Management of anaemia in patients with breast cancer: role of epoetin

Real-world data on neoadjuvant chemotherapy with dual-anti HER2 therapy in HER2 positive breast cancer

BACKGROUND

Neoadjuvant chemotherapy with dual-targeted therapy is the standard treatment for human epidermal growth factor 2 (HER2)-positive breast cancer. Although the dual-targeted therapy has significantly improved the pathological complete response (pCR) rate, further investigation is needed to identify biomarkers that predict the response to neoadjuvant therapy.

METHODS

This retrospective study analyzed 353 patients with HER2-positive breast invasive ductal carcinoma. The correlation between clinicopathological factors and pCR rate was evaluated. A nomogram was constructed based on the results of the multivariate logistic regression analysis to predict the probability of pCR.

RESULTS

The breast pCR (b-pCR) rate was 56.1% (198/353) and the total pCR (t-pCR) rate was 52.7% (186/353). Multivariate analysis identified ER status, PR status, HER2 status, Ki-67 index, and neoadjuvant chemotherapy regimens as independent indicators for both b-pCR and t-pCR. The nomogram had an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI: 0.68-0.78). According to the nomogram, the t- pCR rate was highest in the ER-PR- HER2-positive patients (131/208) and lowest in the ER + PR + HER2-positive patients (19/73). The subgroup analyses showed that there was no significant difference in pCR rate among the neoadjuvant chemotherapy regimens in ER positive, PR positive, HER2 IHC 2 + , Ki67 index < 30% population. However, for ER-PR-HER2-positive patients, the neoadjuvant chemotherapy regimen has a great influence on the pCR rates.

CONCLUSIONS

Patients with ER-negative, PR-negative, HER2 3 + and high KI-67 index were more likely to achieve pCR. THP may be used as an alternative to AC-THP or TCbHP in selected HER2-positive patients.

Platelet count and MCHC as independent prognostic markers for feline mammary carcinomas

Mammary neoplasms are common in felines species and represent a significant disease for its unfavorable prognosis. Changes in the blood count and serum biochemical profile of these patients have potential as non-invasive prognostic markers prior to mastectomy, however, they are poorly described in literature. In this study univariate and multivariate analyses were performed using these factors to determine the effect of each parameter on the one-year survival time after the surgical procedure in these animals. The median overall survival (OS) and the disease-free survival (DFS) were 365 and 242 days, respectively. In univariate analysis, values within the reference range of monocyte, platelet and creatinine counts were identified as significant prognostic factors for OS and only creatinine was significant for DFS (P < 0.05). In the multivariate analysis, platelets and mean corpuscular hemoglobin concentration (MCHC) remained independent prognostic factors for OS. The results presented suggest that monocytes, platelets and creatinine may be important non-invasive pre-surgical prognostic markers, and that platelet count and MCHC are independent prognostic markers for feline mammary carcinomas (FMC). The correlation between such alterations is of important relevance for veterinary oncology, and prospective studies are needed to validate their clinical use and that platelet count and MCHC are independent prognostic markers for FMC. The results found in this study can also be studied in human medicine, regarding blood markers in human breast cancer (HBC).

Exploration of hemocompatibility and intratumoral accumulation of paclitaxel after loco-regional administration of thermoresponsive hydrogel composed of poloxamer and xanthan gum: An application to dose-dense chemotherapy

Although paclitaxel is a front-line chemotherapeutic agent for the treatment of metastatic breast cancer, its intravenous therapy produces deleterious adverse effects. In an attempt to address the issue, the present study aimed to develop a paclitaxel loaded thermosensitive/thermoresponsive hydrogel (PTXNp-TGel) for loco-regional administration to breast tumors to provide dose-dense chemotherapy. Poloxamer and xanthan gum were used to prepare TGel by the cold method. In vitro and in vivo performance of PTXNp-TGel was compared with TGel, pure drug loaded TGel (PTX-TGel) and marketed formulation, Taxol®. The formulated PTXNp-TGel showed acceptable gelation temperature and time (37 °C and 57 s), lower viscosity at room temperature and higher viscosity at body temperature to support sol-gel transition with increasing temperature, and sustained drug release up to 21 days. Additionally, PTXNp-TGel showed negligible hemolytic toxicity as compared to PTX-TGel and Taxol®. Intratumoral administration of PTXNp-TGel produced significantly higher antitumor activity as indicated by lowest relative tumor volume (1.50) and relative antitumor proliferation rate (27.71 %) in comparison with PTX-TGel, Taxol®, and PTXNp (p < 0.05). Finally, insignificant body weight loss during the experimental period, lack of hematotoxicity, nephrotoxicity, and hepatotoxicity imply improved therapeutic performance of the locally administrated dose-dense therapy of PTXNp-TGel as compared to Taxol®.

Anaemia and pathologic complete response rate according to carboplatin dose in HER2+ breast cancer treated with neoadjuvant TCHP

Grade 3/4 anaemia, which is mainly induced by carboplatin, frequently occurs in patients treated with neoadjuvant docetaxel/carboplatin/trastuzumab/pertuzumab (TCHP). However, dose reduction of carboplatin may raise concerns about the oncological outcome. This study investigated the pathologic complete response (pCR) rate, occurrence of grade 3/4 anaemia, and transfusion rate according to carboplatin dose in patients treated with neoadjuvant TCHP. We retrospectively analysed 294 patients treated with neoadjuvant TCHP between April 2015 and December 2020. Case matching was performed using propensity score matching. Among patients treated with neoadjuvant TCHP, carboplatin area under the plasma concentration-time curve 6 (AUC6) was used in 234 patients (79.6%) and upfront carboplatin AUC5 was used in 60 patients (20.4%). No significant difference in pCR rate was found between the two groups (AUC6: 70.9%, AUC5: 80.0%). In both oestrogen receptor-positive (ER+) and ER- patients, no significant differences were observed between the AUC6 and AUC5 groups (ER+: 54.3% vs. 50.0%, ER-: 81.7% vs. 86.0%). The case-matched cohort showed consistent findings. The AUC5 group had lower frequencies of grade 3/4 anaemia (18.3% vs. 34.2%) and transfusion events (10.0% vs. 21.8%) than the AUC6 group. Compared with AUC5, carboplatin at AUC6 would associate with a 2.7-fold increased risk of grade 3 or 4 chemotherapy-induced anaemia. Carboplatin AUC5 has comparable cytotoxic effects to carboplatin AUC6 in patients with HER2+ breast cancer treated with six cycles of neoadjuvant TCHP, with fewer complications associated with clinically meaningful anaemia. AUC5 may be the optimal carboplatin dose to reduce TCHP-induced anaemia in patients with HER2+ breast cancer treated with TCHP.

Fever and breast cancer: A critical review of the literature and possible underlying mechanisms

Fever is a common feature in various pathological conditions that manifests a series of molecular events in the internal milieu. Much less attention has been paid to the clinical importance and the management of fever in breast cancer patients. However, several studies have reported an association between postoperative fever and poor treatment outcomes in breast cancer patients. The fever is a side effect of chemotherapy and a manifestation of cancer recurrence. The postmenopausal breast cancer patients experience another body temperature disturbance that is known as a hot flashes. Here, we reviewed the literature regarding postoperative fever and the possible underlying molecular and cellular mechanisms. Then the efficacy of non-steroidal anti-inflammatory drugs was discussed as a therapeutic option to control postoperative fever. Finally, we reviewed the chemotherapy-induced neutropenic fever and cancer vaccination-induced fever.

Gene expression of Epithelial Membrane Protein 2 gene and β1-Integrin gene in patients with breast cancer

Background

Breast cancer is the most common invasive cancer and the leading cause of cancer death in women. The function of over a thousand genes is reported as affected by genetic modifications in breast cancer.

Objectives

To study the gene expression of Epithelial Membrane 2 (EMP2) and β1-Integrin genes in patients with breast cancer.

Subjects and methods

This study was carried out by cooperation between the Biochemistry Division Department of Chemistry, Faculty of Science and Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Menoufia University. This study included 120 subjects divided into 2 groups Group I: Included 60 women with breast cancer undergoing modified radical mastectomy. Tissue specimens were taken from the cancerous breast tissue and from the marginal healthy breast tissues. Group II: Included 60 age and sex-matched apparently healthy women served as a control group. All patients participants were subjected to full history taking, general clinical examination, abdominal ultrasound, CT-scan for abdomen, mammography, fine needle biopsy, histopathological examination, immunostaining of tissues, metastatic work up (chest x-ray and bone scan) and laboratory investigations including: Complete blood count (patients and controls), serum carbohydrate antigen 15–3 (patients and controls), detection of EMP2 and β1-Integrin genes expression in the tissue samples by formation of cDNA by reverse transcription PCR after RNA extraction and real-time PCR using SYBR Green technique.

Results

Compared to healthy tissues, the breast cancer tissues had significant higher EMP2 and β1-Integringene expression levels. Also, there was a significant increase in CA15-3 in patients group as compared with the control group. It was found that EMP2 and β1-Integrin expression in malignant tissue samples correlates with advanced and metastatic disease.

Conclusion

The gene expression of EMP2 and β1-Integrin are important markers for the severity of breast cancer and they are good indicators of its prognosis.

Is Rajyoga helpful in maintaining patient's biochemical and hematological profile during breast cancer treatment?

The present study is the case of a breast cancer patient who visited the local unit of the Brahma Kumaris (BK). Conversations with the patient revealed that the patient was being treated in the Post Graduate Institute of Medical Education and Research, Chandigarh, India. The treatment of the patient included the surgery, radiotherapy, and chemotherapy. The patient narrated her ability to manage the psychological stress associated with the cancer treatment. She ascribed it to the positive attitude developed by her practice of the Rajyoga meditation from last 15 years. Rajyoga involved the daily meditation and regular listening to the specified commentary recommended by BK. Patient's health remains stable during the whole treatment process as analyzed by the mammography, histopathology and PET scan. The patient was also able to maintain the total body weight, biochemical and hematological profile within normal physiological range. The present case study is an attempt to provide Rajyoga as supportive means to the maintenance of patient's biochemical and hematological profile, and overall general health during breast cancer treatment.

The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) are commonly used to treat chemotherapy-induced anemia (CIA). However, about half of patients do not benefit.

OBJECTIVES

To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA.

SEARCH METHODS

We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high-quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response.The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate-quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient.We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low-quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response.Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low-quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI -0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI -0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02).We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI -0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high-quality evidence).We found no evidence for a difference in risk of grade III-IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate-quality evidence). The incidence of treatment-related mortality (TRM) was 0% (997 participants; four comparisons; high-quality evidence).Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms.Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow-up duration (up to 20 weeks), the long-term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results.

AUTHORS' CONCLUSIONS

Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation.

On the origin of cancer metastasis

Metastasis involves the spread of cancer cells from the primary tumor to surrounding tissues and to distant organs and is the primary cause of cancer morbidity and mortality. In order to complete the metastatic cascade, cancer cells must detach from the primary tumor, intravasate into the circulatory and lymphatic systems, evade immune attack, extravasate at distant capillary beds, and invade and proliferate in distant organs. Currently, several hypotheses have been advanced to explain the origin of cancer metastasis. These involve an epithelial mesenchymal transition, an accumulation of mutations in stem cells, a macrophage facilitation process, and a macrophage origin involving either transformation or fusion hybridization with neoplastic cells. Many of the properties of metastatic cancer cells are also seen in normal macrophages. A macrophage origin of metastasis can also explain the long-standing "seed and soil" hypothesis and the absence of metastasis in plant cancers. The view of metastasis as a macrophage metabolic disease can provide novel insight for therapeutic management.

Unresolved issues in diffuse large B-cell lymphomas

For more than 25 years, the combination of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) was considered the 'gold standard' for the treatment of aggressive lymphomas, 90% of which are diffuse large B-cell lymphomas (DLBCLs). After the demonstration of rituximab's single-agent activity in DLBCL, a pivotal trial in elderly patients demonstrated that combining rituximab with eight applications of CHOP significantly improved complete remission rates, and event-free and overall survival rates compared with CHOP alone. These positive results have meanwhile been confirmed by two additional randomized trials and have been extended to young patients with good-prognosis DLBCL by a fourth trial and rituximab, in combination with CHOP, has become accepted worldwide as the new standard for all DLBCL. Remaining issues concern biology-based approaches and the guidance of therapy by PET, the definition of the optimal dosage and schedule of rituximab for DLBCL, as well as the optimal chemotherapy regimen partner for rituximab. Finally, patients failing after rituximab-containing immunochemotherapy have a dismal prognosis and the treatment of these patients has become a prime challenge in the rituximab era.

Does epoetin alfa improve health-related quality of life in chronically ill patients with anemia? Summary of trials of cancer, HIV/AIDS, and chronic kidney disease

OBJECTIVES

Anemia, defined as having low levels of hemoglobin (HGB), is caused by disease-related (e.g., bone marrow suppression, nutritional deficiency) or treatment-related (e.g., chemotherapy, antiretroviral therapy) factors. Although epoetin alfa has been shown to improve HGB outcomes in cancer, HIV/AIDS, and chronic kidney disease (CKD), these results have been viewed in isolation, rather than across populations. The purpose of this article is to review findings from trials that evaluated the impact of epoetin alfa on HGB and health-related quality of life (HRQL) across various populations with different underlying causes of anemia.

METHODS

A review of clinical trials published in English between January 1993 and September 2005. Searches were conducted using MEDLINE and EMBASE. Between- and within-group changes in HGB and HRQL were examined.

RESULTS

One hundred ten articles were retrieved and 18 were reviewed. Statistically significant improvements in HGB were generally seen (1) between groups for cancer patients receiving epoetin alfa compared with those receiving placebo or standard of care (SOC) (between-group differences in changes from baseline to end point ranging from 1.2 to 1.9 g/dl); and (2) within groups for HIV/AIDS and CKD patients receiving epoetin alfa (changes from baseline to end point of 2.5 and 2.9 g/dl and 2.7 g/dl, respectively). Statistically and clinically significant improvements in HRQL, particularly with regard to fatigue, were seen across chronic conditions based on the Linear Analog Scale Assessment energy scale; where improvements of at least 8 mm-considered clinically relevant-were generally seen (1) between groups for cancer patients receiving epoetin alfa compared with those receiving placebo or SOC (differences in changes from baseline to end point from 0.8 to 19.8 mm); and (2) within groups for HIV/AIDS and CKD patients receiving epoetin alfa (changes from baseline to end point of 23 and 25 mm and 28 mm, respectively).

CONCLUSIONS

Results of published clinical trials suggest that treatment of anemia associated with cancer, HIV/AIDS and CKD can have a significant impact on HRQL, particularly fatigue, and that this impact is both statistically and clinically significant.

Pre-treatment haemoglobin levels and the prediction of response to neoadjuvant chemotherapy in breast cancer

AIMS

A low pre-treatment haemoglobin level has been shown to negatively influence outcome in the treatment of tumours of the cervix, bladder and head and neck by radiotherapy. The purpose of this study was to assess the influence of baseline haemoglobin levels on the response to neoadjuvant chemotherapy for breast cancer.

MATERIALS AND METHODS

One hundred and thirty-nine women receiving neoadjuvant chemotherapy for operable breast tumours (T2-4, N0-1, M0) were accessed from our prospective database. Women were treated between March 1999 and June 2004. The median age was 47 years (range 25-70). Most women were treated with 5-fluorouracil, epirubicin and cyclophosphamide chemotherapy (122/139 patients). Baseline haemoglobin levels were compared for clinical responders (partial or complete) and non-responders (stable or progressive disease) using Student's t test and logistic regression. The analysis was adjusted for nodal status, tumour size, tumour grade and menopausal status.

RESULTS

The overall response rate was 84.9% (118/139), with a complete clinical response in 24.5% (34/139). Mean haemoglobin levels were 13.3 g/dl in responders and 13.4 g/dl in non-responders (range 7.9-15.8). The distributions of haemoglobin levels were not significantly different when comparing either responders with non-responders or 'good' responders with 'poor' responders (P = 0.70 and P = 0.32, respectively). If haemoglobin is treated as a binary variable using 12.0 g/dl as the threshold, there is a non-significant trend towards a reduction in the probability of achieving a good response if baseline haemoglobin is below 12.0 g/dl (odds ratio = 0.26, confidence interval = 0.06-1.21; P = 0.086). The rate of complete pathological response was 4.3% (6/139). The mean haemoglobin level in these patients was 14.2 g/dl (range = 12.8-15.7), but the small numbers precluded further analysis.

CONCLUSIONS

There is no evidence for an influence of pre-treatment haemoglobin levels on the clinical response to neoadjuvant chemotherapy in breast cancer. It is unlikely that correction of anaemia above that which is warranted clinically will improve outcomes.

Rituximab for the treatment of diffuse large B-cell lymphomas

For more than 25 years, the combination of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) was considered the gold standard for the treatment of aggressive lymphomas, 90% of which are diffuse, large B-cell lymphomas (DLBCLs). Attempts to improve results by more intensive chemotherapy regimens, including high-dose chemotherapy approaches necessitating stem-cell support, have not convincingly shown improved outcome of DLBCL. The chimeric monoclonal antibody rituximab, which binds to the CD20 antigen expressed on normal B cells and the malignant cells of more than 90% of DLBCLs, and mediates lysis of these cells by direct induction of apoptosis, activation of complement- and antibody-dependent cellular cytotoxicity in vitro, is an attractive candidate for the treatment of B-cell lymphomas. Initial studies in follicular lymphoma demonstrated its efficacy as a single agent or in combination with chemotherapy without adding relevant toxicity. After the demonstration of rituximab single-agent activity in DLBCL, a pivotal trial in elderly patients demonstrated that combining rituximab with eight applications of CHOP significantly improved complete remission, event-free and overall survival rates when compared with CHOP alone. These positive results have meanwhile been confirmed by two additional randomized trials in elderly patients and have been extended to young patients with good-prognosis DLBCL by a fourth trial. While not yet formally established in young, poor-prognosis patients, rituximab in combination with CHOP has become accepted worldwide as the new standard for the treatment of DLBCL. Questions remain concerning the optimal dosage and schedule of rituximab for DLBCL, as well as the optimal chemotherapy regimen partner for rituximab. Rituximab is the first monoclonal antibody to consistently improve survival rates of patients with a malignant disease. Its excellent efficacy in combination with cytotoxic chemotherapy, together with its favorable toxicity profile, establishes rituximab as an indispensable component of modern standard immunochemotherapy of DLBCL.

Clinical and economic impact of epoetin in adjuvant-chemotherapy for breast cancer

INTRODUCTION

Anaemia is a common toxicity in cancer patients and epoetins (EPOs) are now an established treatment. The economic profile of EPO treatment was assessed in patients with breast cancer treated by adjuvant-chemotherapy.

MATERIALS AND METHODS

Two strategies were compared: without treatment by EPO and with the possible use of treatment by EPO (epoetin alfa) when required. The clinical effectiveness criterion was time adjusted to quality of life and economic data included only direct medical costs.

MAIN RESULTS

One hundred ninety-two patients were included. In the group with the strategy containing the possible use of EPO, 45.5% of patients effectively received EPO. A significant difference in the haemoglobin level profile over time was observed which provided a significant overall benefit of 0.0052 (p<10(-4)) quality-adjusted life year (QALY) associated with an extra cost of <euro>1,615 (p<10(-4)). In the base case analysis, the cost per added QALY was estimated as <euro>310,577 with the strategy containing the possible use of EPO.

CONCLUSION

This robust result seems to be unacceptable, but the only relevant point of discussion might be the level of acceptable incremental cost-effectiveness ratio (ICER) for a patient.

Current and future use of hematopoietic growth factors in cancer medicine

Myelosuppression, in particular neutropenia and anemia are serious complications of malignancy and its treatment. Neutropenia can make patients vulnerable to potentially life-threatening infection. It often results in dose reductions and delay of planned chemotherapy, which can have a significant detrimental effect on tumour response and survival. Anemia can be associated with a range of debilitating effects, which can severely impair patients' QOL. In addition, there is some evidence recognizing anemia as a poor prognostic indicator, associated with reduced treatment efficacy. Reduction in the duration and severity of neutropenia and anemia is possible by initiation of appropriate growth factors during the first and subsequent cycles of chemotherapy. New and improved growth factor support with agents such as pegfilgrastim and darbepoetin alfa has the potential to improve the management of chemotherapy-induced neutropenia and anemia further. Thrombopoietin is currently in clinical trials to assess its potential role in the treatment of thrombocytopenia in patients with cancer.