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Case History

image A 65-year-old patient recovers from a neutropenic event without problems and is seen in clinic a week later. She has been receiving palliative chemotherapy for metastatic breast cancer. She asks why she was not given a granulocyte-colony stimulating factor (G-CSF) with her first cycle of chemotherapy and requests it with her next.

How may neutropenia be avoided?

Can this be done for more intensive therapy?

Does this help older patients?

Is it useful for established neutropenia?


How may neutropenia be avoided?

image Neutropenia is a major dose-limiting toxicity in cancer patients treated with myelosuppressive chemotherapy. The incidence of chemotherapy dose reductions or treatment delays, which can impact on overall dose intensity and compromise treatment outcomes, may be reduced by the proactive use of drugs that stimulate the growth and development of neutrophils in the bone marrow such as granulocyte-colony stimulating factors (G-CSFs). To guide the targeted use of supportive care before complications occur, risk assessment should be conducted before the first cycle of chemotherapy treatment. For patients who do not receive G-CSF in the first cycle, risk should be re-evaluated before each subsequent cycle as a patient's risk categorization may change. If a patient experiences febrile neutropenia or a dose-limiting neutropenic event in any cycle, G-CSF use should be considered in the next cycle.


image Primary prophylactic use of G-CSF is its use to prevent febrile neutropenia in patients who are at a high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. The American Society of Clinical Oncology (ASCO) guidelines, based on two large randomized clinical trials, support the use of G-CSF when the risk of febrile neutropenia is approximately 20% or higher and no other equally effective regimen that does not require G-CSF is available.1 Vogel et al.2 randomized 928 patients with breast cancer receiving 100 mg/m2 docetaxel every 3 weeks for four cycles, to pegfilgrastim or no pegfilgrastim. The incidence of febrile neutropenia (1% versus 17%, respectively) and hospitalization (1% versus 14%, respectively) was reduced by more than 90% (P image0.001). A trial in 171 patients with small cell lung cancer, with randomization to prophylactic G-CSF and/or antibiotics showed a reduction in the rate of overall febrile neutropenia from 32% to 18% (P image0.01).3

Secondary prophylactic use of G-CSF is its use in patients who have experienced a neutropenic complication from a prior cycle of chemotherapy (for which primary prophylaxis was not received), in whom a reduced dose may compromise disease-free or overall survival or treatment outcome. Riveria et al.4 conducted a prospective clinical trial in which women receiving adjuvant breast cancer chemotherapy who had experienced neutropenia image500/mm3 in cycle 1 were given G-CSF in subsequent cycles. The G-CSF recipients had lower rates of hospitalization for febrile neutropenia and greater dose intensity. ...

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