A novel approach to improving ambulatory outpatient management of low risk febrile neutropenia: an Enhanced Supportive Care (ESC) clinic

Low-Risk Febrile Neutropenia Management: An Audit of Practice in a UK Cancer Center

BACKGROUND

Febrile neutropenia (FN) is a known complication of chemotherapy. Guidelines from American Society of Clinical Oncology and National Institute for Health and Care Excellence support outpatient management for low-risk FN patients; however, implementation varies across United Kingdom (UK) cancer centers. While some centers have adopted outpatient pathways, others continue to rely on inpatient care, leading to inequities in FN management. Standardized use of risk stratification tools, such as the Multinational Association of Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, is essential for equitable FN management. Globally, oncology nurses play a critical role in optimizing FN care to reduce hospital admissions in low-risk patients.

OBJECTIVES

This retrospective study aimed to determine the proportion of FN patients classified as low risk using the MASCC and CISNE scores, evaluate their clinical outcomes, and assess the feasibility of outpatient management.

METHODS

A retrospective audit of adult patients with solid tumors admitted with FN was conducted at a UK NHS cancer center over a 6-month period. Data on MASCC/CISNE scores, clinical outcomes, length of stay, and antibiotic use were extracted from electronic records. Statistical analyses, including Mann-Whitney U and Kruskal-Wallis tests, were performed. A cost analysis estimated potential financial savings from outpatient management.

RESULTS

Of 18 FN admissions, 11 (61.1%) were classified as low risk by MASCC, and 6 (54.5%) of these were also low risk by CISNE. No adverse events were observed. The median length of stay was shorter for MASCC low-risk patients v high-risk patients (6 v 8 days, P = .043). Estimated cost savings were approximately £30,000 over 6 months. Some UK centers have successfully implemented outpatient FN pathways, but variation in risk stratification and systemic inequities exist.

CONCLUSIONS

Oncology nurses are key to standardizing FN risk assessment and advocating for equitable outpatient FN care. Addressing disparities in low-risk FN management may optimize healthcare resources and improve patient experience.

Successful Management of Pediatric Patients with Low-Risk Febrile Neutropenia Using a Clinical Care Pathway in Egypt

BACKGROUND

Criteria for home management of low-risk febrile neutropenia remain challenging in supportive care. Careful selection of low-risk febrile neutropenic pediatric patients can improve outcomes and decrease complications. In the current study, we implemented a clinical pathway for pediatric patients presenting to the emergency room department with low-risk febrile neutropenia by using strict inclusion criteria.

MATERIALS AND METHODS

This is a prospective study from December 2021 to September 2022; all patients presented to the emergency room department were screened for pathway evaluation, and risk stratification was performed using a strict checklist. Patients were included if they met the low-risk criteria. Thorough clinical and laboratory assessments were performed on these patients. All patients started oral antibiotics and were instructed about alarming signs. Patients were followed up at the outpatient clinic on days 3 and 7.

RESULTS

Two hundred and three patients with 200 episodes of low-risk febrile neutropenia were enrolled; one hundred and ten were males, and 90 were females; underlying hematological malignancies accounted for 54.0%. On day three, 181 patients out of 200 were afebrile for 24 hours (90.0%), and 47.5% were still neutropenic. At day seven, all study patients were afebrile, had recovering counts, and stopped antibiotics regardless of the count. Absolute neutrophil count recovery on day seven was achieved in 95.5% of patients.

CONCLUSION

Our inclusion criteria for patients with low-risk febrile neutropenia proved to be safe without deaths or intensive care unit admission and successful with the lowest admission rate, so it can be used for a stewardship program to avoid unnecessary patient admissions and help healthcare givers to optimize patient allocation and follow-up safely.

Low-risk febrile neutropenia: does combined chemotherapy/immune checkpoint inhibitor necessitate a change in approach?

PURPOSE

Management of patients with low-risk febrile neutropenia in an outpatient setting guided by the MASCC score is proven to be safe and effective. Most patients on ambulatory low-risk febrile neutropenia pathways are undergoing treatment for breast cancer. Recent data has shown benefit of the addition of immune checkpoint inhibitor therapy to cytotoxic chemotherapy in the neoadjuvant setting for patients with early triple-negative breast cancer. We examined whether the addition of ICI therapy altered the clinical severity of febrile neutropenia in this cohort and the ability to manage these patients in an ambulatory setting.

METHODS

An observational analysis was performed at a specialist oncology hospital in the North West of England. We compared patients with triple negative breast cancer presenting with febrile neutropenia following treatment with PC-EC/pembrolizumab to those treated with PC-EC in the neoadjuvant setting.

RESULTS

In the study periods, 152 patients received PC-EC and 151 PC-EC/Pembro. Twenty-five patients presented with FN in the PC-EC/Pembro group compared to 16 in those receiving PC-EC (16% vs 11%, p > 0.05). Patients with febrile neutropenia treated with PC-EC/Pembro had more severe clinical presentations as assessed by the MASCC score (18 vs 24; p = 0.01), had worse physiological parameters (NEWS2 at presentation 3 vs 2; p = 0.023) and had a longer length of hospital stay (median 5 days vs 0 days; p = 0.044). There were no deaths at 30 or 90 days in either cohort.

CONCLUSION

Triple-negative breast cancer patients receiving neoadjuvant pembrolizumab in addition to PC-EC appear to have more severe presentations with febrile neutropenia. This may necessitate greater caution in pathways for ambulatory management for this cohort.

Enhanced supportive care

Enhanced supportive care is a care model providing earlier access to multiprofessional, coordinated care for patients from the point of cancer diagnosis. As a proactive model of care, it stands as a contrast to providing access to a multidisciplinary team once a patient has hit a crisis point, or when their prognosis has become sufficiently poor that they are able to access traditional end-of-life services. Its arrival in the UK through palliative care teams working in cancer care has led to enhanced supportive care being synonymous with early palliative care. While enhanced supportive care has enabled early palliative care, as it has become more embedded in the UK, it has taken on a wider remit for patients living longer with cancer and the management of side effects. Enhanced supportive care services have also begun to provide care for cancer survivors. Enhanced supportive care services have a key role in modern cancer care in maintaining and improving patients' quality of life alongside cancer treatment and ensuring that patients' priorities and preferences for treatment are considered. Furthermore, enhanced supportive care has been shown to support the wider healthcare system by creating capacity within the NHS, reducing demand on hospital services and saving money. As enhanced supportive care services continue to grow and venture into the care and support of cancer survivors and those receiving potentially curative treatments, ongoing work is needed to determine how these services can be made available throughout the NHS and how a shared vision of the way enhanced supportive care operates can be realised.

Ambulatory management of low-risk febrile neutropenia in adult oncological patients. Systematic review

PURPOSE

Recent clinical practice guidelines have recommended ambulatory management of febrile neutropenia in patients with low risk of complications. Although some centers have begun developing management protocols for these patients, there appears to be a certain reluctance to implement them in clinical practice. Our aim is to evaluate the strengths and weaknesses of this strategy according to available evidence and to propose new lines of research.

METHODS

Systematic review using a triple aim approach (efficacy, cost-effectiveness, and quality of life), drawing from literature in MEDLINE (PubMed), Embase, and Cochrane Library databases. The review includes studies that assess ambulatory management for efficacy, cost-efficiency, and quality of life.

RESULTS

The search yielded 27 articles that met our inclusion criteria.

CONCLUSION

In conclusion, based on current evidence, ambulatory management of febrile neutropenia is safe, more cost-effective than inpatient care, and capable of improving quality of life in oncological patients with this complication. Ambulatory care seems to be an effective alternative to hospitalization in these patients.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

IMPORTANCE

An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

OBJECTIVE

To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

RESULTS

Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

CONCLUSIONS AND RELEVANCE

In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BACKGROUND

Chemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED.

METHODS

A PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: "febrile neutropenia" OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review.

RESULTS

The search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%).

CONCLUSIONS

FN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.

Early Warning Scores and Their Application in the Inpatient Oncology Settings

Early Warning Score (EWS) systems are tools that use alterations in vital signs to rapidly identify clinically deteriorating patients and escalate care accordingly. Since its conception in 1997, EWSs have been used in several settings, including the general inpatient ward, intensive care units, and the emergency department. Several iterations of EWSs have been developed with varying levels of sensitivity and specificity for use in different populations. There are multiple strengths of these tools, including their simplicity and their ability to standardize communication and to reduce inappropriate or delayed referrals to the intensive care unit. Although early identification of deteriorating patients in the oncology population is vital to reduce morbidity and mortality and to improve long-term prognosis, the application in the oncology setting has been limited. Patients with an oncological diagnosis are usually older, medically complex, and can have increased susceptibility to infections, end-organ damage, and death. A search using PubMed and Scopus was conducted for articles published between January 1997 and November 2020 pertaining to EWSs in the oncology setting. Seven relevant studies were identified and analyzed. The most commonly used EWS in this setting was the Modified Early Warning Score. Of the seven studies, only two included prospective validation of the EWS in the oncology population and the other five only included a retrospective assessment of the data. The majority of studies were limited by their small sample size, single-institution analysis, and retrospective nature. Future studies should assess dynamic changes in scores over time and evaluate balance measures to identify use of health care resources.

The role of serum albumin/globulin ratio in combination with prognostic risk indexes of febrile neutropenia

OBJECTIVES

The aim of this study was to evaluate the effect of the serum albumin/globulin ratio (AGR) on the 30-day mortality of febrile neutropenia (FEN). The second aim of the study was to evaluate the effect of the combination of the AGR with the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) risk indexes on 30-day mortality of FEN.

METHODS

A retrospective study evaluating the effect of serum AGR, MASCC and CISNE scores on 30-day FEN mortality.

RESULTS

A total of 137 FEN episodes in 120 patients were included in this study. Nineteen patients (14%) died within the first 30 days of FEN episodes. The 30-day mortality rate was calculated as 4% in patients with high AGR and 23% in patients with low AGR (P = .002). According to the MASCC and CISNE risk scores, the mortality rates in low-risk patients were 8% and 6%, respectively, and in the high-risk group 22% and 29%, respectively (P = .024 vs P < .001). In the group of patients with MASCC <21 and CISNE ≥3, the 30-day mortality rate was 7%, when the AGR was >1.13, and in those with AGR ≤1.13 mortality rate increased to 50% (P = .012).

CONCLUSION

A low AGR in a patient with FEN was found to be associated with an increased risk of 30-day mortality. Combining the AGR with MASCC and CISNE risk indexes might increase the predictive value of these scoring systems on 30-day mortality.

Supportive care for new cancer therapies

PURPOSE OF REVIEW

The past decade has witnessed unprecedented delivery to the clinical arena of a range of novel, innovative, and effective targeted anticancer therapies. These include immunotherapies, most prominently immune checkpoint inhibitors, as well as agents that target growth factors and cancer-related mutations. Many of these new cancer therapies are, however, associated with an array of toxicities, necessitating insight and vigilance on the part of attending physicians to achieve high-quality supportive care alongside toxicity management. In this review, we consider some of the key supportive care issues in toxicity management.

RECENT FINDINGS

Although both supportive care and targeted therapies have brought significant benefits to cancer care, the management of novel cancer therapy toxicities is nevertheless often complex. This is due in large part to the fact that target organs differ widely, particularly in the case of checkpoint inhibitors, with minor dermatological disorders being most common, while others, such as pneumonitis, are more severe and potentially life threatening. Accordingly, efficient management of these immune-related adverse events requires collaboration between multiple medical specialists.

SUMMARY

Supportive care is a key component in the management of new cancer therapy toxicities and needs to be incorporated into treatment pathways.

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

PURPOSE

Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).

METHODS

A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.

RESULTS

During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).

CONCLUSIONS

This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC)

INTRODUCTION

Patients with hematological and advanced solid malignancies have acquired immune dysfunction, often exacerbated by treatment, posing a significant risk for the development of infections. This review evaluates the utility of current clinical and treatment guidelines, in the setting of management of infections in cancer patients.

AREAS COVERED

These include causes of infection in cancer patients, management of patients with high-risk and low-risk febrile neutropenia, management of low-risk patients in an outpatient setting, the role of granulocyte colony-stimulating factor (G-CSF) in the prevention and treatment of neutropenia-related infections, management of lung infections in various clinical settings, and emerging challenges surrounding the risk of infection in cancer patients treated with novel treatments. The literature search was performed by accessing PubMed and other databases, focusing on published clinical trials of relevant anti-cancer agents and diseases, primarily covering the recent past, but also including several key studies published during the last decade and, somewhat earlier in a few cases.

EXPERT REVIEW

Notwithstanding the promise of gene therapy/gene editing in hematological malignancies and some types of solid cancers, innovations introduced in clinical practice include more discerning clinical management such as the generalized use of biosimilar formulations of G-CSF and the implementation of novel, innovative immunotherapies.

Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD

RATIONALE & OBJECTIVE

Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.

STUDY DESIGN

Scoping review of quantitative and qualitative studies.

SETTING & POPULATION

Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).

SELECTION CRITERIA FOR STUDIES

MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.

DATA EXTRACTION

Intervention and study characteristics were extracted using standardized tools.

ANALYTICAL APPROACH

Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.

RESULTS

77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.

LIMITATIONS

Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.

CONCLUSIONS

Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.

Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper

Patients with cancer are at higher risk of more severe COVID-19 infection and have more associated complications. The position paper describes the management of cancer patients, especially those receiving anticancer treatment, during the COVID-19 pandemic. Dyspnea is a common emergency presentation in patients with cancer with a wide range of differential diagnoses, including pulmonary embolism, pleural disease, lymphangitis, and infection, of which SARS-CoV-2 is now a pathogen to be considered. Screening interviews to determine whether patients may be infected with COVID-19 are imperative to prevent the spread of infection, especially within healthcare facilities. Cancer patients testing positive with no or minimal symptoms may be monitored from home. Telemedicine is an option to aid in following patients without potential exposure. Management of complications of systemic anticancer treatment, such as febrile neutropenia (FN), is of particular importance during the COVID-19 pandemic where clinicians aim to minimize patients' risk of infection and need for hospital visits. Outpatient management of patients with low-risk FN is a safe and effective strategy. Although the MASCC score has not been validated in patients with suspected or confirmed SARS-CoV-2, it has nevertheless performed well in patients with a range of infective illnesses and, accordingly, it is reasonable to expect efficacy in the clinical setting of COVID-19. Risk stratification of patients presenting with FN is a vital tenet of the evolving sepsis and pandemic strategy, necessitating access to locally formulated services based on MASCC and other national and international guidelines. Innovative oncology services will need to utilize telemedicine, hospital at home, and ambulatory care services approaches not only to limit the number of hospital visits but also to anticipate the complications of the anticancer treatments.

Supportive Care: An Indispensable Component of Modern Oncology

The advent of new cancer therapies, alongside expected growth and ageing of the population, better survival rates and associated costs of care, is uncovering a need to more clearly define and integrate supportive care services across the whole spectrum of the disease. The current focus of cancer care is on initial diagnosis and treatment, and end of life care. The Multinational Association of Supportive Care in Cancer defines supportive care as 'the prevention and management of the adverse effects of cancer and its treatment'. This encompasses the entire cancer journey, and necessitates involvement and integration of most clinical specialties. Optimal supportive care can assist in accurate diagnosis and management, and ultimately improve outcomes. A national strategy to implement supportive care is needed to acknowledge evolving oncology practice, changing disease patterns and the changing patient demographic.

National cost savings from an ambulatory program for low-risk febrile neutropenia patients in Australia

Objective The management of low-risk febrile neutropenia (FN) patients through ambulatory programs has demonstrated comparative safety and effectiveness to in-patient strategies. However, there is limited evidence of benefits of changing practice, particularly on a national scale. The aim of this study was to estimate costs and benefits of the program over a 10-year time horizon. Methods A comparative cost analysis from a health system perspective was performed, comparing costs and length of stay (LOS) of patients enrolled in an ambulatory program to a historical cohort who did not receive the program. Generalised linear models were used for analysis and bootstrapped to account for uncertainty. National data of identified FN admissions were used to inform future projections, with varying proportions of low-risk patients and eligibility for the ambulatory program. Results The overall LOS for patients in ambulatory cohort was 1.9 days shorter (95% confidence interval (CI) 1.0-2.8 days), a 50% reduction in in-patient bed-days. Although patients in the ambulatory cohort incurred additional costs due to care received outside hospital (mean (± s.d.) A$828.03 ± 124.30), the mean total cost incurred remained substantially lower than that of the historical cohort (A$2979 lower; 95% CI A$772-5391). On a national scale, this could translate into A$62.7 million in costs averted and 41347 bed-days saved over 10 years if the low-risk prediction rate and eligibility for ambulatory programs remained at currently observed rates. Conclusions The wider implementation of a safe and effective ambulatory program to manage low-risk FN patients can result in significant return-on-investment for the healthcare system by eliminating avoidable costs due to unnecessary lengthy hospital admissions. What is known about the topic? There is strong evidence demonstrating out-patient treatment of low-risk FN patients to be an effective and cost-effective strategy compared with continued in-patient hospitalisation. What does this paper add? This study demonstrates the sustainability of the ambulatory program in ensuring cost benefits and in-patient beds through real-life implementation data. It also provides evidence of the substantial cost and bed-days potentially averted when the cost savings and difference in LOS are estimated on a national scale over a 10-year time horizon. What are the implications for practitioners? The management of low-risk FN patients through ambulatory or out-patient programs is a safe and effective approach. There is strong evidence demonstrating the likely cost savings and considerable bed-days saved, which can be reallocated to meet other medical demands.

Bacterial Infection Among Patients With Multiple Myeloma Treated With Bortezomib-based Induction Therapy: Real-World Experience in an Asian Cancer Center

BACKGROUND

The treatment landscape for multiple myeloma (MM) has progressed significantly, and over the past decade, bortezomib-based induction therapy has been a standard of care. However, the practice of antibacterial prophylaxis during induction therapy has been diverse. The aim of our study is to evaluate the proportion of patients with febrile episodes and bacteremia among patients with MM, during the first 12 weeks of bortezomib-based induction therapy, without routine fluoroquinolone prophylaxis, but with routine Pneumocystis Carinii prophylaxis (mostly with trimethoprim-sulfamethoxazole), in a region with high fluoroquinolone resistance rate. Of note, these patients have direct access to health care facilities and timely supportive care.

PATIENTS AND METHODS

We evaluated newly diagnosed MM patients from 2014 to 2018 receiving bortezomib-based induction therapy for the proportion of patients who had febrile episodes and bacteremia in the first 12 weeks of bortezomib-based induction therapy. We also evaluated if there were factors associated with increased febrile episodes including age, absolute neutrophil count, creatinine clearance, M-band level at diagnosis, nadir platelet count, International Staging System, and Revised International Staging System.

RESULTS

Of the 108 evaluable patients, there were a total of 25 (23.1%) patients who had febrile episodes, and 1 (0.9%) patient who had bacteremia during the first 12 weeks of bortezomib-based induction therapy. All patients recovered well. No deaths were seen. Febrile episodes were associated with lower absolute neutrophil count (P = .036), renal impairment (P = .013), and ISS stage (P = .026).

CONCLUSION

The proportion of patients with significant bacterial infection during the first 12 weeks of bortezomib-based induction therapy without routine fluoroquinolone prophylaxis, but with routine Pneumocystis Carinii prophylaxis (mostly with trimethoprim-sulfamethoxazole), is low in a population with adequate access to health care facilities and timely supportive care.

Ambulatory emergency oncology: A key tenet of future emergency oncology care

Ambulatory emergency oncology The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients' needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low-risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory-sensitive presentations.

Emergency Ambulatory Management of Low-Risk Febrile Neutropenia: Multinational Association for Supportive Care in Cancer Fits-Real-World Experience From a UK Cancer Center

BACKGROUND

Emergency patient presentations with febrile neutropenia are a heterogeneous group. A small minority of these patients proceed to develop significant medical complications. Risk stratification using scores, such as the Multinational Association for Supportive Care in Cancer score, have been advocated to identify patients who are at low risk of adverse outcome suitable for treatment on an ambulatory care pathway.

OBJECTIVES

We sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion.

METHODS

Patients presenting as an emergency with low-risk febrile neutropenia managed in an ambulatory setting between January 2017 and February 2019 at a tertiary cancer hospital in England were prospectively studied. Patients with a fever >38.0°C and an absolute neutrophil count <1.0 × 10⁹/L were included. All patients with a Multinational Association for Supportive Care in Cancer score ≥21 and a National Early Warning Score ≤3 were potentially eligible for the pathway. Complications were classified as serious if the patient developed persistent hypotension, respiratory failure, intensive care unit admission, altered mental status, disseminated intravascular coagulation, renal failure requiring renal replacement therapy, electrocardiogram changes requiring antidysrhythmic treatment, and 30-day mortality.

RESULTS

One hundred patients with low-risk febrile neutropenia consecutively managed in an emergency ambulatory fashion were prospectively analyzed. Eighty-one patients were female and the median age was 51 y (range 17-79 y). No patients developed serious complications. Eight (8% [95% confidence interval 4.1-15.0%]) patients had a 7-day readmission.

CONCLUSION

Outpatient ambulatory care for emergency patients with low-risk febrile neutropenia can be delivered in a safe and effective fashion. Collaboration between acute care physicians and oncologists is required to develop local models based on national guidelines to facilitate individualised care for emergency oncology patients.