Delivering adjuvant chemotherapy to women with early-stage breast carcinoma: current patterns of care

Ginsenoside Rg3 for Chemotherapy-Induced Myelosuppression: A Meta-Analysis and Systematic Review

Patients with advanced cancer often undergo myelosuppression after receiving chemotherapy. However, severe myelosuppression results in treatment delay, and some can even be life-threatening. At present, cancer patients undergoing chemotherapy urgently need effective intervention strategies to prevent myelosuppression. Fortunately, ginsenoside Rg3 has shown promise as an anti-myelosuppression agent. Therefore, this study was conducted to evaluate the effectiveness of ginsenoside Rg3 in preventing chemotherapy-induced myelosuppression in cancer patients. The PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu (VIP), and Wanfang databases were searched in this study. A total of 18 trials which reported on 2,222 subjects were identified. All trials concerning the use of ginsenoside Rg3 for the prevention of chemotherapy-induced myelosuppression (the decline of leukocyte, hemoglobin, platelet, and neutrophil counts) were randomized-controlled trials. Dichotomous data were expressed as odds ratio (OR) with their respective 95% confidence intervals (CI). The Cochrane evidence-based medicine systematic evaluation was used to evaluate the methodological quality of the included trials. The Review Manager 5.3 and Stata 12.0 software were used to perform the statistical analyses. The trial sequential analysis (TSA) was used to evaluate information size and prevention benefits. The results revealed obvious ginsenoside Rg3-induced improvement in the leukocyte (OR, 0.46; 95% CI, 0.37–0.55), hemoglobin (OR, 0.64; 95% CI, 0.53–0.77), platelet (OR, 0.60; 95% CI, 0.48–0.75) and neutrophil (OR, 0.62; 95% CI, 0.43–0.90) counts at toxic grades I–IV, and leukocyte (OR, 0.39; 95% CI, 0.28–0.54) counts at toxic grades III–IV. The sensitivity analysis revealed that the results were robust. The Egger’s test indicated that there was no publication bias in the results. Overall, this study suggested that ginsenoside Rg3 is beneficial for alleviating the chemotherapy-induced decrease in leukocyte, hemoglobin, platelet, and neutrophil counts. However, the confirmation of the ginsenoside Rg3 can be recommended for myelosuppression patients was limited due to poor methodological quality. Thus, more rigorously designed randomized-controlled trials (RCTs) are required to assess the efficacy of ginsenoside Rg3 for myelosuppression.

Patterns of Anthracycline-Based Chemotherapy-Induced Adverse Drug Reactions and Their Impact on Relative Dose Intensity among Women with Breast Cancer in Ethiopia: A Prospective Observational Study

BACKGROUND

The breast cancer chemotherapy leads to diverse aspects of noxious or unintended adverse drug reactions (ADRs) that cause the relative dose intensity (RDI) reduced to below optimal (i.e., if the percentage of actual dose received per unit time divided by planned dose per unit time is less than 85%). Hence, this prospective observational study was conducted to evaluate chemotherapy-induced ADRs and their impact on relative dose intensity among women with breast cancer in Ethiopia.

METHODS

The study was conducted with a cohort of 146 patients from January 1 to September 30, 2017, Gregorian Calendar (GC) at the only nationwide oncology center, Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia. The ADRs of the chemotherapy were collected using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) (version 4.03). The patients were personally interviewed for subjective toxicities, and laboratory results and supportive measures were recorded at each cycle. SPSS version 22 was used for analysis.

RESULTS

Grade 3 neutropenia (23 (15.8%)) was the most frequently reported ADR among grade 3 hematological toxicity on cycle 4. However, overall grade fatigue (136 (93.2%)) and grade 3 nausea (31 (21.2%)) were the most frequently reported nonhematological toxicities on cycle 1. The majority of ADRs were reported during the first four cycles except for peripheral neuropathy. Oral antibiotics and G-CSF use (17 (11.6%)) and treatment delay (31 (21.2%)) were frequently reported on cycle 3. Overall, 61 (41.8%) and 42 (28.8%) of study participants experienced dose delay and used G-CSF, respectively, at least once during their enrollment. Of the 933 interventions observed, 95 (10%) cycles were delayed due to toxicities in which neutropenia attributed to the delay of 89 cycles. Forty-four (30.1%) of the patients received overall RDI < 85%. Pretreatment hematological counts were significant predictors (P < 0.05) for the incidence of first cycle hematological toxicities such as neutropenia, anemia, and leukopenia and nonhematological toxicities like vomiting.

CONCLUSION

Ethiopian women with breast cancer on anthracycline-based AC and AC-T chemotherapy predominantly experienced grade 1 to 3 hematological and nonhematological ADRs, particularly during the first four cycles. Neutropenia was the only toxicity that led to RDI < 85%. Thus, enhancing the utilization of G-CSF and other supportive measures will improve RDI to above 85%.

Prophylactic administration of granulocyte colony-stimulating factor in epirubicin and cyclophosphamide chemotherapy for Japanese breast cancer patients: a retrospective study

PURPOSE

Epirubicin and cyclophosphamide (EC) therapy, a major chemotherapy for patients with early-stage breast cancer, has a low risk (< 10%) of febrile neutropenia (FN). However, data used in reports on the incidence rate of FN were derived primarily from non-Asian populations. In this study, we investigated the FN incidence rate using EC therapy among Japanese patients with breast cancer and evaluated the significance of prophylactic administration of granulocyte colony-stimulating factor (G-CSF).

METHODS

We evaluated medical records of patients with early-stage breast cancer who had been treated with EC therapy as neoadjuvant or adjuvant therapy between November 2014 and July 2018.

RESULTS

The incidence rate of FN was 23.9%. In patients who received G-CSF as primary prophylaxis, FN expression was completely suppressed. The incidence rate of severe leucopenia/neutropenia, emergency hospitalization, and the use of antimicrobial agents were low in patients receiving primary prophylaxis with G-CSF compared with those not receiving G-CSF (27.3% vs. 64.8%, 9.1% vs. 27.3%, and 27.3% vs. 71.6%, respectively). Furthermore, in all patients who received primary prophylaxis with G-CSF, a relative dose intensity > 85% using EC therapy was maintained.

CONCLUSION

The incidence of FN in EC therapy among Japanese patients was higher than expected, EC therapy appears to be a high-risk chemotherapy for FN, and prophylactic administration of G-CSF is recommended. Maintaining high therapeutic intensity is associated with a positive prognosis for patients with early breast cancer, and prophylactic administration of G-CSF is likely to be beneficial in treatment involving EC therapy.

Pathway-Based Analysis of Genome-Wide Association Data Identified SNPs in HMMR as Biomarker for Chemotherapy- Induced Neutropenia in Breast Cancer Patients

Neutropenia secondary to chemotherapy in breast cancer patients can be life-threatening and there are no biomarkers available to predict the risk of drug-induced neutropenia in those patients. We previously performed a genome-wide association study (GWAS) for neutropenia events in women with breast cancer who were treated with 5-fluorouracil, epirubicin and cyclophosphamide and recruited to the SUCCESS-A trial. A genome-wide significant single-nucleotide polymorphism (SNP) signal in the tumor necrosis factor superfamily member 13B (TNFSF13B) gene, encoding the cytokine B-cell activating factor (BAFF), was identified in that GWAS. Taking advantage of these existing GWAS data, in the present study we utilized a pathway-based analysis approach by leveraging knowledge of the pharmacokinetics and pharmacodynamics of drugs and breast cancer pathophysiology to identify additional SNPs/genes associated with the underlying etiology of chemotherapy-induced neutropenia. We identified three SNPs in the hyaluronan mediated motility receptor (HMMR) gene that were significantly associated with neutropenia (p < 1.0E-04). Those three SNPs were trans-expression quantitative trait loci for the expression of TNFSF13B (p < 1.0E-04). The minor allele of these HMMR SNPs was associated with a decreased TNFSF13B mRNA level. Additional functional studies performed with lymphoblastoid cell lines (LCLs) demonstrated that LCLs possessing the minor allele for the HMMR SNPs were more sensitive to drug treatment. Knock-down of TNFSF13B in LCLs and HL-60 promyelocytic cells and treatment of those cells with BAFF modulated the cell sensitivity to chemotherapy treatment. These results demonstrate that HMMR SNP-dependent cytotoxicity of these chemotherapeutic agents might be related to TNFSF13B expression level. In summary, utilizing a pathway-based approach for the analysis of GWAS data, we identified additional SNPs in the HMMR gene that were associated with neutropenia and also were correlated with TNFSF13B expression.

Is it reasonable to administer pegfilgrastim on day 1 of a myelosuppressive chemotherapy regimen? A cost-utility analysis

BACKGROUND

There is recent evidence supporting the safety and efficacy of same-day dosing of pegfilgrastim in patients undergoing chemotherapy.

OBJECTIVE

To determine the cost-effectiveness of pegfilgrastim on day 1 (D1) versus day 2 (D2) for primary prevention of neutropenia in women receiving chemotherapy.

MATERIALS AND METHODS

A cost-utility model was designed comparing standard D2 versus D1 administration of pegfilgrastim to ovarian cancer patients receiving chemotherapy with an intermediate risk (10-15%) of febrile neutropenia (FN). Rates of FN despite prophylaxis were modeled as 10% for D1 and 5% for D2. Societal costs associated with D2 injection ($175.71) were incorporated. Quality of life (QOL) was modeled from published data; we assumed a small decrement in QOL on treatment days. Sensitivity analyses were performed.

RESULTS

D1 administration was less costly ($17,195 versus $17,681) and resulted in higher QOL (0.2298 quality adjusted life years (QALYs) versus 0.2288 QALYs) than D2. Results were sensitive to the risk of FN. D1 remained dominant or cost-effective (ICER less than $50,000/QALY) compared to D2 if the FN rate with D1 was assumed less than 14.5% (baseline estimate 10%). If the FN rate with D1 was assumed greater than or equal to 15%, D1 was not cost-effective compared to D2, with an ICER greater than $100,000/QALY. Findings are insensitive to variations in the modeled cost of treating FN, the additional cost of D2 injection, and the reduced QOL associated with treatment visits.

CONCLUSION

Administration of D1 pegfilgrastim is cost-effective in women with ovarian cancer who are treated with intermediate risk chemotherapy.

Chemotherapy-induced moderate tolife-threatening anemia in early-stage breast cancer

Purpose. We evaluated the incidence and severity of anemia experienced by women treated with doxorubicin and cyclophosphamide (AC) therapy for early-stage breast cancer are described. We also explored the possibility of identifying clinical characteristics that will allow early identification of women more likely to develop anemia and may require anemia treatment.

Methods. This study used a historic case series from 13 oncology practices that participated in the Oncology Practice Pattern Study. The analysis focused on 411 patients who received AC chemotherapy from 1993 through 1999. Seventeen percent of the study population was excluded from the analysis due to missing data. Anemia was defined as a hemoglobin (Hb) value of < 12 g/dL. Hb ≤10 g/dL was considered the threshold value for treatment.

Results. Among patients receiving AC, 18.0% was anemic prior to chemotherapy. Overall, 14.9 -16.9% of women with early-stage breast cancer who started AC chemotherapy with a normal Hb (≥12 g/dL) developed anemia. Nearly 11% developed severe to life-threatening anemia (Hb < 8 g/dL). Data on blood transfusions and erythropoietic therapy were unavailable. Multivariate logistic regression analysis showed that patients who started with a normal prechemotherapy Hb and dropped to ≤10 g/dL at some point during chemotherapy were more likely to be ≥65 years of age, have a low body surface area (< 1.78), and have four or more positive nodes.

Conclusion. The incidence of anemia increased substantially from baseline to post-chemotherapy. The data suggested the importance of monitoring and managing Hb levels of patients at increased risk for developing chemotherapy-induced anemia.

Management of breast cancer patients with chemotherapy-induced neutropenia or febrile neutropenia

Chemotherapy-induced neutropenia (CIN) is a common toxicity caused by the administration of anticancer drugs. This side effect is associated with life-threatening infections and may alter the chemotherapy schedule, thus impacting on early and long-term outcomes. Elderly breast cancer patients with impaired health status or advanced disease as well as patients undergoing dose-dense anthracycline/taxane- or docetaxel-based regimens have the highest risk of CIN. A careful assessment of the baseline risk for CIN allows the selection of patients who need primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) and/or antimicrobial agents. Neutropenic cancer patients may develop febrile neutropenia and CIN-related severe medical complications. Specific risk assessment scores, along with comprehensive clinical evaluation, are able to define a group of febrile patients with low risk for complications who can be safely treated as outpatients. Conversely, patients with higher risk of severe complications should be hospitalized and should receive intravenous antibiotic therapy with or without G-CSF.

Dose schedule optimization and the pharmacokinetic driver of neutropenia

Toxicity often limits the utility of oncology drugs, and optimization of dose schedule represents one option for mitigation of this toxicity. Here we explore the schedule-dependency of neutropenia, a common dose-limiting toxicity. To this end, we analyze previously published mathematical models of neutropenia to identify a pharmacokinetic (PK) predictor of the neutrophil nadir, and confirm this PK predictor in an in vivo experimental system. Specifically, we find total AUC and Cmax are poor predictors of the neutrophil nadir, while a PK measure based on the moving average of the drug concentration correlates highly with neutropenia. Further, we confirm this PK parameter for its ability to predict neutropenia in vivo following treatment with different doses and schedules. This work represents an attempt at mechanistically deriving a fundamental understanding of the underlying pharmacokinetic drivers of neutropenia, and provides insights that can be leveraged in a translational setting during schedule selection.

The impact of dose/time modification in irinotecan- and oxaliplatin-based chemotherapies on outcomes in metastatic colorectal cancer

PURPOSE

This study was designed to evaluate (1) the impact of relative dose intensity (RDI) on tumor response and survival outcomes and (2) the influence of dose reduction and schedule modification on outcomes in patients with metastatic colorectal cancer (mCRC).

METHODS

Pooled datasets from two previous phase II trials of FOLFIRI (CCOG-0502; n = 36) and mFOLFOX6 (CCOG-0704; n = 30) in patients with mCRC were analyzed retrospectively. The RDIs of irinotecan and oxaliplatin were compared to response rate (RR), disease control rate (DCR), progression-free survival (PFS) and overall survival (OS). To assess the effects of dose reduction and schedule modification, the effects of dose index (DI) and time index (TI) on outcomes were evaluated.

RESULTS

The median RDIs of irinotecan in FOLFIRI and oxaliplatin in mFOLFOX6 were 80 and 79 %, respectively. Higher RDI of irinotecan in FOLFIRI was associated with significant improvements in RR (65 vs. 6 %, p < 0.01), DCR (100 vs. 59 %, p < 0.01), PFS (9.9 vs. 5.6 months, p < 0.01) and OS (26.7 vs. 12.9 months, p = 0.01) and was the only independent factor associated with PFS [hazard ratio (HR) 8.48, p < 0.01). Higher RDI of oxaliplatin in FOLFOX was significantly associated with DCR (65 vs. 6 %, p < 0.01), and higher TI of oxaliplatin was the only independent factor associated with PFS (HR 2.74, p = 0.04).

CONCLUSION

RDIs of irinotecan and oxaliplatin affected clinical outcomes. Dose reductions in irinotecan, as indicated by DI, and time delays in oxaliplatin, as indicated by TI, were the only independent prognostic factors predicting PFS in patients receiving FOLFIRI and FOLFOX6, respectively.

Improving the relative dose intensity of systemic chemotherapy in a community-based outpatient cancer center

PURPOSE

This three-phase study was performed to improve the mean relative dose intensity (RDI) of chemotherapy administered to patients in a community-based outpatient cancer center.

METHODS

Medical records were reviewed for patients who began receiving systemic chemotherapy for lymphoma or cancer of the breast, lung, endometrium, ovary, or colon. During phase 1, records were reviewed and the mean RDI was determined through collection of demographic, diagnostic, chemotherapy, and laboratory data. Phase 2 involved implementation of quality improvement initiatives to improve the RDI: development of a febrile neutropenia risk assessment tool, revision of our dose cancellation policy, and interdisciplinary education. Finally, after implementation of these initiatives, the mean RDI was prospectively determined in phase 3, similar to phase 1.

RESULTS

The mean RDI was determined to be 83% during phase 1 compared with 91% during phase 3 (P=.0087). For adjuvant chemotherapy, the mean RDI was 85% and 95% for phases 1 and 3, respectively (P=.0035). Likewise, for metastatic disease, the mean RDI was 76% and 82% for phases 1 and 3, respectively (P=.3935). The proportion of regimens that met or exceeded the recommended minimum goal RDI of 85% was 54% for phase 1 and 80% for phase 3. Granulocyte colony-stimulating factor use increased from 69% preintervention to 81% postintervention.

CONCLUSION

The mean overall RDI improved above the threshold goal of 85%, with the RDI for adjuvant chemotherapy reaching 95%, after implementation of three quality-improvement initiatives. With continued education and following policies already in place, further improvements in RDI could be demonstrated.

Optimal use of recombinant granulocyte colony-stimulating factor with chemotherapy for solid tumors

Neutropenia is a frequent complication of anticancer chemotherapy (CT) often associated with life-threatening infections, hospitalization, dose reduction and/or delay in the administration of CT. Administration of recombinant granulocyte colony-stimulating factor (rG-CSF) reduces the duration and the degree of CT-neutropenia. rG-CSF that stimulates both neutropoiesis and neutrophil function, has become an integral part of supportive care during cytotoxic CT, to prevent febrile neutropenia (FN), particularly in patients with a risk of FN ≥ 20%. International guidelines have standardized conditions for rG-CSF administration, however, some 'gray zones' still exist around optimal timing and tailoring of this therapy. We report here the results of a research project aimed to extend the consensus on the optimal use of rG-CSF in association with CT in patient with solid tumours. We also propose a recently developed pharmacodynamic model, based on the biological effects of CT and rG -CSF on bone marrow compartments that clearly indicates within the prophylactic rather than therapeutic setting the better way of rG-CSF administration.

Pegfilgrastim on the Same Day Versus Next Day of Chemotherapy in Patients With Breast Cancer, Non-Small-Cell Lung Cancer, Ovarian Cancer, and Non-Hodgkin's Lymphoma: Results of Four Multicenter, Double-Blind, Randomized Phase II Studies

PURPOSE

To compare data on severe (grade 4) neutropenia duration and febrile neutropenia incidence in patients receiving chemotherapy with pegfilgrastim administered the same day or 24 hours after chemotherapy.

PATIENTS AND METHODS

These were similar, randomized, double-blind phase II noninferiority studies of patients with lymphoma or non-small-cell lung (NSCLC), breast, or ovarian cancer. Each study was analyzed separately. The primary end point in each study was cycle-1 severe neutropenia duration. Approximately 90 patients per study were to be randomly assigned at a ratio of 1:1 to receive pegfilgrastim 6 mg once per cycle on the day of chemotherapy or the day after (with placebo on the alternate day).

RESULTS

In four studies, 272 patients received chemotherapy and one or more doses of pegfilgrastim (133 same day, 139 next day). Three studies (breast, lymphoma, NSCLC) enrolled an adequate number of patients for analysis. However, in the NSCLC study, the neutropenic rate was lower than expected (only two patients per arm experienced grade 4 neutropenia). In the breast cancer study, the mean cycle-1 severe neutropenia duration was 1.2 days (95% confidence limit [CL], 0.7 to 1.6) longer in the same-day compared with the next-day group (mean, 2.6 v 1.4 days). In the lymphoma study, the mean cycle-1 severe neutropenia duration was 0.9 days (95% CL, 0.3 to 1.4) longer in the same-day compared with the next-day group (mean, 2.1 v 1.2 days). In the breast and lymphoma studies, the absolute neutrophil count profile for same-day patients was earlier, deeper, and longer compared with that for next-day patients, although the results indicate that same-day administration was statistically noninferior to next-day administration according to neutropenia duration.

CONCLUSION

For patients receiving pegfilgrastim with chemotherapy, pegfilgrastim administered 24 hours after chemotherapy completion is recommended.

Dose intensity in early-stage breast cancer: a community practice experience

Although nodal status, grade, size, and receptor status play roles in determining breast cancer prognosis, there is increasing evidence that maintaining dose intensity of adjuvant chemotherapy increases disease-free survival rate.

Costs and outcomes associated with hospitalized cancer patients with neutropenic complications: A retrospective study

The average total hospitalization costs for adult cancer patients with neutropenic complications were quantified and the average length of hospital stay (LOS), all-cause mortality during hospitalization and reimbursement rates were determined. This observational retrospective cohort study identified adult patients with cancer who were hospitalized from January 2005 through June 2008 using a large private US health care database (>342 inpatient facilities). ICD-9-CM diagnosis codes identified patients by cancer type and who had neutropenic complications. The utilization and accounting systems of the hospitals were used to calculate mean (±95% confidence interval) hospitalization costs and LOS and percent all-cause mortality and reimbursement. Costs were adjusted to 2009 US dollars. There were 3,814 patients who had cancer and neutropenia, 1,809 (47.4%) also had an infection or fever and 1,188 (31.1%) had infection. Mean hospitalization costs were $18,042 (95% CI 16,997-19,087) for patients with neutropenia, $22,839 (95% CI 21,006-24,672) for patients with neutropenia plus infection or fever and $27,587 (95% CI 24,927-30,247) for patients with neutropenia plus infection. Mean LOS were 9 days (95% CI 8.7-9.3), 10.7 days (95% CI 10.2-11.2) and 12.6 days (95% CI 11.9-13.3), respectively. Mortality followed a similar trend; 8.3, 13.7 and 19.4%, respectively. By cancer type, hematologic malignancies had the highest average hospitalization costs and longest mean LOS of $52,579 (95% CI 42,183-62,975) and 20.3 days (95% CI 17.4-23.2), and a high mortality rate of 20.0%, while primary breast cancer patients had the lowest cost of $8,413 (95% CI 6,103-10,723), shortest LOS of 5.5 days (95% CI 4.2-6.8) and lowest mortality (0%). Mean reimbursement rates were 100.0, 101.5 and 95.4% for patients with neutropenia, neutropenia plus infection or fever and neutropenia plus infection, respectively. Hospitalized cancer patients with neutropenic complications had a higher all-cause mortality rate and higher inpatient hospitalization costs than those previously published. Results from this study suggest that costs for inpatient hospitalized cancer patients with neutropenic complications are principally reimbursed by payers.

Evaluating the impact of Relative Total Dose Intensity (RTDI) on patients' short and long-term outcome in taxane- and anthracycline-based chemotherapy of metastatic breast cancer- a pooled analysis

Background

Chemotherapy dose delay and/or reduction lower relative total dose intensity (RTDI) and may affect short- and long-term outcome of metastatic breast cancer (MBC) patients.

Methods

Based on 933 individual patients' data of from 3 randomized MBC trials using an anthracycline and taxane we examined the impact of RTDI on efficacy and determined the lowest optimal RTDI for MBC patients.

Results

Median time to disease progression (TTDP) and overall survival (OS) of all patients were 39 and 98 weeks. Overall higher RTDI was correlated with a shorter TTDP (log-rank p = 0.0525 for 85% RTDI cut-off). Proportional hazards assumption was violated, there was an early drop in the TTDP-curve for the high RTDI group. It was explained by the fact that patients with primary disease progression (PDP) do have a high RTDI per definition. Excluding those 114 patients with PDP the negative correlation between RTDI and TTDP vanished. However, non-PDP patients with RTDI-cut-off levels <85% showed a shorter OS than patients with higher RTDI levels (p = 0.0086).

Conclusions

Optimizing RTDI above 85% appears to improve long-term outcome of MBC patients receiving first-line chemotherapy. Lowering RTDI had no negative influence on short term outcome like OR and TTDP.

Prophylaxis of chemotherapy-induced febrile neutropenia with granulocyte colony-stimulating factors: where are we now?

Updated international guidelines published in 2006 have broadened the scope for the use of granulocyte colony-stimulating factor (G-CSF) in supporting delivery of myelosuppressive chemotherapy. G-CSF prophylaxis is now recommended when the overall risk of febrile neutropenia (FN) due to regimen and individual patient factors is ≥20%, for supporting dose-dense and dose-intense chemotherapy and to help maintain dose density where dose reductions have been shown to compromise outcomes. Indeed, there is now a large body of evidence for the efficacy of G-CSFs in supporting dose-dense chemotherapy. Predictive tools that can help target those patients who are most at risk of FN are now becoming available. Recent analyses have shown that, by reducing the risk of FN and chemotherapy dose delays and reductions, G-CSF prophylaxis can potentially enhance survival benefits in patients receiving chemotherapy in curative settings. Accumulating data from ‘real-world’ clinical practice settings indicate that patients often receive abbreviated courses of daily G-CSF and consequently obtain a reduced level of FN protection. A single dose of PEGylated G-CSF (pegfilgrastim) may provide a more effective, as well as a more convenient, alternative to daily G-CSF. Prospective studies are needed to validate the importance of delivering the full dose intensity of standard chemotherapy regimens, with G-CSF support where appropriate, across a range of settings. These studies should also incorporate prospective evaluation of risk stratification for neutropenia and its complications.

Attitudes regarding the use of hematopoietic colony-stimulating factors and maintenance of relative dose intensity among gynecologic oncologists

OBJECTIVE

To assess the attitudes regarding the use of colony-stimulating factor (CSF) and the maintenance of relative dose intensity (RDI) by gynecologic oncologists during the administration of chemotherapy to patients with epithelial ovarian cancer.

METHODS

A nationwide survey of 608 gynecologic oncologists was performed using a 19-point questionnaire. The questionnaire assessed the following domains: (1) demographic information, (2) patterns of CSF use during first-line and relapse chemotherapies for patients with epithelial ovarian cancer, and (3) use of CSFs to maintain RDI.

RESULTS

The response rate to the survey was 42% (n = 255). Eighty-six percent (220/255) of the respondents routinely administer chemotherapy. In the first-line setting, 67% of physicians who routinely administer chemotherapy preferred to use CSFs for secondary prophylaxis after a neutropenic complication, whereas only 2% would use CSFs for primary prophylaxis. In the recurrent disease setting, physicians were more likely to administer a regimen with minimal myelosuppression (74% reported "likely" or "very likely"), to dose delay or modify if neutropenic complications occur (78%), or to administer CSFs for secondary prophylaxis (85%) than to dose attenuate upon initiation of chemotherapy (49%) or to administer CSFs for primary prophylaxis (46%). Most physicians would administer CSFs to maintain RDI in both the first-line (75%) and palliative settings (62%), and 49% would strive to maintain a dose intensity of more than 85%.

CONCLUSIONS

Most gynecologic oncologists use CSFs as secondary prophylaxis for neutropenic complications rather than as primary prophylaxis. Most gynecologic oncologists monitor RDI and use CSFs to maintain RDI in their patients with ovarian carcinoma.

Cost-effectiveness of primary versus secondary prophylaxis with pegfilgrastim in women with early-stage breast cancer receiving chemotherapy

OBJECTIVE

Prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. We estimated the incremental cost-effectiveness of G-CSF pegfilgrastim primary (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) versus secondary (only after an FN event) prophylaxis in women with early-stage breast cancer receiving myelosuppressive chemotherapy with a >or=20% FN risk.

METHODS

A decision-analytic model was constructed from a health insurer's perspective with a lifetime study horizon. The model considers direct medical costs and outcomes related to reduced FN and potential survival benefits because of reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values.

RESULTS

The incremental cost-effectiveness ratio (ICER) of pegfilgrastim as primary versus secondary prophylaxis was $48,000/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $110,000/life-year gained (LYG) or $116,000/quality-adjusted life-year (QALY) gained. The most influential factors included FN case-fatality, FN relative risk reduction from primary prophylaxis, and age at diagnosis.

CONCLUSIONS

Compared with secondary prophylaxis, the cost-effectiveness of pegfilgrastim as primary prophylaxis may be equivalent or superior to other commonly used supportive care interventions for women with breast cancer. Further assessment of the direct impact of G-CSF on short- and long-term survival is needed to substantiate these findings.

Patients' Perceptions of Physician-Patient Discussions and Adverse Events with Cancer Therapy

Objectives

Patients with cancer who are treated with chemotherapy report adverse events during their treatment, which can affect their quality of life and increase the likelihood that their treatment will not be completed. In this study, patients' perceptions of the physician-patient relationship and communication about cancer-related issues, particularly adverse events were examined.

Methods

We surveyed 508 patients with cancer concerning the occurrence of adverse events and their relationship and communication with their physicians regarding cancer, treatment, and adverse events.

Results

Most individuals surveyed (>90%) discussed diagnosis, treatment plan, goals, and schedule, and potential adverse events with their physicians before initiating chemotherapy; approximately 75% of these individuals understood these topics completely or very well. Physician-patient discussions of adverse events were common, with tiredness, nausea and vomiting, and loss of appetite discussed prior to chemotherapy in over 80% of communications. These events were also the most often experienced (ranging in 95% to 64% of the respondents) along with low white blood cell counts (WBCs), which were experienced in 67% of respondents. Approximately 75% of the individuals reported that their overall quality of life was affected by adverse events.

Conclusions

These findings suggest that discussions alone do not provide patients with sufficient understanding of the events, nor do they appear to adequately equip patients to cope with them. Therefore, efforts to improve cancer care should focus on developing tools to improve patients' understanding of the toxicities of chemotherapy, as well as providing resources to reduce the effects of adverse events.

Impact of neutropenia on delivering planned chemotherapy for solid tumours

The ability to deliver the planned dose and intensity of chemotherapy (the amount of drug administered/unit of time) is important for tumour control and survival. In clinical practice, neutropenic events are the main limiting factors towards achieving this aim. We assessed the impact of neutropenic events [defined as either hospital admission due to febrile neutropenia (FN), dose delay > or =7 days due to neutropenia or dose reduction of > or =15% due to neutropenia] on dose intensity (DI) in a random sample of 50 patients with various solid tumours. Fifty patients who received systemic chemotherapy for solid tumours were assessed as part of this study. Using a pre-programmed data collection tool via computer, retrospective data were collected. The neutropenic events were defined before data collection. The patient characteristics are as follows: breast 26 patients (stage I-6; II-3; III-17), colorectal 16 patients (stage I-6; II-3; III-7) and others 8 patients [small cell lung cancer (SCLC), ovarian, peritoneal and oesophageal cancers]. The chemotherapy regimens used are Flourouracil, Epirubicin, cyclophosphamide (FEC) 14 patients (28%); 5 Flourouracil/folinic acid (5FU/FA) 12 patients (24%); Adriamycin, cyclophosphamide (AC) 11 patients (22%); other 13 patients (26%). Neutropenic events occurred in a significant proportion of patients (overall 40%; breast 26%; colorectal 56%; others 25% of patients) and in a significant number (21%) of chemotherapy cycles. Overall, dose delay was the most common neutropenic event, occurring in 30% of patients (breast 32%; colorectal 31%; others 25%% of patients). Dose reduction due to neutropenia was noted in 20% of patients (breast 12% colorectal 38% others 13%% of patients). Hospitalizations due to FN affected 8% of patients. Only two patients had granulocyte colony-stimulating factor (GCSF) as treatment for two cycles. Relative dose intensity (RDI) in patients with neutropenic events was 81% compared with 92% in patients without an event and the results were consistent for different cancers. In total, 65% of patients who experienced one neutropenic event were likely to experience subsequent events. In conclusion neutropenic events have a significant impact on the ability to deliver planned DI. Hence, proactive use of GCSF has the potential to improve adherence to the planned schedule of chemotherapy.

Management of Chemotherapy-Induced Neutropenia: Opportunities for Pharmacist Involvement

Purpose

This article highlights the clinical impact of chemotherapy-induced neutropenia (CIN) and reviews the clinical evidence supporting the updated guideline recommendations from leading scientific organizations that focus on cancer care regarding the use of myeloid growth factors to reduce the incidence of febrile neutropenia (FN) from chemotherapy. The aim is to provide insight for practicing pharmacists regarding how they can be more proactive in developing best-practice strategies for the management of CIN as well as the prevention of FN.

Summary

CIN, the primary dose-limiting toxicity of chemotherapy, is common in many tumor types that are treated with myelosuppressive chemotherapy and occurs with the greatest frequency in the first cycle of treatment. Treatment with myeloid growth factors, or colony-stimulating factors (CSFs), has shown to be effective in reducing the risk, severity, and duration of FN from chemotherapy. Despite recent revisions to various clinical guidelines that have resulted in alignment on the recommendation for prophylactic CSF use in patients with a greater than or equal to 20% risk of developing FN, a gap remains between actual clinical usage and best practice. Pharmacists are key members of multidisciplinary health care teams and are uniquely positioned to evaluate current practice and develop strategies that ensure appropriate CSF use. This paper summarizes the recent changes to CSF guidelines, reviews clinical data that support those changes, and discusses strategies for pharmacist involvement in the management of CIN and FN prevention using real-world examples of improvement initiatives.

Conclusion

Neutropenia is a dose-limiting toxicity of chemotherapy that has significant implications for effective cancer treatment and patient health outcomes. Pharmacists are uniquely positioned to perform various interventions, which help ensure appropriate CSF use and improve the management of CIN.

Low incidence of neutropenic events in patients with lymphoma receiving first-cycle pegfilgrastim with chemotherapy: results from a prospective community-based study

BACKGROUND

Most alterations to chemotherapy dose and schedule are because of neutropenic events, which mainly occur in the first chemotherapy cycle. This prospective, community-based study evaluated the effectiveness of pegfilgrastim in patients with lymphoma who were also receiving chemotherapy.

PATIENTS AND METHODS

Patients aged > or = 18 years with cancer other than leukemia or myelodysplastic syndromes were eligible, including patients with major comorbidities who were generally not eligible for most clinical trials. Key exclusions were weekly chemotherapy and concurrent radiation therapy. Patients received pegfilgrastim 6 mg approximately 24 hours after chemotherapy in each cycle (up to 8 cycles). Endpoints included neutropenic complications and serious adverse events.

RESULTS

This open-label single-arm study enrolled 2249 patients at 319 sites. Of these 2249 patients, 325 patients with non-Hodgkin lymphoma (NHL) and 46 patients with Hodgkin disease were included in the primary analysis set. The median age was 65 years for patients with NHL and 41 years for patients with Hodgkin disease, and 31% and 26% had major comorbidities, respectively. Few patients experienced neutropenic complications, including grade 4 febrile neutropenia (patients with Hodgkin disease: 0 [95% confidence interval (CI), 0-8%]; patients with NHL: 13% [95% CI, 10%-17%]); febrile neutropenia-related hospitalization (patients with Hodgkin disease: 0 [95% CI, 0-8%]; patients with NHL: 10% [95% CI, 7%-14%]), neutropenia-related dose reduction (patients with Hodgkin disease: 0 [95% CI, 0-8%]; patients with NHL: 5% [95% CI, 3%-8%]), and neutropenia-related dose delay (patients with Hodgkin disease: 0 [95% CI, 0-8%]; patients with NHL: 5% [95% CI, 3%-8%]). Serious adverse events were consistent with those observed in patients receiving myelosuppressive chemotherapy.

CONCLUSION

Patients with lymphoma receiving myelosuppressive chemotherapy supported by pegfilgrastim experienced few neutropenic complications or neutropenia-related alterations in chemotherapy dose and schedule.

Does chemotherapy-induced neutropaenia result in a postponement of adjuvant or neoadjuvant regimens in breast cancer patients? Results of a retrospective analysis

In 2005, 224 patients received adjuvant/neoadjuvant chemotherapy for breast cancer in a single institution according to daily practices. Regimens consisted of epirubicin-based chemotherapy (FEC100, four or six cycles), or three cycles of FEC100 followed by three cycles of docetaxel. An absolute blood count was carried out every 3 weeks, 1–3 days before planned chemotherapy cycle. Overall, 1238 cycles were delivered. An absolute neutrophil count (ANC) <1.5 × 10⁹ l⁻¹ before planned chemotherapy was found in 171 cycles. Of these, 130 cycles (76%) were delivered as planned regardless of whether ANC levels recovered, and 41 (24%) were delayed. None of these patients developed a febrile neutropaenia. Haematopoietic support (granulocyte colony-stimulating factor (G-CSF)) was required in 12 cycles. We found that the majority of patients with an ANC <1.5 × 10⁹ l⁻¹ before planned chemotherapy received planned doses, without complications and need for G-CSF.

Contribution of modelling chemotherapy-induced hematological toxicity for clinical practice

Anticancer chemotherapies are responsible for numerous adverse events. Among these, hematological toxicity is one of the main causes for ending treatment. These toxicities decrease production of red blood cells (anemia), production of white blood cells (neutropenia or granulocytopenia), and production of platelets (thrombocytopenia), which may be life-threatening to the patient. Preventing such discontinuation would be valuable for treating patients more effectively. In order to achieve this goal, numerous mathematical and physiological or semiphysiological models have been developed. The complexity of models has increased over the years, from empiric E(max) models to mechanistic models including physiological mechanisms such as feedback control. This review discusses several approaches of modelling hematological toxicities illustrated with some examples: pharmacodynamic models for the hematological toxicity of 5-fluorouracil, epirubicin, melphalan, paclitaxel, topotecan, and indisulam.

Neutropenic events in community practices reduced by first and subsequent cycle pegfilgrastim use

The impact of first- and subsequent-cycle growth factor use in the community setting has not been studied extensively. We conducted this large, prospective, noncomparative study to assess neutropenia and related complications in patients receiving myelotoxic chemotherapy with pegfilgrastim support in community practices. Patients > or = 18 years old with cancers other than leukemia or myelodysplastic syndrome, including those with major comorbidities, were eligible. Pegfilgrastim (6 mg) was to be administered approximately 24 hours after chemotherapy in all cycles (minimum, four cycles). A total of 2,112 patients was included in the analyses. The most common tumor types were breast cancer (46%), non-Hodgkin's lymphoma (15%), and non-small cell lung cancer (13%). Chemotherapies administered most often were a platinum plus a taxane (18%), and anthracycline plus an alkylating agent (18%), and a taxane plus an anthracycline plus an alkylating agent (16%). The percentage of patients with neutropenia-related hospitalization was 2.9% in cycle 1 and 5.6% across all cycles. Chemotherapy dose reductions and delays were attributed to neutropenia in 1.8% and 0.9% of patients, respectively, in cycle 2 and 2.9% and 2.1% of patients, respectively, across all cycles. Febrile neutropenia (absolute neutrophil count <1.0 x 10(9)/l with temperature > or = 38.2 degrees C) occurred in 3.6% of patients in cycle 1 and in 6.3% of patients across all cycles. The most frequently reported serious adverse events were febrile neutropenia (3.4%), neutropenia (2.6%), and dehydration (2.6%). Bone pain (0.1%) was the only related serious adverse event reported in more than one patient. Data from this community-based study suggest that patients undergoing chemotherapy benefit from pegfilgrastim support beginning in the first cycle of chemotherapy.

Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy

PURPOSE

The purpose of this study was to investigate the relationship between socioeconomic status (SES) and the use of intentionally reduced doses of chemotherapy in the adjuvant treatment of breast cancer.

PATIENTS AND METHODS

Patients with breast cancer treated with a standard chemotherapy regimen (n = 764) were enrolled in a prospective registry after signing informed consent. Detailed information was collected on patient, disease, and treatment, including chemotherapy doses. Zip code level data on median household income, proportion of people living below the poverty level, and educational attainment were obtained from the US Census. Doses for the first cycle of chemotherapy lower than 85% of standard were considered to be reduced. Univariate analyses and multivariate logistic regression were performed to identify factors associated with the use of reduced first cycle doses.

RESULTS

In univariate analysis, individual education attainment, zip code SES measures, body mass index, and geographic region were all significantly associated with receipt of intentionally reduced doses of chemotherapy. In multivariate analysis, controlling for geography, factors independently associated with reduced doses were obesity (odds ratio [OR], 2.47; 95% CI, 1.36 to 4.51), severe obesity (OR, 4.04; 95% CI, 1.46 to 11.19), and education less than high school (OR, 3.07; 95% CI, 1.57 to 5.99).

CONCLUSION

Social disparities in breast cancer outcomes may be in part the result of lower quality chemotherapy doses in the adjuvant treatment of breast cancer. Efforts to address such prescribing patterns may help reduce SES disparities in breast cancer survival.

Neutropenia: state of the knowledge part I

PURPOSE/OBJECTIVES

To review neutrophil physiology, consequences of chemotherapy-induced neutropenia (CIN), CIN risk assessment models, national practice guidelines, the impact of febrile neutropenia and infection, and what is known and unknown about CIN.

DATA SOURCES

Extensive review and summary of published neutropenia literature, guidelines, meta-analyses, currently funded National Institutes of Health and Oncology Nursing Society studies, and invited expert panel symposium presentations.

DATA SYNTHESIS

A comprehensive review of current literature regarding CIN risk assessment, practice guidelines, management, impact on dose-dense and dose-intense cancer treatment, complications, costs related to hospitalizations, and treatment strategies has been compiled.

CONCLUSIONS

CIN is the most common dose-limiting toxicity of cancer therapy. Medical practice guidelines and risk assessment models for appropriate use of myeloid growth factors and management of febrile neutropenia have been developed to assess patients for CIN complications prechemotherapy and during CIN episodes. CIN affects patients, families, practitioners, and the healthcare system. Although much is known about this common chemotherapy complication, a great deal remains to be learned.

IMPLICATIONS FOR NURSING

CIN is a serious and global problem in patients receiving cancer therapy. Oncology nurses need to critically analyze their own practices when assessing, managing, and educating patients and families about CIN.

Dose-dense adjuvant chemotherapy for breast cancer

Dose intensity, the amount of drug delivered per unit of time, is an important predictor of outcome in adjuvant chemotherapy for breast cancer. It can be increased by using higher doses of chemotherapy (dose escalation) or by shortening the interval between cycles (dose density). Dose-escalation strategies (adjuvant high-dose chemotherapy with bone marrow or peripheral blood progenitor cell support) have shown no benefit in patients with breast cancer. In contrast, dose-dense regimens (given every 2 weeks) are associated with greater disease-free and overall survival than are conventional, 3-week regimens. Toxicity with dose-dense regimens should be managed as it is with conventional regimens, but the timing of interventions may differ, and supportive care, such as providing granulocyte colony-stimulating factor support in all cycles of chemotherapy to reduce the incidence and duration of neutropenia, can help facilitate the safe delivery of dose-dense regimens. Oncology nurses should be involved in developing and implementing educational plans that help patients become aware of the potential advantages of dose-dense therapy and the potentially greater risk of toxicity. With conventional and dose-dense regimens alike, maintaining dose intensity through the optimal management of adverse events can help ensure better outcomes.

Trends in recommendations of myelosuppressive chemotherapy for the treatment of breast cancer: evolution of the national comprehensive cancer network guidelines and the cooperative group studies

Breast cancer, the most commonly occurring cancer in women in the United States, is the second most common cause of cancer-related mortality. Mortality rates in breast cancer have, however, declined by 2.3% per year from 1990 to 2001, partly because of the development of better chemotherapy agents and regimens, which have resulted in major changes in the standards of care. To study the changes in the past decade in expert opinion about the preferred chemotherapy for breast cancer, we compared the treatment guidelines of the National Comprehensive Cancer Network (NCCN) for 1996, 2000, and 2005. The myelotoxicity associated with the NCCN-recommended agents was also assessed by using data from the prescribing information for the drugs. This review showed that many of the agents, combinations of agents, and new dosing schedules currently recommended in the NCCN guidelines for the treatment of breast cancer are associated with myelosuppression. Many of these myelosuppressive regimens, which were used in the past to treat advanced-stage or metastatic disease, are now prescribed for early-stage disease. Furthermore, the cytotoxic agents and regimens recommended by the NCCN are more myelosuppressive than those recommended a decade ago. Many oncologists are aware of this trend toward the more intensive treatment of patients with cancer and take proactive steps to minimize the risk of myelosuppression and its complications.

Randomised trial: survival benefit and safety of adjuvant dose-dense chemotherapy for node-positive breast cancer

We evaluated the survival benefit, safety, feasibility, and tolerability of dose-dense (DD) adjuvant chemotherapy with epirubicin and paclitaxel for women with node-positive primary breast cancer. Randomised patients (n=216) received DD or conventional-schedule (CS) chemotherapy. Dose-dense regimen patients (n=108) received epirubicin 90 mg m⁻² plus paclitaxel 175 mg m⁻² in four 14-day cycles, then cyclophosphamide 600 mg m⁻², methotrexate 40 mg m⁻², and fluorouracil 600 mg m⁻² (CMF 600/40/600) in three 14-day cycles, plus filgrastim 5 μg kg day⁻¹ as growth support in every cycle. Conventional-schedule regimen patients (n=108) received epirubicin 90 mg m⁻² plus cyclophosphamide 600 mg m⁻² in four 21-day cycles, then CMF 600/40/600 in three 21-day cycles, plus filgrastim if required. After a median follow-up of 38.4 months, 71 patients (33%) relapsed or died: DD, 33 patients (15 deaths); CS, 38 patients (22 deaths). Dose dense showed a trend for improved disease-free survival (DFS) and overall survival (OS). Four-year rates of DFS and OS were 64 and 85% for DD, and 58 and 75% for CS. All seven cycles were administered to 208 patients (96%). Rates of cycle delay, discontinuation, dose reduction, and adverse events were similar in both groups. Dose-dense sequential chemotherapy with epirubicin/paclitaxel then CMF, supported by filgrastim, is safe and improves survival for patients with node-positive breast cancer.

Neutropenic event risk and impaired chemotherapy delivery in six European audits of breast cancer treatment

GOALS OF WORK

The aims of this study were to assess chemotherapy treatment characteristics, neutropenic event (NE) occurrence and related risk factors in breast cancer patients in Western Europe.

MATERIALS AND METHODS

Six retrospective audits of breast cancer chemotherapy were combined into a dataset of 2,860 individuals. NEs were defined as neutropenia-related hospitalisation, dose reduction > or = 15% or dose delay > or = 7 days. Summation dose intensity (SDI) was calculated to compare different types of chemotherapy regimens on a single scale. Risk factors of NE occurrence and of low relative dose intensity (RDI) < or = 85% were identified by multiple logistic regression.

MAIN RESULTS

Patient populations were comparable between audits. Until 1998, cyclophosphamide, methotrexate and fluorouracil regimens were most frequently used, but thereafter, anthracycline-based regimens were most common. NEs occurred in 20% of the patients and low RDI in 16%. NE occurrence predicted low RDI and was associated with higher age, bigger body surface area, lower body mass index, regimen type, more chemotherapy cycles planned, normal to high SDI, concomitant radiotherapy and year of treatment. First cycle NE occurrence predicted NEs from cycle 2 onwards. A risk score using age, SDI, number of planned chemotherapy cycles and concomitant radiotherapy differentiated patients with increasing NE risk (9-37%). An alternative score version not using concomitant radiotherapy performed moderately less well.

CONCLUSIONS

NEs occurred frequently in this combined dataset and they affected treatment delivery. Identifying patients at high NE risk enables targeted prophylaxis and may avoid dose limitations.

The Prognostic Effect of the Number of Histologically Examined Axillary Lymph Nodes in Breast Cancer: Stage Migration or Age Association?

BACKGROUND

The number of pathologically examined axillary nodes has been associated with breast cancer survival, and examination of >or=10 nodes has been advocated for reliable axillary staging. The considerable variation observed in axillary staging prompted this population-based study, which evaluated the prognostic effect of a variable number of pathologically examined nodes.

METHODS

In total, 5314 consecutive breast cancer patients who underwent mastectomy or breast-conserving surgery and axillary dissection between 1994 and 1999 were included. The prognostic effect of the examined number of nodes was assessed with crude and relative survival analysis.

RESULTS

A median number of 12 (range, 1-43) nodes were histologically examined, and 59% of the patients had no nodal tumor involvement. The number of examined nodes decreased with age (P<.001) and increased with tumor size (P<.001). Stratified for the number of tumor-positive nodes, overall survival seemed to be worse for patients with <10 compared with patients with >or=10 examined nodes (P<.001), whereas the relative survival did not differ. After adjusting for age, tumor size, number of positive nodes, and detection by screening in a multivariate analysis, the number of examined nodes was not associated with relative survival.

CONCLUSIONS

This study shows that the association between the number of pathologically examined axillary nodes and overall survival in node-negative and node-positive patients results from stage migration. The absence of an association between the number of examined nodes and relative survival further indicates that the association between the number of examined nodes and crude survival is confounded by age.

Reducing the Global Breast Cancer Burden: The Importance of Patterns of Care Research

Breast cancer treatment guidelines are not uniformly followed in clinical practice, with evidence for substantial variations in treatment patterns, quality of care, and patient outcomes among and within countries. The factors that drive treatment decisions are unclear. Furthermore, the impact of different treatment strategies on survival is poorly understood outside the clinical trial setting. Sources of patterns of care information often have limitations in completeness, quality, timeliness of reporting, and relevance to the larger population. Patterns of care studies frequently lack details on cancer stage at diagnosis, tumor biology, and treatment received. It is difficult to compare data between studies and/or track changes over time because of variations in data sources and collection techniques. Thus, the design and implementation of a global registry is sorely needed in order to prospectively evaluate worldwide patterns of care and outcomes in patients with breast cancer. Components of this registry should include random selection of centers of variable practice settings in multiple countries and accurate and rapid data reporting at prestudy and follow-up timepoints. Data collected would include tumor and demographic factors, staging information, treatment rendered, and survival. Variables that influenced the treatment selected would be assessed. This unique international effort would allow the development of strategies to improve diagnostic and treatment-related standards of care and survival outcomes, thus reducing the breast cancer burden worldwide.