Multinational Association Of Supportive Care In Cancer Research Articles

Justification of more expensive antiemetic use with FOLFOX at an ambulatory cancer center.

27 Background: According to NCCN, ASCO, and Multinational Association of Supportive Care in Cancer (MASCC) guidelines, palonosetron in combination with dexamethasone is the preferred 5-HT3 antagonist for use with moderately-emetogenic chemotherapy (MEC). NCCN gives all 5-HT3 antagonists a category one recommendation. Currently at the Massachusetts General Hospital (MGH), ondansetron is the 5-HT3 antagonist of choice due to its significant cost advantage and flexibility in dosing. Palonosetron is currently restricted to use in the second-line setting at MGH based on limitations of the evidence currently available supporting its preferred use. The primary objective of this study is to assess antiemetic utilization in patients receiving FOLFOX +/- bevacizumab(B) in an outpatient infusion unit and measure palonosetron and NK-1 antagonist usage. Methods: A retrospective review was conducted of all outpatient chemotherapy orders for FOLFOX +/- B for a six month period from 11/13-4/14. Prophylactic antiemetic use was evaluated over that time period. Data was captured using electronic MARs, prescription records, and drug utilization reports. Results: 184 patients were identified; 858 FOLFOX +/- B treatments were administered during the study period. For emesis prophylaxis, 74.5% received the MGH standard ondansetron and dexamethasone, 10.3% received palonosetron, 9.8% received an NK-1 antagonist, and 5.4% received a combination of palonosetron plus NK-1 antagonist. Mean patient age was 60.8 years; 59.8% of patients were male; 63.6% had a diagnosis of colorectal cancer; 42.9% had metastatic disease. Conclusions: The majority of patients receiving FOLFOX +/- B were well managed on ondansetron and dexamethasone and did not require the use of more costly antiemetics. However 25.5% of patients required alternative/additional antiemetics, suggesting further investigation to determine which patients could benefit from these therapies up-front may be prudent. Study data support continued use of palonosetron as a second line therapy. Larger, pharmacoeconomic comparison studies are necessary to justify frontline use of palonsetron.

C-reactive protein and the MASCC risk index identify high-risk patients with febrile neutropenia and hematologic neoplasms.

The objective of this study is to assess the prognostic usefulness of the Multinational Association of Supportive Care in Cancer (MASCC) risk score in association with the value of C-reactive protein (CRP) to identify high-risk patients with febrile neutropenia and hematologic neoplasms. A retrospective cohort study in which the MASCC score and the CRP values were used to assess the mortality risk at 30 days among patients with febrile neutropenia and hematologic malignancies was performed. Two hundred thiry-seven patients with febrile neutropenia were analyzed; the mortality rate within 30 days was 9 %. High-risk patients according to the MASCC score were significantly more likely to experience adverse outcomes, such as being transferred to the intensive care unit (RR 3.55; CI 95 % 2.73-6.62, p < 0.001) and death (RR 2.21; CI 95 % 1.74-2.79, p < 0.001). Multivariate analysis showed a strong association between the high-risk group identified by the MASCC score (HR 3.0; CI 95 % 1.12-13.54, p = 0.032) and the mean levels of CRP (HR 17; CI 95 % 2.21-136.48, p = 0.007) and survival. The survival rate within 30 days was 100 % for the patients with a low-risk MASCC score and a mean CRP less than 15 mg/dL. This rate was only 64 % for high-risk patients with a mean CRP greater than 15 mg/dL. The MASCC risk score combined with the mean CRP value successfully identifies patients with febrile neutropenia and hematological malignancies and a high risk of death.

Association of Aprepitant and Palonosetron in Prevention of Acute and Delayed Nausea and Vomiting in High Emetogenic Chemotherapy Regimens

ABSTRACT Aim: The recently published Multinational Association of Supportive Care in Cancer (MASCC) and European Society of Medical Oncology (ESMO) guidelines in the prevention of nausea and vomiting, recommended the use of aprepitant, dexametasone, and a serotonin antagonist (5HT3 receptor antagonist), to prevent nausea and vomiting in high emetogenic chemotherapy (HEC) schedules, although there is debate on which should be the ideal 5HT3 antagonist. Many studies have compared palonosetron with ondansetron and granisetron in the prevention of cisplatin-induced acute nausea and vomiting. The complete response was similar in the first 24 hours, but significantly superior with palonosetron on days 2–5, and on days 1–5, suggesting that palonosetron induced more protection from delayed emesis before HEC. The aim of our study is to test the efficacy of the concomitant use of palonosetron and aprepitant in preventing nausea and vomiting in HEC. Methods: We analyzed data collected from 100 consecutive patients who received HEC chemotherapy between April 2013 and May 2014 at our Institute, with various schedules for different type and stage of disease. Patients were pretreated with an antiemetogenic schedule consisting in aprepitant (oral 125 mg, on day one; oral 80 mg, on days 2 and 3), palonosetron (i.v. 0.25 mg, on day 1), and dexametasone (i.v. 12 mg, on day 1). Nausea and vomiting were classified as acute phase (within 24 hours from infusion) or delayed phase (days 2 to 5), and intensity of disorder was classified according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) criteria, version 4.0. Data were collected at baseline and every cycle of therapy. Results: Day 1 complete response was 84.9%, while complete response from days 2 to 5 was 79.5%. Outcome for complete protection, total control, no vomiting, no nausea were respectively 61.2%, 52.9%, 90.3% and 53.6% for acute phase, and 54.7%, 43.2%, 89.2% and 43.9% for the delayed phase. Most reported side effect were hiccups, fatigue, constipation, headache and anorexia; no serious adverse event was reported. Conclusions: Association of aprepitant and palonosetron is an effective prophylaxis of acute and delayed emesis, with no serious toxicity reported. Phase 3 trials to compare different 5HT3 antagonists are warranted to clarify the best antiemetogenic strategy. Disclosure: All authors have declared no conflicts of interest.

Baseline patient characteristics, incidence of CINV, and physician perception of CINV incidence following moderately and highly emetogenic chemotherapy in Asia Pacific countries.

This paper describes the incidence of chemotherapy-induced nausea and vomiting (CINV) after highly or moderately emetogenic chemotherapy (HEC or MEC) for cancer in six Asia Pacific countries. Sequential adult patients naïve to chemotherapy and scheduled to receive at least two cycles of single-day HEC or MEC were enrolled in this prospective observational study. Patients completed the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool on post-chemotherapy days 2 and 6 to record acute-phase (first 24 h) and delayed-phase (days 2-5) CINV. There were 648 evaluable patients (318 HEC, 330 MEC) from Australia (n = 74), China (153), India (88), Singapore (57), South Korea (151), and Taiwan (125). Mean (SD) patient age was 56 (12) and 58% of patients were women; the most common primary cancers were breast (27%), lung (22%), and colon (20%). Overall in cycle 1, complete response (no emesis or rescue antiemetics) was recorded by 69% (95% confidence interval (CI), 66-73) of all evaluable patients, with country percentages ranging from 55 to 78% (p < 0.001). After HEC, no emesis was recorded by 75% and no nausea by 38% of patients. After MEC, 80% had no emesis and 50% no nausea. Acute-phase CINV was better controlled than delayed-phase CINV, and the control of nausea was the lowest of any CINV measure in all phases. In a CINV perception survey, physicians tended to overestimate emesis rate and underestimate nausea rate. CINV remains a substantial problem, and country-specific information about CINV can be useful in developing strategies to improve outcomes for patients undergoing chemotherapy.

Editorial introductions

Editorial introductions

Feasibility of using the Multinational Association of Supportive Care in Cancer Antiemesis Tool for assessment of chemotherapy-induced nausea and vomiting at the Tom Baker Cancer Centre.

Chemotherapy-induced nausea and vomiting (CINV) has been shown to adversely impact patient anxiety, quality of life, treatment adherence, and use of health care resources. CINV control still remains a challenge, and lack of effective communication between the patient and clinician has been highlighted in the literature as the main barrier to optimal control. The Multinational Association of Supportive Care in Cancer (MASCC) has developed a tool (MASCC Antiemesis Tool (MAT)) to improve assessment and subsequent management of CINV by enhancing communication between patients and their clinicians. This study assessed the feasibility of using the MAT in patients at the Tom Baker Cancer Centre. The secondary objective was to describe the incidence of CINV as identified by the tool. This study involved a prospective survey using the MAT in patients receiving intravenous chemotherapy. Subjects completed the MAT twice post-chemotherapy regarding CINV symptoms and returned it at their next clinic appointment. Participants were also surveyed to evaluate feasibility with regard to using the MAT. Of the 50 patients recruited, 56% returned surveys. The majority of patients reported that the MAT facilitated communication with their clinician, particularly those who had experienced CINV. Fifty-four percent of patients who returned the MAT reported CINV; however, less than half of them had received American Society of Clinical Oncology-recommended antiemetic regimens. Only four patients with CINV had antiemetic changes made for subsequent cycles. The MAT is a feasible tool which can improve communication of CINV symptoms between patients and clinicians, a foundational step toward improving CINV management.

Growth factor therapy may have a clinical benefit for patients with cancer with established febrile neutropenia

Growth factor therapy may have a clinical benefit for patients with cancer with established febrile neutropenia

Management of febrile neutropenia in malignancy using the MASCC score and other factors: Feasibility and safety in routine clinical practice.

The current standards for empirical broad-spectrum intravenous antibiotic (AB) treatment, combined with hospitalization, are cautious and safe, but lead to over-treatment of a substantial group of patients. We need to validate parameters to identify these low-risk febrile-neutropenia (FN) patients, who could then be safely treated in an outpatient setting with minimal/no AB treatment. A retrospective analysis for validation of a risk-assessment model in FN patients was done on a patient population from January 2007 to December 2008. Inclusion criteria were a histological diagnosis of malignancy, FN secondary to chemotherapy, absolute-neutrophil-count of ≤ 500/μl, axillary temperature of ≥ 38°C, and age ≥ 14 years. Other clinical and laboratory parameters were explored for risk stratification during the FN episodes. Receiver-operating characteristic curves were used to find the threshold value, an Chi-square analysis was done to find the association between the outcome and the parameters. A total of 178 FN episodes were documented; 22 in solid tumors and 156 in hematolymphoid malignancies. Culture positivity was documented in 59 episodes; peripheral blood was the most common source, with Escherichia coli being the most common organism identified. Risk stratification was done using the Multinational Association of Supportive Care in Cancer (MASCC) risk-index score. The association between the MASCC score and risk stratification could not be established (P = not significant) at a score of ≤ 21; however, it was found to be significant at a score of ≤ 18. The total number of complications was 23 (sepsis 22, mortality 23). Other factors found to be significantly associated with a high risk of complications in the univariate analysis were, mucositis (P = 0.03), maximum temperature ≥ 103°F (P = 0.01), tachycardia (P < 0.001), tachypnea (P = <0.001), age (P = 0.006), high dose of steroid (P < 0.001), total duration of fever (≥ 2.5 days (for which sensitivity (S) and specificity (Sp) were 87 and 81%, respectively), serum-creatinine (≥ 0.45 mg%, S = 100%, Sp = 97%), serum-bilirubin (≥ 0.5 mg/dl, S = 100%. Sp = 90%), requirement of second-line antibiotics (P = 0.02), intensive-care (P ≤ 0.001), ventilatory support (P < 0.001), and requirement of packed cell (PC) transfusion (P = 0.02). In the multivariate analysis, mucositis (P = 0.02), HD steroid use (P = 0.026), and PC requirement (0.026) were identified as independent variables. The MASCC risk-index score was found to be meaningful at a score of ≤ 18. Other clinical and laboratory parameters were found to have a strong association with risk stratification in cancer patients during FN episodes.

Pattern of infection, therapy, outcome and risk stratification of patients with febrile neutropenia in a tertiary care oncology hospital in India.

Indian febrile neutropenia (FN) data are limited, especially in adult solid tumor patients. The aim was to study patterns of presentation, source of infection, management and outcome and to evaluate the factors which may correlate with outcome. A retrospective analysis of prospective data of FN patients at a tertiary care oncology teaching hospital in India between 2007 and 2012. A standardized form was filled for each patient. Patient management was at the discretion of the treating physician. Multinational Association for Supportive Care in Cancer (MASCC) score was retrospectively calculated. Failure of therapy was defined as death, organ failure, shifting from outpatient to inpatient or requirement of intensive care support. SPSS version 16 was used for analysis. A total of 388 FN episodes were included: 256 in hematolymphoid and 132 in solid tumor patients. 156 episodes were high-risk by MASCC score. Focus of infection was clinical in 45% and radiologic in 16%. Blood cultures were positive in 18% cases, most commonly Gram-negative organisms (72%). 93% patients were treated with an antibiotic combination of third-generation cephalosporin/beta-lactamase inhibitor, with aminoglycoside or fluoroquinolone. Antibiotic sensitivity to ceftriaxone was low at 38% while sensitivity to cefoperazone/sulbactam and piperacillin/tazobactam ranged between 50% and 55% and for carbapenems 75%. Failure of therapy occurred in 156 episodes, most commonly due to the need for second line antibiotics. Mortality was 5.5%. On univariate analysis, MASCC score, age, type of malignancy, prophylactic growth factors, presence of focus of infection, hemoglobin and nadir platelet count correlated with FN complications. Gram-negative bacteremia continues to be the predominant cause of FN in our setup.

Nausea and Vomiting in Cancer Patients: Topic Review

Nausea and vomiting are known side effects for cancer therapy. The prevalence is around 40-80%. The level of emetoginicity varies based on different factors. The potential receptors involved in emesis pathway are dopamine receptors, 5-hydroxytryptamine type 3 receptors and neurokinin receptors. The main guidelines for prevention of nausea and vomiting are ASCO, NCCN, MASCC/ESMO. These guidelines recommend three antiemetic drugs for highly emetic chemotherapy and two antiemetic drugs for moderately emetic chemotherapy. While for low risk regimens single antiemetic might be used and for minimal risk regimens antiemetic is not routinely recommended. Non pharmacological therapy might be considered as well. There are different tools for assessment of nausea and vomiting such as EORTC-QLQ-C30 and FACT-G. The Multinational Association of Supportive Care in Cancer (MASCC) tool individually address both acute and delayed nausea and vomiting, available in different languages and has iPhone/iPad application. Proper prevention of this side effect is highly recommended to improve patient quality of life, to avoid further complications as dehydration, electrolyte imbalance and to ensure continuation of treatment plan.

Independent factors for prediction of poor outcomes in patients with febrile neutropenia.

BackgroundFebrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN.Material/MethodsWe retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred.ResultsThe platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome.ConclusionsThe results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Piperacillin/tazobactam vs. cefoperazone/sulbactam in adult low-risk febrile neutropenia cases

The aim of this study was to compare the efficacy of piperacillin/tazobactam (P/T) and cefoperazone/sulbactam (C/S) in the empirical treatment of adult neutropenic fever. Data and outcomes of low-risk adult cases with neutropenic fever and treated with P/T (4.5 g q6h) or C/S (2 g q8h) between 2005 and 2011 June were extracted from our database. Risk evaluation was made according to criteria of Multinational Association for Supportive Care in Cancer (MASCC) and a score of ≥ 21 was considered as low risk. Data were collected prospectively by daily visits and evaluated retrospectively. Primary outcome was - fever defervescence at 72 h in combination with success without modification (referring to episodes where the patient recovered from fever with disappearance of signs of infection without modification to initial empirical treatment). All-cause mortality referred to death resulting from a documented or presumed infection or unidentified reason during the treatment and 30-day follow-up period. A total of 172 patients (113 cases P/T and 59 cases C/S) fulfilled the study inclusion criteria. Persistent response in P/T arm was 73.5%, whereas it was 64.5% in C/S arm (p > 0.05). Rates of any modification were also similar in both treatment arms. All-cause mortality during the treatment and 30-day follow-up period was not significantly different (P/T: 4/113 vs. C/S: 2/59, p > 0.05). There was no severe adverse effect requiring antibiotic cessation in both cohorts. In conclusion, our data suggest that C/S may be a safe alternative to P/T in the empirical treatment of adult low-risk febrile neutropenia cases.

Clinical efficacy of adjunctive G-CSF on solid tumor and lymphoma patients with established febrile neutropenia

The use of granulocyte colony-stimulating factor (G-CSF) as a prophylaxis against febrile neutropenia (FN) is well documented in the literature; however, the therapeutic use of G-CSF in the treatment of FN remains controversial. This study assessed the efficacy of adjunctive G-CSF in the treatment of FN by evaluating clinical outcomes. This was a single-center, prospective cohort study conducted at the National Cancer Center in Singapore. Adult patients who had received chemotherapy and developed FN between January 2009 and January 2012 were included in the analysis. The clinical efficacy of adjunctive G-CSF was evaluated by investigating the duration of hospitalization, duration to absolute neutrophil count (ANC) recovery, duration of grade IV neutropenia, duration to fever resolution, duration of antibiotic therapy, and incidence of documented infections. A multivariate analysis was performed to identify patients who could potentially benefit from adjunctive G-CSF. Four hundred and thirty patients were analyzed. Majority manifested low-risk FN (81.2%) based on the Multinational Association of Supportive Care in Cancer (MASCC) scoring. Compared to patients who did not receive adjunctive G-CSF, patients receiving adjunctive G-CSF had a nonsignificant reduction in the duration of hospitalization (3.5 vs. 3.7 days, p = 0.41) and in ANC recovery time (3.4 vs. 3.5 days, p = 0.76). Neutropenia-related mortality was lower among those who have received adjunctive G-CSF (2.4 vs. 8.4%, p = 0.006). Patients of Indian ethnicity and those who underwent gemcitabine-containing chemotherapy were less likely to receive adjunctive G-CSF treatment. This observational study suggested that adjunctive G-CSF may confer clinical benefits among solid tumor and lymphoma patients with established febrile neutropenia. Further research should be conducted to validate the findings.

Important Clinical Findings for Chemotherapy-Induced Nausea and Vomiting: Commentary on Molassiotis et al.

In this issue, Molassiotis et al. report the predictors of chemotherapy-induced nausea and vomiting (CINV) in the largest prospective observational study to date. The impact of Multinational Association of Supportive Care in Cancer (MASCC) guideline compliance on CINV has been reported in a previous publication using the same data set. This well-conducted study found that female gender was not a key predictor of CINV. Three other predictors of CINV emerged and must be appraised by every physician involved in cancer care. Complete response in the first cycle of chemotherapy, as defined by the study, was a determinant factor for CINV in the following cycles. This suggests that complete response in the first cycle of chemotherapy may be a more important clinical goal. Second, factors related to the patients themselves, such as anticipatory nausea and prechemotherapy anxiety, were demonstrated for the first time in a prospective study to be important risk factors for CINV. This illustrates a possible role of behavioral and symptomatic therapy during treatment planning and before the start of chemotherapy.

A systematic literature review of the impact of 5-HT3RA use on health care utilization in patients with chemotherapy-induced nausea and vomiting in the United States.

269 Background: Uncontrolled chemotherapy-induced nausea and vomiting (CINV) can lead to nutrient depletion, diminished function, disruption of chemotherapy, and increased costs. Standard antiemetic therapy includes 5-HT3RAs for CINV prophylaxis, with palonosetron recommended in National Comprehensive Cancer Network (NCCN), Multinational Association of Supportive Care in Cancer (MASCC), and ASCO guidelines as the preferred 5-HT3RA for CINV prophylaxis with MEC. There is evidence that using 5-HT3RAs can reduce costs but no comprehensive review of the evidence is available. Methods: We searched MEDLINE, National Institute for Health Research (NIHR), Centre for Reviews and Dissemination (CRD databases, 4 conferences (Academy of Managed Care Pharmacy, ASCO, International Society for Pharmacoeconomics and Outcomes Research, MASCC), and bibliographies of included articles. We queried Medical Subject Headings (MeSH) and key terms: “ondansetron,” “granisetron,” “palonosetron,” “dolasetron mesylate,” “costs,” “cost analysis,” and “economics.” Included records reported data on cost/utilization (rescue medication, outpatient/inpatient services) related to 5-HT3RA use for CINV in English, in human subjects, and published after 1997. Results: Of the 433 identified records, the 16 reporting utilization in the US were reviewed (excluded: 29 duplicates, 388 off-topic records). Studies varied significantly in designs, patients, 5-HT3RA regimens, and definition of outcomes. Twelve studies reported rescue medication use for CINV in patients using different 5-HT3RAs. In 5 studies, fewer patients treated with palonosetron required rescue medication versus ondansetron users (56% vs. 61%, 28% vs. 83%, 14% vs. 24%, 8% vs. 11%, 6% vs. 11%); 2 studies found palonosetron users had fewer outpatient services versus ondansetron users (5% vs. 10%, 8% vs. 10%). Four studies, with a variety of patients and outcomes, reported fewer patients treated with palonosetron versus ondansetron or other 5-HT3RAs used inpatient care (e.g., 0.2% vs. 0.4%, 16% vs. 23%, 7% vs. 10%, 0% vs. 5%), while 2 studies reported similar use (1% vs. 1%, 0% vs. 0%). Conclusions: CINV prophylaxis with palonosetron is generally associated with lower use of rescue medications, outpatient and inpatient services compared to ondansetron or other 5-HT3RAs. Use of palonosetron as a standard treatment may lead to reduced utilization of rescue medications and healthcare services for CINV and subsequent cost savings.

Updates from the Multinational Association for Supportive Care in Cancer (MASCC)

Abstract: The motto of the Multinational association for Supportive Care in Cancer is “supportive care makes excellent cancer care possible.”

Influenza vaccination in children being treated with chemotherapy for cancer

Influenza infection is a potential cause of severe morbidity in children with cancer; therefore vaccination against influenza is recommended. However, data are conflicting regarding the immune response to influenza vaccination in children with cancer, and the value of vaccination remains unclear. 1. To assess the efficacy of influenza vaccination in stimulating an immunological response in children with cancer during chemotherapy, compared with control groups.2. To assess the efficacy of influenza vaccination in preventing confirmed influenza and influenza-like illness and/or in stimulating immunological response in children with cancer treated with chemotherapy, compared with placebo, no intervention or different dosage schedules.3. To identify the adverse effects associated with influenza vaccines in children with cancer treated with chemotherapy, compared with other control groups. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2012) and EMBASE (1980 to 2012) up to August 2012. We also searched reference lists of relevant articles and conference proceedings of the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), the Infectious Diseases Society of America (IDSA), the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Paediatric Oncology (SIOP). We considered randomised controlled trials (RCTs) and controlled clinical trials (CCTs) in which the serological response to influenza vaccination of children with cancer was compared with that of control groups. We also considered RCTs and CCTs that compared the effects of influenza vaccination on clinical response and/or immunological response in children with cancer being treated with chemotherapy, compared with placebo, no intervention or different dosage schedules. Two independent review authors assessed the methodological quality of included studies and extracted the data. We included 1 RCT and 9 CCTs (total number of participants = 770). None of the included studies reported clinical outcomes. All included studies reported on influenza immunity and adverse reactions to vaccination. In five studies, immune responses to influenza vaccine were compared in 272 children receiving chemotherapy and 166 children not receiving chemotherapy. In four studies, responses to influenza vaccine were assessed in 236 children receiving chemotherapy compared with responses in 142 healthy children. Measures used to assess immune responses included a four-fold rise in antibody titre after vaccination, development of a haemagglutination inhibition (HI) titre > 32 and pre- and post-vaccination geometric mean titres (GMTs). Immune responses in children receiving chemotherapy were consistently weaker (four-fold rise of 38% to 65%) than those in children who had completed chemotherapy (50% to 86%) and in healthy children (53% to 89%). In terms of adverse effects, 391 paediatric oncology patients received influenza vaccine, and the adverse effects described included mild local reactions and low-grade fever. No life-threatening or persistent adverse effects were reported. Paediatric oncology patients receiving chemotherapy are able to generate an immune response to the influenza vaccine, but it remains unclear whether this immune response protects them from influenza infection or its complications. We are awaiting results from well-designed RCTs addressing the clinical benefit of influenza vaccination in these patients.

Editorial introductions

Editorial introductions

Antibiotic and other lock treatments for tunnelled central venous catheter-related infections in children with cancer.

The risk of developing a tunnelled central venous catheter (CVC)-related infection ranges between 0.1 and 2.3 per 1000 catheter days for children with cancer. These infections are difficult to treat with systemic antibiotics (salvage rate 24% - 66%) due to biofilm formation in the CVC. Lock treatments can achieve 100 - 1000 times higher concentrations locally without exposure to high systemic concentrations. Our objective was to investigate the efficacy of antibiotic and other lock treatments in the treatment of CVC-related infections in children with cancer compared to a control intervention. We also assessed adverse events of lock treatments. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 3, 2011), MEDLINE/PubMed (1945 to August 2011) and EMBASE/Ovid (1980 to August 2011). In addition we searched reference lists from relevant articles and the conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2010), American Society of Clinical Oncology (ASCO) (from 2006 to 2010), the Multinational Association of Supportive Care in Cancer (MASCC) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2010) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the ISRCTN Register and the National Institute of Health Register for ongoing trials (www.controlled-trials.com) (August 2011). Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing an antibiotic lock or other lock treatment (with or without concomitant systemic antibiotics) with a control intervention (other lock treatment with or without concomitant systemic antibiotics or systemic antibiotics alone) for the treatment of CVC-related infections in children with cancer. For the description of adverse events, cohort studies were also eligible for inclusion. Two authors independently selected studies, extracted data and performed 'Risk of bias' assessments of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. Two RCTs evaluated urokinase lock treatment with concomitant systemic antibiotics (n = 56) versus systemic antibiotics alone (n = 48), and one CCT evaluated ethanol lock treatment with concomitant systemic antibiotics (n = 15) versus systemic antibiotics alone (n = 13). No RCTs or CCTs evaluating antibiotic lock treatments were identified. All studies had methodological limitations and clinical heterogeneity between studies was present. We found no evidence of significant difference between ethanol or urokinase lock treatments with concomitant systemic antibiotics and systemic antibiotics alone regarding the number of participants cured, the number of recurrent CVC-related infections, the number of days until the first negative blood culture, the number of CVCs prematurely removed, ICU admission and sepsis. Not all studies were included in all analyses. No adverse events occurred in the five publications of cohort studies (one cohort was included in two publications) assessing this outcome; CVC malfunctioning occurred in three out of five publications of cohort studies assessing this outcome. No significant effect of urokinase or ethanol lock in addition to systemic antibiotics was found. However, this could be due to low power or a too-short follow-up. The cohort studies identified no adverse events; some cohort studies reported CVC malfunctioning. No RCTs or CCTs were published on antibiotic lock treatment alone. More well-designed RCTs are needed to further explore the effect of antibiotic or other lock treatments in the treatment of CVC-related infections in children with cancer.

Inpatient versus outpatient management of neutropenic fever in gynecologic oncology patients: Is risk stratification useful?

ObjectiveThis study aimed to evaluate the utility of risk stratification of gynecologic oncology patients with neutropenic fever (NF). MethodsA retrospective chart review of gynecologic cancer patients admitted with NF from 2007 to 2011 was performed, wherein demographic, oncologic, and NF characteristics (hospitalization length, complications, and death) were collected. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score was calculated; low risk was considered ≥21. SAS 9.2 was used for statistical analyses. ResultsEighty-three patients met the study criteria. Most (92%) were Caucasian and had advanced stage disease (71%). Primary tumors were 58% ovary, 35% endometrium, and 6% cervix. All patients were receiving chemotherapy on admission (72% for primary, 28% for recurrent disease). Forty-eight percent had a positive culture, and most (58%) positive cultures were urine. Seventy-six percent of patients were considered low risk. High-risk patients were more likely to have a severe complication (10% versus 50%, p=0.0003), multiple severe complications (3% versus 20%, p=0.0278), ICU admission (2% versus 40%, p<0.0001), overall mortality (2% versus 15%, p=0.0417), and death due to neutropenic fever (0% versus 15%, p=0.0124). MASCC had a positive predictive value of 50% and negative predictive value of 90%. The median MASCC score for all patients was 22 (range, 11–26), but the median MASCC score for those with death or a severe complication was 17 (range, 11–24). ConclusionBased on this pilot data, MASCC score appears promising in determining suitability for outpatient management of NF in gynecologic oncology patients. Prospective study is ongoing to confirm safety and determine impact on cost.