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Corticosteroids, IV antibiotics increase risk for chemotherapy-induced febrile neutropenia
Use of corticosteroids, certain dermatologic or mucosal conditions, and antibiotics all appeared to increase risk for chemotherapy-induced febrile neutropenia among a cohort of patients undergoing cancer treatment with myelosuppressive chemotherapy, according to study findings published in Journal of the National Comprehensive Cancer Network.
“Febrile neutropenia is life threatening and often requires hospitalization. Furthermore, febrile neutropenia can lead to chemotherapy dose delay and dose reduction, which, in turn, negatively impacts antitumor efficacy,” Chun Rebecca Chao, PhD, researcher in the department of research and evaluation at Kaiser Permanente Southern California, said in a press release. “However, it can be prevented if high-risk individuals are identified and treated prophylactically.
“One way to reduce the incidence rate for febrile neutropenia could be to schedule prior corticosteroid use and subsequent chemotherapy with at least 2 weeks between them,” Chao added. “Physicians should also consider which patients are at higher risk for febrile neutropenia, as identified by our study, when making decisions about using prophylactic treatment like granulocyte-colony stimulating factor.”
Chao spoke with HemOnc Today about the rationale for the study, what the results showed, the implications of the findings and the next steps for research.
Question: How common is febrile neutropenia among individuals undergoing chemotherapy?
Answer: This depends on the chemotherapy regimen. Some regimens are more myelosuppressive than others, so febrile neutropenia incidence can range from less than 5% to greater than 20%. NCCN guidelines define high-risk regimens as those with a 20% or higher risk for febrile neutropenia, whereas medium-risk regimens are those with 10% to 20% risk, and low-risk regimens are those associated with febrile neutropenia risks less than 10%.
Q: How does the condition affect morbidity and mortality?
A: Research shows that hospital mortality for patients with chemotherapy-induced febrile neutropenia is approximately 10%. Other research showed that febrile neutropenia increased risk for death during the course of chemotherapy by 35%.
Q: Can you describe the rationale for your study?
A: Successful prevention and management of febrile neutropenia risk is critical to mitigate the human and economic toll of febrile neutropenia in oncology. Modification of febrile neutropenia risk is possible through the use of granulocyte-colony stimulating factor. However, it is only cost-effective for high-risk individuals. Our group has been studying patient-level and chemotherapy regimen-based risk factors for febrile neutropenia for several years. This study represents a continuation of our effort to identify novel risk factors to aid clinical febrile neutropenia risk prediction.
Q: How did you conduct the study?
A: We examined the cancer treatment history and the development of febrile neutropenia during the first cycle of chemotherapy among 15,971 patients diagnosed with one of six malignancies — breast, lung, colorectal, ovarian or gastric cancers, or non-Hodgkin lymphoma — treated with myelosuppressive chemotherapy between 2000 and 2009 at Kaiser Permanente Southern California. We ascertained the clinical history of interest using patients’ electronic health records. We then used statistical methods to evaluate whether there is an independent relationship between the clinical history of interest and the risk for febrile neutropenia among these patients.
Q: What did results show?
A: Use of corticosteroids, IV antibiotics, and certain dermatologic and mucosal conditions prior to chemotherapy are associated with increased risk for febrile neutropenia in the first cycle of chemotherapy. Corticosteroids appeared to increase risk most significantly. Long-term use was associated with a doubling of risk and recent use was associated with a tripling of risk. Other factors — such as prior surgery, prior and concurrent radiotherapy, and prior oral antibiotic use — were not associated with febrile neutropenia risk.
Q: What are the implications of the results?
A: The relationship between recent use of corticosteroids and febrile neutropenia deserves the most attention, given the magnitude of the risk increase and the prevalence of this risk factor. Corticosteroids are commonly used in non-Hodgkin lymphoma and patients with lung cancer prior to chemotherapy. If possible, timing corticosteroid use and subsequent chemotherapy to be at least 2 weeks apart may help reduce the risk for febrile neutropenia induced by the immunosuppressive effect of corticosteroids. Physicians also should consider risk factors as identified by this study when making prophylactic decisions, especially for patients who receive chemotherapy regimens that are ranked intermediate risk for febrile neutropenia.
Q: What is next for research?
A: Prediction models that incorporate these new risk factors will help physicians determine whether use of prophylactic granulocyte-colony stimulating factor is appropriate. Next steps for research also will include deciphering patient genetic factors that predispose patients to risk for chemotherapy-induced complications such as febrile neutropenia. – by Jennifer Southall
Reference:
Family L, et al. J Natl Compr Canc Netw. 2018;doi:10.6004/jnccn.2018.7051.
For more information:
Chun Rebecca Chao, PhD, can be reached at Southern California Permanente Medical Group, 2nd Floor, 100 S. Los Robles Ave., Pasadena, CA 91101; email: chun.r.chao@kp.org.
Disclosure: Chao reports research funding from Amgen.