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Chapter 43: Indications for Growth Factors in Hematology-Oncology

Pamela W. McDevitt; James N. Frame; Lee S. Schwartzberg

FEBRILE NEUTROPENIA

Epidemiology

Febrile neutropenia is a major dose-limiting toxicity of chemotherapy. Studies have demonstrated that selective use of colony-stimulating factors (CSFs) in patients at high-risk for complications of neutropenia can enhance cost-effectiveness by reducing the risk, severity and duration of febrile neutropenia

NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Neutrophil Count Decreased3

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NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Neutrophil Count Decreased3
Grade ANC/AGC
0 Normal
1 ≥1500/mm3 to LLN
2 ≥1000 to <1500/mm3
3 ≥500 to <1000/mm3
4 <500/mm3

AGC, absolute granulocyte count; ANC, absolute neutrophil count; LLN, lower limit of normal range

WHO Toxicity Criteria

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WHO Toxicity Criteria
Grade ANC/AGC
0 2000/mm3
1 1500–1900/mm3
2 1000–1400/mm3
3 500–900/mm3
4 <500/mm3

AGC, absolute granulocyte count; ANC, absolute neutrophil count; WHO, World Health Organization

Examples of Regimens with >20% Risk of Febrile Neutropenia2

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Examples of Regimens with >20% Risk of Febrile Neutropenia2

(The list is not comprehensive)
Cancer Type Regimen
Bladder MVAC (methotrexate, vinblastine, doxorubicin
Breast Dose Dense AC→T (doxorubicin, cyclophosphamide, paclitaxel)
Docetaxel, trastuzumab
TAC (docetaxel, doxorubicin, cyclophosphamide)
Esophageal and gastric DCF (docetaxel, cisplatin, fluorouracil)
Hodgkin lymphoma BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone)
Kidney Doxorubicin, gemcitabine
Non-Hodgkin lymphoma ICE (ifosfamide, carboplatin, etoposide)
CFAR (cyclophosphamide, fludarabine, alemtuzumab, rituximab)
RICE (rituximab, ifosfamide, carboplatin, etoposide)
CHOP-14 (cyclophosphamide, doxorubicin, vincristine, prednisone ± rituximab)
MINE (mesna, ifosfamide, mitoxantrone, etoposide)
ESHAP (etoposide, methylprednisolone, cisplatin, cytarabine)
Hyper-CVAD + rituximab (cyclophosphamide, vincristine, doxorubicin, dexamethasone, + rituximab)
DHAP (dexamethasone, cisplatin, cytarabine)
ESHAP (etoposide, methylprednisolone, cisplatin, cytarabine)
Melanoma Dacarbazine-based combinations (with: cisplatin, vinblastine, aldesleukin [IL-2])
Myelodysplastic syndromes Antithymocyte globulin, rabbit/cyclosporine
Decitabine
Ovarian Topotecan
Paclitaxel
Docetaxel
Soft tissue sarcoma MAID (mesna, doxorubicin, ifosfamide, dacarbazine)
Doxorubicin
Doxorubicin/ifosfamide
Lung, small cell Topotecan
Testicular VeIP (vinblastine, ifosfamide, cisplatin)
VIP (etoposide, ifosfamide, cisplatin)
BEP (bleomycin, etoposide, cisplatin)
TIP (paclitaxel, ifosfamide, cisplatin)

Treatment Overview

NCCN Guidelines® (V.1.2013)2 and ASCO Guidelines (2006 Update)5 recommend routine use of CSFs support for patients at high risk (defined >20%) of developing febrile neutropenia who are receiving treatment with curative intent, adjuvant therapy, or treatment expected to prolong survival or to improve quality of life (QOL)2,5

 

ASCO Guidelines also recommends CSFs for:

  • Patients with diffuse aggressive lymphomas aged ≥65 years treated with curative chemotherapy (CHOP or more aggressive regimens)

  • Patients exposed to lethal doses of total-body irradiation (TBI) (CSFs or pegylated G-CSF)5

 

NCCN Guidelines (V.1.2013) also recommend evaluation of patients for the use of myeloid growth factors before every cycle of cytotoxic chemotherapy

  • If febrile neutropenia or a dose-limiting neutropenic event previously occurred during chemotherapy without CSFs use, the guidelines recommend considering CSFs use during repeated treatment cycles

  • If fever with neutropenia or a dose-limiting neutropenic ...

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