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Managing cancer toxicities: Neutropenia
Dr Pere Gascon
Summary of the presentation given at the TAO Congress on 8/9 December 2016
Dr Gascon gave a talk about chemotherapy-induced neutropenia (CIN) and importance of primary prophylaxis with G-CSF. He first explained the maturation process in the bone marrow from myeloblast to neutrophil that lasts approximately 21 days. Then, he reviewed the available data that strengthened the concept of primary prophylaxis with G-CSF.
Approximately 60% of febrile neutropenia (FN) episodes have an impact on the chemotherapy administration. In addition, following hospitalization for FN, overall mortality rate is 9.5% and it increases to more than 21.4% in case of presence of more than one major comorbidity. Thereby, it is essential to decrease the risk of treatment discontinuation and dose reduction because of FN.
G-CSF such as filgastrim has qualitative and quantitative effects on neutrophils when it is administered 24 hours after chemotherapy. Primary prophylaxis with G-CSF reduces the degree and duration of neutropenia. It also reduces neutropenia-related clinical consequences. Specifically, compared with placebo or untreated control, primary prophylaxis with G-CSF reduces the relative risk of FN by 46%, the risk of early mortality by more than 40% and infection-related mortality by 45%. Moreover, it increases overall survival since it improves chemotherapy dose-intensity and allows us to avoid chemotherapy delays and dose reductions. Adverse events include bone or musculoskeletal pain.
According to the EORTC patient assessment algorithm that has been updated in 2010, primary prophylaxis is recommended if overall FN risk with the scheduled chemotherapy protocol is evaluated to be ≥ 20%. Factors that increase FN risk can be classified as follows:
- High risk: Age> 65 years
- Increased risk (levels of evidence I and II): Advanced disease, History of prior FN, No antibiotic prophylaxis, No G-CSF use
- Other factors (levels of evidence III and IV):
Poor performance and/or nutritional status, Female gender, Hemoglobin < 12 g/dL, Liver, renal or cardiovascular disease.
Recently, female gender is not a risk factor anymore according to the results of a recent meta-analysis presented at the last ESMO congress.
Finally, pegfilgastrim, a long-acting form of filgastrim has been developed. Its clearance is autoregulated because it is eliminated when the levels of neutrophils are normalized. It can be given with 2 weeks chemotherapy regimens and not weekly ones.
Speaker: Dr Pere Gascon, Hôpital Clinique, Barcelona, Spain