The Lynx Group

Use of G-CSF Agents Prevents Febrile Neutropenia, but High Cost Limits Their Utilization

September 2012, Vol 3, No 6

New York, NY—Two major advances over the past decades have improved the management of febrile neutropenia (FN)—the MASCC (Multinational Association of Supportive Care in Cancer) scoring system for predicting the risk of FN, and the use of granulocyte colony-stimulating factors (G-CSFs) for the prevention of FN. However, the need for improvement still exists, said Jean Klastersky, MD, Professor, Institut Jules Bordet, Brussels, Belgium, at the 2012 MASCC International Symposium. Among the remaining challenges is refining the optimal use of these agents.

According to Dr Klastersky, current guidelines restricting the use of prophylactic G-CSFs to high-risk patients are based on economic, not on scientific, considerations. He believes that the criteria should be expanded to incorporate patients at a lower risk of developing FN, because when FN develops, costly and life-threatening complications are similar in all risk groups. Furthermore, studies show that the benefits of preventing FN are similar in low-risk and high-risk patients.

Over the past 3 decades, FN-related mortality and morbidity have de­clined, and therapies are less toxic and more appropriately geared toward risk status. The complications of FN can include hypotension, respiratory failure, intensive care unit admission, and confusion; 30 years ago, these complications were fatal for many patients. Currently, the rate of com­plications is 10% to 20%, and the mortality rate is about 5%, but even a 5% mortality rate is too high, Dr Klastersky said.

Treating low-risk patients on an outpatient basis reduces the cost of FN treatment by approximately 50%. The mean cost of treating 1 episode is $7700 in an outpatient setting and $15,231 in the inpatient setting. Growth factors account for a good part of the costs associated with hospitalization, Dr Klastersky said.

The MASCC scoring index for FN predicts the risk for complications, which is calculated based on total symptom burden and on individual symptoms. A MASCC index score >20 predicts a 5% (ie, low) risk for complications. Low-risk patients can be effectively treated as outpatients, with oral antibiotics after a 24-hour observation period in the hospital.

Patients with a MASCC score <15 are at higher risk of severe sepsis and mortality if FN develops. According to Dr Klastersky, the management of this group of patients should be more aggressive. Protocols are needed and treatment should be initiated with intravenous antibiotics before several hours elapse.

Because of the high cost associated with the G-CSFs, their use is typically recommended in patients with a ≥20% risk for FN, and growth factors are typically withheld from patients with a 10% risk of developing FN.

Dr Klastersky said that further study is needed to determine whether the criteria for G-CSF prophylaxis should include lower-risk patients.

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