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Flashcards in Use of WBC Growth Factors Deck (15)
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1

In adults treated with chemotherapy for a solid tumor or lymphoma, what factors should clinicians consider when selecting patients for primary prophylaxis of febrile neutropenia with a CSF?

Primary prophylaxis with a CSF starting in the first cycle and continuing through subsequent cycles of chemotherapy is recommended in patients who have an approximately 20% or higher risk for febrile neutropenia on the basis of patient-, disease-, and treatment related
factors.


Primary CSF prophylaxis should also be administered in patients receiving dose-dense chemotherapy when considered appropriate.


Consideration should be given to alternative, equally effective, and safe chemotherapy regimens not requiring CSF support when available.

[ASCO 2015 Use of WBC growth Strength of recommendation: strong.]

2

Why is primary CSF prophylaxis important in certain patients?

In addition to the risk of neutropenic complications associated with chemotherapy regimens in patients who are eligible for clinical trials, the risk and consequences of neutropenic complications may be increased in the elderly, those previously treated with chemotherapy
or radiation therapy, and those with medical comorbidities

Primary CSF prophylaxis has been consistently associated with significant reductions in the risk of febrile neutropenia and infectious complications and also enables delivery of full-dose chemotherapy on schedule when considered important in patient management

3

What are patient risk factors for febrile neutropenia?

-Age greater than 65 years
-Advanced disease
-Previous chemotherapy or radiation therapy
-Preexisting neutropenia or bone marrow involvement with tumor
-Infection
-Open wounds or recent surgery
-Poor performance status or poor nutritional status
-Poor renal function
-Liver dysfunction, most notably elevated bilirubin
-Cardiovascular disease
-Multiple comorbid conditions
-HIV infection

4

What are patient risk factors for poor clinical outcomes with febrile neutropenia?

-Sepsis syndrome
-Age greater than 65 years
-Profound neutropenia (absolute neutrophil count < 0.1 x 10^9/L)
-Neutropenia expected to last > 10 days
-Pneumonia
-Invasive fungal infection
-Other clinically documented infections
-Hospitalization at time of fever
-Prior episode of febrile neutropenia

5

Among adults treated with chemotherapy for a solid tumor or lymphoma, what factors should clinicians use to select patients for secondary prophylaxis of febrile neutropenia with a CSF?

Secondary prophylaxis with CSFs is recommended for patients who experienced a neutropenic complication from a previous cycle of chemotherapy (for which primary prophylaxis was not received), in which a reduced dose or treatment delay may compromise disease-free or OS or treatment outcome.

In many clinical situations, dose reduction or delay may be a reasonable alternative.

ASCO 2015 Use of WBC factors: Strength of recommendation: strong.

6

Are there circumstances in which CSFs should be considered for the treatment of neutropenia in adults with cancer?

Therapy for patients with afebrile neutropenia.
-CSFs should not be routinely used for patients with neutropenia who are afebrile.
(ASCO 2015 Use of WBC factors: Strength of recommendation: strong)


Therapy for febrile patients with neutropenia.
-CSFs should not be routinely used as adjunctive treatment with antibiotic therapy for patients with fever and neutropenia.
-However, CSFs should be considered
in patients with fever and neutropenia who are at high risk for infection-associated complications or who have prognostic factors that are predictive of poor clinical outcomes.
-High-risk features include expected prolonged (>10 days) and profound (<0.1x10^9/L) neutropenia, age greater than 65 years, uncontrolled primary disease, pneumonia, hypotension and multiorgan dysfunction (sepsis syndrome), invasive fungal infection, or hospitalization at the time of fever development.

ASCO 2015 Use of WBC factors: Strength of recommendation: strong.

7

In what settings should CSFs be used to increase chemotherapy dose density?

Dose-dense regimens with CSF support should only be used within an appropriately designed clinical trial or if supported by convincing efficacy data.

"There are now several trials that support the use of CSFs in the setting of adjuvant dose-dense chemotherapy for high-risk breast cancer and one large study supporting CSF use with HD-M-VAC in urothelial cancer. Outside of a clinical trial, CSF-supported dose dense chemotherapy should be restricted to these settings."

8

What is the role of CSFs as adjuncts to progenitor cell
transplantation?

CSFs may be used alone, after chemotherapy, or in combination with plerixafor to mobilize peripheral-blood progenitor cells. Choice of mobilization strategy depends in part on type of cancer and type of transplantation.

CSFs should be administered after autologous SCT to reduce the duration of severe neutropenia.

CSFs may be administered after allogeneic SCT to reduce the duration of severe neutropenia.

ASCO 2015 Use of WBC factors: strong

9

Should CSFs be avoided in patients receiving concomitant chemotherapy and radiation therapy?

-CSFs should be avoided in patients receiving concomitant chemotherapy and radiation therapy, particularly involving the mediastinum.
-In the absence of chemotherapy, therapeutic use of CSFs may be considered in patients receiving radiation therapy alone if prolonged delays secondary to neutropenia are expected.

ASCO 2015 Use of WBC factors: strong

10

Are there CSF recommendations that apply specifically to older adults and that differ from recommendations in younger adults?

Prophylactic CSFs for patients with diffuse aggressive lymphoma age65 years treated with curative chemotherapy (CHOP-R) should be considered, particularly in the presence of comorbidities.

ASCO 2015 Use of WBC factors: moderate

11

What are recommendations for the initiation, duration, dosing, and administration of CSFs?

Please see ASCO 2015 Recommendations for Use of WBC factors Table 3

12

Do CSFs differ in efficacy?

Pegfilgrastim, filgrastim, tbo-filgrastim, and filgrastim-sndz (and other biosimilars as they become available) can be used for the prevention of treatment-related febrile neutropenia. The choice of agent depends on convenience, cost, and clinical situation. There have been no additional data comparing G-CSF and GM-CSF since the 2006 update; therefore, there has been no change in the recommendation regarding their therapeutic equivalency.

13

What is the role of CSFs in the treatment of radiation injury?

Current recommendations for the management of patients exposed to lethal doses of total-body radiotherapy, but not doses high enough to lead to certain death as a result of injury to other organs,
include the prompt administration of CSFs or pegylated G-CSFs.

Accidental or intentional (eg, resulting from terrorist attack or war) total-body radiation leads to probable or certain death resulting from bone marrow failure at doses of 3 to 10 Gy without supportive care, CSFs, and/or bone marrow transplantation. Doses below that level are almost always survivable with excellent nursing care; higher doses are lethal because of injury to other organs, such as the GI tract. The chance of mortality from any radiation dose rises with combined injuries to the skin, lungs, and so on.

Hematopoietic growth factors can increase the survival, proliferation, amplification, and differentiation of granulocyte progenitors to produce neutrophils.

14

What is the impact of comorbidities on febrile neutropenia?

Compared with patients with no comorbid
conditions, patients with >= three comorbid conditions had an 81% increased risk of febrile neutropenia. The presence of renal, hepatic, or cardiovascular disease has been associated with febrile neutropenia or febrile neutropenia–related hospitalization in patients with NHL
treated with CHOP-based chemotherapy

15

Most common side-effect of G-CSF is _____. How do you treat this?

Bone pain

-Acetaminophen and nonsteroidal antiinflammatory
drugs are common first-line options for the prevention
or treatment of G-CSF–related bone pain in adults.
-Other approaches that may be considered include antihistamines, opioids, and G-CSF dose reduction