastim. Despite the acceleration in recovery from neutropenia and fever, it also reduced the duration of hospital stay and usage of intravenous (IV) antibiotic. Only two adverse events were reported, which were of mild nature.

Conclusion:

Filgrastim, when used in patients with chemotherapy-induced neutropenia, exhibited efficacy in accelerating the recovery from neutropenia and fever comparable to that reported with filgrastim in literature. The data from this study suggest that filgrastim is effective in the treatment of chemotherapy-induced neutropenia and is well tolerated by Indian patients.

[Antineoplastic drug-induced neutropenia: use of granulocyte colony stimulating factors]

Neutropenia is a frequent adverse event of the pharmacologic treatment of cancer. Morbidity and mortality-associated neutropenia can be successfully treated and prevented with granulocyte-colony stimulating factors (G-CSF). European and American Guidelines recommend their prophylactic use when the expected percentage of febrile neutropenia exceeds 20% or there are concomitant risk factors. Afebrile neutropenia is not considered to benefit from G-CSF treatment. Other approved indications include stem cell mobilization, and an adequate delivery of dose-intense and dose-dense chemotherapy regimens.

Predictive factors of poor prognosis in cancer patients with chemotherapy-induced febrile neutropenia

OBJECTIVES

We intended to determine the predictive factors of poor prognosis in cancer patients with chemotherapy-induced febrile neutropenia (FN).

METHODS

From January 1, 2007 to December 31, 2008, 396 episodes of FN in 346 cancer patients were retrospectively analyzed. Clinical and laboratory findings and Multinational Association of Supportive Care in Cancer (MASCC) risk-index score were analyzed and correlated with outcome.

RESULTS

Of the 396 episodes, 73 (18.4%) had serious medical complications including 15 (3.8%) deaths. There was significant difference between unfavorable and favorable outcomes in age, gender, hypotension, tachypnea, duration of fever ≤24 h before admission (44.4% vs. 61.3%), interval of ≤7 days since last chemotherapy (34.2% vs. 16.1%), and duration of neutropenia ≥4 days (34.2% vs. 15.8%; P < 0.05 each), as did C-reactive protein (CRP; 15.0 vs. 7.5 mg dL(-1)) and platelet count (66.4 × 10(3) vs. 123.7 × 10(3) mm(-3);P < 0.001 each). MASCC score was significantly lower in unfavorable outcomes than favorable outcomes (19.0 vs. 24.6, P < 0.001). However, prophylactic antibiotics, treatment with granulocyte colony-stimulating factor (G-CSF), and history of FN were not associated with outcome. On multivariate analysis, MASCC risk-index score (OR 23.2, 95% CI 10.48-51.37), tachypnea (OR 3.61, 95% CI 1.44-9.08), thrombocytopenia (OR 3.41, 95% CI 1.69-6.89), increased CRP (OR 3.23, 95% CI 1.62-6.45), and prolonged neutropenia (OR 2.52, 95% CI 1.21-5.25) were independent predictors of unfavorable outcomes.

CONCLUSION

MASCC risk-index score <21, tachypnea, thrombocytopenia, increased CRP, and prolonged neutropenia may be strongly associated with poor outcomes in cancer patients with FN.

Perioperative management for a patient with chronic pancytopenia: a case of aplastic anemia with persistent neutropenia following preoperative administration of G-CSF

The patient, a 62-year-old male suffering from aplastic anemia for 6 years, was admitted in order to undergo laparoscopic cholecystectomy for cholecystitis. Results of laboratory tests at the time of admission revealed pancytopenia: white blood cell count, 1.94 x 10(3)/microl (neutrophil count, 1.23 x 10(3)/microl); red blood cell count, 2.09 x 10(6)/microl; Hb 7.5 g/dl; and platelet count, 3.7 x 10(4)/microl. The patient received supportive therapy prior to surgery, including blood transfusion of red blood cells, platelets and granulocyte colony-stimulating factor (G-CSF). On the day of surgery, the white blood cell count increased to 3.93 x 10(3)/microl (neutrophil count, 2.75 x 10(3)/microl). Surgery ended with no intraoperative complications, but neutropenia progressed and persisted postoperatively: the neutrophil count decreased to 180/microl at its lowest and stayed at about 400-600/microl. This suggests the possibility that repeated preoperative administration of G-CSF may lead to the depletion of granulocyte precursor cells and thus cause harm. Although the patient fortunately achieved a favorable outcome without severe infection, this case is a stark reminder of the difficulties involved in perioperative supportive therapy for patients with chronic pancytopenia.

Cisplatin overdose: toxicities and management

Cisplatin is one of the most widely used antineoplastic agents in the treatment of solid tumour and haematological malignancies, including cancers of the testes, ovary, bladder, head and neck, oesophagus, stomach and lung, as well as lymphoma and osteosarcoma. Its non-specific targeting commonly results in adverse effects and toxicities affecting the gastrointestinal, renal, neurological and haematological systems even when administered at standard doses. Since cisplatin-related toxicities are dose-dependent, these may be more pronounced in the setting of a cisplatin overdose, resulting in significant morbidity and/or mortality. The incidence of cisplatin overdoses is unknown; however, early-phase clinical trials utilizing high-dose cisplatin, and case reports in the overdose setting have characterized the clinical features associated with cisplatin overdoses, highlighting some therapeutic strategies for consideration. To date, no published guidelines exist for managing a cisplatin overdose. The major toxicities of a cisplatin overdose include nausea and vomiting, renal insufficiency, electrolyte abnormalities, myelosuppression, ototoxicity, peripheral neuropathy, hepatotoxicity and retinopathy. Diarrhoea, pancreatitis, seizures and respiratory failure have also been reported. No specific antidote for cisplatin exists. Key management principles and strategies to lessen toxicities include renoprotection and enhancing drug elimination with aggressive intravenous hydration with or without the use of an osmotic diuretic, and avoidance of nephrotoxic medications. Sodium thiosulfate and plasmapheresis, with or without haemodialysis support, should be strongly considered. Close monitoring of clinical and laboratory parameters, and institution of supportive therapies, including antiemetics and haematopoietic colony stimulating factor support, are warranted. Based on the current literature, experimental therapies such as amifostine, ditiocarb sodium (diethyldithiocarbamate), acetylcysteine, fosfomycin and colestipol are of limited clinical effectiveness and remain investigational. This review serves to highlight the clinical spectrum of toxicities resulting from a cisplatin overdose, to critically appraise the available literature and to present a suggested algorithmic approach for the initial management of a cisplatin overdose.

Spanish Society of Medical Oncology consensus for the use of haematopoietic colony-stimulating factors in cancer patients

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.

Critical care management of cancer patients: cause for optimism and need for objectivity

PURPOSE OF REVIEW

In the 1990s, cancer patients were described as poor candidates for ICU admission on the basis of high mortality rates and management costs. Over the last decade, however, advances in the management of malignancies and organ failures have led to substantial increases in survival. This review discusses current outcomes of critically ill cancer patients and recent insights into prognostic factors. Persistent areas of uncertainty are emphasized.

RECENT FINDINGS

New drugs, diagnostic tools, and management strategies are available for malignancies and organ failures. Survival after ICU admission has increased in patients with solid tumors, hematological malignancies, or autologous hematopoietic cell transplantation. A few patient subgroups remain poor candidates for ICU management (i.e., allogeneic hematopoietic cell transplantation recipients and patients with advanced lung cancer). Careful evaluation of potential benefits from ICU admission is crucial to limit inappropriate ICU admission, nonbeneficial care, and suboptimal resource utilization.

SUMMARY

ICU admission of selected cancer patients leads to meaningful survival. The optimal time of ICU admission needs to be determined, and patient selection criteria by both hemato-oncologists and intensivists should be improved. Long-term studies of overall survival, disease-free survival, and quality of life are needed.