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De Oliveira Brandao C, Lewis S, Sandschafer D, Crawford J. Two decades of pegfilgrastim: what have we learned? Where do we go from here? Curr Med Res Opin 2023; 39:707-718. [PMID: 36976784 DOI: 10.1080/03007995.2023.2196197] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Chemotherapy-induced febrile neutropenia (FN) is a medical emergency that may occur in patients with malignancies receiving myelosuppressive chemotherapy. FN requires early therapeutic intervention since it is associated with increased hospitalizations and high mortality risk of 5%-20%. FN-related hospitalizations are higher in patients with myeloid malignancies than in those with solid tumors due to the myelotoxicity of chemotherapy regimens and the compromised bone marrow function. FN increases the burden of cancer by causing chemotherapy dose reductions and delays. The administration of the first granulocyte colony-stimulating factor (G-CSF), filgrastim, reduced the incidence and duration of FN in patients undergoing chemotherapy. Filgrastim later evolved into pegfilgrastim, which has a longer half-life than filgrastim and was associated with a lower rate of severe neutropenia, chemotherapy dose reduction, and treatment delay. Nine million patients have received pegfilgrastim since its approval in early 2002. The pegfilgrastim on-body injector (OBI) is an innovative device facilitating the time-released auto-injection of pegfilgrastim approximately 27 hours after chemotherapy, as clinically recommended for the prevention of FN, thus eliminating the need for a next-day hospital visit. Since its introduction in 2015, one million patients with cancer have received pegfilgrastim using the OBI. Subsequently, the device has been approved in the United States (US), European Union, Latin America, and Japan, with studies and a postmarketing commitment demonstrating device reliability. A recent prospective observational study conducted in the US demonstrated that the OBI substantially improved the adherence to and compliance with clinically recommended pegfilgrastim therapy; patients receiving pegfilgrastim via the OBI experienced a lower incidence of FN than those receiving alternatives for FN prophylaxis. This review discusses the evolution of G-CSFs leading to the development of the OBI, current recommendations for G-CSF prophylaxis in the clinic, continued evidence supporting next-day pegfilgrastim administration, and improvements in patient care made possible with the OBI.
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Affiliation(s)
| | - Sandra Lewis
- Global Research & Development, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Jeffrey Crawford
- Medical Oncology, Division of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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2
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Mahdi Seyedzadeh Sani S, Sahranavard M, Jannati Yazdanabad M, Seddigh Shamsi M, Elyasi S, Hooshang Mohammadpour A, Sathyapalan T, Arasteh O, Ghavami V, Sahebkar A. The effect of concomitant use of Colony-Stimulating factors on bleomycin pulmonary toxicity - A systematic review and meta-analysis. Int Immunopharmacol 2022; 112:109227. [PMID: 36099787 DOI: 10.1016/j.intimp.2022.109227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/06/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Changes in the incidence of bleomycin pulmonary toxicity (BPT) as a result of adding colony-stimulating factors (CSF) to bleomycin regimens has been investigated in numerous studies. We performed a systematic review and meta-analysis to assess the outcomes of these studies. METHODS A systematic search was performed using Pubmed, Scopus, Web of Science, and Embase on April 2021. Studies evaluating the incidence of BPT in patients receiving bleomycin with and without CSF were included. In addition, meta-analysis was performed by pooling odds ratios using R. RESULTS Out of 340 obtained records, our qualitative and quantitative analysis included 3234 and 1956 patients from 22 and 14 studies, respectively. The quantitative synthesis showed that addition of CSF significantly increased the risk of BPT incidence (OR = 1.82, 95 % CI: 1.37-2.40, p < 0.0001; I2 = 10.7 %). Subgroup analysis did not show any association between continent, bleomycin dose, cancer type, type of study, and pulmonary function test with BPT incidence. CONCLUSION This systematic review and meta-analysis showed that co-administration of CSF with bleomycin increases the incidence of BPT. The physicians need to consider this finding while deciding the best strategy for this cohort of patients.
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Affiliation(s)
| | - Mehrdad Sahranavard
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Science, Mashhad, Iran
| | - Mahdi Jannati Yazdanabad
- Department of Biostatistics and Epidemiology, School of Health, Mashhad University of Medical Science, Mashhad, Iran
| | - Mohsen Seddigh Shamsi
- Department of Hematology Oncology, Faculty of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Sepideh Elyasi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Science, Mashhad, Iran
| | - Amir Hooshang Mohammadpour
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Science, Mashhad, Iran
| | - Thozhukat Sathyapalan
- Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, UK
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Science, Mashhad, Iran.
| | - Vahid Ghavami
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Science, Mashhad, Iran.
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; School of Medicine, The University of Western Australia, Perth, Australia; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Cho JS, Oh HJ, Jang YE, Kim HJ, Kim A, Song JA, Lee EJ, Lee J. Synthetic pro-peptide design to enhance the secretion of heterologous proteins by Saccharomyces cerevisiae. Microbiologyopen 2022; 11:e1300. [PMID: 35765186 PMCID: PMC9178654 DOI: 10.1002/mbo3.1300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 12/02/2022] Open
Abstract
Heterologous protein production in Saccharomyces cerevisiae is a useful and effective strategy with many advantages, including the secretion of proteins that require posttranslational processing. However, heterologous proteins in S. cerevisiae are often secreted at comparatively low levels. To improve the production of the heterologous protein, human granulocyte colony‐stimulating factor (hG‐CSF) in S. cerevisiae, a secretion‐enhancing peptide cassette including an hIL‐1β‐derived propeptide, was added and used as a secretion enhancer to alleviate specific bottlenecks in the yeast secretory pathway. The effects of three key parameters—N‐glycosylation, net negative charge balance, and glycine‐rich flexible linker—were investigated in batch cultures of S. cerevisiae. Using a three‐stage design involving screening, selection, and optimization, the production and secretion of hG‐CSF by S. cerevisiae were significantly increased. The amount of extracellular mature hG‐CSF produced by the optimized propeptide after the final stage increased by 190% compared to that of the original propeptide. Although hG‐CSF was used as the model protein in the current study, this strategy applies to the enhanced production of other heterologous proteins, using S. cerevisiae as the host.
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Affiliation(s)
- Ji Sung Cho
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Hye Ji Oh
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Young Eun Jang
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Hyun Jin Kim
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Areum Kim
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Jong-Am Song
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
| | - Eun Jung Lee
- Department of Chemical Engineering, School of Applied Chemical Engineering, Kyungpook National University, Daegu, Korea
| | - Jeewon Lee
- Department of Chemical and Biological Engineering, College of Engineering, Korea University, Seoul, Korea
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Epstein RS, Weerasinghe RK, Parrish AS, Krenitsky J, Sanborn RE, Salimi T. Real-world burden of chemotherapy-induced myelosuppression in patients with small cell lung cancer: a retrospective analysis of electronic medical data from community cancer care providers. J Med Econ 2022; 25:108-118. [PMID: 34927520 DOI: 10.1080/13696998.2021.2020570] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS Chemotherapy-induced myelosuppression, which commonly exhibits as neutropenia, anemia, or thrombocytopenia, represents a substantial burden for patients with cancer that affects health-related quality of life and increases healthcare resource utilization (HCRU). We evaluated the burden of myelosuppression among chemotherapy-treated patients with small cell lung cancer (SCLC) using real-world data from community cancer care providers in the Western United States. MATERIALS AND METHODS This was a retrospective, observational analysis of electronic medical records (EMRs) from Providence St. Joseph Health hospital-associated oncology clinics between January 2016 and December 2019. Patient demographics were assessed from the date of first SCLC diagnosis in adult patients with chemotherapy-induced grade ≥3 myelosuppression in first-line (1L) or second-line-and-beyond (2L+) treatment settings. Myelosuppressive adverse events (AEs), treatment patterns, and HCRU were assessed from the date of chemotherapy initiation (index date) until 12 months, date of the last visit, date of death, or study end, whichever occurred earliest. RESULTS Of 347 eligible patients with SCLC who had received chemotherapy (mean age 66; 49% female), all had received at least 1L treatment, and 103 (29.7%) had a 2L + treatment recorded within the EMR during the study period. Of 338 evaluable patients with longitudinal laboratory data, 206 (60.9%) experienced grade ≥3 myelosuppressive AEs, most commonly neutropenia, anemia, and thrombocytopenia (44.9, 41.1, and 25.4 per 100 patients, respectively). Rates of granulocyte colony-stimulating factor use and red blood cell transfusions were 47.0 and 41.7 per 100 patients, respectively. There was a trend toward increasing the use of supportive care interventions and visits to inpatient and outpatient facilities in patients with myelosuppressive AEs in more than one cell lineage. CONCLUSIONS Chemotherapy-induced myelosuppression places a substantial real-world burden on patients with SCLC in the community cancer care setting. Innovations to protect bone marrow from chemotherapy-induced damage have the potential to reduce this burden.
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Affiliation(s)
| | | | | | | | - Rachel E Sanborn
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, OR, USA
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5
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Matsuda K, Jo T, Miyauchi M, Toyama K, Nakazaki K, Matsui H, Fushimi K, Yasunaga H, Kurokawa M. Difference of preventing effects of G-CSF according to age in patients with malignant lymphoma: A nation-wide analysis in Japan. J Infect Chemother 2021; 27:1151-1155. [DOI: 10.1016/j.jiac.2021.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
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Tralongo AC, Antonuzzo A, Pronzato P, Sbrana A, Turrini M, Zoratto F, Danova M. Management of chemotherapy-induced neutropenia in patients with cancer: 2019 guidelines of the Italian Medical Oncology Association (AIOM). TUMORI JOURNAL 2020; 106:273-280. [PMID: 32538316 DOI: 10.1177/0300891620927093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Neutropenia is the most frequent side effect of commercially available myelosuppressive drugs and its most significant complication is febrile neutropenia. It is associated with increased hospital admissions and higher probability of death. Prophylaxis with the administration of granulocyte colony-stimulating factor can prevent neutropenia caused by anticancer drugs. The correct administration of these drugs and the management of febrile neutropenia are extremely important in the treatment of patients with cancer.
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Affiliation(s)
| | | | - Paolo Pronzato
- Medical Oncology, AOU San Martino IRCCS IST Genova, Genova, Italy
| | | | | | | | - Marco Danova
- Internal Medicine and Medical Oncology, ASST Pavia, Pavia, Italy
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7
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Edelsberg J, Weycker D, Bensink M, Bowers C, Lyman GH. Prophylaxis of febrile neutropenia with colony-stimulating factors: the first 25 years. Curr Med Res Opin 2020; 36:483-495. [PMID: 31834830 DOI: 10.1080/03007995.2019.1703665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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8
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Yamao K, Takenaka M, Yoshikawa T, Ishikawa R, Okamoto A, Yamazaki T, Nakai A, Omoto S, Kamata K, Minaga K, Hagiwara S, Sakurai T, Nishida N, Chiba Y, Watanabe T, Kudo M. Clinical Safety and Efficacy of Secondary Prophylactic Pegylated G-CSF in Advanced Pancreatic Cancer Patients Treated with mFOLFIRINOX: A Single-center Retrospective Study. Intern Med 2019; 58:1993-2002. [PMID: 30996164 PMCID: PMC6702006 DOI: 10.2169/internalmedicine.2234-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective Although modified FOLFIRINOX (mFOLFIRINOX, mFFX) is widely used for patients with advanced pancreatic ductal adenocarcinoma (PDAC), maintenance of the standard dose intensity is often difficult due to the high incidence of neutropenic events. Pegylated granulocyte colony-stimulating factor (G-CSF) (Peg G) is a long-lasting G-CSF agent that is applicable for prophylaxis against neutropenic complications. The aim of this study was to assess the clinical safety and efficacy of mFFX combined with secondary prophylaxis using Peg G in advanced PDAC patients. Methods Advanced PDAC patients who had received more than two cycles of mFFX were analyzed. The clinical safety and efficacy were compared between patients in the Peg G group and those in the non-Peg G group in a retrospective manner. Results Among 45 patients treated with mFFX, 28 exhibited grade 3-4 neutropenia or febrile neutropenia. Among these 28 patients, 4 who received only 1 or 2 mFFX cycles were excluded from this study. Finally, 11 patients in the Peg G group and 13 in the non-Peg G group were enrolled. The combination therapy with Peg G and mFFX markedly prolonged the progression-free survival compared with the non-Peg G group, and its effects were associated with a reduced incidence of neutropenic events as well as lower rates of dosage reduction, delayed chemotherapy due to neutropenic events and altered blood cell counts after chemotherapy. Conclusion The scheduled administration of secondary prophylactic Peg G prolonged the progression-free survival in patients treated with mFFX. The combination therapy of Peg G and mFFX may be recommended in patients who exhibit grade 3-4 neutropenic events after prior mFFX cycles.
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Affiliation(s)
- Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Tomoe Yoshikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Rei Ishikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Ayana Okamoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Tomohiro Yamazaki
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Atsushi Nakai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Satoru Hagiwara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
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9
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G-CSF-induced aortitis: Two cases and review of the literature. Autoimmun Rev 2019; 18:615-620. [DOI: 10.1016/j.autrev.2018.12.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 12/26/2018] [Indexed: 12/14/2022]
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10
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Abstract
The recombinant G-CSF filgrastim was first approved in 1991, and its value has been evolving ever since. Initial health technology assessments suggested low value due to high drug cost and no evidence for significant gain in overall survival. However, more recent meta-analyses of placebo-controlled randomized trial data show falling costs due to biosimilar competition and absolute overall survival gains of 3.2% (95% CI: 2.1-4.2%) from filgrastim support of cytotoxic chemotherapy. The launch of biosimilar alternatives merits a re-evaluation of decisions by health technology assessments and explains the first inclusion of filgrastim in the WHO Essential Drug List for cancer >20 years after its original approval in 1991, thus demonstrating the power of biosimilar medicines in transforming healthcare.
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11
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Enstone A, Greaney M, Povsic M, Wyn R, Penrod JR, Yuan Y. The Economic Burden of Small Cell Lung Cancer: A Systematic Review of the Literature. PHARMACOECONOMICS - OPEN 2018; 2:125-139. [PMID: 29623624 PMCID: PMC5972116 DOI: 10.1007/s41669-017-0045-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Small cell lung cancer (SCLC), the most aggressive form of lung carcinoma, represents approximately 15% of all lung cancers; however, the economic and healthcare burden of SCLC is not well-defined. OBJECTIVE The aim of this study was to explore the impact of SCLC on healthcare costs through a systematic literature review (SLR). METHODS Using the OVID search engine, the SLR was conducted in PubMed, MEDLINE In-Process, EMBASE, EconLIT and the National Health Service Economic Evaluation Database (NHS EED). Searches were limited to studies published between January 2005 and 24 February 2016, and excluded preclinical studies. Additional internet-based searches were conducted. In total, 229 abstracts were retrieved and systematically screened for eligibility, with 17 publications retained. RESULTS The majority of publications provided data on limited and extensive disease of SCLC. The reported burden was categorised as direct costs and indirect costs, with the majority of the publications (n = 16) reporting on direct costs and one reporting on both direct and indirect costs. The only indirect costs reported for SCLC were lost productivity (premature mortality costs) and caregiver burden. Chemotherapy, diagnostic costs and treatment costs were identified as significant costs when managing SCLC patients, including the associated treatment costs such as hospitalisation, nurse visits, emergency room visits, follow-up appointments and outpatient care. CONCLUSIONS SCLC and its treatment have a substantial impact on costs. The scarcity and heterogeneity of economic cost data negated meaningful cost comparison, highlighting the need for further research. Capturing the economic burden of SCLC may help patients and clinicians make informed treatment choices and improve SCLC management.
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Affiliation(s)
| | - Maire Greaney
- Adelphi Values, Adelphi Mill, Bollington, Cheshire UK
| | - Manca Povsic
- Adelphi Values, Adelphi Mill, Bollington, Cheshire UK
| | - Robin Wyn
- Adelphi Values, Adelphi Mill, Bollington, Cheshire UK
| | | | - Yong Yuan
- Bristol-Myers Squibb, Princeton, NJ USA
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12
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Shimanuki M, Imanishi Y, Sato Y, Nakahara N, Totsuka D, Sato E, Iguchi S, Sato Y, Soma K, Araki Y, Shigetomi S, Yoshida S, Uno K, Ogawa Y, Tominaga T, Ikari Y, Nagayama J, Endo A, Miura K, Tomioka T, Ozawa H, Ogawa K. Pretreatment monocyte counts and neutrophil counts predict the risk for febrile neutropenia in patients undergoing TPF chemotherapy for head and neck squamous cell carcinoma. Oncotarget 2018; 9:18970-18984. [PMID: 29721176 PMCID: PMC5922370 DOI: 10.18632/oncotarget.24863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background Febrile neutropenia (FN) is the most serious hematologic toxicity of systemic chemotherapy. However, accurate prediction of FN development has been difficult because the risk varies largely depending on the chemotherapy regimen and various individual factors. Methods We retrospectively analyzed diverse clinical factors including pretreatment hematological parameters to clarify the reliable predictors of FN development during chemotherapy with a docetaxel, cisplatin, and fluorouracil (TPF) regimen in patients with head and neck squamous cell carcinoma. Results Among the 50 patients, grade ≥3 neutropenia, grade 4 neutropenia, and FN developed in 36 (72%), 21 (42%), and 12 (24%) patients, respectively. Multivariate logistic regression revealed that a pretreatment absolute monocyte count (AMC) <370/mm3 is an independent predictor of TPF chemotherapy-induced FN (odds ratio=6.000, p=0.017). The predictive performance of the model combining AMC and absolute neutrophil count (ANC), in which the high-risk group was defined as having an AMC <370/mm3 and/or ANC <3500/mm3, was superior (area under the curve [AUC]=0.745) to that of the model with a cutoff for AMC alone (AUC=0.679). Conclusions On the basis of our results, we recommend primary prophylactic use of granulocyte colony-stimulating factor and/or antibiotics selectively for patients predicted to be at high risk for TPF chemotherapy-induced FN.
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Affiliation(s)
- Marie Shimanuki
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Yorihisa Imanishi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Yoichiro Sato
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Nana Nakahara
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Daisuke Totsuka
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Emiri Sato
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Sena Iguchi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Yasuo Sato
- Department of Otorhinolaryngology, Kyosai Tachikawa Hospital, Tachikawa, Tokyo, Japan
| | - Keiko Soma
- Department of Otorhinolaryngology, Matsumoto Dental University, Matsumoto, Nagano, Japan
| | - Yasutomo Araki
- Department of Otorhinolaryngology-Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Seiji Shigetomi
- Department of Otorhinolaryngology, Yokohama Municipal Citizen's Hospital, Yokohama, Kanagawa, Japan
| | - Satoko Yoshida
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kosuke Uno
- Department of Otolaryngology-Head and Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yusuke Ogawa
- Department of Otorhinolaryngology, International University of Health and Welfare Atami Hospital, Atami, Shizuoka, Japan
| | - Takehiro Tominaga
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yuichi Ikari
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Junko Nagayama
- Department of Otorhinolaryngology, Yokohama Municipal Citizen's Hospital, Yokohama, Kanagawa, Japan
| | - Ayako Endo
- Department of Otorhinolaryngology, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Koshiro Miura
- Department of Otorhinolaryngology, Kamio Memorial Hospital, Chiyoda, Tokyo, Japan
| | - Takuya Tomioka
- Department of Otorhinolaryngology, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Hiroyuki Ozawa
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology-Head and Neck Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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Danova M, Chiroli S, Rosti G, Doan QV. Cost-Effectiveness of Pegfilgrastim versus Six Days of Filgrastim for Preventing Febrile Neutropenia in Breast Cancer Patients. TUMORI JOURNAL 2018; 95:219-26. [DOI: 10.1177/030089160909500214] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Febrile neutropenia (FN) is a major complication of chemotherapy and is associated with substantial morbidity, mortality and costs. The aim of this study was to evaluate the cost-effectiveness of primary prophylaxis with pegfilgrastim versus six-day filgrastim in preventing FN in Italian patients with early-stage breast cancer receiving adjuvant chemotherapy associated with a ≥20% FN risk. Methods The pharmacoeconomic evaluation was based on a decision-analytic model taking into account the possible consequences of FN (e.g., death and reduction/delay of chemotherapy dose). Parameters included in the model were relative risk of FN with pegfilgrastim versus six-day filgrastim; direct costs (drug purchase and FN-related hospitalizations); relative risk of relative dose intensity <85% with pegfilgrastim versus filgrastim; impact on long-term survival due to relative dose intensity <85%; and impact of age on FN and relative dose intensity <85%. Results Under base-case assumptions, pegfilgrastim was cost-effective compared to six-day filgrastim in Italy. The estimated cost, life expectancy and quality-adjusted life years per person for pegfilgrastim were € 3078, 16.47 years, and 15.32; the corresponding figures for six-day filgrastim were € 3033, 16.35 years, and 15.22. The corresponding incremental cost-effectiveness ratio with pegfilgrastim was € 409 per life-year gained and € 429 per quality-adjusted life year gained. One-way sensitivity analyses showed that the results were most sensitive to the relative risk of FN for 6-day filgrastim versus pegfilgrastim. The results were moderately sensitive to the cost of pegfilgrastim and filgrastim, cost of drug administration, cost of FN hospitalization, and number of chemotherapy cycles. Pegfilgrastim remained cost-effective, with an incremental cost-effectiveness ratio well below the accepted limit of € 50,000 per life year gained in all one-way sensitivity analyses. A two-way sensitivity analysis on cost of drugs showed a range of pegfilgrastim dominance over six-day filgrastim. Conclusions At the current official price in Italy, primary prophylaxis with pegfilgrastim improved health outcomes with a very limited cost increase for the National Health Service payer. Even when very low prices of filgrastim and high prices of pegfilgrastim were considered in the model, the resulting incremental cost-effectiveness ratio remained well within the acceptable cost-effectiveness limit of € 50,000/quality-adjusted life year.
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Affiliation(s)
- Marco Danova
- Medical Oncology, IRCCS Foundation S. Matteo, Pavia, Italy
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MODEL-BASED COST-EFFECTIVENESS OF CONVENTIONAL AND INNOVATIVE CHEMO-RADIATION IN LUNG CANCER. Int J Technol Assess Health Care 2017; 33:681-690. [PMID: 29122046 DOI: 10.1017/s0266462317000939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Optimizing radiotherapy with or without chemotherapy through advanced imaging and accelerated radiation schemes shows promising results in locally advanced non-small-cell lung cancer (NSCLC). This study compared the cost-effectiveness of positron emission tomography-computed tomography based isotoxic accelerated sequential chemo-radiation (SRT2) and concurrent chemo-radiation with daily low-dose cisplatin (CRT2) with standard sequential (SRT1) and concurrent chemo-radiation (CRT1). METHODS We used an externally validated mathematical model to simulate the four treatment strategies. The model was built using data from 200 NSCLC patients treated with curative sequential chemo-radiation. For concurrent strategies, data from a meta-analysis and a single study were included in the model. Costs, utilities, and resource use estimates were obtained from literature. Primary outcomes were the incremental cost-effectiveness and cost-utility ratio (ICUR) of each strategy. Scenario analyses were carried out to investigate the impact of uncertainty. RESULTS Total undiscounted costs and quality-adjusted life-years (QALYs) for SRT1, CRT1, SRT2, and CRT2 were EUR 17,288, EUR 18,756, EUR 19,072, EUR 17,360 and QALYs 1.10, 1.15, 1.40, and 1.40, respectively. Compared with SRT1, the ICURs were EUR 38,024/QALY for CRT1, EUR 6,249/QALY for SRT2, and EUR 346/QALY for CRT2. CRT2 was highly cost-effective compared with SRT1. Moreover, CRT2 was more effective and less costly than CRT1 and SRT2. Therefore, these strategies were dominated by CRT2. CONCLUSION Optimized sequential and concurrent chemo-radiation strategies are more effective and cost-effective than the current conventional sequential and concurrent strategies. Concurrent chemo-radiation with a daily low dose cisplatin regimen is the most cost-effective treatment option for locally advanced inoperable NSCLC patients.
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Goyal RK, Tzivelekis S, Rothman KJ, Candrilli SD, Kaye JA. Time trends in utilization of G-CSF prophylaxis and risk of febrile neutropenia in a Medicare population receiving adjuvant chemotherapy for early-stage breast cancer. Support Care Cancer 2017; 26:539-548. [PMID: 28921379 DOI: 10.1007/s00520-017-3863-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to assess temporal trends in the use of granulocyte colony-stimulating factor (G-CSF) prophylaxis and risk of febrile neutropenia (FN) among older women receiving adjuvant chemotherapy for early-stage breast cancer. METHODS Women aged ≥ 66 years with diagnosis of early-stage breast cancer who initiated selected adjuvant chemotherapy regimens were identified using the SEER-Medicare data from 2002 to 2012. Adjusted, calendar-year-specific proportions were estimated for use of G-CSF primary prophylaxis (PP) and secondary prophylaxis and FN risk in the first and the second/subsequent cycles during the first course of chemotherapy, using logistic regression models. calendar-year-specific mean probabilities were estimated with covariates set to modal values. RESULTS Among 11,107 eligible patients (mean age 71.7 years), 74% received G-CSF in the first course of chemotherapy. Of all patients, 5819 (52%) received G-CSF PP, and among those not receiving G-CSF PP, only 5% received G-CSF secondary prophylaxis. The adjusted proportion using G-CSF PP increased from 6% in 2002 to 71% in 2012. During the same period, the adjusted risk of FN in the first cycle increased from 2% to 3%; the adjusted risk increased from 1.5% to 2.9% among those receiving G-CSF PP and from 2.3% to 3.5% among those not receiving G-CSF PP. CONCLUSION The use of G-CSF PP increased substantially during the study period. Although channeling of higher-risk patients to treatment with G-CSF PP is expected, the adjusted risk of FN among patients treated with G-CSF PP tended to be lower than among those not receiving G-CSF PP.
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Affiliation(s)
- Ravi K Goyal
- RTI Health Solutions, 300 Park Offices Drive, Research Triangle Park, NC, 27709, USA.
| | | | - Kenneth J Rothman
- RTI Health Solutions, 307 Waverley Oaks Road, Suite 101, Waltham, MA, 02452, USA
| | - Sean D Candrilli
- RTI Health Solutions, 300 Park Offices Drive, Research Triangle Park, NC, 27709, USA
| | - James A Kaye
- RTI Health Solutions, 307 Waverley Oaks Road, Suite 101, Waltham, MA, 02452, USA
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Fust K, Parthan A, Maschio M, Gu Q, Li X, Lyman GH, Tzivelekis S, Villa G, Weinstein MC. Granulocyte colony-stimulating factors in the prevention of febrile neutropenia: review of cost-effectiveness models. Expert Rev Pharmacoecon Outcomes Res 2017; 17:39-52. [DOI: 10.1080/14737167.2017.1276829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly Fust
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Anju Parthan
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Michael Maschio
- Health Economics & Outcomes Research, Optum, Burlington, ON, Canada
| | - Qing Gu
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Xiaoyan Li
- Global Health Economics, Amgen Inc., Thousand Oaks, CA, USA
| | - Gary H. Lyman
- Public Health Sciences Division and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Guillermo Villa
- Global Health Economics, Amgen (Europe) GmbH, Zug, Switzerland
| | - Milton C. Weinstein
- Department of Health Policy and Management; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Petru E, Singer CF, Polterauer S, Galid A, Schauer C, Klocker J, Seifert M, Reinthaller A, Benedicic C, Hubalek M, Hefler L, Marth C, Scholl-Firon T, Bogner G, Zeimet AG. Prophylactic long-acting granulocyte-colony stimulating factors (G-CSF) in gynecologic malignancies: an oncologic expert statement. Wien Med Wochenschr 2015; 165:387-94. [PMID: 26471371 DOI: 10.1007/s10354-015-0392-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 12/01/2022]
Abstract
We reviewed the status of the use of the prophylactic long-acting granulocyte colony-stimulating factors (G-CSFs) pegfilgrastim and lipegfilgrastim in gynecologic malignancies. Long-acting G-CSFs should not be used in weekly regimens. Filgrastim is not indicated in patients with febrile and/or severe neutropenia after administration of long-acting G-CSF in the same cycle. One study has shown a moderate effect on febrile neutropenia of ciprofloxacin when co-administered with pegfilgrastim. There is broad evidence from meta-analyses that pegfilgrastim effectively reduces severe neutropenia. In parallel, its adverse effects have been studied extensively. All-cause mortality was significantly reduced by pegfilgrastim. The glycopegylated long-acting G-CSF, lipegfilgrastim has demonstrated antineutropenic efficacy similar to that of pegfilgrastimin in one breast cancer study. In another pivitol non-small cell lung cancer study, impaired survival was observed in the lipegfilgrastim group during the first 30 days of study. The European Medicines Agency claimed more profound safety data to be provided for lipegfilgrastim by 2017.
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Affiliation(s)
- Edgar Petru
- Division of Gynecology, Department of Obstetrics and Gynecology, Medical University of Graz, Auenbruggerplatz 14, 8036, Graz, Austria.
| | - Christian F Singer
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Stephan Polterauer
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Arik Galid
- Department of Obstetrics and Gynecology, Hanuschkrankenhaus, Vienna, Austria
| | - Christian Schauer
- Department of Gynecology, Hospital Barmherzige Brüder Graz, Graz, Austria
| | - Johann Klocker
- Department of Internal Medicine, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Michael Seifert
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Alexander Reinthaller
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Christoph Benedicic
- Division of Gynecology, Department of Obstetrics and Gynecology, Medical University of Graz, Auenbruggerplatz 14, 8036, Graz, Austria
| | - Michael Hubalek
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Hefler
- Department of Gynecology, Hospital Barmherzige Schwestern, Linz, Austria
| | - Christian Marth
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tonja Scholl-Firon
- Department of Obstetrics and Gynecology, Wilhelminenspital, Vienna, Austria
| | - Gerhard Bogner
- Department of Obstetrics and Gynecology, Paracelsus University of Salzburg, Salzburg, Austria
| | - Alain-Gustave Zeimet
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
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Moriyama Y, Horita N, Kudo M, Shinkai M, Fujita H, Yamanaka T, Ishigatsubo Y, Kaneko T. Monocyte nadir is a possible indicator for neutrophil nadir during lung cancer chemotherapy. CLINICAL RESPIRATORY JOURNAL 2015; 11:453-458. [DOI: 10.1111/crj.12358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/17/2015] [Accepted: 08/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Yusuke Moriyama
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Nobuyuki Horita
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Makoto Kudo
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Masaharu Shinkai
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Hiroyuki Fujita
- Department of Hematology; Saiseikai Yokohamashi Nanbu Hospital; Yokohama Japan
| | - Takeharu Yamanaka
- Department of Biostatistics and Epidemiology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Yoshiaki Ishigatsubo
- Department of Internal Medicine and Clinical Immunology; Yokohama City University Graduate School of Medicine; Yokohama Japan
| | - Takeshi Kaneko
- Department of Pulmonology; Yokohama City University Graduate School of Medicine; Yokohama Japan
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Hill G, Barron R, Fust K, Skornicki ME, Taylor DCA, Weinstein MC, Lyman GH. Primary vs secondary prophylaxis with pegfilgrastim for the reduction of febrile neutropenia risk in patients receiving chemotherapy for non-Hodgkin's lymphoma: cost-effectiveness analyses. J Med Econ 2014; 17:32-42. [PMID: 24028444 DOI: 10.3111/13696998.2013.844160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate the cost-effectiveness of primary vs secondary prophylaxis (PP vs SP) with pegfilgrastim to reduce the risk of febrile neutropenia (FN) in Non-Hodgkin's Lymphoma (NHL) patients receiving myelosuppressive chemotherapy from a US payer perspective. METHODS A Markov model was used to compare PP vs SP with pegfilgrastim in a cohort of patients receiving six cycles of cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) or CHOP plus rituximab (CHOP-R) chemotherapy. Model inputs, including efficacy of pegfilgrastim in reducing risk of FN and costs, were estimated from publicly available sources and peer-reviewed publications. Incremental cost-effectiveness was evaluated in terms of net cost per life-year saved (LYS), per quality-adjusted life-year (QALY) gained, and per FN event avoided over a lifetime horizon. Deterministic and probabilistic analyses were performed to assess sensitivity and robustness of results. RESULTS Lifetime costs for PP were $5000 greater than for SP; however, PP was associated with fewer FN events and more LYs and QALYs gained vs SP. Incremental cost-effectiveness ratios (ICERs) for PP vs SP for CHOP were $13,400 per FN event avoided, $29,500 per QALY gained, and $25,800 per LYS. CHOP-R results were similar ($15,000 per FN event avoided, $33,000 per QALY gained, and $28,900 per LYS). Results were most sensitive to baseline FN risk, cost per FN episode, and odds ratio for reduced relative dose intensity due to prior FN event. PP was cost-effective vs SP in 85% of simulations at a $50,000 per QALY threshold. LIMITATIONS In the absence of NHL-specific data, estimates for pegfilgrastim efficacy and relative risk reduction of FN were based on available data for neoadjuvant TAC in patients with breast cancer. Baseline risks of FN for CHOP and CHOP-R were assumed to be equivalent. CONCLUSIONS PP with pegfilgrastim is cost-effective compared to SP with pegfilgrastim in NHL patients receiving CHOP or CHOP-R.
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Rossi L, Tomao F, Lo Russo G, Papa A, Zoratto F, Marzano R, Basso E, Giordani E, Verrico M, Ricci F, Pasciuti G, Francini E, Tomao S. Efficacy and safety analysis of once per cycle pegfilgrastim and daily lenograstim in patients with breast cancer receiving adjuvant myelosuppressive chemotherapy FEC 100: a pilot study. Ther Clin Risk Manag 2013; 9:457-62. [PMID: 24255599 PMCID: PMC3832460 DOI: 10.2147/tcrm.s48387] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Neutropenia is a common toxicity in patients receiving myelosuppressive chemotherapy. In this prospective pilot study, we compared the efficacy and safety profiles of pegfilgrastim administered subcutaneously once per cycle and lenograstim administered subcutaneously daily six times per cycle, for primary neutropenia prophylaxis in women with breast cancer receiving adjuvant anthracycline-based chemotherapy. Materials and methods Twenty women were enrolled. All patients received epirubicin 100 mg/m2 with 5-fluorouracil 500 mg/m2 and cyclophosphamide 500 mg/m2 on day 1 and every 21 days thereafter, according to the FEC 100 chemotherapy regimen. Eight patients received a single dose of pegfilgrastim on day 2, while 12 patients were treated with daily administration of lenograstim from days five to ten. Absolute neutrophil count and duration of grade 3–4 neutropenia were monitored using seriated blood samples. The incidence of bone pain was evaluated using the visual analog scale (VAS). Results The incidence of grade 3–4 neutropenia was 75% in patients who received pegfilgrastim, and 25% in patients who received lenograstim. One case of febrile neutropenia was shown in pegfilgrastim patients. The mean duration of grade 3–4 neutropenia was 2 days in pegfilgrastim group versus 1.4 days in the lenograstim group. Bone pain was present in 37.5% of pegfilgrastim patients versus 58.3% of lenograstim patients. The mean duration of bone pain in the pegfilgrastim group was 4 days versus 6 days in the lenograstim group. Conclusion In our experience, a single injection of pegfilgrastim was less effective for controlling neutropenia than six daily injections of lenograstim. The safety profiles of pegfilgrastim and lenograstim were similar with a lower incidence of bone pain in patients treated with pegfilgrastim.
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Affiliation(s)
- Luigi Rossi
- Oncology Unit, ICOT Hospital, Policlinico Umberto I Hospital, University of Rome, Italy
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Aarts MJ, Grutters JP, Peters FP, Mandigers CM, Dercksen MW, Stouthard JM, Nortier HJ, van Laarhoven HW, van Warmerdam LJ, van de Wouw AJ, Jacobs EM, Mattijssen V, van der Rijt CC, Smilde TJ, van der Velden AW, Temizkan M, Batman E, Muller EW, van Gastel SM, Joore MA, Borm GF, Tjan-Heijnen VC. Cost effectiveness of primary pegfilgrastim prophylaxis in patients with breast cancer at risk of febrile neutropenia. J Clin Oncol 2013; 31:4283-9. [PMID: 24166522 DOI: 10.1200/jco.2012.48.3644] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Guidelines advise primary granulocyte colony-stimulating factor (G-CSF) prophylaxis during chemotherapy if risk of febrile neutropenia (FN) is more than 20%, but this comes with considerable costs. We investigated the incremental costs and effects between two treatment strategies of primary pegfilgrastim prophylaxis. METHODS Our economic evaluation used a health care perspective and was based on a randomized study in patients with breast cancer with increased risk of FN, comparing primary G-CSF prophylaxis throughout all chemotherapy cycles (G-CSF 1-6 cycles) with prophylaxis during the first two cycles only (G-CSF 1-2 cycles). Primary outcome was cost effectiveness expressed as costs per patient with episodes of FN prevented. RESULTS The incidence of FN increased from 10% in the G-CSF 1 to 6 cycles study arm (eight of 84 patients) to 36% in the G-CSF 1 to 2 cycles study arm (30 of 83 patients), whereas the mean total costs decreased from € 20,658 (95% CI, € 20,049 to € 21,247) to € 17,168 (95% CI € 16,239 to € 18,029) per patient, respectively. Chemotherapy and G-CSF determined 80% of the total costs. As expected, FN-related costs were higher in the G-CSF 1 to 2 cycles arm. The incremental cost effectiveness ratio for the G-CSF 1 to 6 cycles arm compared with the G-CSF 1 to 2 cycles arm was € 13,112 per patient with episodes of FN prevented. CONCLUSION We conclude that G-CSF prophylaxis throughout all chemotherapy cycles is more effective, but more costly, compared with prophylaxis limited to the first two cycles. Whether G-CSF prophylaxis throughout all chemotherapy cycles is considered cost effective depends on the willingness to pay per patient with episodes of FN prevented.
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Affiliation(s)
- Maureen J Aarts
- Maureen J. Aarts, Vivianne C. Tjan-Heijnen, Janneke P. Grutters, Manuela A. Joore, Maastricht University Medical Center, Maastricht; Frank P. Peters, Orbis Medical Centre, Sittard; Caroline M. Mandigers, Canisius Wilhelmina Hospital, Nijmegen; M. Wouter Dercksen, Maxima Medical Center, Veldhoven; Jacqueline M. Stouthard, Maasstad Medical Center, Rotterdam; Hans J. Nortier, Leiden University Medical Center, Leiden; Hanneke W. van Laarhoven, George F. Borm, Radboud University Nijmegen Medical Centre, Nijmegen; Laurence J. van Warmerdam, Catharina Hospital, Eindhoven; Agnes J. van de Wouw, VieCuri Medical Center, Venlo; Esther M. Jacobs, Elkerliek Hospital, Helmond; Vera Mattijssen, Rijnstate Hospital, Arnhem; Carin C. van der Rijt, Erasmus Medical Center Daniel den Hoed Cancer Center, Rotterdam; Tineke J. Smilde, Jeroen Bosch Hospital, 's-Hertogenbosch; Annette W. van der Velden, Martini Hospital, Groningen; Mehmet Temizkan, Hospital St Jansdal, Harderwijk; Erdogan Batman, Diaconessenhuis Leiden, Leiden; Erik W. Muller, Slingeland Hospital, Doetinchem; Saskia M. van Gastel, Comprehensive Cancer Center East, Nijmegen the Netherlands
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Ramaekers BL, Joore MA, Lueza B, Bonastre J, Mauguen A, Pignon JP, Le Pechoux C, De Ruysscher DK, Grutters JP. Cost Effectiveness of Modified Fractionation Radiotherapy versus Conventional Radiotherapy for Unresected Non–Small-Cell Lung Cancer Patients. J Thorac Oncol 2013; 8:1295-307. [DOI: 10.1097/jto.0b013e31829f6c55] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Kreys ED, Koeller JM. Documenting the Benefits and Cost Savings of a Large Multistate Cancer Pathway Program From a Payer's Perspective. J Oncol Pract 2013; 9:e241-7. [DOI: 10.1200/jop.2012.000871] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Broadly implemented clinical pathways can achieve reasonable physician compliance, resulting in substantial cost savings.
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Affiliation(s)
- Eugene D. Kreys
- University of Texas at Austin, Austin; and University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jim M. Koeller
- University of Texas at Austin, Austin; and University of Texas Health Science Center at San Antonio, San Antonio, TX
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Lathia N, Isogai PK, Angelis CD, Smith TJ, Cheung M, Mittmann N, Hoch JS, Walker S. Cost-Effectiveness of Filgrastim and Pegfilgrastim as Primary Prophylaxis Against Febrile Neutropenia in Lymphoma Patients. ACTA ACUST UNITED AC 2013; 105:1078-85. [DOI: 10.1093/jnci/djt182] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Aarts MJ, Peters FP, Mandigers CM, Dercksen MW, Stouthard JM, Nortier HJ, van Laarhoven HW, van Warmerdam LJ, van de Wouw AJ, Jacobs EM, Mattijssen V, van der Rijt CC, Smilde TJ, van der Velden AW, Temizkan M, Batman E, Muller EW, van Gastel SM, Borm GF, Tjan-Heijnen VCG. Primary granulocyte colony-stimulating factor prophylaxis during the first two cycles only or throughout all chemotherapy cycles in patients with breast cancer at risk for febrile neutropenia. J Clin Oncol 2013; 31:4290-6. [PMID: 23630211 DOI: 10.1200/jco.2012.44.6229] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Early breast cancer is commonly treated with anthracyclines and taxanes. However, combining these drugs increases the risk of myelotoxicity and may require granulocyte colony-stimulating factor (G-CSF) support. The highest incidence of febrile neutropenia (FN) and largest benefit of G-CSF during the first cycles of chemotherapy lead to questions about the effectiveness of continued use of G-CSF throughout later cycles of chemotherapy. PATIENTS AND METHODS In a multicenter study, patients with breast cancer who were considered fit enough to receive 3-weekly polychemotherapy, but also had > 20% risk for FN, were randomly assigned to primary G-CSF prophylaxis during the first two chemotherapy cycles only (experimental arm) or to primary G-CSF prophylaxis throughout all chemotherapy cycles (standard arm). The noninferiority hypothesis was that the incidence of FN would be maximally 7.5% higher in the experimental compared with the standard arm. RESULTS After inclusion of 167 eligible patients, the independent data monitoring committee advised premature study closure. Of 84 patients randomly assigned to G-CSF throughout all chemotherapy cycles, eight (10%) experienced an episode of FN. In contrast, of 83 patients randomly assigned to G-CSF during the first two cycles only, 30 (36%) had an FN episode (95% CI, 0.13 to 0.54), with a peak incidence of 24% in the third cycle (ie, first cycle without G-CSF prophylaxis). CONCLUSION In patients with early breast cancer at high risk for FN, continued use of primary G-CSF prophylaxis during all chemotherapy cycles is of clinical relevance and thus cannot be abandoned.
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Affiliation(s)
- Maureen J Aarts
- Maureen J. Aarts and Vivianne C.G. Tjan-Heijnen, Maastricht University Medical Center, Maastricht; Frank P. Peters, Orbis Medical Center, Sittard-Geleen; Caroline M. Mandigers, Canisius Wilhelmina Hospital; Hanneke W. van Laarhoven and George F. Borm, Radboud University Nijmegen Medical Center; Saskia M. van Gastel; Comprehensive Cancer Centre East; George F. Borm, Nijmegen I, Nijmegen; M. Wouter Dercksen, Maxima Medical Center, Veldhoven; Laurence J. van Warmerdam, Catharina Hospital, Eindhoven; Jacqueline M. Stouthard, Maasstad Medical Center; Carin C. van der Rijt, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam; Hans J. Nortier, Leiden University Medical Center; Erdogan Batman, Diaconessenhuis Leiden, Leiden; Agnes J. van de Wouw, VieCuri Medical Center, Venlo; Esther M. Jacobs, Elkerliek Hospital, Helmond; Vera Mattijssen, Rijnstate Hospital, Arnhem; Tineke J. Smilde, Jeroen Bosch Hospital, 's-Hertogenbosch; Annette W. van der Velden, Martini Hospital, Groningen; Mehmet Temizkan, Hospital St Jansdal, Harderwijk; and Erik W. Muller, Slingeland Hospital, Doetinchem, the Netherlands
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Wiernik PH, Goldman JM, Dutcher JP, Kyle RA. Evaluation and Management of Bacterial and Fungal Infections Occurring in Patients with a Hematological Malignancy: A 2011 Update. NEOPLASTIC DISEASES OF THE BLOOD 2013. [PMCID: PMC7120157 DOI: 10.1007/978-1-4614-3764-2_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with a hematological malignancy are a heterogeneous patient population who are afflicted with diseases that range from rapidly fatal acute leukemia to indolent lymphoma or chronic leukemia. Treatment options for these patients range from observation to hematopoietic stem cell transplantation (HSCT), but all patients are more susceptible to infection. The problem of infection is dynamic with continued shifts in pathogenic organisms and microbial susceptibilities, new treatment regimens that further diminish immune function, and patients receiving treatment who are now older and frailer. The classic patterns of immunodeficiency for patients with a hematological malignancy include: periods of profound neutropenia, increased iatrogenic risks (i.e., central vascular catheters), and cellular immune suppression that affects HSCT recipients, patients with lymphoid malignancies, and those receiving treatment with corticosteroids or agents like alemtuzumab [1–4]. Recent advances in antimicrobial drug development, new technology, clinical trial results, and further clinical experience have enhanced the database on which to make infection prophylaxis and treatment decisions. However, the practicing clinician must remember that the majority of basic infection management principles for patients who are neutropenic remain unchanged.
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Affiliation(s)
- Peter H. Wiernik
- Beth Israel Hospital, Cancer Center, St. Lukes-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - John M. Goldman
- , Department of Hematology, Imperial College of London, Du Cane Road 150, London, W12 0NN United Kingdom
| | - Janice P. Dutcher
- Continuum Cancer Centers, Department of Medicine, St. Luke's-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - Robert A. Kyle
- , Division of Hematology, Mayo Clinic, First Street SW. 200, Rochester, 55905 Minnesota USA
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Fishman ML, Kumar A, Davis S, Shimp W, Hrushesky WJM. Guideline-Based Peer-to-Peer Consultation Optimizes Pegfilgrastim Use With No Adverse Clinical Consequences. J Oncol Pract 2012; 8:e14s-7s. [PMID: 22942828 DOI: 10.1200/jop.2012.000540] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Practice guidelines do not recommend the routine use of colony-stimulating factors when there is a low risk (< 10%) of febrile neutropenia (FN). We prospectively determined whether expert peer-to-peer consultation with prescribing oncologists would improve adherence to guidelines and whether there would be any adverse events associated with that adherence. METHODS Commencing in March 2010, we reviewed requests for pegfilgrastim from 22 community oncology practices comprising 78 physicians providing service to approximately 97,000 Medicare members. Paid claims data on all chemotherapy and supportive care medications were reviewed from fourth quarter (Q4) 2009 through third quarter (Q3) 2010. In total, 82 patients received pegfilgrastim. If the prescribed chemotherapy was associated with a low risk (< 10%) for FN, then a peer review was initiated. The treating physician made the final decision to use, or not use, pegfilgrastim, and no denials were issued. RESULTS A total of 245 units (1 unit = 6 mg) of pegfilgrastim were administered during the four quarters analyzed. Use in the low-risk category decreased from 52 units in Q4 2009 to 15 units in Q3 2010. The per-member per-month (PMPM) cost of pegfilgrastim decreased across quarters, with an average cost of $1.07 PMPM for Q4 2009 and $0.57 PMPM for Q3 2010. No studied patient was admitted for neutropenic fever. CONCLUSION Active expert peer-to-peer consultation with prescribing oncologists can promote adherence to guidelines and potentially lead to significant cost reductions without significant risk of neutropenic fever, with or without hospitalization, for patients with cancer.
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Petru E, Zeimet AG, Sevelda P, Seifert M, Singer C, Hubalek M, Angleitner-Boubenizek L, Speiser P, Benedicic C, Stummvoll W, Reinthaller A. Austrian Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) guideline for prophylaxis with granulocyte colony-stimulating factors (G-CSF) in gynecologic malignancies, including breast cancer. Wien Klin Wochenschr 2012; 124:412-8. [PMID: 22739650 DOI: 10.1007/s00508-012-0185-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 05/16/2012] [Indexed: 11/26/2022]
Abstract
The current knowledge and recommendations on the clinical use of granulocyte colony-stimulating factors (G-CSF) in gynecologic cancers including breast cancer, along with the clinical experience of the members of the working group of the Austrian Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO), have been summarized. G-CSF is either administered as primary or secondary prophylaxis of febrile neutropenia. The term "primary prophylaxis" denotes the prophylactic use of G-CSF as early as during the first cycle of a new chemotherapeutic regimen. Secondary prophylaxis, on the other hand, defines the use of G-CSF after development of grade 4 neutropenia or febrile neutropenia in a preceding cycle of a particular chemotherapeutic regimen. When chemotherapy regimens are associated with a > 20 % risk of febrile neutropenia such as TAC (docetaxel-doxorubicin-cyclophosphamide), primary prophylaxis with G-CSF is indicated. When chemotherapy regimens are associated with a 10-20 % risk of febrile neutropenia, the decision for primary prophylaxis with G-CSF is based upon patient-related risk factors such as age > 65 years, previous cytotoxic treatment(s) and/or radiation therapy, preexisting tumor-related neutropenia or bone marrow involvement, preexisting neutropenia, infections/open sores, reduced Karnofsky performance status/WHO performance status and reduced nutritional status, advanced malignant disease, history of prior febrile neutropenia, impaired kidney function, and hepatic failure particularly with hyperbilirubinaemia. The patient's individual overall febrile neutropenia risk should be assessed prior to each chemotherapy cycle.
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Affiliation(s)
- Edgar Petru
- Department of Obstetrics and Gynecology, Division of Gynecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria.
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Hirsch BR, Lyman GH. Pharmacoeconomics of the myeloid growth factors: a critical and systematic review. PHARMACOECONOMICS 2012; 30:497-511. [PMID: 22540394 DOI: 10.2165/11590130-000000000-00000] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND The pharmacoeconomics of the myeloid growth factors (MGFs) is an important topic that has received substantial attention in recent years. The use of the MGFs as primary prophylaxis to prevent febrile neutropenia (FN) has grown considerably over the past decade and professional guidelines regarding their use have broadened the settings in which these agents are indicated. Recent data also suggest a potential role for them in reducing infection-related and all-cause mortality. The cost and effectiveness of these agents will continue to gain visibility as companies pursue approval for biosimilar agents in the US, similar to their recent approval in Europe. OBJECTIVES The objective of this paper is to review the available pharmacoeconomic literature on the MGFs, which is particularly timely in light of the recent passage of healthcare reform and the increasing focus on cost control. The cost of treating cancer in the US is rising faster than the already rapid increase in overall medical expenditure. The clinical utility and cost effectiveness of supportive care measures in oncology must therefore be weighed carefully. This review focuses on the use of different formulations of MGFs for primary and secondary prophylaxis of chemotherapy-induced neutropenia. METHODS A MEDLINE search was performed to find studies that became available since the prior review of this topic was published in Pharmacoeconomics in 2003. RESULTS Acceptable cost-minimization estimates for primary prophylaxis with the MGFs in patients receiving cancer chemotherapy have been provided by several studies in the US. Of the commonly used agents in the US, pegfilgrastim appears to be superior to the currently recommended dose and schedule of filgrastim in terms of cost minimization, and primary prophylaxis appears to be less costly than secondary prophylaxis. However, the cost benefits of primary prophylaxis in Europe are not as pronounced as in the US, due to the lower costs of medical care. Data continue to emerge suggesting a decreased risk of early mortality from averted infections as well as the possibility of a disease-specific mortality benefit through maintaining the relative dose intensity of chemotherapy with MGF support. CONCLUSION This evidence will prove valuable in assessing the overall cost effectiveness and cost utility of the MGFs in patients receiving cancer chemotherapy.
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Affiliation(s)
- Bradford R Hirsch
- Department of Medicine, Duke University and the Duke Cancer Institute, Durham, NC, USA
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Schnipper LE, Smith TJ, Raghavan D, Blayney DW, Ganz PA, Mulvey TM, Wollins DS. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol 2012; 30:1715-24. [PMID: 22493340 DOI: 10.1200/jco.2012.42.8375] [Citation(s) in RCA: 447] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Lowell E Schnipper
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Puhalla S, Bhattacharya S, Davidson NE. Hematopoietic growth factors: personalization of risks and benefits. Mol Oncol 2012; 6:237-41. [PMID: 22497867 PMCID: PMC5528376 DOI: 10.1016/j.molonc.2012.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/05/2012] [Indexed: 11/20/2022] Open
Abstract
A common side effect of cancer treatment is bone marrow suppression. The resulting myelosuppression and anemia can cause significant morbidity and mortality for patients. Agents such as granulocyte colony stimulating factors (GCSF) and erythropoietin stimulating agents (ESAs) may be helpful to ameliorate this depression of blood counts; however these agents have risks which also need to be carefully weighed.
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Affiliation(s)
- Shannon Puhalla
- University of Pittsburgh Cancer Institute, UPMC Cancer Centers, UPMC Cancer Pavillon, Pittsburgh, PA 15232, USA.
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Chan KKW, Siu E, Krahn MD, Imrie K, Alibhai SMH. Cost-utility analysis of primary prophylaxis versus secondary prophylaxis with granulocyte colony-stimulating factor in elderly patients with diffuse aggressive lymphoma receiving curative-intent chemotherapy. J Clin Oncol 2012; 30:1064-71. [PMID: 22393098 DOI: 10.1200/jco.2011.36.8647] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The 2006 American Society of Clinical Oncology (ASCO) guideline recommended primary prophylaxis (PP) with granulocyte colony-stimulating factor (G-CSF) instead of secondary prophylaxis (SP) for elderly patients with diffuse aggressive lymphoma receiving chemotherapy. We examined the cost-effectiveness of PP when compared with SP. METHODS We conducted a cost-utility analysis to compare PP to SP for diffuse aggressive lymphoma. We used a Markov model with an eight-cycle chemotherapy time horizon with a government-payer perspective and Ontario health, economic, and cost data. Data for efficacies of G-CSF, probabilities, and utilities were obtained from published literature. Probabilistic sensitivity analysis (PSA) was conducted. RESULTS The incremental cost-effectiveness ratio of PP to SP was $700,500 per quality-adjusted life-year (QALY). One-way sensitivity analyses (willingness-to-pay threshold = $100,000/QALY) showed that if PP were to be cost-effective, the cost of hospitalization for febrile neutropenia (FN) had to be more than $31,138 (2.5 × > base case), the cost of G-CSF per cycle less than $960 (base case = $1,960), the risk of first-cycle FN more than 47% (base case = 24%), or the relative risk reduction of FN with G-CSF more than 91% (base case = 41%). Our result was robust to all variables. PSA revealed a 10% probability of PP being cost-effective over SP at a willingness-to-pay threshold of $100,000/QALY. CONCLUSION PP is not cost-effective when compared with SP in this population. PP becomes attractive only if the cost of hospitalization for FN is significantly higher or the cost of G-CSF is significantly lower.
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Affiliation(s)
- Kelvin K W Chan
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Effect of primary prophylactic granulocyte-colony stimulating factor use on incidence of neutropenia hospitalizations for elderly early-stage breast cancer patients receiving chemotherapy. Med Care 2011; 49:649-57. [PMID: 21478779 DOI: 10.1097/mlr.0b013e318215c42e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Gruber M, Fleiss K, Porpaczy E, Skrabs C, Hauswirth AW, Gaiger A, Vanura K, Heintel D, Shehata M, Einberger C, Thalhammer R, Fonatsch C, Jäger U. Prolonged progression-free survival in patients with chronic lymphocytic leukemia receiving granulocyte colony-stimulating factor during treatment with fludarabine, cyclophosphamide, and rituximab. Ann Hematol 2011; 90:1131-6. [PMID: 21617923 DOI: 10.1007/s00277-011-1260-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 05/16/2011] [Indexed: 11/25/2022]
Abstract
The clinical benefit of the addition of granulocyte colony-stimulating factor (G-CSF) to standard immunochemotherapy of chronic lymphocytic leukemia (CLL) with fludarabine, cyclophosphamide, and rituximab (FCR) is still unclear. In this retrospective study we analyzed the outcome of 32 consecutive patients with CLL during treatment with FCR. Sixteen patients received G-CSF for treatment of CTC grade 3 or 4 neutropenia or febrile neutropenia at some point during therapy and 16 did not. Both groups were well balanced for clinical and biological risk factors. Overall response rates were not significantly different (94% vs. 75%; p=0.144). Interestingly, a significantly better progression-free survival (100% vs. 35.4% at 24 months; p<0.001) and even overall survival (100% vs. 77.8% at 24 months; p=0.022) was observed in patients receiving G-CSF. While the underlying cause remains to be elucidated, these data strongly suggest an association of the addition of G-CSF to FCR therapy with final patient outcome.
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MESH Headings
- Aged
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antibodies, Monoclonal, Murine-Derived/adverse effects
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cohort Studies
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/adverse effects
- Cyclophosphamide/therapeutic use
- Drug Monitoring
- Female
- Granulocyte Colony-Stimulating Factor/therapeutic use
- Hematologic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Male
- Middle Aged
- Neutropenia/chemically induced
- Pilot Projects
- Recombinant Proteins
- Retrospective Studies
- Rituximab
- Survival Analysis
- Vidarabine/administration & dosage
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
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Affiliation(s)
- Michaela Gruber
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56-93. [PMID: 21258094 DOI: 10.1093/cid/cir073] [Citation(s) in RCA: 1794] [Impact Index Per Article: 138.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care-associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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36
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Executive Summary: Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:427-31. [DOI: 10.1093/cid/ciq147] [Citation(s) in RCA: 508] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia.
Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving.
What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens.
Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care–associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G. Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Eric J. Bow
- Departments of Medical Microbiology and Internal Medicine, the University of Manitoba, and Infection Control Services, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Kent A. Sepkowitz
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York
| | - Michael J. Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research, Seattle, Washington
| | - James I. Ito
- Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California
| | - Craig A. Mullen
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Issam I. Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kenneth V. Rolston
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jo-Anne H. Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - John R. Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
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Kuderer NM. Meta-analysis of randomized controlled trials of granulocyte colony-stimulating factor prophylaxis in adult cancer patients receiving chemotherapy. Cancer Treat Res 2011; 157:127-143. [PMID: 21052954 DOI: 10.1007/978-1-4419-7073-2_8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Bonilla L, Ben-Aharon I, Vidal L, Gafter-Gvili A, Leibovici L, Stemmer SM. Dose-dense chemotherapy in nonmetastatic breast cancer: a systematic review and meta-analysis of randomized controlled trials. J Natl Cancer Inst 2010; 102:1845-54. [PMID: 21098761 PMCID: PMC3001963 DOI: 10.1093/jnci/djq409] [Citation(s) in RCA: 171] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Dose-dense chemotherapy has become a mainstay regimen in the adjuvant setting for women with high-risk breast cancer. We performed a systematic review and meta-analysis of the existing data from randomized controlled trials regarding the efficacy and toxicity of the dose-dense chemotherapy approach in nonmetastatic breast cancer. Methods Randomized controlled trials that compared a dose-dense chemotherapy protocol with a standard chemotherapy schedule in the neoadjuvant or adjuvant setting in adult women older than 18 years with breast cancer were identified by searching The Cochrane Cancer Network register of trials, The Cochrane Library, and LILACS and MEDLINE databases (from January 1966 to January 2010). Hazard ratios (HRs) of death and recurrence and relative risks of adverse events were estimated and pooled. All statistical tests were two-sided. Results Ten trials met the inclusion criteria and were classified into two categories based on trial methodology. Three trials enrolling 3337 patients compared dose-dense chemotherapy with a conventional chemotherapy schedule (similar agents). Patients who received dose-dense chemotherapy had better overall survival (HR of death = 0.84, 95% confidence interval [CI] = 0.72 to 0.98, P = .03) and better disease-free survival (HR of recurrence or death = 0.83, 95% CI = 0.73 to 0.94, P = .005) than those on the conventional schedule. No benefit was observed in patients with hormone receptor–positive tumors. Seven trials enrolling 8652 patients compared dose-dense chemotherapy with regimens that use standard intervals but with different agents and/or dosages in the treatment arms. Similar results were obtained for these trials with respect to overall survival (HR of death = 0.85, 95% CI = 0.75 to 0.96, P = .01) and disease-free survival (HR of recurrence or death = 0.81, 95% CI = 0.73 to 0.88, P < .001). The rate of nonhematological adverse events was higher in the dose-dense chemotherapy arms than in the conventional chemotherapy arms. Conclusion Dose-dense chemotherapy results in better overall and disease-free survival, particularly in women with hormone receptor–negative breast cancer. However, additional data from randomized controlled trials are needed before dose-dense chemotherapy can be considered as the standard of care.
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Affiliation(s)
- Luisa Bonilla
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
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39
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Chemotherapy characteristics are important predictors of primary prophylactic CSF administration in older patients with breast cancer. Breast Cancer Res Treat 2010; 127:511-20. [DOI: 10.1007/s10549-010-1216-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 10/05/2010] [Indexed: 10/18/2022]
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40
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Seftel MD. Controversies in the management of fever in the neutropenic cancer patient. Transfus Apher Sci 2010; 42:151-6. [PMID: 20106722 DOI: 10.1016/j.transci.2010.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The febrile neutropenic episode (FNE) constitutes a medical emergency, primarily because of the attendant risks of overwhelming infection and death. Infection, particularly bacterial in nature, is the most important cause of FNE, although there are other potential causes that depend on host, disease, and therapy related factors. The spectrum of microbiological pathogens varies both temporally and geographically, rendering it difficult to provide universal recommendations for antimicrobial therapy in FNE. Nonetheless, there are unifying principles in the management of FNE that are helpful in guiding therapeutic decisions. Using a case-based approach in a patient with lymphoma, the following controversies regarding the management of FNE are discussed: the role of prophylactic anti-bacterial antimicrobials, the management of febrile patients in the out-patient setting, and the choice of initial antimicrobials.
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Affiliation(s)
- Matthew D Seftel
- Section of Haematology/Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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41
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Lodato F, Azzaroli F, Tamè MR, Girolamo MD, Buonfiglioli F, Mazzella N, Cecinato P, Roda E, Mazzella G. G-CSF in Peg-IFN induced neutropenia in liver transplanted patients with HCV recurrence. World J Gastroenterol 2009; 15:5449-54. [PMID: 19916175 PMCID: PMC2778101 DOI: 10.3748/wjg.15.5449] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of granulocyte colony stimulating factors (G-CSF) in liver transplanted patients with hepatitis C (HCV) recurrence and Pegylated-IFN α-2b induced neutropenia, and to evaluate the impact of G-CSF administration on virological response.
METHODS: Sixty-eight patients undergoing antiviral treatment for post-liver transplantation (OLT) HCV recurrence were enrolled. All patients developing neutropenia received G-CSF.
RESULTS: Twenty three (34%) received G-CSF. Mean neutrophil count at the onset of neutropenia was 700/mmc (range 400-750/mmc); after 1 mo of G-CSF it increased to 1210/mmc (range 300-5590/mmc) (P < 0.0001). Three patients did not respond to G-CSF. Treatment duration was similar in neutropenic and non-neutropenic patients. No differences in the rate of discontinuation, infections or virological response were observed between the two groups. G-CSF was protective for the onset of de novo autoimmune hepatitis (P < 0.003).
CONCLUSION: G-CSF administration is effective in the case of Peg-IFN induced neutropenia increasing neutrophil count, prolonging treatment and leading to sustained virological response (SVR) rates comparable to non-neutropenic patients. It prevents the occurrence of de novo autoimmune hepatitis.
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Wingard JR, Elmongy M. Strategies for minimizing complications of neutropenia: Prophylactic myeloid growth factors or antibiotics. Crit Rev Oncol Hematol 2009; 72:144-54. [PMID: 19237297 DOI: 10.1016/j.critrevonc.2009.01.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 01/05/2009] [Accepted: 01/15/2009] [Indexed: 11/29/2022] Open
Affiliation(s)
- John R Wingard
- Division of Hematology/Oncology, University of Florida College of Medicine, P.O. Box 103633, 1376 Mowry Road, Gainesville, FL 32610-3633, USA.
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Lyman GH, Lalla A, Barron RL, Dubois RW. Cost-effectiveness of pegfilgrastim versus filgrastim primary prophylaxis in women with early-stage breast cancer receiving chemotherapy in the United States. Clin Ther 2009; 31:1092-104. [PMID: 19539110 DOI: 10.1016/j.clinthera.2009.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prophylaxis with granulocyte colony-stimulating factor reduces the risk for febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. OBJECTIVE We estimated the incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 of chemotherapy) with pegfilgrastim versus filgrastim in women with early-stage breast cancer receiving myelosuppressive chemotherapy in the United States. METHODS A decision-analytic model was constructed from a health payer's perspective with a lifetime study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality and on-time receipt of full-dose chemotherapy. Sensitivity analyses were conducted. RESULTS Pegfilgrastim was cost-saving and more effective (ie, dominant strategy) than 11-day filgrastim. The incremental cost-effectiveness ratio (ICER) for pegfilgrastim versus 6-day filgrastim was $12,904 per FN episode avoided. Adding the survival benefit due to reduced FN mortality and receipt of optimal chemotherapy dose yielded an ICER of $31,511 per quality-adjusted life year (QALY) gained and $14,415 per QALY gained, respectively. The most influential factors included inpatient FN case-fatality rate, cost of pegfilgrastim and filgrastim, baseline probability of FN, relative risk for FN between filgrastim and pegfil-grastim, and cost of administration of filgrastim. CONCLUSION Pegfilgrastim was cost-saving compared with 11-day filgrastim and cost-effective compared with 6-day filgrastim from a health payer's perspective for the primary prophylaxis of FN in these women with early-stage breast cancer receiving myelosuppressive chemotherapy.
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Affiliation(s)
- Gary H Lyman
- Division of Medical Oncology, Department of Medicine, Duke University School of Medicine and the Duke Comprehensive Cancer Center, Durham, North Carolina, USA
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Should the indications for the use of myeloid growth factors for the prevention of febrile neutropenia in cancer patients be extended? Curr Opin Oncol 2009; 21:297-302. [PMID: 19509500 DOI: 10.1097/cco.0b013e32832c9651] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Prevention of infectious complications of chemotherapy-induced granulocytopenia is a major issue in preventive medicine, as febrile neutropenia is still associated with an overall 10% mortality and extensive morbidity and cost. RECENT FINDINGS The prescription of granulocyte colony-stimulating factors should not be determined according to a risk prediction of febrile neutropenia considering solely type of chemotherapy and according to cost-effectiveness; other factors appear now to be important for making the decision, namely age and the presence of various comorbid factors. SUMMARY It is likely that the consideration of these newly recognized risk factors and the availability of more affordable granulocyte colony-stimulating factors will lead, in the near future, to an extension of the presently recognized indications for the prescription of granulocyte colony-stimulating factors.
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Tan Sean P, Chouaid C, Hettler D, Baud M, Hejblum G, Tilleul P. Economic implications of using pegfilgrastim rather than conventional G-CSF to prevent neutropenia during small-cell lung cancer chemotherapy. Curr Med Res Opin 2009; 25:1455-60. [PMID: 19419340 DOI: 10.1185/03007990902918156] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For the prevention of chemotherapy-induced febrile aplasia, a single injection of pegfilgrastim per cycle has the same efficacy as six to ten injections of conventional granulocyte colony-stimulating factor (G-CSF). However, there are few data on the economic impact of pegfilgrastim use, especially in the context of small-cell lung cancer. METHODS This retrospective study involved 31 patients and 129 treatment cycles (32 with pegfilgrastim and 97 with granulocyte colony-stimulating factor (G-CSF)). We estimated the direct costs for preventing and managing febrile aplasia from the payer's perspective and also conducted a willingness-to-pay study with 100 healthy subjects, in order to estimate how highly a single-jab strategy was valued relative to multiple injections. RESULTS The costs per cycle were respectively 1743 euros+/- 837 euros and 1466 euros +/- 836 euros for the pegfilgrastim and G-CSF strategies (p < 0.001). The excess cost of the pegfilgrastim strategy was partly compensated for by the perceived value of the single-jab strategy: 88% of interviewees would prefer the pegfilgrastim strategy; 16% would be willing to pay all the excess cost (277 euros) and 67% would be willing to pay half the excess cost. CONCLUSION In this willingness-to-pay survey, the excess cost associated with pegfilgrastim relative to other G-CSF-based prophylactic strategies is partly offset by the perceived convenience of a single injection.
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Affiliation(s)
- P Tan Sean
- AP-HP, Hôpital Saint-Antoine, Service de Pharmacie, Paris, France
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46
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Haines IE, Olver I. Are guidelines on use of colony-stimulating factors in solid cancers flawed? Intern Med J 2009; 39:259-62. [DOI: 10.1111/j.1445-5994.2009.01899.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ramsey SD, Liu Z, Boer R, Sullivan SD, Malin J, Doan QV, Dubois RW, Lyman GH. Cost-effectiveness of primary versus secondary prophylaxis with pegfilgrastim in women with early-stage breast cancer receiving chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:217-225. [PMID: 18673353 DOI: 10.1111/j.1524-4733.2008.00434.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. We estimated the incremental cost-effectiveness of G-CSF pegfilgrastim primary (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) versus secondary (only after an FN event) prophylaxis in women with early-stage breast cancer receiving myelosuppressive chemotherapy with a >or=20% FN risk. METHODS A decision-analytic model was constructed from a health insurer's perspective with a lifetime study horizon. The model considers direct medical costs and outcomes related to reduced FN and potential survival benefits because of reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values. RESULTS The incremental cost-effectiveness ratio (ICER) of pegfilgrastim as primary versus secondary prophylaxis was $48,000/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $110,000/life-year gained (LYG) or $116,000/quality-adjusted life-year (QALY) gained. The most influential factors included FN case-fatality, FN relative risk reduction from primary prophylaxis, and age at diagnosis. CONCLUSIONS Compared with secondary prophylaxis, the cost-effectiveness of pegfilgrastim as primary prophylaxis may be equivalent or superior to other commonly used supportive care interventions for women with breast cancer. Further assessment of the direct impact of G-CSF on short- and long-term survival is needed to substantiate these findings.
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Affiliation(s)
- Scott D Ramsey
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center and University of Washington Department of Medicine, Seattle, WA 98109, USA.
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48
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Lyman G, Lalla A, Barron R, Dubois RW. Cost-effectiveness of pegfilgrastim versus 6-day filgrastim primary prophylaxis in patients with non-Hodgkin's lymphoma receiving CHOP-21 in United States. Curr Med Res Opin 2009; 25:401-11. [PMID: 19192985 DOI: 10.1185/03007990802636817] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Prophylaxis with granulocyte-colony stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. Randomized clinical trials have shown that pegfilgrastim, a 2nd-generation G-CSF, is at least as effective as the 1st-generation G-CSF filgrastim. In the meta-analysis of trials pegfilgrastim performed better than filgrastim with respect to FN risk. The incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) with pegfilgrastim versus filgrastim used for 6 days (as is often used in clinical practice) was estimated in patients with aggressive non-Hodgkin's lymphoma (NHL) receiving myelosuppressive chemotherapy in the United States. METHODS A decision-analytic model was constructed from a health insurer's perspective with a life-time study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values. RESULTS The incremental cost-effectiveness (ICER) of pegfilgrastim versus 6-day filgrastim primary prophylaxis was $2167/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $5532/LY gained or $6190/QALY gained. When the potential benefit of optimized chemotherapy was included, the ICER was $1494/LY gained or $1677/QALY gained. The most influential factors included cost of pegfilgrastim, relative risk of FN between pegfilgrastim and filgrastim, FN case-fatality rate, cost of filgrastim and baseline FN risk. CONCLUSIONS Pegfilgrastim is cost-effective in primary prophylaxis of FN compared to 6 days per cycle of filgrastim, in patients with NHL receiving myelosuppressive chemotherapy (e.g., cyclophosphamide + doxorubicin + vincristine + prednisolone [CHOP-21]) chemotherapy. Study limitations included lack of direct evidence linking G-CSF use with a reduction in FN-related mortality and limited data that show a relationship between relative dose intensity (RDI) and cancer-specific patient survival.
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Affiliation(s)
- Gary Lyman
- Duke University School of Medicine and the Duke Comprehensive Cancer Center, Chapel Hill, NC, USA
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Liu Z, Doan QV, Malin J, Leonard R. The economic value of primary prophylaxis using pegfilgrastim compared with filgrastim in patients with breast cancer in the UK. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2009; 7:193-205. [PMID: 19799473 DOI: 10.1007/bf03256152] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Febrile neutropenia (FN) is a serious adverse event associated with myelotoxic chemotherapy that predisposes patients to life-threatening bacterial infections. Prophylaxis with granulocyte colony-stimulating factors (G-CSFs) from the first cycle of chemotherapy is recommended by the 2006 American Society of Clinical Oncology, 2008 National Comprehensive Cancer Network and 2006 European Organisation for Research and Treatment of Cancer guidelines when the overall risk of FN is approximately 20% or higher. Once-per-cycle pegfilgrastim and daily filgrastim are two commonly used G-CSFs with different dosing schedules and associated costs. OBJECTIVE To evaluate the cost effectiveness of pegfilgrastim versus filgrastim primary prophylaxis in women with early-stage breast cancer receiving chemotherapy in the UK. METHODS A decision-analytic model was constructed from the UK NHS perspective with a lifetime study horizon. The model simulated three clinical scenarios: scenario 1 assumed that pegfilgrastim and filgrastim had differential impact on the risk of FN; scenario 2 assumed additional differential impact on FN-related mortality; and scenario 3 assumed additional differential impact on chemotherapy relative dose intensity (RDI) with long-term survival effects. The base-case population included 45-year-old women with stage II breast cancer receiving four chemotherapy cycles, with an FN risk of approximately 20% or higher. Model inputs, including FN risk, FN case-fatality, RDI, impact of RDI on survival and utility scores, were based on a review of the literature and expert panel validation. Using data from the literature, it was estimated that the absolute risk of FN associated with pegfilgrastim was 5.5% lower than with 11-day filgrastim (7% vs 12.5%), and 10.5% lower than with 6-day filgrastim (7% vs 17.5%). Costs were taken from official price lists or the literature and included drugs, drug administration, FN-related hospitalizations and subsequent medical costs. Breast cancer mortality and all-cause mortality were obtained from official statistics. The main outcome measures were the costs ( pound, year 2006 values) per percentage decrease in (absolute) FN risk, per FN event avoided, per life-year gained (LYG), and per QALY gained. Model robustness was tested using deterministic and probabilistic sensitivity analyses. RESULTS Pegfilgrastim was cost saving compared with 11-day filgrastim ( pound 3196 vs pound 4315). Compared with 6-day filgrastim, pegfilgrastim was associated with a cost of pound 4200 per FN event avoided, or pound 42 per 1% decrease in absolute risk of FN, in scenario 1. In scenario 2, pegfilgrastim provided 0.055 more LYGs or 0.052 more QALYs at a minimal cost increase of pound 441 ( pound 3196 vs pound 2754) per person, yielding an incremental cost-effectiveness ratio (ICER) of pound 8075/LYG or pound 8526/QALY. In scenario 3, when all potential benefits of G-CSF were considered, the ICER became pound 3955/LYG or pound 4161/QALY. Results were most sensitive to the relative risk of FN for 6-day filgrastim versus pegfilgrastim. CONCLUSION In this UK analysis, pegfilgrastim appears to dominate 11-day use of filgrastim. The value of pegfilgrastim versus 6-day filgrastim at pound 4161-8526/QALY was very favourable compared with the commonly used threshold in the UK. In this setting, primary prophylaxis with pegfilgrastim may be cost effective compared with filgrastim.
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Affiliation(s)
- Zhimei Liu
- Cerner LifeSciences, Beverly Hills, California, USA.
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50
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Eldar-Lissai A, Cosler LE, Culakova E, Lyman GH. Economic analysis of prophylactic pegfilgrastim in adult cancer patients receiving chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:172-179. [PMID: 18380630 DOI: 10.1111/j.1524-4733.2007.00242.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Neutropenia and its complications, including febrile neutropenia (FN), are a common side effect of cancer chemotherapy. Results of clinical trials showed that prophylactic use of granulocyte colony-stimulating factors (G-CSF) is effective in preventing FN. In this study, the cost effectiveness (measured as cost per quality-adjusted time [days]) of three treatment alternatives were evaluated: no G-CSF, filgrastim administered daily for 7-12 days after chemotherapy, and a pegylated form of G-CSF pegfilgrastim, administered once per cycle. METHODS A cost-utility model based on standard clinical practice of treating FN with immediate hospitalization or with ambulatory treatment, from a societal perspective was developed. Direct medical cost estimates for hospitalization were derived from claims data reported by 115 US academic medical centers. Indirect medical costs, productivity costs, probabilities, and utilities are based on published literature. Results were subjected to sensitivity analyses and 95% confidence intervals are based on a Monte Carlo simulation. RESULTS Mean estimated costs/day of hospitalization were $1984 (SD $1040, N = 24,687) for surviving patients and $3139 (SD $2014, N = 1437) for dying patients. Under baseline conditions, pegfilgrastim dominated both filgrastim and no G-CSF, with expected costs and effectiveness of $4203 and 12.361 quality adjusted life-days (QALDs) for no G-CSF, $3058 and 12.967 QALDs for pegfilgrastim, and $5264 and 12.698 QALDs for filgrastim. CONCLUSIONS This cost-utility analysis provides strong evidence that pegfilgrastim is not only cost-effective but also cost-saving in most common clinical and economic settings. There appear to be both clinical and economic benefits from prophylactic administration of pegfilgrastim.
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Affiliation(s)
- Adi Eldar-Lissai
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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