Temporal and geographic variation in the use of hematopoietic growth factors in older women receiving breast cancer chemotherapy: findings from a large population-based cohort

Trends in the use of granulocyte colony stimulating factors for older patients with cancer, 2010 to 2019

INTRODUCTION

Older patients with cancer receiving myelosuppressive treatment are at an increased risk for developing febrile neutropenia (FN) or having chemotherapy dose-reductions or delays, resulting in suboptimal health outcomes. Granulocyte colony stimulating factors (G-CSF) are effective medications to reduce these adverse events and are recommended for patients ≥65 years receiving chemotherapy with >10 % FN risk. We sought to characterize the trends and predictors of G-CSF use between the youngest-old (66-74 years), middle-old (75-84 years), and oldest-old (≥85 years) patients with cancer.

MATERIALS AND METHODS

We used registry data from SEER-Medicare for breast, lung, ovarian, colorectal, esophageal, gastric, uterine, prostate, pancreatic cancer, and non-Hodgkin lymphoma (NHL) diagnoses from 2010 to 2019. Cox proportional hazard analysis was used.

RESULTS

Overall, 41.4 % of patients received G-CSF from chemotherapy initiation to three days after completion of the first chemotherapy course. The use rate remained relatively stable for all cancers, except for an increase in use for those with pancreatic cancer. G-CSF use decreased as patients got older. The oldest-old were 43.0 % (95 % confidence interval: 40.7-45.2 %) less likely to receive G-CSF compared to the youngest-old. Patients with breast cancer or NHL were more likely to receive G-CSF than those with other cancers. Patients who were female, married, White or Hispanic, and had fewer comorbidities were more likely to receive G-CSF.

DISCUSSION

G-CSF is used less often in populations at higher risk of developing FN and related complications. Improving adherence to recommendations can improve health outcomes, especially in the oldest adults, older males, and Black patients.

Association between age and the presence and mortality of breast cancer synchronous brain metastases in the United States: A neglected SEER analysis

BACKGROUND

The extent of the relationship between age and the presence of breast cancer synchronous brain metastases (BCSBMs) and mortality has not yet been well-identified or sufficiently quantified. We aimed to examine the association of age with the presence of BCSBMs and all-cause and cancer-specific mortality outcomes using the SEER database.

METHODS

Age-associated risk of the presence and survival of BCSBMs were evaluated on a continuous scale (restricted cubic spline, RCS) with logistic or Cox regression models. The main endpoints were the presence of BCSBMs and all-cause mortality or cancer-specific mortality. Cox proportional hazards regression and competing risk models were used in survival analysis.

RESULTS

Among 374,132 adult breast cancer patients, 1,441 (0.38%) had BMs. The presence of BCSBMs displayed a U-shaped relationship with age, with the highest point of the curve occurring at the age of 62. In both the younger (age ≤ 61) and older (age ≥ 62) groups, the observed curve showed a nearly linear relationship between age and the presence of BCSBMs. The relationship between age and all-cause mortality (ASM) and cancer-specific mortality (CSM) was linear. Older age at diagnosis was associated with a higher risk of ASM (HR 1.019, 95% CI: 1.013-1.024, p < 0.001) and CSM (HR 1.016, 95% CI: 1.010-1.023, p < 0.001) in multivariable Cox models. Age (sHR 1.007, 95% CI 1-1.013, p = 0.049) was substantially related to a significantly increased risk of CSM in competing risk models.

CONCLUSION

Age had a non-linear U-shaped relationship with the presence of BCSBMs and a linear relationship with BCSBMs mortality.

Underutilisation of prophylactic G-CSF in breast cancer patients receiving adjuvant docetaxel/cyclophosphamide chemotherapy

Docetaxel/cyclophosphamide (TC) is a widely used adjuvant chemotherapy regimen, especially in patients with node-negative or low-risk node-positive breast cancer. Guidelines recommend the use of prophylactic granulocyte colony-stimulating factor (G-CSF) to prevent febrile neutropenia. In this study, we aimed to explore the use of G-CSF as a primary prophylactic and determine the factors influencing its use. This retrospective study used nationwide claims data from the National Inpatient Sample compiled by the Health Insurance Review and Assessment Service in South Korea from 2018. The claims data included 10% of inpatients admitted at least once in 2018 and 1% of outpatients who were not admitted. Female patients with breast cancer who received an adjuvant TC regimen after surgery were selected. Primary prophylactic G-CSF was defined as G-CSF prescribed within two days of the first cycle of TC. The factors influencing its utilisation were investigated using the chi-square test and a multiple logistic regression model. A total of 229 patients were included in the analysis. The proportion of patients who received primary prophylactic G-CSF treatment after the first cycle of TC was 55.5%. The factors positively influencing G-CSF utilization were patients' age ≥65 years, location (i.e. metropolitan areas), and the type of healthcare facility (i.e. non-tertiary hospitals). The use of prophylactic G-CSF in patients with breast cancer who received the adjuvant TC regimen was insufficient. The use of primary G-CSF prophylaxis should be emphasised to reduce the risk of febrile neutropenia among patients receiving a myelosuppressive TC regimen.

Prophylaxis of febrile neutropenia with colony-stimulating factors: the first 25 years

Filgrastim prophylaxis, both primary and secondary, was rapidly incorporated into clinical practice in the 1990s. When pegfilgrastim became available in 2002, it quickly replaced filgrastim as the colony-stimulating factor (CSF) of choice for prophylaxis. Use of prophylaxis increased markedly in the first decade of this century and has stabilized during the present decade. Data concerning real-world CSF prophylactic practice patterns are limited but suggest that both primary and secondary prophylaxis are common, and that use is frequently inappropriate according to guidelines. The extent of inappropriate use is controversial, as are issues concerning the cost-effectiveness of prophylaxis versus no prophylaxis and the cost-effectiveness of primary prophylaxis versus secondary prophylaxis. Nevertheless, CSF prophylaxis is firmly established as a valuable adjunct to chemotherapy and will almost certainly continue to be widely used for the foreseeable future. In this article, we chronicle the use and impact of CSF prophylaxis in US patients receiving myelosuppressive chemotherapy for non-myeloid malignancies. We emphasize the interplay of expert opinion, clinical evidence, and economic factors in shaping the use of CSFs in clinical practice over time, and, with the recent introduction of new CSF agents and options, we aim to provide useful clinical and economic information for healthcare decision makers.

Medication overuse in oncology: current trends and future implications for patients and society

The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.

Improved survival in Medicare patients with multiple myeloma: findings from a large nationwide and population-based cohort

The aim of this study was to examine whether novel agents proteasome inhibitor bortezomib and immunomodulatory drugs lenalidomide and thalidomide are effective in prolonging overall survival (OS) for patients with newly diagnosed multiple myeloma (MM) in the real-world practice setting. A nationwide and population-based retrospective cohort of elderly patients with advanced newly diagnosed MM from 2000 to 2009 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked data. Survival was compared between cases in 2005-2009 and in 2000-2004, and between patients treated with anti-MM therapy and the untreated among cases in 2005-2009, using Cox proportional hazards models, Kaplan-Meier methods, and propensity score adjustment to further control for baseline confounding. Of 8839 patients, 4028 (45.6%) cases were in 2000-2004 and 4811 (54.4%) in 2005-2009. OS was significantly longer for patients in 2005-2009 than patients in 2000-2004 (27.9 vs. 20.0 months, P < 0.001). The hazard ratio for OS for cases in 2005-2009 compared with those in 2000-2004 was 0.78 (95% CI 0.74-0.82). Among 4811 cases in 2005-2009, 54% (n = 2587) received anti-MM therapy. Compared to those untreated, OS was significantly longer (41.1 vs. 27.9 months, P < 0.001) and hazard ratio was 0.58 (95% CI 0.54-0.62) in the treated patients. This study demonstrated improved survival in newly diagnosed MM patients in a more recent 5-year cohort compared with those in the previous 5 years. The survival benefit was significant across different demographic and patient characteristics. However, there were still a substantial number of MM patients not receiving anti-MM therapy.

Use of Hematopoietic Growth Factors in Elderly Lung Cancer Patients Receiving Chemotherapy: A SEER-Medicare-based Study

OBJECTIVES

Hematopoietic growth factors (HGFs) are essential for successful completion of chemotherapy in lung cancer patients. However, because of their adverse effects, clinical guidelines recommend their use in only selective clinical scenarios. This study, for the first time, explores patient characteristics and temporal trends associated with HGF utilization among elderly lung cancer patients receiving chemotherapy.

METHODS

This is a retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data containing 80,940 patients, aged 65 years and older, diagnosed with stage I to IV lung cancer between 1992 and 2009, and who received chemotherapy. Descriptive statistics and logistic regressions were used to examine the characteristics associated with 2 types of HGFs-colony stimulating factors (CSFs) and erythropoiesis-stimulating agents (ESAs).

RESULTS

Twenty-five percent of the patients received CSFs and 42% received ESAs. Temporal variations were most predictive of HGF utilization, with an increase from 2.6% in 1992 to 47.3% in 2009 for CSFs and 1.3% to 30.5% for ESAs. Higher chemotherapy-based risk profiles increased the odds of HGF receipt 2 to 3 times (P<0.0001). Even after controlling for relevant clinical characteristics, unexplained sociodemographic associations persisted, suggesting lack of compliance with HGF guidelines.

CONCLUSIONS

There has been a significant increase in the use of HGFs over time. Although chemotherapy-based risk profiles were significant predictors of HGF receipt, the study results suggest possible lack of compliance with treatment guidelines, which should be investigated. Given the high cost of HGFs, future studies are also needed to determine cost-effectiveness of these drugs among lung cancer patients.

The role of acuity of illness at presentation in early mortality in black children with acute myeloid leukemia

Black patients with acute myeloid leukemia (AML) experience higher mortality than White patients. We compared induction mortality, acuity of illness prior to chemotherapy, and insurance type between Black and White patients to assess whether acuity of presentation mediates the disparity. Within a retrospective cohort of 1,122 children with AML treated with two courses of standard induction chemotherapy between 2004 and 2014 in the Pediatric Health Information System (PHIS) database, the association between race (Black versus White) and inpatient mortality during induction was examined. Intensive Care Unit (ICU)-level resource utilization during the first 72 hours following admission for initial AML chemotherapy was evaluated as a potential mediator. The total effect of race on mortality during Induction I revealed a strong association (unadjusted HR 2.75, CI: 1.18, 6.41). Black patients had a significantly higher unadjusted risk of requiring ICU-level resources within the first 72 hours after initial presentation (17% versus 11%; RR 1.52, CI: 1.04, 2.24). Mediation analyses revealed the indirect effect of race through acuity accounted for 61% of the relative excess mortality during Induction I. Publicly insured patients experienced greater induction mortality than privately insured patients regardless of race. Black patients with AML have significantly greater risk of induction mortality and are at increased risk for requiring ICU-level resources soon after presentation. Higher acuity amongst Black patients accounts for a substantial portion of the relative excess mortality during Induction I. Targeting factors affecting acuity of illness at presentation may lessen racial disparities in AML induction mortality.

Associations between hematopoietic growth factors and risks of venous thromboembolism, stroke, ischemic heart disease and myelodysplastic syndrome: findings from a large population-based cohort of women with breast cancer

PURPOSE

To determine the risk of venous thromboembolism (VTE), stroke, ischemic heart disease, and myelodysplastic syndrome (MDS) in association with the receipt of colony-stimulating factors (CSFs) and/or erythropoiesis-stimulating agents (ESAs) in women with breast cancer.

METHODS

We studied 77,233 women with breast cancer aged ≥65 in 1992-2009 from the Surveillance, Epidemiology, and End Results-Medicare linked data with up to 19 years of follow-up.

RESULTS

Incidence of VTE increased from 9 cases in women receiving no chemotherapy and no CSFs/ESAs to 22.79 cases per 1,000 person-years in those receiving chemotherapy with CSFs and ESAs. Women with chemotherapy who received both CSFs and ESAs (adjusted hazard ratio and 95 % confidence interval 2.01, 1.80-2.25) or received ESAs without CSFs (2.03, 1.74-2.36) were twice as likely to develop VTE than those receiving no chemotherapy and no CSFs/ESAs, whereas those receiving CSF alone without ESA were 64 % more likely to have VTE (1.64, 1.45-1.85). Risk of MDS was significantly increased by fivefold in patients receiving ESA following chemotherapy.

CONCLUSIONS

Receipts of CSFs and ESAs were significantly associated with an increased risk of VTE in women with breast cancer. Use of ESAs was significantly associated with substantially increased risks of MDS. These findings support those of previous studies.

Safety and Tolerability of Anthracycline-Containing Adjuvant Chemotherapy in Elderly High-Risk Breast Cancer Patients

BACKGROUND

Intensive chemotherapy confers benefit to patients with high-risk early breast cancer (BC). We characterized the feasibility and toxicity profile of anthracycline-containing adjuvant chemotherapy (ACAC) in older women with early BC.

PATIENTS AND METHODS

Available data from women who received ACAC for BC in 3 randomized trials were retrieved. We identified women aged >65 years and we examined differences in tolerability and delivery of chemotherapy, toxicity, and treatment outcome.

RESULTS

From a total of 2640 patients, we identified 453 patients (17%) as being >65 years old, 89% of whom had tumors that were node-positive, with 77% who were hormone receptor-positive. At least 90% of the planned doses were delivered in 37% of the elderly, compared with 49% in the younger patients (P < .0001). Grade 3 and 4 hematological toxicity was observed in 32% of elderly patients, compared with 21% of the younger (P < .0001). Febrile neutropenia occurred in 4.5% of the elderly patients, as opposed to 2.0% in the younger patients (P < .002). Elderly patients experienced more frequent Grade 3 and 4 fatigue, mucositis, and sensory neuropathy. Relative dose intensities were significantly lower in elderly patients. Treatment discontinuation was not different in the 2 groups. At a median follow-up of 120 months, competing risks analysis showed a significant benefit in disease-free survival for elderly patients.

CONCLUSION

Elderly BC patients treated with ACAC derive clinical benefit comparable to that in younger patients, mainly at the cost of increased risk of hematological toxicity. This should be taken into account in decision-making and treatment individualization in high-risk BC patients.

Myelodysplastic syndrome and acute myeloid leukemia following adjuvant chemotherapy with and without granulocyte colony-stimulating factors for breast cancer

Risk of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) post-breast cancer treatment with adjuvant chemotherapy and granulocyte colony-stimulating factors (G-CSF) is not fully characterized. Our objective was to estimate MDS/AML risk associated with specific breast cancer treatments. We conducted a retrospective cohort study of women aged ≥66 years with stage I-III breast cancer between 2001 and 2009 using the Surveillance, Epidemiology, and End Results-Medicare database. Women were classified as receiving treatment with radiation, chemotherapy, and/or G-CSF. We used multivariable Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (CI) for MDS/AML risk. Among 56,251 breast cancer cases, 1.2 % developed MDS/AML during median follow-up of 3.2 years. 47.1 % of women received radiation and 14.3 % received chemotherapy. Compared to breast cancer cases treated with surgery alone, those treated with chemotherapy (HR = 1.38, 95 %-CI 0.98-1.93) and chemotherapy/radiation (HR = 1.77, 95 %-CI 1.25-2.51) had increased risk of MDS/AML, but not radiation alone (HR = 1.08, 95 % CI 0.86-1.36). Among chemotherapy regimens and G-CSF, MDS/AML risk was differentially associated with anthracycline/cyclophosphamide-containing regimens (HR = 1.86, 95 %-CI 1.33-2.61) and filgrastim (HR = 1.47, 95 %-CI 1.05-2.06), but not pegfilgrastim (HR = 1.10, 95 %-CI 0.73-1.66). We observed increased MDS/AML risk among older breast cancer survivors treated with anthracycline/cyclophosphamide chemotherapy that was enhanced by G-CSF. Although small, this risk warrants consideration when determining adjuvant chemotherapy and neutropenia prophylaxis for breast cancer patients.

Risks of Venous Thromboembolism, Stroke, Heart Disease, and Myelodysplastic Syndrome Associated With Hematopoietic Growth Factors in a Large Population-Based Cohort of Patients With Colorectal Cancer

PURPOSE

To determine the relationship between the receipt of colony-stimulating factors (CSFs) with erythropoiesis-stimulating agents (ESAs) and the risk of developing venous thromboembolism (VTE), stroke, heart disease, and myelodysplastic syndrome (MDS) in patients with colorectal cancer.

METHODS

We studied 80,925 patients diagnosed with colorectal cancer at age ≥ 65 years in 1992-2009 from the nationwide 16 areas of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. Cumulative incidence and the time to events Cox hazard regressions were used to explore the risks of outcomes in association with the receipt of CSFs and ESAs.

RESULTS

Patients who received chemotherapy (CT) with both CSF and ESA were 58% more likely to develop VTE than those who received CT without CSF and ESA (hazard ratio, 1.58; 95% confidence interval, 1.43-1.76). The risk of stroke appeared to be not associated with the use of CSF and ESA, whereas the risk of heart disease was only significantly elevated in those patients who did not receive CT but received ESA. The risk of acute myeloid leukemia or MDS was significantly increased 4- to 9-fold in patients who received ESA, regardless of receipt of CT or CSF.

CONCLUSION

The use of ESAs was significantly associated with a substantially increased risk of MDS in patients with colorectal cancer. The use of CSFs and ESAs was also significantly associated with a moderately increased risk of VTE and a slightly elevated risk of heart disease.

CMF-regimen preferred as first-course chemotherapy for older and sicker women with breast cancer: Findings from a SEER-Medicare-based population study

OBJECTIVE

The objective of this study was to determine the sociodemographic and clinical characteristics associated with Cyclophosphamide, Methotrexate, and 5-Fluorouracil (CMF) utilization as a first-course chemotherapy regimen among female Medicare patients with early-stage breast cancer.

METHODS

A longitudinal study was conducted with women 66 years and older, diagnosed with stage I to III breast cancer from 1993 to 2004, and receiving chemotherapy using the Surveillance, Epidemiology, and End Result-Medicare data. First-course CMF chemotherapy was defined as chemotherapy initiation within 6 months of breast cancer diagnosis, with at least 1 claim of CMF each within 1 year of diagnosis. Logistic regression was used to perform the analysis.

RESULTS

Older and sicker women, living in census tracts with lower average education, and diagnosed with advanced stage, hormone receptor-negative tumors have a higher probability of CMF administration. Receipt of lymph node dissection and nonreceipt of radiation therapy were also associated with CMF administration. CMF administration has declined over the years and has significant regional variation.

CONCLUSIONS

Reduction in CMF use overtime indicates the increased use of newer and more effective systemic therapies among breast cancer patients. In spite of the reduction in CMF use over time, CMF is more frequently administered to older and sicker women, possibly because of higher risk of anthracycline-induced toxicities in these patients. Clinical guidelines have no recommendations for CMF administration in breast cancer patients with certain clinical characteristics. Hence, it is important to understand if the associations observed in this study can be clinically justified in order to reduce unjustified use of less-effective regimens.

A Decade of Research on the Quality of Systemic Cancer Therapy in Routine Care: What Aspects of Quality Are We Measuring?

Most studies evaluating quality of systemic cancer therapy have focused on access to cytotoxic chemotherapy in early-stage disease. Studies on other aspects of quality and in different clinical settings are needed.

G-CSF utilization rate and prescribing patterns in United States: associations between physician and patient factors and GCSF use

Febrile neutropenia (FN) is a common complication among patients with chemotherapy-induced myelotoxicity and is associated with a number of negative outcomes including prolonged hospitalization, increased medical costs, increased risk of mortality, dose reductions, and delays. Granulocyte-colony-stimulating factor (G-CSF), granulocyte-macrophage-colony stimulating factor (GM-CSF), and pegylated G-CSF are effective at reducing risk and duration of neutropenia-related events. However, despite guidelines, the use of G-CSF and pegylated G-CSF in the United States has not been consistent and pattern of care studies have focused primarily on G-CSF. A number of studies found that G-CSF is underutilized in patients undergoing chemotherapy treatments associated with a high risk of FN, while being over utilized in patients with a low-risk FN. Wide variations in overuse, underuse, and misuse of G-CSF are associated with a number of physician and patient factors. Improved awareness of the guidelines, feedback to providers regarding proper usage, and understanding of chemotherapy regimens associated with very low risks as well as high risks (>20%) of FN is some of the approaches that could lead to improving care.

Use of pegfilgrastim primary prophylaxis and risk of infection, by chemotherapy cycle and regimen, among patients with breast cancer or non-Hodgkin's lymphoma

PURPOSE

This study aims to examine granulocyte colony-stimulating factor (G-CSF) prophylaxis by cancer type, chemotherapy regimen, and cycle in a real-world setting to assess if practice conforms to clinical guidelines, which recommend G-CSF prophylaxis every cycle when a patient's risk of febrile neutropenia (FN) is 20% or greater, and to describe the incidence of FN among patients who discontinue pegfilgrastim (peg) prophylaxis.

METHODS

The cohort was selected from administrative claims data and includes adults diagnosed with non-Hodgkin's lymphoma (NHL) or breast cancer (BC) who began chemotherapy 2005-2010.

RESULTS

About 83.2% of the 4,470 patients with BC treated with dose-dense doxorubicin, cyclophosphamide (ddAC), 83.6% of 2,197 patients with BC treated with docetaxel, doxorubicin, cyclophosphamide (TAC), and about 55.6% of the 2,722 patients with NHL treated with cyclophosphamide, doxorubicin, vincristine, with or without prednisone for 3-week cycles (CHOP-R Q3W) received peg prophylaxis in cycle 1. Among patients on these regimens who received peg prophylaxis in cycle 1 and were still on the regimen in cycle 4, about 90% received peg prophylaxis in that cycle. Among patients with BC or NHL who discontinued G-CSF, the incidence proportion of infection or FN varied by regimen and cycle, with a range from 0 to 14%.

CONCLUSIONS

Despite clinical guidelines recommending G-CSF prophylaxis with chemotherapy regimens with a high risk of FN, many NHL and BC patients do not receive FN prophylaxis in cycle 1. However, among patients who receive G-CSF in cycle 1 and remain on the regimen, the majority appear to continue prophylaxis as indicated.

Patterns of colorectal cancer care in the United States and Canada: a systematic review

Colorectal cancer is the third most common cancer in the United States and Canada. Given the high incidence and increased survival of colorectal cancer patients, prevalence is increasing over time in both countries. Using MEDLINE, we conducted a systematic review of the literature published between 2000 and 2010 to describe patterns of colorectal cancer care. Specifically we examined data sources used to obtain treatment information and compared patterns of cancer-directed initial care, post-diagnostic surveillance care, and end-of-life care among colorectal cancer patients diagnosed in the United States and Canada. Receipt of initial treatment for colorectal cancer was associated with the anatomical position of the tumor and extent of disease at diagnosis, in accordance with consensus-based guidelines. Overall, care trends were similar between the United States and Canada; however, we observed differences with respect to data sources used to measure treatment receipt. Differences were also present between study populations within country, further limiting direct comparisons. Findings from this review will allow researchers, clinicians, and policy makers to evaluate treatment receipt by patient, clinical, or system characteristics and identify emerging trends over time. Furthermore, comparisons between health-care systems in the United States and Canada can identify disparities in care, allow the evaluation of different models of care, and highlight issues regarding the utility of existing data sources to estimate national patterns of care.

Granulocyte colony-stimulating factor (G-CSF) patterns of use in cancer patients receiving myelosuppressive chemotherapy

PURPOSE

Febrile neutropenia (FN) is a common and serious complication of myelosuppressive chemotherapy. Guidelines recommend primary granulocyte colony-stimulating factors (G-CSF) prophylaxis (PPG) in patients with a high risk (HR, >20 %) of developing FN. We performed a retrospective analysis using a subset of the Medicare 5 % database to assess patterns of G-CSF use and FN occurrence among elderly cancer patients receiving myelosuppressive chemotherapy.

METHODS

Chemotherapy courses for patients aged 65+ years were identified; only the first course was used for this analysis. Using clinical guidelines, chemotherapy regimens were classified as HR or intermediate risk (IR) for FN. The first administration of G-CSF was classified as either PPG (within the first 5 days of the first cycle), secondary prophylaxis, or reactive.

RESULTS

Twelve thousand seven hundred seven courses across five tumor types were classified as having a HR or IR regimen. G-CSF was used in 24.5-73.8 % of patients receiving a HR FN regimen, with the highest use in breast cancer or NHL. Except for breast cancer (where PPG was used in 52.1 %), PPG was given in less than half of patients receiving a HR regimen. Depending on the tumor type, 4.8-22.6 % of patients with a HR regimen had a neutropenia-related hospitalization.

CONCLUSIONS

Guidelines recommend PPG with HR FN regimens and older age (>65 years), an important risk factor for developing severe neutropenic complications. However, our results show that in this elderly population, PPG was not routinely used (range 4.8-52.1 %) in patients receiving HR FN regimens. Careful attention to FN risk factors, including chemotherapy regimen and patient age, is needed when planning treatment strategies.

Temporal and Geographic Variations in the Receipt of Colony-Stimulating Factors and Erythropoiesis-Stimulating Agents in a Large Retrospective Cohort of Older Women With Breast Cancer From 2000 to 2009

The purpose of this study was to use the most recent national data for a large cohort of patients diagnosed with breast cancer to evaluate temporal trend of receiving hematopoietic growth factors from 2000 to 2009 and to examine significant factors associated with increasing trends and geographic variations. We identified 26,130 women aged 65-89 years who were diagnosed with breast cancer and received chemotherapy in 2000-2009 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Colony-stimulating factors (CSFs) were identified if there was a claim from the following procedure codes: filgrastim, pegfilgrastim, or sargramostim. Erythropoiesis-stimulating agents (ESAs) were identified if there was a claim from the following procedure codes: epoetin or darbepoetin. Overall, 51.7% of patients with breast cancer received CSFs, which increased from 21.7% in 2000 to 63.2% in 2009. The percentage of patients receiving pegfilgrastim increased from 2.7% in 2000 to 19.5% in 2003 and then continuously to 49.7% in 2009. The overall percentage of patients receiving ESAs was 39.3%, which increased from 26.4% in 2000 to 60.8% in 2006, and then decreased significantly from 40.7% in 2007 to 12.9% in 2009. The receipt of both CSFs and ESAs differed significantly across different geographic areas. The receipt of CSFs continued to increase from 2000 to 2009, and pegfilgrastim started to replace filgrastim since 2003. The receipt of ESAs increased until 2006 and then declined substantially due to the black box warning. There were substantial geographic variations in the use of these hematopoietic growth factors.

Effect of primary prophylactic granulocyte-colony stimulating factor use on incidence of neutropenia hospitalizations for elderly early-stage breast cancer patients receiving chemotherapy

OBJECTIVE

Chemotherapy is vital for breast cancer management, but early-onset toxicities like neutropenia hinder its administration, especially in the elderly. Primary prophylactic (PP) use of granulocyte-colony stimulating factors (G-CSF) helps prevent neutropenia and its complications while receiving chemotherapy. Nevertheless, evidence supporting the effectiveness of PPG-CSF in the elderly is limited. Thus, the American Society of Clinical Oncology (ASCO) guidelines for PPG-CSF use in the elderly are not explicit. This study analyzed the effects of administration of PPG-CSF and duration of administration on the occurrence of chemotherapy-induced neutropenia hospitalizations in elderly breast cancer patients.

METHODS

This retrospective observational study of newly diagnosed breast cancer patients receiving chemotherapy used Surveillance, Epidemiology, and End Results-Medicare data from 1994 to 2003. To account for the nonrandom nature of the observational data, a nonparametric matching technique was used to preprocess the data before parametrically estimating the treatment effects.

RESULTS

Administration of PPG-CSF during the first course chemotherapy reduced neutropenia hospitalizations by 16% within the first 3 months and 17% within the first 6 months of chemotherapy initiation (P < 0.05). Hospitalization rates within the first 3 months of chemotherapy initiation were 3 times higher in women receiving less than 5 consecutive days of PPG-CSF compared with women receiving PPG-CSF for 5 or more days (P < 0.05). Hospitalization rates within the first 1 and 6 months were also lower with longer PPG-CSF duration (≥5 d) (P < 0.10).

CONCLUSIONS

PPG-CSF use is associated with reductions in in-patient healthcare utilization. These findings have implications for ASCO guidelines and Medicare coverage policies for PPG-CSF administration in elderly breast cancer patients.

Comparative effectiveness of white blood cell growth factors on neutropenia, infection, and survival in older people with non-Hodgkin's lymphoma treated with chemotherapy

OBJECTIVES

To determine the effect of colony-stimulating factor (CSF) on incidence of febrile neutropenia, infection, and survival in older people with non-Hodgkin's lymphoma (NHL) treated with chemotherapy.

DESIGN

Retrospective cohort study.

SETTING

The Surveillance, Epidemiology, and End Results-Medicare database.

PARTICIPANTS

Thirteen thousand two hundred twenty-three people diagnosed with NHL at age 65 and older (mean age 74.9, range 65-102) in 1992 to 2002 who received chemotherapy within 12 months of diagnosis.

MEASUREMENTS

Primary prophylaxis was defined as CSF administered at the start of chemotherapy before febrile neutropenia or infection; secondary prophylaxis was defined as CSF use after febrile neutropenia or infection.

RESULTS

Participants with five to nine administrations of primary prophylactic CSF had a 42% lower risk of febrile neutropenia (odds ratio (OR)=0.58, 95% confidence interval (CI)=0.41-0.83), and participants with 10 or more administrations had a 48% lower risk (OR=0.52, 95% CI=0.36-0.76) after adjusting for age, stage, histology, and comorbidity. Results did not differ significantly after adjusting for propensity score of receiving CSF. There was no significant association between primary prophylactic CSF and overall survival, but secondary prophylactic CSF was significantly associated with better survival. Four to 10 administrations of secondary prophylactic CSF was associated with 9% lower mortality risk (hazard ratio (HR)=0.91, 95% CI=0.84-0.99), 11 to 23 administrations was associated with 23% lower mortality risk (HR=0.77, 95% CI=0.71-0.84) and 24 or more administrations was associated with 13% lower mortality risk (HR=0.87, 95% CI+0.79-0.95) than in participants not receiving CSF after neutropenia or infection.

CONCLUSION

Primary prophylactic CSF was observed to be effective in reducing the incidence of neutropenia and infection. These findings substantiate the clinical guidelines for recommending prophylactic CSF in older people with NHL receiving chemotherapy.

Chemotherapy and survival for patients with multiple myeloma: findings from a large nationwide and population-based cohort

OBJECTIVE

To assess the patterns of chemotherapy use for patients with multiple myeloma and to determine if chemotherapy is effective in prolonging survival outside the clinical trial settings.

METHODS

We studied a nationwide and population-based retrospective cohort of 4902 patients > or =65 years of age with stage II or III multiple myeloma from 1992 to 1999, identified from the Surveillance, Epidemiology, and End-Results-Medicare data. Multivariate logistic regression was used to estimate the odds ratio of receiving chemotherapy and Cox proportional hazard model was used to estimate the hazard ratio of mortality associated with chemotherapy.

RESULTS

Of 4902 patients with stage II or III multiple myeloma, 52.0% received chemotherapy during the course of the disease. The receipt of chemotherapy decreased significantly with age from 65.7% in the 65- to 69-year age group to 34.3% in those > or =80 years. Blacks (47.6%) were less likely to receive chemotherapy than whites (52.8%). Use of chemotherapy decreased significantly with comorbidity scores and increased over time. Risk of all-cause mortality was significantly reduced in patients who received chemotherapy compared with those who did not (adjusted hazard ratio = 0.65; 95% confidence interval = 0.61-0.69). A similar pattern as observed for myeloma-specific mortality (0.61; 0.56-0.67). Survival benefit increased with increasing cycles of chemotherapy (P < 0.001 for trend) and was significant across different age groups, gender, ethnic groups, and comorbidity scores.

CONCLUSION

Chemotherapy was significantly associated with increased survival in patients with multiple myeloma outside the clinical trial settings. This survival benefit was significant across different groups by age, gender, race, and comorbidity. A substantial number of patients with multiple myeloma did not receive chemotherapy.

Acute myeloid leukemia or myelodysplastic syndrome following use of granulocyte colony-stimulating factors during breast cancer adjuvant chemotherapy

BACKGROUND

Recently, increasing numbers of women receiving adjuvant chemotherapy for breast cancer have also received granulocyte colony-stimulating factors (G-CSFs) or granulocyte-macrophage colony-stimulating factors (GM-CSFs). Although these growth factors support chemotherapy, their long-term safety has not been evaluated. We studied the association between G-CSF use and incidence of leukemia in a population-based sample of breast cancer patients.

METHODS

Among women aged 65 years or older in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stages I-III breast cancer from January 1, 1991, to December 31, 1999, we identified those who received G-CSF or GM-CSF concurrently with chemotherapy. We used Cox proportional hazards models to estimate hazard ratios for the association of treatment with G-CSF or GM-CSF and subsequent (through December 31, 2003) diagnosis of acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). All statistical tests were two-sided.

RESULTS

Of 5510 women treated with chemotherapy, 906 (16%) received G-CSF or GM-CSF therapy, and 64 (1.16%) were subsequently diagnosed with either MDS or AML before a cancer recurrence. Use of G-CSF and GM-CSF was associated with more recent diagnosis, younger age, urban residence, fewer comorbidities, receipt of radiation therapy, positive lymph nodes, and cyclophosphamide treatment. Of the 906 patients who were treated with G-CSF, 16 (1.77%) developed AML or MDS; of the 4604 patients not treated with G-CSF, 48 (1.04%) developed AML or MDS. The hazard rate ratio for AML or MDS among those treated with G-CSF or GM-CSF compared with those who were not was 2.14 (95% confidence interval [CI] = 1.12 to 4.08). AML or MDS developed within 48 months of breast cancer diagnosis in 1.8% of patients who received G-CSF or GM-CSF but only in 0.7% of patients who did not (hazard ratio = 2.59, 95% CI = 1.30 to 5.15).

CONCLUSIONS

The use of G-CSF was associated with a doubling in the risk of subsequent AML or MDS among the population that we studied, although the absolute risk remained low. Even if this association is confirmed, the benefits of G-CSF may still outweigh the risks. Meanwhile, however, G-CSF use should not be assumed to be risk free.

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.