Abstract

To the editor:Febrile neutropenia (FN) constitutes a medical emergencygenerally necessitating admission to hospital for evaluationand administration of broad-spectrum antibiotics. Additionally,FNmayleadtotreatmentdelaysanddosereductionspotentiallycompromising long-term clinical outcomes. Recently, Weyckeret al. reported on the risk of FN in patients receiving emergingchemotherapy regimens, including docetaxel + cyclophospha-mide (TC) and docetaxel + carboplatin + trastuzumab (TCH)[1]. Guidelines from the European Organisation for ResearchandTreatmentofCancerandtheNationalComprehensiveCan-cer Network recommend the use of prophylactic granulocytecolony-stimulatingfactor(G-CSF)whenthechemotherapyreg-imen is associated with a high risk (≥20 % incidence) of FN [2,3]. Many organizations, such as the Pharmaceutical BenefitsScheme in Australia, use these guidelines when determiningfunding for G-CSF. Hence, neither TC nor TCH protocols arefunded for primary prophylaxis of FN in Australia as in thepivotal adjuvant trials the reported incidence of FN with TCand TCH was 5 and 9.6 %, respectively [ 4, 5].Recently, several Australian retrospective studies haveinvestigated the incidence of FN following adjuvant chemo-therapy for early stage breast cancer with TC [6, 7] and TCH[8]. Patients did not receive primary G-CSF or antibiotic pro-phylaxis. Lakhanpal et al. conducted a multicenter audit inseven centers [6]. Of 300 evaluable patients, 73 (24.3 %)developed FN with the incidence higher after cycle one.Gilbar et al. performed a similar study in four institutionsand reported an incidence of 38 % after cycle one and41.7 % (70/168) with all cycles [7]. Gilbar et al. also investi-gated the incidence of FN following TCH chemotherapy [8].After the first cycle, 33.3 % (26/78) of patients developed FNand after all cycles this rose to 41 %. It is very difficult tocompare data from the Weycker study to either the Australianstudiesorthelargeinternational trialsduetothehighpercent-age of patients receiving primary G-CSF prophylaxis (53.7–57.1 %) and antibiotic prophylaxis (7.2–8.3 %). Jones et al.prohibited prophylactic G-CSF but allowed oral antibiotics atthediscretionofthetreatingphysician,Slamonetal.permittedG-CSF at physician discretion, while no primary prophylaxiswas permitted in the Valero et al. and Australian studies [4, 5,9]. It would have been extremely useful for Weycker et al. tohave determined the incidence of FN both with and withoutprimary G-CSF prophylaxis.AsadiagnosiscodeforFNwasnotavailable,Weyckeretal.used codes for neutropenia or infection or fever for patientsidentified from two integrated healthcare claims repositoriesin the USA to determine the incidence of FN [1]. Therefore,itappearsthatapatientwouldbeclassifiedashavingFNiftheywere coded for any or a combination of these three diagnoses.Inclinicaltrials,FNisdefinedaccordingtothecurrentNationalCancer Institute Common Toxicity Criteria at the time of thestudy and relies on the patient having a documented fever inconjunctionwithneutropenia.Infectionisnotarequirement.Amore accurate method would have been for a patient to becoded for both neutropenia and fever.When they compared their data for TC and TCH to otherclinicalstudies,theyhavemadesomeconfusingassumptions.Instead of comparing their incidence of FN directly with therate of FN in the pivotal TC trial, they have comparedagainst

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