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

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

Recombinant Hemopoietic Growth Factors: Comparative Hemopoietic Response in Younger and Older Subjects

OBJECTIVE

To study the effectiveness of hemopoietic growth factors in older patients.

DESIGN

Literature review. All articles published in English language between 1987 and 1990 were reviewed. Those reporting studies without age limits as entry criteria and describing the effects of growth factors in individual patients were suitable for analysis. Bone marrow transplantation related articles were excluded.

MAIN OUTCOME MEASURES

The meanfold increase of granulocytes for Granulocyte-Colony Stimulating Factor, Granulocyte Macrophage-Colony Stimulating Factor, and Interleukin 3 and of hemoglobin for erythropoietin were compared in subjects younger and older than 65, by Mann-Whitney U test.

RESULTS

Of 68 studies, 23 were suitable for analysis. These included patients with myelodysplastic syndromes, aplastic anemia, chemotherapy-induced myelosuppression, chronic granulocytopenia, anemia, and myelosuppression of malignancies and of chronic disease. Of 204 patients, 67 were 65 years of age or older and 42 were over 70. No difference was seen in meanfold increase of granulocyte and hemoglobin in time of response to growth factors or in response in presence of an absolute neutrophil count lower than 1000/microliters between younger and older patients.

CONCLUSION

Early response to hemopoietic growth factors appears well maintained with advanced age. Prospective studies of the prolonged effects of these factors in older and younger patients are needed.

Management of aplastic anemia: the role of systematic reviews and meta-analyses

Aplastic anemia is a rare bone marrow failure disorder. Allogeneic hematopoietic cell transplantation (alloHCT) and immunosuppressive therapy (IST) are the main therapeutic modalities currently used to treat patients with aplastic anemia. Systematic reviews and meta-analyses of randomized controlled trials (RCTs) are regarded as the highest level of evidence and as such aid practitioners in solving clinical questions. The objective of this review is to assess the base of evidence for the common practice and the current guidelines for the management of aplastic anemia. It focuses on data obtained from systematic reviews and meta-analyses of RCTs conducted in this field. Specifically, it focuses on four major therapeutic questions: the roles of alloHCT, IST, hematopoietic growth factors and supportive care.

Auto-mobilized adult hematopoietic stem cells advance neovasculature in diabetic retinopathy of mice

BACKGROUND

Hematopoietic stem cells (HSCs) can be used to deliver functionally active angiostatic molecules to the retinal vasculature by targeting active astrocytes and may be useful in targeting pre-angiogenic retinal lesions. We sought to determine whether HSC mobilization can ameliorate early diabetic retinopathy in mice.

METHODS

Mice were devided into four groups: normal mice control group, normal mice HSC-mobilized group, diabetic mice control group and diabetic mice HSC mobilized group. Murine stem cell growth factor (murine SCF) and recombined human granulocyte colony stimulating factor (rhG-csf) were administered to the mice with diabetes and without diabetes for continuous 5 days to induce autologous HSCs mobilization, and subcutaneous injection of physiological saline was used as control. Immunohistochemical double staining was conducted with anti-mouse rat CD31 monoclonal antibody and anti-BrdU rat antibody.

RESULTS

Marked HSCs clearly increased after SCF plus G-csf-mobilization. Non-mobilized diabetic mice showed more HSCs than normal mice (P=0.032), and peripheral blood significantly increased in both diabetic and normal mice (P=0.000). Diabetic mice showed more CD31 positive capillary vessels (P=0.000) and accelerated endothelial cell regeneration. Only diabetic HSC-mobilized mice expressed both BrdU and CD31 antigens in the endothelial cells of new capillaries.

CONCLUSION

Auto-mobilized adult hematopoietic stem cells advance neovasculature in diabetic retinopathy of mice.

Supportive care and chelation therapy in MDS: are we saving lives or just lowering iron?

The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of transformation to acute myeloid leukemia (AML). Although new treatments are available, a mainstay in MDS remains supportive care, which aims to minimize the impact of cytopenias and transfusion of blood products. Red blood cell (RBC) transfusions place patients at risk of iron overload (IOL). In beta-thalassemia major (BTM), IOL from chronic RBC transfusions inevitably leads to organ dysfunction and death. With iron chelation therapy (ICT), survival in BTM improved from the second decade to near normal and correlated with ICT compliance. Effects of ICT in BTM include reversal of cardiac arrhythmias, improvement in left ventricular ejection fraction, arrest of hepatic fibrosis, and reduction of glucose intolerance. It is not clear whether these specific outcomes are applicable to MDS. Although retrospective, recent studies in MDS suggest an adverse effect of transfusion dependence and IOL on survival and AML transformation, and that lowering iron minimizes this impact. These data raise important points that warrant further study. ICT is potentially toxic and cumbersome, is costly, and in MDS patients should be initiated only after weighing potential risks against benefits until further data are available to better justify its use. Since most MDS patients eventually require RBC transfusions, the public health implications both of transfusion dependence and ICT in MDS are considerable. This paper summarizes the impact of cytopenias in MDS and treatment approaches to minimize their impact, with a focus on RBC transfusions and their complications, particularly with respect to iron overload.

Have hematopoietic growth factors made an impact on the management of liver disease?

It is clear that the major indication for the use of hematopoietic growth factors in hepatology is to counteract the adverse effects of interferons (neutropenia and thrombocytopenia) and ribavirin (hemolytic anaemia) during the treatment of hepatitis C infection. This is important because the probability of SVR depends on proper adherence to therapy (at least 80% of the requisite dose maintained for at least 80% of the requisite duration) and proper adherence can only be achieved if the side effects are reduced to a minimum. Even though the studies have demonstrated beyond doubt that the use of hematopoietic growth factors does indeed reduce the incidence and severity of these adverse effects and helps the patients to complete the course of therapy, the data on improvement of SVR is still limited. There is only one study of darbepoetin and filgrastim showing the beneficial effect on SVR. Even among the hematological side effects, possibly the only significant effect which limits the use of optimal HCV therapy is the hemolytic anaemia induced by ribavirin. The other two main side effects, i.e. neutropenia and thrombocytopenia are not clinically problematic. The use of such growth factors would be particularly effective if patients who have advanced liver disease or cirrhosis are able to receive adequate anti-viral therapy as has been demonstrated in the study of eltrombopag among HCV cirrhotics. Apart from this, other indications of G-CSF or GM-CSF use are still in the experimental stage. So, as of now, apart from erythropoietic factors, the role played by other hematopoietic growth factors in hepatology is limited. But future research, especially in the areas of immunotherapy of liver cancers and stem cell therapy for endstage liver disease, is surely going to give these factors their due place in hepatology.

Patterns of primary degranulation as indicated by the mean myeloperoxidase index (MPXI) during bacteraemia in lymphoma transplants treated with growth factors

The pattern of changes in neutrophil myeloperoxidase (MPO) before, during and after bacteraemia was studied in 34 patients recovering from autologous bone marrow transplantation for relapsed Hodgkin's disease and non Hodgkin's lymphomas. Thirteen patients received haemopoietic growth factors (7 received M-CSF, 3 received G-CSF and 3 GM-CSF). The mean peroxidase index (MPXI) produced as part of a routine FBC performed by a flow cytochemistry blood autoanalyser (Technicon H*1) was used as a parameter to assess the MPO and subsequently the azurophil degranulation. The manufacturer's normal values for MPXI range from -10 to +10. Median MPXI on the day of documented bacteraemia was just below normal in the control and M-CSF groups (-10.8 and -8.9 respectively), but it was much below normal in the G-CSF (-16.5, P < 0.05) and even lower in the GM-CSF group (-39.6, P < 0.02); this correlated well with the decreased bacteraemia incidence in the last two groups. Although contact of neutrophils with bacterial chemoattractants resulted in primary degranulation in all groups, the pattern of changes in MPO content was different, suggesting that neutrophils primed in vivo with various haemopoietins respond to the challenge of microbial agents via different pathways.

Haematopoietic growth factors and their therapeutic use

Haematopoietic growth factors constitute an important group of proteins that predominantly regulate the process of haematopoiesis. While some of these proteins have a very broad array of action on very early haematopoietic progenitors leading to multi-lineage increases in haematopoietic cell production and differentiation, others act in a restricted manner on specific committed terminally differentiated cell types. On the basis of their unique spectrum of activities, several factors are approved for clinical use in various indications while others are under investigation in the clinic either alone or as combination therapy. In this review, we have described factors which directly and in some cases indirectly influence haematopoiesis with particular focus on those factors which are either approved or show potential for clinical use. A brief description of the products that are currently available for clinical use is also provided. At present, several new products which include fusion proteins, peptide mimetics are either at the pre-clinical stage or in clinical development for various indications and these are also briefly described.

Hematopoietic growth factors for hematopoietic stem cell mobilization and expansion

During inflammation and cytopenia, increased levels of hematopoietic growth factors (HPGFs) induce mobilization and proliferation of hematopoietic stem cells and hematopoietic progenitor cells (HPCs), resulting in spatial and quantitative in vivo expansion of the hematopoietic tissue. Exogenous administration of recombinant HPGFs, particularly granulocyte colony-stimulating factor (G-CSF), is routine for mobilization of stem cells, followed by collection and transplantation of autologous or allogeneic stem cells. In this review, we summarize experience using different HPGFs and HPGF combinations for stem cell mobilization, such as G-CSF, granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-3 (IL-3), stem cell factor (SCF), and others. Preclinical and clinical studies of so-called early- and late-acting HPGFs for ex vivo expansion of HPCs are discussed, also with respect to the unresolved question whether expansion of repopulating stem cells can be achieved in vitro.

Hematopoietic growth factors for the treatment of inherited cytopenias

The clinical availability of recombinant hematopoietic growth factors was initially thought to be breakthrough in the treatment of bone marrow failure syndromes. However, in most disorders of hematopoeisis, the clinical use was rather disappointing. Only in congenital neutropenias (CNs) has the long-term administration of granulocyte colony-stimulating factor (G-CSF) led to a maintained increase in absolute neutrophil count (ANC) and a reduction of severe bacterial infections. In other disorders of hematopoiesis, the use of lineage-specific growth factors is either not possible due to mutations in the growth factor receptor or leads to a transient benefit only. Initial clinical trials with multilineage hematopoietic growth factors, such as stem cell factor (SCF; c-kit ligand) were discontinued due to adverse events. It is well known that bone marrow failure syndromes are pre-leukemic disorders. So far, there is no evidence for induction of leukemia by hematopoietic growth factors. However, it has been shown in patients with CN and Fanconi anemia that hematopoietic growth factors might induce preferential outgrowth of already transformed cells. Thus, it is strongly recommended to monitor patients for clonal aberrations prior to and during long-term treatment with hematopoietic growth factors.

Hematopoietic Growth Factors in the Treatment of Acquired Bone Marrow Failure States

In severe aplastic anemia (SAA), the use of hematopoietic growth factors (HGFs) to support blood counts is of limited value, as predicted by in vitro studies and measurement of endogenous serum levels of hematopoietic growth factors (HGF), which are markedly elevated. Benefit is usually only seen in those with less severe disease who are unlikely to require HGFs in practice. HGFs administered alone play no role in the treatment of SAA. The main indication for using HGFs, most often granulocyte colony-stimulating factor (G-CSF), in SAA has been to determine whether they increase the response rate to immunosuppressive therapy (IST) and improve survival. While earlier neutrophil recovery occurs when G-CSF is administered with IST, studies to date show no significant advantage in hematologic response or overall survival. Conflicting results have been reported concerning whether G-CSF increases the known risk of myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) after IST; follow-up of at least 10 years is required, lacking in many clinical studies reported to date. In MDS, HGFs have been used to counteract the intramedullary apoptosis, which leads to ineffective hematopoiesis. In several uncontrolled and controlled studies, especially in low-risk MDS, high-dose erythropoietin (EPO) or its glycosylated derivative darbepoetin (DPO), alone or in combination with G-CSF, increased hemoglobin levels and diminished the need for red blood cell transfusions, in selected patients with prior transfusion frequency of less than 2 units per month and EPO levels below 500 IU/L. Quality-of-life measures were claimed to have improved, but the cost-effectiveness of this approach is debated, as is safety with regard to the risk of progression. G-CSF is used in supportive care of MDS to improve neutropenia during infectious complications, but to date there is no compelling evidence for a survival benefit or alteration of the course of the disease through the use of HGFs in MDS.

Hematopoietic Growth Factors Including Keratinocyte Growth Factor in Allogeneic and Autologous Stem Cell Transplantation

The aim of hematopoietic stem cell transplantation (HSCT) is to cure patients of malignancies, autoimmune diseases, and immunodeficiency disorders by redirecting the immune system: the often described graft-versus-leukemia (GVL) or graft-versus-tumor (GVT) effects. Unfortunately, fulfillment of this goal is often hampered by relapse of the underlying disease, graft-versus-host disease (GVHD), or severe opportunistic infections, which account for the majority of post-transplantation deaths. Moreover, studies of long-term survivors of transplantation indicate an accelerated immune aging due to the transplantation procedure itself, preceding chemo- or radiotherapy, and acute and chronic GVHD. Significant advances have been made towards overcoming these obstacles by enhancing immune reconstitution with hematopoietic growth factors (HGFs) such as granulocyte colony-stimulating factor (G-CSF) or erythropoietin (EPO) or through the application of cytokines. In addition, there are approaches to promote the thymic-dependent development of naive T cells, which are prepared for the interaction with a multitude of pathogens. Examples are the application of keratinocyte growth factor (KGF), neuroendocrine hormones such as growth hormone or prolactin, sex hormone ablation, or the invention of a three-dimensional artificial thymus based on a cytomatrix. Might these measures result in a higher rate of healthy and fully recovered patients? Here we review progress in each of these areas.

Human progenitor cells rapidly mobilized by AMD3100 repopulate NOD/SCID mice with increased frequency in comparison to cells from the same donor mobilized by granulocyte colony stimulating factor

AMD3100 inhibits the interaction between SDF-1 and CXCR4, and rapidly mobilizes hematopoietic progenitors for clinical transplantation. However, the repopulating function of human cells mobilized with AMD3100 has not been characterized in comparison to cells mobilized with granulocyte-colony stimulating factor (G-CSF) in the same donor. Therefore, healthy donors were leukapheresed 4 hours after injection with AMD3100; after 10 days of drug clearance the same donor was mobilized with G-CSF, allowing a paired comparison of repopulation by mobilized cells. Transplantation of mononuclear cells (MNC) or purified CD34(+) cells was compared at limiting dilution into NOD/SCID mice. Human AMD3100-mobilized MNC possessed enhanced repopulating frequency in comparison to G-CSF-mobilized MNC from paired donors, and purified CD34(+) progenitors were at least as efficient as the G-CSF mobilized cells. The frequencies of NOD/SCID repopulating cells (SRC) were 1 SRC in 8.7 x 10(6) AMD3100-mobilized MNC compared to 1 SRC in 29.0 x 10(6) G-CSF-mobilized MNC, and 1 SRC in 1.2 x 10(5) AMD3100-mobilized CD34(+) cells compared to 1 SRC in 1.8 x 10(5) G-CSF-mobilized CD34(+) cells. Hematopoietic differentiation of transplanted progenitors was similar after AMD3100 or G-CSF-mobilization. Thus, AMD3100 mobilized peripheral blood represents a rapidly obtained, highly repopulating source of hematopoietic progenitors for clinical transplantation.

Intravenous immunoglobulins and haematopoietic growth factors in the prevention and treatment of neonatal sepsis: ground reality or glorified myths?

Neonatal sepsis is a significant cause of morbidity and mortality in the neonatal intensive care unit. The epidemiology of neonatal infections is complex; however, they are in large part secondary to developmentally immature host defence mechanisms. These immunodeficiencies, which are exaggerated in premature and sick neonates, include quantitative and qualitative deficits in phagocytes, complement components, cytokines and immunoglobulins. Therapies that modulate or augment host defences may attenuate the virulence of neonatal infections. In this paper, we have reviewed immunotherapies that modulate the immune system of the neonate, including intravenous immunoglobulins and myeloid haematopoietic growth factors. Future studies should focus on investigating other abnormalities of neonatal host defence and/or combined immunotherapy approaches in an attempt to circumvent the immaturity of host defence and potentially reduce both the incidence and severity of neonatal sepsis.

A national French survey on the use of growth factors as adjuvant treatment of chronic hepatitis C

We conducted a national retrospective survey on hospital practitioners to evaluate the magnitude of erythropoietin (EPO) or granulocyte colony-stimulating factor (G-CSF) prescriptions in patients treated for chronic hepatitis C. Four hundred seventy-one questionnaires were sent, and 274 practitioners (58.2%) responded. Forty-six percent of practitioners used EPO, and 31% used G-CSF. The total number of HCV-infected patients receiving antiviral therapy per year was estimated at 6,630 patients, of whom 8.8% and 4% received EPO and G-CSF, respectively. EPO-beta was the main EPO molecule prescribed at a median dose of 30,000 IU/wk (range: 2,000-80,000). The indications for prescribing EPO varied greatly, including "fragile patients" (34%), "low" Hb level (8-11 g/dL) (19%), "rapid decline" in Hb level (2-5 g/dL during the first month of therapy) (12%), and symptomatic anemic patients (7%). G-CSF was mainly prescribed for a "low" level of neutrophils ranging from 400 to 750 neutrophils/mm3. In multivariate analysis, independent predictors of EPO and G-CSF prescription were age of practitioner less than 45 years (EPO: OR = 1.96, P = 0.03; G-CSF: OR = 2.27, P = 0.004), practice in university hospital (EPO: OR = 5.89, P < 0.0001; G-CSF: OR = 2.39, P = 0.003), and the high number of CHC treated/year (EPO: OR = 6.18, P < 0.0001; G-CSF: OR = 2.58, P = 0.002).

CONCLUSION

Our survey reveals an important rate of EPO and G-CSF prescriptions but with considerable disparity in the schedule of injections, the molecules used, and above all the indications. The suitable role of EPO and G-CSF as complements to HCV therapy urgently needs to be clarified.

[Hematopoietic growth factors and autologous or allogeneic stem cell transplantation]

Hematopoietic growth factors are usually administered in autologous and allogeneic stem cell transplantation. RhuG-CSF and rhuEPO are the most frequently used, either for mobilization of peripheral stem cells or after transplantation for the improvement of hematologic recovery. G-CSF (filgrastim or lenograstim) can be administered alone or in combination with stem cell factor to enhance stem cells mobilization. IL-3 and sargramostim are not used anymore. The protocol of administration of rhuG-CSF is well established. Furthermore, stem cell transplantation with peripheral cells is less expensive than with bone marrow. RhuEPO (erythropoietin) is not effective in mobilization. After transplantation, filgrastim or lenograstim can shorten the neutropenic period and decrease infectious complications. The potential effect of these growth factors on the incidence and the severity of GvHD is still unknown and under debate. The use of rhuEPO after transplantation might be of interest to reduce the need of red blood cell transfusion. Some studies suggest that the administration of rhuEPO should start before delivering the conditioning regimen. The new long acting growth factors such as pegfilgrastim are still under evaluation and their use in mobilization seems promising.

[Prognostic factors for febrile neutropenia]

Cytotoxic chemotherapy suppresses the haematopoietic system, impairing host protective mechanisms and limiting the doses of chemotherapy that can be tolerated. Febrile neutropenia, the most serious haematological toxicity, is associated with the risk of life-threatening infections as well as chemotherapy dose reductions and delays that may compromise treatment outcomes. The recent literature in chemotherapy-induced neutropenia and its complications and impact was provided an update on research, and the implications for improving the management of patients with cancer who are treated with myelosuppressive chemotherapy was discussed. Despite its importance as the primary dose-limiting toxicity of chemotherapy, much concerning neutropenia and its consequences and impact remains unknown. Recent surveys indicate that neutropenia remains a prevalent problem associated with substantial morbidity, mortality, and costs. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat febrile neutropenia and to assist patients receiving dose-intensive chemotherapy. A meta-analysis of the available randomized controlled trials (RCTs) has confirmed the efficacy of prophylactic CSFs. Much research has sought to identify risk factors that may predispose patients to neutropenic complications, including febrile neutropenia, in an effort to predict better which patients are at risk and to use preventive strategies, such as prophylactic colony-stimulating factors, more cost-effectively. Research in quantifying the risk of neutropenic complications may make it possible in the near future to target patients at greater risk with appropriate preventive strategies, thereby maximizing the benefits and minimizing the costs.

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

PURPOSE

Hematopoietic growth factors have played a major role in preventing infection and shortening the duration of neutropenia in patients receiving cancer chemotherapy. Little information is available on how these growth factors are used in patients with cancer outside the clinical trial setting. We performed descriptive and exploratory analyses on the patterns and correlates of the use of hematopoietic growth factors in community-dwelling elderly patients.

PATIENTS AND METHODS

We identified 5,843 women from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data cohorts who were diagnosed with breast cancer at age 65 or older in 1992 to 1999 from the 11 SEER areas and received chemotherapy.

RESULTS

Overall, 17.3% of the elderly women with breast cancer chemotherapy received filgrastim and 6.8% received epoetin. The use of the growth factors increased significantly over time from 1992 to 1999 (P < .001 for trend). Compared with patients diagnosed in 1992 to 1994, patients diagnosed in 1998 to 1999 were more than five times and 65 times more likely to receive filgrastim and epoetin, respectively, after controlling for other factors such as age and comorbidity. There also was substantial geographic variation in the use of hematopoietic growth factors, ranging from 10.6% in Seattle to 22.9% in Atlanta. Significant predictors of growth factors included patient age, race, tumor stage, and comorbidity.

CONCLUSION

There were substantial temporal and geographic variations in the use of hematopoietic growth factors among patients receiving chemotherapy for breast cancer. The nationwide and population-based Medicare claims provide potential for examining the effectiveness, medical costs, and cost effectiveness of hematopoietic growth factors in the community.

[Geriatric urology -- tumour diseases]

Due to demographic developments malignancies of urogenital origin will gain increasing importance. The urologist will face a growing group of patients with co-morbidities and functional disabilities as these neoplasms increase with age. Optimisation of peri-interventional management successfully reduces the risks of surgery. Integration of taxane-based cytostatic regimes achieves a prolongation of survival in hormone-refractory metastatic prostatic cancer. The introduction of gemcitabine in the management of malignancies of the bladder seems to have reduced toxicity while maintaining anti-tumour activity in comparison to MVAC. The role of haematopoetic growth factors remains to be defined in urologic malignancies - increasing dose intensity for better activity or reduction of toxicity. Individualisation of treatment requires early cooperation of the urologist, the oncologist and the geriatrician for an optimal outcome.

Current and future use of hematopoietic growth factors in cancer medicine

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

High-dose chemotherapy with autologous haemopoietic support for advanced ovarian cancer in first complete remission: retrospective analysis from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT)

The majority of advanced ovarian cancer patients achieve an objective response following chemotherapy; however, only 20-30% are in remission after 5 years. Intraperitoneal or high-dose chemotherapy (HDC) may prolong disease-free and overall survival (OS) in patients with platinum-sensitive, small volume disease. To better define the subsets of patients who might benefit from HDC, we performed a retrospective analysis on 91 patients in 1st complete remission (CR) treated from 21 centres of the EBMT group. At a median follow-up of 48 months, median time-to-progression (TTP) and OS were 21.2 and 44.4 months, respectively. Tumour grade, stage, residual disease, disease status before HDC, type and year of transplant, source of haemopoietic progenitors and use of haemopoietic growth factors (HGF) after transplant were analysed for TTP and OS. The only significant parameter was the use of HGF: median OS for patients receiving or not receiving HGF was 46.2 vs 17.8 months, respectively (P: 0.035); this difference was maintained after multivariate analysis (P: 0.02). Our analysis does not identify any subgroup of patients in 1st CR who can benefit from HDC; however, median survival of patient with no residual disease has not been reached. The role of HGF after HDC deserves further investigation.

Quality of Life and Chemotherapy-induced Neutropenia

This report summarizes recent data on neutropenia-related quality of life (QOL), including measures and interventions. Neutropenia is a common adverse effect of cytotoxic chemotherapy. The clinical significance of QOL in patients with chemotherapy-induced neutropenia (CIN) remains largely unexplored, although recent studies have shown a correlation between severe CIN and impaired QOL. Neutropenia typically occurs at the same time as other adverse effects. Data indicate that other toxicities are worse in the presence of febrile neutropenia and that these concurrent events may have a greater effect on QOL. Precautions that are taken to minimize the incidence of infection in patients with neutropenia may also affect their QOL. Future research should focus on accurately defining and measuring QOL in patients with CIN as well as on assessing ways to manage CIN more effectively and thus improve QOL. A number of interventions may have a positive influence on QOL in patients with cancer and neutropenia. Hematopoietic growth factor support, for example, reduces the incidence and sequelae of neutropenia and may provide a QOL benefit. To assess the effect of such interventions, neutropenia-specific QOL instruments, such as the Functional Assessment of Cancer Therapy-Neutropenia (FACT-N), may be valuable tools.

Haemopoietic growth factors in myelodysplastic syndromes: towards patient-oriented therapy?

Recombinant human erythropoietin (r-EPO) has been used in Myelodysplastic Syndrome (MDS) patients with anaemia since the early nineties. In low-risk MDS patients, other haemopoietic growth factors (HGFs) (granulocyte-colony stimulating factor, G-CSF, granulocyte-macrophage-colony stimulating factor, GM-CSF, and interleukin 3, IL-3) have been used to synergise the effects of r-EPO on erythroid growth and to increase neutrophil count in patients with severe neutropenia. In high-risk MDS, or in patients with post-MDS AML, myeloid HGFs have been used to push blasts into the S-phase, thus increasing their sensitivity to antiblastic drugs. Several trials have shown that r-EPO can increase haemoglobin levels and improve QoL in patients with anaemia associated to MDS. The selection of patients with a high probability of response to HGFs is based on the careful consideration of several clinical and biological parameters, i.e., among others, basal EPO and transfusional needs, disease duration, FAB or WHO subtypes, and IPSS score. Treatment of anaemic MDS patients with HGFs should become "patient oriented" and different types, schedules, and duration of treatment have to be designed according to the specific criteria which most likely predict, for each individual patient, the best chance of responding favourably to therapy.

Prognostic factors of hematological recovery in life-threatening nonchemotherapy drug-induced agranulocytosis

OBJECTIVES

We studied clinical factors that may influence the duration of hematological recovery to reach neutrophil counts and thus, indirectly, the prognosis in patients with life-threatening drug-induced agranulocytosis (DIA).

METHODS

Using univariate and multivariate analyses with Cox's proportional hazard models, we determined the prognostic factors for hematological recovery, defined as neutrophil counts>0.5 and>1.5.10(9)/L, in 91 patients with established life-threatening DIA.

RESULTS

Multivariable analysis showed that neutrophil count<0.1.10(9)/L (at diagnosis) and infection profile: severe infections or septic shock, adversely influenced the neutrophil recovery (for the two neutrophil levels). Hematopoietic growth factors were significantly associated with rapid hematological recovery (for the two neutrophil levels). Documented microbial infections and antiplatelet DIA were also associated with rapid hematological recovery (for a neutrophil count>1.5.10(9)/L).

CONCLUSION

Our findings demonstrate that in life-threatening DIA, hematological recovery is mainly dependent of the neutrophil level, the type of infections and the utilization of hematopoietic growth factors.

Dendritic Cell-Based Immunotherapy of Malignant Gliomas

The failure of conventional treatment modalities for gliomas, in spite of tremendous progress in research in the past two decades, has led to increasing interest in alternative treatment strategies, including immunotherapy. It has become evident that vaccination with dendritic cells (DC), designed to express tumor antigens, is a potent strategy to elicit anti-tumor immune response in both pre-clinical and clinical settings. Various methods have been applied in order to induce DC to express tumor antigens including: pulsing with isolated tumor peptides or whole tumor lysate; fusion with tumor cells; and pulsing with apoptotic tumor cells. Herein, we review the recent progress in DC biology with regard to tumor immunity and discuss current DC-based strategies and future prospects in immunotherapy for malignant gliomas.

Advances in chemotherapy for chronic lymphocytic leukemia

While chemotherapy based on alkylating agents has been the standard treatment of chronic lymphocytic leukemia (CLL) for decades, purine analogues and their combinations have emerged as effective new therapies for previously untreated and pretreated patients. As single agents, fludarabine and cladribine are the most promising, showing higher remission rates compared to chlorambucil. For younger and physically fit patients, the combination of fludarabine and cyclophosphamide has shown benefit. Fludarabine plus epirubicin appears equally potent. The addition of monoclonal antibodies, such as rituximab and alemtuzumab, to purine analogues alone or in combination seems to be even more effective for chemotherapy-naive and pretreated CLL patients. Another promising agent in the armamentarium of therapies for CLL is bendamustine, which has properties of both an alkylating agent and a purine analogue. Clinical trials are ongoing with novel drugs that interfere with cell cycle regulation and signaling molecules in CLL, including flavopiridol, UCN-01, bryostatin 1, depsipeptide, and oblimersen. It remains to be seen whether these chemotherapeutic approaches offer real benefit for patients by prolonging survival with an improved quality of life.

The use of hematopoietic growth factors in the treatment of acute leukemia

Cytokines are centrally involved in the regulation of normal hematopoiesis, the production of mature blood cells by bone marrow stem cells. Cytokines influence stem survival, proliferation, and differentiation commitment, as well as controlling the orderly maturation of progenitor cells into functional leucocytes, erythrocytes, and platelets. Acute leukemias result from malignant transformation of bone marrow stem cells. Although cytokines do not appear to be centrally involved in the pathogenesis of acute leukemias, leukemic cells express receptors for many of the cytokines regulating normal hematopoiesis, particularly G-CSF, GM-CSF, IL-3, and stem cell factor. These molecules have demonstrable effects on acute leukemia cells in vitro, inducing proliferation and enhancing survival, but their biological activity when administered as recombinant proteins in pharmaceutical doses to patients with active leukemia are less well understood. Because of the stimulatory effects of cytokines such as G-CSF and GM-CSF on normal hematopoiesis in vitro and in normal individuals, these two molecules have been extensively studied in randomised clinical trials of chemotherapy for cancer, including acute leukemia. Concerns about the potential for G-CSF and GM-CSF to accelerate the growth of acute myeloid leukemia, which expresses receptors for both molecules, have not been realised. Conversely, the concept of using either of these two cytokines to induce acute myeloid leukemia cells into active DNA synthesis, thus potentially sensitising them to the effects of S-phase-specific drugs, has not been shown to be clinically beneficial. Both G-CSF and GM-CSF have been demonstrated to accelerate the recovery of normal granulopoiesis after intensive initial cytotoxic chemotherapy for acute leukemia, significantly shortening the duration of severe treatment-induced neutropenia, and resulting in a number of tangible benefits including reduction in infection, use of intravenous antibiotics, and duration of hospital stay. However, the final role for these agents in the treatment of acute leukemia remains controversial and still to be fully defined.

Are prophylactic haematopoietic growth factors of value in the management of patients with aggressive non-Hodgkin's lymphoma?

Combination chemotherapy used to treat patients with aggressive non-Hodgkin's lymphoma is associated with neutropenia and subsequent infection, hospital admission and treatment delays. Haematopoietic growth factors (HGF) can prevent neutropenia and improve quality of life. We undertook a meta-analysis of six randomised and one nonrandomised trials to quantify the effect in previously untreated patients, and a simple cost-effectiveness analysis. The trials compared HGF plus chemotherapy with chemotherapy alone. In total, there were 779 patients aged between 15 and 82 years. Haematopoietic growth factors was associated with a statistically significant 44% reduction in the incidence of severe neutropenia (neutrophil count <0.5 × 10⁹ l⁻¹), a 60% reduction in the number of hospital admissions due to infection, an 80% reduction in the number of patients who had a treatment delay due to neutropenia and a 50% reduction in hospital stay. These data together with UK G-CSF drug costs were combined to develop a simple cost-effectiveness model, based on direct costs. Given the current cost of G-CSF, it would only be cost-effective among patients in which high rates of hospital stay due to neutropenia or infection are expected. Alternatively, if the cost could be reduced then all patients may be able to obtain the benefits. However, the evidence that prophylactic HGFs are clinically worthwhile is clear.

Résultats d’une enquête de pratique en onco-hématologie réalisée en France en 2001

Further to the organisation of out-patient management, it appeared necessary to understand the type of organisation of the hospital teams working in oncology and haematology. Questions were asked on the medical workforce in the hospital, the rules for the organisation of the management fo these patients, the type of organisation in the patients homes and the choice of treatment. THE PERCENTAGE OF RESPONSE: Thiry-one centres (46%) replied to the survey: 20 hospital centres with 5 departments of paediatrics and 11 oncology departments. Around two thirds of the centres in France confronted with short lasting neutropenia with fever opted for their treatment at home. WHAT IS IMPORTANT: Although the responsibility of those surrounding the patient and that of the treating physician are clearly implied, the general practitioner frequently has no access to training or to the information necessary to be able to manage the initial assessment and the potentially unfavourable evolution. And this is the pivotal point of the external hospital treatment system.

Haemopoietic growth factors for neonates: assessing risks and benefits

This review summarises the rationale, clinical trial evidence for benefit and potential toxicities of Erythropoietin, Thrombopoietin, Granulocyte Colony Stimulating Factor and Granulocyte-Macrophage Colony Stimulating Factor. Erythropoietin has failed to have a clinical impact on red cell transfusion requirement in very low birth weight infants; it is uncertain whether Thrombopoietin will find a significant clinical role in neonatal thrombocytopenia and there is, as yet, insufficient evidence for the routine use of Granulocyte- or Granulocyte-Macrophage Colony Stimulating Factor to prevent or treat bacterial infection. A number of theoretical risks of haemopoietic growth factor use in neonates have been suggested, but no toxicities have been observed during their clinical use. Exploring the potential for benefit in selected groups of infants should be encouraged.

Managing hematologic toxicities

This overview of the hematologic toxicities of cancer chemotherapy addresses the frequency and clinical significance of neutropenia, anemia, and thrombocytopenia and attempts to provide evidence-based guidelines, based on clinical trials, for the use of cytokine growth factors and transfusion support. The current emphasis on high-dose and dose-dense chemotherapy increases the need for close attention to the amelioration ofhematologic toxicities. The latter is highly dependent upon the appropriate and judicious use of cytokine support. Although these supportive agents may be relatively nontoxic, it is important to understand their potential side effects and to use them only when warranted by evidence-based studies.

5-azacitidine: An alternative treatment of myelodysplastic syndromes in patient with refractory response to hematopoietic growth factor, a case report and review of literatures

Myelodysplastic Syndrome (MDS) comprises a heterogeneous group of clonal hemopathies derived from an abnormality affecting a multipotent hematopoietic stem cell and characterized by maturation defects resulting in ineffective hematopoiesis. It most frequently occurs in elderly patients. Despite trials testing numerous agents in patients with MDS, no single drug has yet emerged as the accepted standard of treatment. Most MDS patients, due to their age and co morbidity, are not eligible for allogeneic hematopoietic stem cell transplantation; the only established curative regimen. The effect of available lineage-specific growth factors is limited to improvement of single lineages and has not resulting in the survival benefit. Treatment with low dose Ara-C is disappointing in regard to response rate or duration. No benefit has been demonstrated in differentiation inducers such as retinoids and Vitamin D3 as single agents. We report a case of a patient with transfusion dependent MDS who was not a candidate for allogeneic stem cell transplantation or cytotoxic chemotherapy, who also failed to response to erythropoietin support but had a favorable response to 5-azacitidine. His blood transfusion requirement reduced significantly, and was correlated with the remarkable improvement of the pancytopenia, particularly anemia and thrombocytopenia after receiving the investigational therapy with 5-azacitidine. In summary, 5-azacitidine appears to be a promising alternative therapy for patient with refractory anemia secondary to MDS.

Optimizing the management of chemotherapy-induced neutropenia

Chemotherapy-induced neutropenia (CIN), the most common dose-limiting toxicity of cancer chemotherapy, is associated with numerous clinical, personal, and economic consequences. The principal strategies for managing CIN are reducing the dose intensity of the chemotherapy, using antibiotics, and using colony-stimulating factors (CSFs). Reducing or delaying the chemotherapy dose is effective, but this can compromise treatment outcomes. Antibiotics can be lifesaving, but they are associated with numerous adverse effects and the emergence of resistant pathogens. The granulocyte CSF (G-CSF) filgrastim can reduce the incidence, duration, and severity of CIN, as well as the risk of infection, in patients treated with myelosuppressive chemotherapy. The availability of pegfilgrastim, a sustained-duration G-CSF that has benefits comparable to those of filgrastim with a single injection per chemotherapy cycle, has simplified CSF therapy.

Hematopoietic growth factors in myelodysplastic syndromes

The myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematopoietic stem cell disorders characterized clinically by refractory cytopenias in one or more myeloid cell lines and an increased probability of transformation to acute leukemia. Supportive care remains the mainstay of therapy in MDS and frequently includes monotherapy and combination therapy with hematopoietic growth factors, such as erythropoietin, granulocyte colony-stimulating factor, and granulocyte macrophage colony-stimulating factor. Clinical trials have demonstrated the ability of growth factors to improve neutropenia and anemia in selected patients with MDS, which may have clinical, quality-of-life, and economic benefits for patients even though overall survival has not been improved. This paper reviews the role of hematopoietic growth factors in the treatment of MDS.

Non-Hodgkin's lymphoma in the elderly. A review with emphasis on elderly patients, geriatric assessment, and future perspectives

With rising age the incidence of non-Hodgkin's lymphoma (NHL), together with the fact that the proportion of people older than 65 years in Western populations will double during the next 40 years, poses the challenge to adequately meet the needs of elderly patients. After a general introduction on cancer in the elderly, a review is given concerning aspects of epidemiology and prognostic factors of NHL. Therapeutic strategies, including the use of hematopoietic growth factors, for the elderly with aggressive NHL are discussed. The future role for so-called comprehensive geriatric assessment (CGA) to appropriately determine treatment possibilities is emphasized. Much scientific work has to be performed before the true value of CGA instruments can be acknowledged. Screening instruments are discussed and the role for specially trained oncology nurses in the assessment process is stipulated.

Cost effectiveness of myeloid growth factors in cancer chemotherapy

Healthcare costs continue to rise and hospitalization represents the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications, including febrile neutropenia (FN), remain the major dose-limiting toxicity of systemic cancer chemotherapy. Although under-reported, FN often occurs early in the course of chemotherapy and contributes substantially to the morbidity, mortality, and cost of treatment. The risk of FN and its complications are associated with treatment intensity, age, and various comorbidities. Myeloid growth factors (MGFs) have been used effectively in a variety of clinical settings to prevent or treat FN and assist patients receiving dose-intensive chemotherapy with or without stem cell support. A meta-analysis of the available randomized controlled trials has confirmed the efficacy of prophylactic MGFs. The cost of these agents, along with their large-scale clinical use, has prompted several economic investigations. Economic models based on measures of resource use derived from randomized controlled trials have provided estimates of expected treatment costs, along with FN risk threshold estimates for the cost-saving use of prophylactic MGF. Recent studies have demonstrated the potential value of targeting MGFs toward patients at greatest risk based on accurate and valid predictive models. Although an emerging role has become apparent for MGFs in managing adult leukemia and supporting high-dose therapy with stem cell transplantation in adults, their value in the support of children in these settings remains unclear. Continuing clinical and economic evaluation, along with an updating of clinical practice guidelines because of rapid technologic and clinical advances, is encouraged.