Multinational Association For Supportive Care Research Articles

Emergency Ambulatory Management of Low-Risk Febrile Neutropenia: Multinational Association for Supportive Care in Cancer Fits-Real-World Experience From a UK Cancer Center.

Emergency patient presentations with febrile neutropenia are a heterogeneous group. A small minority of these patients proceed to develop significant medical complications. Risk stratification using scores, such as the Multinational Association for Supportive Care in Cancer score, have been advocated to identify patients who are at low risk of adverse outcome suitable for treatment on an ambulatory care pathway. We sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion. Patients presenting as an emergency with low-risk febrile neutropenia managed in an ambulatory setting between January 2017 and February 2019 at a tertiary cancer hospital in England were prospectively studied. Patients with a fever >38.0°C and an absolute neutrophil count <1.0 × 109/L were included. All patients with a Multinational Association for Supportive Care in Cancer score ≥21 and a National Early Warning Score ≤3 were potentially eligible for the pathway. Complications were classified as serious if the patient developed persistent hypotension, respiratory failure, intensive care unit admission, altered mental status, disseminated intravascular coagulation, renal failure requiring renal replacement therapy, electrocardiogram changes requiring antidysrhythmic treatment, and 30-day mortality. One hundred patients with low-risk febrile neutropenia consecutively managed in an emergency ambulatory fashion were prospectively analyzed. Eighty-one patients were female and the median age was 51 y (range 17-79 y). No patients developed serious complications. Eight (8% [95% confidence interval 4.1-15.0%]) patients had a 7-day readmission. Outpatient ambulatory care for emergency patients with low-risk febrile neutropenia can be delivered in a safe and effective fashion. Collaboration between acute care physicians and oncologists is required to develop local models based on national guidelines to facilitate individualised care for emergency oncology patients.

Predictive Factors for Survival Outcomes of High-Risk Febrile Neutropenic Patients: a 3-Year Study at a Single Center in Thailand

Objective: This study aimed to identify the risk factors associated with mortality in febrile neutropenic patients.  Materials and Methods: This 3-year, single center, retrospective, observational study was conducted at Chiangrai Prachanukroh Hospital, Chiangrai Province, Thailand. The inclusion criteria consisted of a patient age of over 15 years and a diagnosis of febrile neutropenia. Results: Most of the 303 febrile neutropenic inpatients had a Multinational Association for Supportive Care in Cancer (MASCC) risk score &lt; 21. The median length of stay was 6 days (interquartile range: 4-11 days). During 30 days of admission, 24.8% of the patients succumbed. In a univariate analysis, patients receiving G-CSF, the post-chemotherapy-related group, patients with MASCC score &gt; 16, and patients admitted in private had significantly higher survival rate. In a multivariate analysis, a MASCC score ≤ 16 and non-chemotherapy-related groups were associated with an increased mortality risk. Conclusion: The 30-day survival rate of febrile neutropenic patients in Thailand is seventy-five percent. Low MASCC score and non-chemotherapy-related neutropenia are associated with a higher risk of unfavorable outcomes.

MASCC recommendations on the management of constipation in patients with advanced cancer.

The Palliative Care Study Group of the Multinational Association for Supportive Care in Cancer formed a subgroup to develop evidence-based recommendations on the management of constipation in patients with advanced cancer. These recommendations were developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The recommendations were categorised by the level of evidence and a "category of guideline" based on the level of evidence (i.e. "recommendation", "suggestion", or "no guideline possible"). The group produced 15 recommendations, with varying levels of evidence and so varying categories of guideline. The recommendations relate to the assessment, the treatment, and the re-assessment of constipation. These recommendations provide a framework for the management of constipation in advanced cancer, although every patient needs individualised management.

Editorial introductions

Current Opinion in Oncology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of psychiatry is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Jean A. KlasterskyJean A. KlasterskyProfessor Klastersky was Head of the Department of Medicine at the Institut Jules Bordet in Brussels, Belgium, and Professor of Medicine, Medical Oncology and Physical Diagnosis at the Université Libre de Bruxelles, Belgium, from 1977. He retired from these positions in 2005. Currently, he is the coordinator of the “Programme des Soins Oncologiques” for the Public Hospitals in Brussels and consultant in medical oncology at the Institut Jules Bordet, Belgium. Professor Klastersky was an intern and resident at the University Hospitals of the Université Libre de Bruxelles between 1962 and 1965, where he gained his MD (Docteur en Médecine, Chirurgie et Accouchements). From 1967 to 1968, he was Chief-Resident at Boston City Hospital, USA, and then a Research Fellow and Assistant in Medicine at Thorndike Memorial Laboratory Harvard Medical School, USA. He became Chief of the Section of Infectious Diseases at the Institut Jules Bordet in 1970, before taking up the position of Head of the Department of Medicine in 1977. Professor Klastersky was a founder member of the European Lung Cancer Working Party and was President from 1978 until 2003. He was President (and founder member) of the International EORTC Antimicrobial Therapy Project Group between 1979 and 1987 and the Group's Secretary General from 1987 to 2000. He was President (and founder member) of the Multinational Association for Supportive Care in Cancer (MASCC) from 1990 to 2000. He has been Visiting Professor of Medical Oncology at the Charles University in Prague, Czech Republic, since 1994. Professor Klastersky is a member of the American Society of Clinical Oncology, the American Association of Cancer Research, the European Society of Medical Oncology, the American Society of Microbiology, the Infectious Diseases Society of America, the International Association for the Study of Lung Cancer, the “Royale Académie de Médecine” of Belgium and various other international and national medical and/or oncological societies. Professor Klastersky is the author of over 400 original articles, nearly 400 review articles and 17 scientific books. He is the Editor of Current Opinion in Oncology. Jean-Yves BlayJean-Yves BlayPr. Blay has published over 600 peer-reviewed articles. He was President of the European Organization for Research and Treatment of Cancer (EORTC) from 2009 to 2012. He has also received numerous awards such as the Hamilton Fairley Award in 2012 from the ESMO and the Henry and Mary-Jane Mitjavile prize in 2013 from the National Academy of Medicine. Currently President of the French Sarcoma Group GETO, he is the network leader of the NETSARC network of reference centers for sarcoma treatment certified by the French National Cancer Institute, the former PI of Conticanet (a FP6 network of excellence), and the current PI of the FP7 project EuroSARC). He is the Director of the Integrated Centre for innovation on Cancer Research of Lyon (LYRIC). He is the Network Director of the European Reference Network EURACAN (euracan.org). His research interests focus on clinical and basic research in sarcomas, targeted treatment of cancer, the biology of breast carcinoma and relation between tumor immunologic microenvironment and malignant cells with the goal of clinical applications in the fields of diagnosis, prognosis and treatment. Alain HendliszAlain HendliszDr Alain Hendlisz is a gastro-enterologist. He gained his MD (Docteur en Médecine, Chirurgie et Accouchements) at the Université Libre de Bruxelles, Belgium in 1988 and has been a specialist in gastroenterology since 1993. He earned his PhD in Medical Sciences at the ULB in 2015. He is currently Head of the Gastroenterology Unit at the Institut Jules Bordet, Anti-Cancer Center of the Université Libre de Bruxelles He is a founding member and is currently serving on the Board of the BGDO (Belgian Group for Digestive Oncology). He is a member of the American Society of Clinical Oncology (ASCO), the European Society of Medical Oncology (ESMO), the Société Royale Belge de Gastro-entérologie (SRBG) and European Organization for Research and Treatment of Cancer (EORTC). He is involved as principal investigator or co-investigator in numerous national and international clinical studies.

Evolution of antiemetic studies for radiation-induced nausea and vomiting within an outpatient palliative radiotherapy clinic.

Radiation-induced nausea and vomiting (RINV) is a common side effect of radiotherapy and can affect up to 50-80% of patients, potentially causing detrimental effects to physical health, clinical efficacy, and patient quality of life. Antiemetic drugs act on receptors involved in the emesis pathway to block the uptake of neurotransmitters and inhibit stimulation of vomiting centers in the brain to prevent and treat RINV. The most commonly prescribed antiemetics for RINV are 5-hydroxytryptamine receptor antagonists (5-HT3 RA). Guidelines describing the optimal management of RINV are produced by the Multinational Association for Supportive Care in Cancer, the European Society of Medical Oncology, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. This review will present findings from research on antiemetic management for RINV conducted at our center. A selective review of research conducted in a palliative outpatient radiotherapy clinic relating to antiemetic management for RINV was performed. Several studies investigating the efficacy of different routes of administration, new antiemetic drug types, and novel combinations of antiemetics have been tested at our clinic to elucidate which approach provides the best response. These include studies on the use of ondansetron rapidly dissolving film, palonosetron, and the addition of a neurokinin-1 receptor antagonist to traditional 5-HT3 RA regimens. These studies provide a framework for future research and could potentially inform changes to future guidelines to include the use of these novel regimens and techniques.

Potential length of stay reduction with outpatient management of low risk febrile neutropenia in a regional cancer centre.

e18000 Background: Febrile neutropenia is a serious complication of chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score can reliably identify patients with febrile neutropenia at low risk of serious complications. Outpatient management programs utilising protocol based risk stratification, daily ambulatory nursing visits, telephone follow up and early outpatient review have been successfully piloted in other Australian cancer treatment centres. Methods: We performed a retrospective review of medical records for all patients admitted at our institution with febrile neutropenia between January 1 2016 and December 31 2018. We collected information regarding patient characteristics, cancer diagnosis and treatment, determined the MASCC risk index score, and if low risk, we determined the potential eligibility for outpatient care and potential reduction in length of stay. Results: A total of 98 hospital admissions with febrile neutropenia were analysed. Of these, 66 were determined to have a MASCC low risk index score. 58 patients met the eligibility criteria for outpatient management. The median age was 67 years. 71% were female. The most common tumour type was breast cancer. 52% were treated with palliative intent. The median length of stay was 3 days. The median potential reduction in length of stay for each admission was 2 days. The total potential reduction in length of stay was 198 days. No admission resulted in serious complications indicating the safety of outpatient care. Conclusions: Febrile neutropenia is a common complication of chemotherapy and a leading cause of hospital admission. This review demonstrates a significant number of hospital admission days can be avoided with outpatient care. We intend to conduct a prospective pilot study at our centre to institute an outpatient febrile neutropenia program for such low risk groups with potential reduction in hospital bed length of stay. This has significant implications on health resource usage, service provision planning and patient quality of life.

Assessment of Chemotherapy-Induced Febrile Neutropenia in Cancer Patients

Abstract Purpose: Chemotherapy-induced febrile neutropenia (CIFN) is an adverse drug reaction which needs medical attention. The treatment options for the CIFN are mandatory to improve treatment outcomes and quality of life. Methods: A prospective observational study was conducted in the in-patients and out-patients of oncology department who received chemotherapy from October 2016 to March 2017. The information such as demographics (age, gender, and comorbidities), complaints on admission, hematological investigations (neutrophil counts, platelet counts, hemoglobin levels, erythrocyte sedimentation rate, and white blood cells), type of tumor, stage of cancer, prophylaxis, cycle of antineoplastic chemotherapy that cause febrile neutropenia, treatment history, and outcome data were obtained from the patient's clinical record. The Multinational Association for Supportive Care in Cancer score and Absolute Neutrophil Count grading was used to predict the patient's risk of developing CIFN. Results: Out of 200 patients, 19 patients developed 22 episodes of CIFN. The overall occurrence of CIFN during the study was 9.5%. The higher incidence of CIFN has been observed among male gender (57.89%), stage III patients (42.10%), solid tumor (73.68%), and double chemotherapy regimen (59.1%). The higher incidence of CIFN was developed in I cycle (36.36%) followed by II cycle (22.72%) and VI cycle (18.18%). Conclusions: The incidence of CIFN during the study was 9.5%. In the 19 chemotherapy-induced FN patients, there has no significant effect of prophylaxis to prevent the febrile neutropenia.

Applications for the MASCC Risk Index for Febrile Neutropenia in Patients with Hematologic Malignancy

Background Neutropenic fever is a common complication in the treatment of malignancy that has historically carried a high rate of mortality. The Multinational Association for Supportive Care in Cancer (MASCC) Risk Index for Febrile Neutropenia has been used to reliably identify patients with chemotherapy-induced febrile neutropenia who are at low risk of serious medical complications. It is often used in the outpatient or emergency room setting to help determine which patients with solid tumors may be able to avoid hospital admission and be appropriate for outpatient management of febrile neutropenia. The MASCC Risk Index is not recommended for use in hematologic malignancy due to its poor positive predictive value for serious medical complications in this population. This study seeks to use this score to retrospectively risk-stratify hematologic malignancy patients and determine if the MASCC risk index is predictive of length of hospitalization or mortality. Methods This is an IRB approved retrospective review that identified patients with a hematologic malignancy who presented to the outpatient clinic or the emergency department of an academic medical center with neutropenic fever between 1/1/2017 and 12/31/2017. Chart review was performed to determine each patient's MASCC risk index in order to stratify as high risk ( =21). This was then compared to length of stay and mortality data. Charlson comorbidity index (CCI) was used to compare baseline characteristics of the patients. Results 73 patients met the inclusion criteria. 31 (42%) patients were deemed high risk and 42 (58%) were deemed low risk by MASCC stratification. There was no difference in length of stay (LOS) between high risk and low risk groups (mean LOS 8.45 days and 8.12 days, respectively, p=0.894). In the first 30 days from admission, 5 patients (16%) died, all from the high risk group. Overall survival was significantly worse in the high risk group with a hazard ratio 4.48 (95% CI, 1.77 – 11.37), and in patients aged 75-84 with a hazard ratio of 3.622 (95% CI, 1.21 – 10.827). High Charlson Comorbidity index scores (liver disease, cerebrovascular disease, peripheral vascular disease, renal disease, paralysis, dementia, mild liver disease, congestive heart failure, COPD, diabetes) did not correlate with worsened survival. Conclusion This study shows that even when not being used to prevent hospitalization, the MASCC risk index has utility in predicting which patients have the highest risk of mortality after developing neutropenic fever.

A Case-Control Study of Real-Life Experience with Ceftolozane-Tazobactam in Patients with Hematologic Malignancy and Pseudomonas aeruginosa Infection.

We present our experience in patients with hematologic malignancy and Pseudomonas aeruginosa infection treated with ceftolozane-tazobactam. We performed a single-center case-control study comparing patients with hematologic malignancy and P. aeruginosa infection treated with ceftolozane-tazobactam (study group) with similar patients not treated with ceftolozane-tazobactam (control group) to assess safety and efficacy. Nineteen cases and 38 controls were analyzed. Cases were younger (45.6 years versus 57.6 years; P = 0.012) and less frequently had bacteremia (52.6% versus 86.8%; P = 0.008). They also had worse Multinational Association for Supportive Care in Cancer (MASCC) scores (10.2 versus 16.1; P = 0.0001), more hospital-acquired infections (78.9% versus 47.4%; P = 0.013), and more extremely drug-resistant (XDR) P. aeruginosa infections (47.4% versus 21.1%; P = 0.015). Cases received a median of 14 days (7 to 18 days) of ceftolozane-tazobactam (monotherapy in 11 cases [57.9.6%]). Ceftolozane-tazobactam was mostly used as targeted therapy (16 cases; 84.2%) because of resistance (9 cases; 47.4%), failure (4 cases; 21.1%), and toxicity (3 cases; 15.8%). Ten cases had bacteremia (52.6%). The sources were pneumonia (26.3%), catheter-related bacteremia (21.1%), primary bacteremia (21.1%), and perianal/genital (15.7%), urinary (10.5%), and skin/soft tissue (5.3%) infection. No toxicity was attributed to ceftolozane-tazobactam. More than 60% had neutropenia, and 15.8% fulfilled the criteria for sepsis. There were no significant differences in clinical cure at day 14 (89.5% versus 71.1%; P = 0.183) or recurrence (15.8% versus 10.5%; P = 0.675). Thirty-day mortality was lower among cases (5.3% versus 28.9%; P = 0.045). Ceftolozane-tazobactam was well tolerated and at least as effective as other alternatives for P. aeruginosa infection in patients with hematologic malignancy, including neutropenic patients with sepsis caused by XDR strains.

Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK

Neutropenic sepsis can be life threatening, with mortality 2-21%. The heterogeneity of patients referred with “suspected neutropenic sepsis” has led to strategies being developed to risk-stratify patients and identify those with a low risk of septic complications that could be managed in the outpatient setting, such as The Multinational Association for Supportive Care in Cancer score (MASCC). Outcomes for patients referred with suspected neutropenic sepsis were assessed before and after use of MASCC guided early-supported discharge. 50/123 (41%) patients over 24 months were eligible for early-supported discharge. 26/50 patients had same-day discharge, 14 had overnight admission, 8 stayed 2 nights and 2 stayed 3 nights. Patients received on average 2 follow-up telephone consultations. There were 5 readmissions (10%) and no adverse events. In comparison group; 8 patients over 3-months would have been suitable, potentially saving 40 bed-days. This shows MASCC guided early-supported discharge is safe and cost-effective.

Editorial introductions

Editorial introductions

Prognostic value of procalcitonin and lipopolysaccharide binding protein in cancer patients with chemotherapy-associated febrile neutropenia presenting to an emergency department.

IntroductionCancer patients with chemotherapy-induced febrile neutropenia are a heterogeneous group with a significant risk of serious medical complications. In these patients, the Multinational Association for Supportive Care in Cancer (MASCC) score is the most widely used tool for risk-stratification. The aim of this prospective study was to analyse the value of procalcitonin (PCT) and lipopolysaccharide binding protein (LBP) to predict serious complications and bacteraemia in cancer patients with febrile neutropenia, compared with MASCC score.Materials and methodsData were collected from 111 episodes of febrile neutropenia admitted consecutively to the emergency department. In all of them, MASCC score was calculated and serum samples were collected for measurement of PCT and LBP by well-established methods. The main and secondary outcomes were the development of serious complications and bacteraemia, respectively.ResultsA serious complication occurred in 20 (18%) episodes and in 16 (14%) bacteraemia was detected. Areas under the receiver operating characteristic curve (ROC AUC) of MASCC score, PCT and LBP to select low-risk patients were 0.83 (95% confidence interval (CI): 0.74 - 0.89), 0.85 (95% CI: 0.77 - 0.91) and 0.70 (95% CI: 0.61 - 0.78), respectively. For bacteraemia, MASCC score, PCT and LBP showed ROC AUCs of 0.74 (95% CI: 0.64 - 0.82), 0.86 (95% CI: 0.78 - 0.92) and 0.76 (95% CI: 0.67 - 0.83), respectively.ConclusionA single measurement of PCT performs similarly as MASCC score to predict serious medical complications in cancer patients with febrile neutropenia and can be a useful tool for risk stratification. Besides, low PCT concentrations can be used to rule-out the presence of bacteraemia.

Editorial introductions

Editorial introductions

A pilot study to assess the pharmacy impact of implementing a chemotherapy-induced nausea or vomiting collaborative disease therapy management in the outpatient oncology clinics.

Collaborative drug therapy management is a formal partnership between a pharmacist and physician to allow the pharmacist to manage a patient's drug therapy. Literature supports collaborative disease therapy management can improve patient outcomes, improve medication adherence, enhance medication safety, and positively influence healthcare expenditures. Chemotherapy induced nausea or vomiting is considered one of the most distressing and feared adverse events among patients receiving chemotherapy. Chemotherapy induced nausea or vomiting can impact a patient's quality of life and may affect compliance with the treatment plan. The objective of this pilot study was to determine the pharmacy impact of implementing a chemotherapy induced nausea or vomiting collaborative disease therapy management protocol in the outpatient oncology clinics at a National Cancer Institute (NCI)-designated cancer center associated with an academic medical center. The primary endpoint was to determine the number and type of chemotherapy induced nausea or vomiting clinical interventions made by the oncology pharmacists. Secondary endpoints included comparing patient's Multinational Association for Supportive Care in Cancer scores and revenue of pharmacists' services. The credentialed oncology pharmacists were consulted by an oncologist to manage chemotherapy induced nausea or vomiting. Patients were included in the chemotherapy induced nausea or vomiting collaborative disease therapy management if they were seen in an outpatient oncology clinic from October 2016 to January 2017 and had a referral from a qualified provider to help manage chemotherapy induced nausea or vomiting. Patients admitted to the hospital at the time of consult were excluded from the study. The pharmacists interviewed patients and provided recommendations. The pharmacists followed up with the patient via a telephone call or during the next scheduled clinic visit to assess their symptoms. The chemotherapy induced nausea or vomiting collaborative disease therapy management pilot study was implemented in October 2016. From October 2016 to January 2017, there were 45 consults for the management of chemotherapy induced nausea or vomiting. The pharmacists made 188 clinical interventions, which included addition of new medications (37%), patient education (34%), deletion of medications (10%), changing a dose/duration/frequency (8%), and other interventions (11%). Multinational Association for Supportive Care in Cancer symptom scores were available for 5 patients, in which all showed improvements from baseline with the pharmacists' clinical interventions. The implementation of our chemotherapy induced nausea or vomiting collaborative disease therapy management pilot study has shown favorable results after a 4-month evaluation period. The pharmacists have made a substantial number of clinical interventions and provided patient education to patients undergoing chemotherapy.

Efficacy of Ginger in Ameliorating Acute and Delayed Chemotherapy-Induced Nausea and Vomiting Among Patients With Lung Cancer Receiving Cisplatin-Based Regimens: A Randomized Controlled Trial.

Nausea and vomiting are among the most common and distressing side effects of chemotherapy. Additional antiemetic drugs are urgently needed to effectively manage and ameliorate chemotherapy-induced nausea and vomiting (CINV). The efficacy of ginger as an antiemetic modality for ameliorating CINV has not been established in previous studies. The aim of this study was to examine the efficacy of ginger, as an adjuvant drug to standard antiemetic therapy, in ameliorating acute and delayed CINV in patients with lung cancer receiving cisplatin-based regimens. In this randomized, double-blind, placebo-controlled clinical trial, 140 patients with lung cancer receiving cisplatin-based regimens were enrolled and allocated to receive either ginger root powder or a placebo. Ginger root powder was administered orally (0.5 g, 2 capsules per day, 0.25 g per capsule, every 12 hours) for 5 days beginning on the first day of chemotherapy. The incidence and severity of acute and delayed nausea and vomiting were assessed using the MASCC (Multinational Association for Supportive Care in Cancer) Antiemesis Tool (MAT). Adverse effects and patient adherence were also assessed in this study. No significant difference was observed between the ginger and control groups in the reduction of the incidence and severity of nausea and vomiting (P > .05). No significant difference in adverse events was observed between the 2 groups (P > .05). No study-treatment-related adverse events were observed in this study. As an adjuvant drug to standard antiemetic therapy, ginger had no additional efficacy in ameliorating CINV in patients with lung cancer receiving cisplatin-based regimens.

A retrospective analysis of clinical acuity markers on hospital length of stay in patients with febrile neutropenia.

The primary objective of this study was to identify factors that have predictive value in determining total hospital length of stay in patients with febrile neutropenia, particularly time to first antibiotic dose. This study was a retrospective chart review analyzing patients admitted to a 443 bed tertiary county teaching hospital from 1 November 2010 through 1 November 2015. Patients were eligible for enrollment into the study if they met Infectious Diseases Society of America accepted criteria for febrile neutropenia. Ninety-three patients were included for analysis. Time to first antibiotic dose, first empirically appropriate antibiotic dose, and time to first isolate-appropriate antibiotic did not show a significant correlation to total hospital length of stay (p = 0.71, p = 0.342, and p = 0.77, respectively). Subject's Multinational Association for Supportive Care in Cancer and Simplified Acute Physiology II scores were significantly correlated with hospital lengths of stay (p = 0.0052, rs = -0.243 and p = 0.0001, rs = 0.344, respectively). Higher median (interquartile ranges) Simplified Acute Physiology II scores were also associated with hospital mortality [dead = 46 (34.8-51.7) vs. alive = 34 (28-43.3), p = 0.0173]. Measures of patient acuity, such as the Multinational Association for Supportive Care in Cancer and Simplified Acute Physiology II scores, did show a correlation to clinical outcomes in patients with febrile neutropenia. Timing of initial antibiotics between 2.32 and 6.27 hours after presentation in patients with febrile neutropenia did not correlate with clinical outcomes.

Comparison of the MASCC and CISNE scores for identifying low-risk neutropenic fever patients: analysis of data from three emergency departments of cancer centers in three continents.

Patients with febrile neutropenia are a heterogeneous group with a minority developing serious medical complications. Outpatient management of low-risk febrile neutropenia has been shown to be safe and cost-effective. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score and Clinical Index of Stable Febrile Neutropenia (CISNE), have been developed and validated to identify low-risk patients. We aimed to compare the performance of these two scores in identifying low-risk febrile neutropenic patients. We performed a pooled analysis of patients presenting with febrile neutropenia to three tertiary cancer emergency centers in the USA, UK, and South Korea in 2015. The primary outcome measures were the occurrence of serious complications. Admission to an intensive care unit (ICU) and 30-day mortality were secondary outcomes. The predictive performance of each score was analyzed. Five hundred seventy-one patients presented with febrile neutropenia. With MASCC risk index, 508 (89.1%) were classified as low-risk febrile neutropenia, compared to 60 (10.5%) with CISNE classification. Overall, the MASCC score had a greater discriminatory power in the detection of low-risk patients than the CISNE score (AUC 0.772, 95% CI 0.726-0.819 vs. 0.681, 95% CI 0.626-0.737, p = 0.0024). Both MASCC and CISNE scores have reasonable discriminatory value in predicting patients with low-risk febrile neutropenia. Risk scores should be used in conjunction with clinical judgment for the identification of patients suitable for outpatient management of neutropenic fever. Developing more accurate scores, validated in prospective settings, will be useful in facilitating more patients being managed in an outpatient setting.

Improving the Management of Patients With Low-Risk Neutropenic Fever at the Cleveland Clinic Taussig Cancer Institute.

Neutropenic fever (NF) is an oncologic emergency and has resulted historically in inpatient management. The Multinational Association for Supportive Care in Cancer (MASCC) score can be used to identify patients with NF at a low risk of complications who can be managed safely as outpatients. Despite established guidelines supporting outpatient management of low-risk neutropenic fever (LRNF), provider awareness is low, and inpatient admission for intravenous antibiotics continues to be standard of care. Inpatient provider algorithm implementation and education began in the second quarter of 2014. Providers calculated MASCC scores for patients with nonleukemia hematologic malignancies and solid tumors at admission. Data were collected in a prospectively maintained registry. Patients identified as low risk by MASCC score were placed under observation and started on oral antibiotics. If exclusion criteria and social barriers were not identified, discharge within 48 hours was planned. Eighty-three patients with NF were admitted to the Taussig Cancer Institute inpatient oncology unit between November 2014 and June 2015. Fifty-three patients (64%) had LRNF by MASCC score. Patients with LRNF had an average length of stay of 3.3 days, compared with 6.2 days in our historical cohort. Sixteen patients (30%) were discharged within 24 hours. Only two patients with LRNF had a culture-proven infection, both Enterococcus urinary tract infections. Three patients required nonelective readmission. There were no deaths caused by NF. This pilot study demonstrates that a formal algorithm for LRNF management combined with provider education can improve current inpatient standard of care and length of stay without an increase in morbidity.

Can Patients with Febrile Neutropenia Be Sent Home from the ED

The Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores are used to

Editorial introductions

Editorial introductions