JCO: Are Hematopoietic Colony-Stimulating Factors Over- or Underused?

Are Hematopoietic Colony-Stimulating Factors
Over- or Underused?

"Since their introduction, there has been debate about the benefits,
risks, and costs of hematopoietic colony-stimulating factors
(CSFs). We suggest that the use of CSFs to allow dose maintenance of
chemotherapy for common metastatic solid tumors is unsupported
by evidence, and we should reconsider using a $3,500-per-cycle injection
for a supportive care drug without major benefit......."

Comments and Controversies -

  A Way Forward on the Medically Appropriate Use of White Cell Growth Factors

 JCO published online on February 27, 2012; DOI:10.1200/JCO.2011.39.9980.

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Table 1. Comparison of Major Guidelines 

 

How Did We Arrive at Widespread Use Without
Clinical Trial Justification?

 

The Way Forward to Evidence-Based Use of CSFs

"Increased concern about escalating costs 46-48 should cause us to
examine each component of current care. Oncology professional societies have demanded some demonstrable improvement in an important outcome before adoption of a new technology.49 The lack of
proven benefit from CSFs in support of therapy in common advanced
solid tumors, the high cost, the disparate US and world use patterns
with no difference in mortality, 50 and the potential for or appearance
of economic self-interest should give the oncology community pause.
There are concrete steps the US oncology community can take to
foster more evidence-based care. The Quality Oncology Practice Initiative 51 could add overuse as a quality criterion 52 and report CSF use in palliative-intent regimens when there is less than a 20% risk of FN. The major guideline groups (European Organisation for Research and Treatment of Cancer,6 National Comprehensive Cancer Network,5
and ASCO4) should endorse dose modification as an equally appropriate and preferred strategy in the absence of proven benefit."

 

 

full free access: Personalized Medicine and Cancer Supportive Care: Appropriate Use of Colony-Stimulating Factor Support of Chemotherapy

"Unfortunately, patients in RCTs (randomized clinical trials) are often highly selected, and toxicities, including FN, are frequently underreported (18). In addition, chemotherapy dose intensity and the use of prophylactic CSF or antibiotics are infrequently reported in RCTs, making it difficult to assess the true burden of neutropenic complications associated with a chemotherapy regimen (18)." "....Although there is little debate that both underuse and overuse of the CSFs occur in clinical practice, accurate estimates of the true magnitude and impact of such considerations remain elusive. What is clear is that there is a need for greater attention to chemotherapy-associated toxicities along with accurate prediction tools for the assessment of individual patient risks, including FN (febrile neutropenia) and its complications. Such tools could improve the evidence base for practice guidelines and aid clinicians in the selection of patients with cancer who are at an individual increased risk for FN, and therefore, appropriate candidates for the clinically effective and cost-effective use of the CSFs (40)."