Abstract
Chemotherapy-induced neutropenia is a major risk factor for infection-related morbidity
and mortality and also a significant dose-limiting toxicity in cancer treatment. Patients
developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently
receive dose reductions and/or delays to their chemotherapy. This may impact the success
of treatment, particularly when treatment intent is either curative or to prolong
survival.
In Europe, prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs),
such as filgrastim (including approved biosimilars), lenograstim or pegfilgrastim
is available to reduce the risk of chemotherapy-induced neutropenia. However, the
use of G-CSF prophylactic treatment varies widely in clinical practice, both in the
timing of therapy and in the patients to whom it is offered. The need for generally
applicable, European-focused guidelines led to the formation of a European Guidelines
Working Party by the European Organisation for Research and Treatment of Cancer (EORTC)
and the publication in 2006 of guidelines for the use of G-CSF in adult cancer patients
at risk of chemotherapy-induced FN. A new systematic literature review has been undertaken
to ensure that recommendations are current and provide guidance on clinical practice
in Europe. We recommend that patient-related adverse risk factors, such as elderly
age (⩾65 years) and neutrophil count be evaluated in the overall assessment of FN risk before
administering each cycle of chemotherapy. It is important that after a previous episode
of FN, patients receive prophylactic administration of G-CSF in subsequent cycles.
We provide an expanded list of common chemotherapy regimens considered to have a high
(⩾20%) or intermediate (10–20%) risk of FN. Prophylactic G-CSF continues to be recommended
in patients receiving a chemotherapy regimen with high risk of FN. When using a chemotherapy
regimen associated with FN in 10–20% of patients, particular attention should be given
to patient-related risk factors that may increase the overall risk of FN. In situations
where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic
G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity
or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis
may be used to maintain chemotherapy. Clinical evidence shows that filgrastim, lenograstim
and pegfilgrastim have clinical efficacy and we recommend the use of any of these
agents to prevent FN and FN-related complications where indicated. Filgrastim biosimilars
are also approved for use in Europe. While other forms of G-CSF, including biosimilars,
are administered by a course of daily injections, pegfilgrastim allows once-per-cycle
administration. Choice of formulation remains a matter for individual clinical judgement.
Evidence from multiple low level studies derived from audit data and clinical practice
suggests that some patients receive suboptimal daily G-CSFs; the use of pegfilgrastim
may avoid this problem.
Keywords
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Article info
Publication history
Published online: November 22, 2010
Accepted:
October 18,
2010
Received:
September 29,
2010
Identification
Copyright
© 2010 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.
