Abstract
ObjectivesTo evaluate the use of granulocyte colony-stimulating factor (G-CSF) prophylaxis in US patients with selected metastatic cancers and chemotherapy-induced febrile neutropenia (FN) incidence and associated outcomes among the subgroup who did not receive prophylaxis.MethodsThis retrospective cohort study was conducted at four US health systems and included adults with metastatic cancer (breast, colorectal, lung, non-Hodgkin lymphoma [NHL]) who received myelosuppressive chemotherapy (2009–2017). Patients were stratified by FN risk level based on risk factors and chemotherapy (low/unclassified risk, intermediate risk without any risk factors, intermediate risk with ≥ 1 risk factor [IR + 1], high risk [HR]). G-CSF use was evaluated among all patients stratified by FN risk, and FN/FN-related outcomes were evaluated among patients who did not receive first-cycle G-CSF prophylaxis.ResultsAmong 1457 metastatic cancer patients, 20.5% and 28.1% were classified as HR and IR + 1, respectively. First-cycle G-CSF prophylaxis use was 48.5% among HR patients and 13.9% among IR + 1 patients. In the subgroup not receiving first-cycle G-CSF prophylaxis, FN incidence in cycle 1 was 7.8% for HR patients and 4.8% for IR + 1 patients; during the course, corresponding values were 16.9% and 15.9%. Most (> 90%) FN episodes required hospitalization, and mortality risk ranged from 7.1 to 26.9% across subgroups.ConclusionIn this retrospective study, the majority of metastatic cancer chemotherapy patients for whom G-CSF prophylaxis is recommended did not receive it; FN incidence in this subgroup was notably high. Patients with elevated FN risk should be carefully identified and managed to ensure appropriate use of supportive care.
Highlights
A common challenge in the treatment of nonmyeloid neoplastic disease is the development of chemotherapyinduced neutropenia [1,2,3,4,5], a condition in which the absolute neutrophil count (ANC) drops below normal (< 0.5 × 109/L or < 1.0 × 109/L with a predicted decrease to
Survival rates have improved, the use of more aggressive myelosuppressive regimens carries considerable risks, including chemotherapy-induced febrile neutropenia (FN), highlighting the increasing importance of granulocyte colony-stimulating factor (G-CSF) prophylaxis among patients in this population for whom its use is recommended. In this retrospective analysis of patients receiving myelosuppressive chemotherapy for metastatic cancer at four US health systems, use of G-CSF prophylaxis varied considerably based on chemotherapy regimen FN risk and presence of patient risk factors for FN, ranging from 13.8% to 48.5% in cycle 1 and 26.2% to 57.5% during the course for IR + 1 and HR patients, respectively
Use of G-CSF prophylaxis varied by cancer type and was greatest among patients with breast cancer and non-Hodgkin lymphoma (NHL) who, consistent with standard of care [11, 25, 26], more commonly received chemotherapy regimens with intermediate or high FN risk (breast cancer: Fig. 1 Prophylaxis with G-CSF in all patients with metastatic cancer and patients with metastatic breast cancer, colorectal cancer, lung cancer, and NHL in cycle 1 (a) and during the treatment coursea (b)
Summary
A common challenge in the treatment of nonmyeloid neoplastic disease is the development of chemotherapyinduced neutropenia [1,2,3,4,5], a condition in which the absolute neutrophil count (ANC) drops below normal (< 0.5 × 109/L or < 1.0 × 109/L with a predicted decrease to 20%) and should be considered in patients with an intermediate risk for FN (10–20%; with ≥ 1 FN risk factor) to reduce the incidence of FN and infection-related complications [6, 11]. Despite available evidence that prophylactic G-CSF is associated with a lower risk of FN, sustained chemotherapy dose intensity, and reduced mortality [15], several studies have reported that many patients for whom prophylaxis is recommended do not receive it in US clinical practice [15,16,17,18]
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