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A Way Forward on the Medically Appropriate Use of White Cell Growth Factors

Year: 2012

Type: editorial

Abstract: Are Hematopoietic Colony-Stimulating Factors Overor Underused? Since their introduction, there has been debate about the benefits, risks, and costs of hematopoietic colony-stimulating factors (CSFs). We suggest that the use of CSFs to allow dose maintenance of chemotherapy for common metastatic solid tumors is unsupported by evidence, and we should reconsider using a $3,500-per-cycle injection for a supportive care drug without major benefit. Recent studies have documented concerns about appropriate CSF use. Potosky et al prospectively identified 1,849 patients with lung or colorectal cancer who received palliative chemotherapy from 2003 to 2005. Only 17% of high-risk patients received appropriate primary prophylaxis. CSFs were used to maintain dose-intensity in 257 patients, of whom 18% were at intermediate risk (10% to 20% risk) and 10% were at low risk ( 10% risk) of febrile neutropenia (FN). Compared with American Society of Clinical Oncology (ASCO) guidelines (Table 1), 96% of CSF use can be judged not appropriate. Two reports from Ramsey et al are relevant. The first found that in 2,728 patients with cancer at low risk of FN, 10% of those with breast, 7% of those with colorectal, and 21% of those with non–smallcell lung cancers received CSFs. Most use did not conform to product labeling or practice guidelines. The second linked Puget Sound Cancer Registry data with insurance claims from four payers representing 75% of those insured from 2002 to 2005 and found no evidence that CSF as primary prophylaxis was associated with a reduction in antibiotic use or inpatient or outpatient visits in breast, colorectal, or non– small-cell lung cancer. Kuderer et al rebutted that CSFs were perhaps underused. They argue that “initiation of the CSFs early in the first cycle of chemotherapy and continuation through all cycles of a chemotherapy regimen (primary prophylaxis) has been shown to substantially reduce the risk of FNaswellas infection-relatedandearlyall-causemortality,whiledecreasing the need for chemotherapy dose reductions and delays,” without referring to any specific cancer types.

Source: Journal of Clinical Oncology

DOI: 10.1200/jco.2011.39.9980

Authors: Thomas J. Smith, Bruce E. Hillner