CIN Prophylaxis: Treating With G-CSFs

Hope S. Rugo, MD, FASCO: It’s interesting to talk about this. It leads nicely into our next section, which is talking about our current standards of care for chemotherapy-induced neutropenia. We’ve talked about some of the issues, but I want to get into more detail about what we’re doing: the goal of growth factor prophylaxis and the agents and regimens we use for prophylaxis, how these agents work, how effective they are, and the adverse effects we’re telling the patients about.

Bill, do you want to start with that topic?

William J. Gradishar, MD: We’ve all become very accustomed to using growth factor support, such as filgrastim or pegfilgrastim, in patients who have a high risk of developing neutropenia or regimens that are known and associated with a heightened risk. Patients who’ve demonstrated that they’re more sensitive as a result have experienced neutropenia in past cycles. In those patients, it’s triggered that subsequent cycles are usually going to be partnered with a growth factor. Generally speaking, most patients who get these agents do OK with them, but there are patients who develop boney pain. In some circumstances, we have to tease out whether it’s the chemotherapy drug, a taxane, or the growth factor support that’s causing the boney pain. These are among the things that we have to think about clinically when we’re seeing these patients.

Hope S. Rugo, MD, FASCO: Interesting thatyou mentioned that because I have a patient who has von Recklinghausen neurofibromatosis and a bunch of other things, including a really unfortunate ER [estrogen receptors]–positive early stage breast cancer. She already has had severe bone pain and went to the ER [emergency department], where they diagnosed her with pericarditis. I pointed out that she didn’t have that, but they didn’t believe me; she just had this drug-induced pain. Consequently, we’re working around that, but it can be a big issue for patients, as you mentioned.

If you have a patient who has CIN [cervical intraepithelial neoplasia], and you’re giving them weekly paclitaxel and they have neutropenia, how do you manage that? What do you do? If the patient had a fever, do you manage it differently? We don’t see febrile neutropenia all that commonly in early stage disease, but we do occasionally. Tiffany?

Tiffany A. Traina, MD: Fortunately, it’s been a long time since I’ve seen febrile neutropenia that has led to hospitalization. In practice, we use a lot of prophylactic growth factor in the adjuvant regimens. In metastatic disease, I often try to use the long-acting growth factor for quality of life and convenience for our patients. Even adjusting in some of our regimens that are 2 weeks on, 1 week off, we dose on day 9 of that regimen to hopefully help them through that 2-week interval before a day 1 start of the next cycle. There’s a lot of creative oncology there, especially in the palliative setting.

William J. Gradishar, MD: We have to take into account that some patients have to come back and start the growth factor. We have on-body and then we’ll get called that night because some light is doing nothing or some light is blinking…

Hope S. Rugo, MD, FASCO: Or it fell out. [Laughter and cross-talk.]

William J. Gradishar, MD: Sometimes I’ve got to go look at what the lights mean. I don’t know what they mean.

Tiffany A. Traina, MD: The challenges with wearing those on-body devices are patients can’t have imaging done or go through TSA [Transportation Security Administration]. There are all these restrictions on what they can and can’t do when wearing the device, but it certainly helps prevent a patient from having to come back to the doctor’s office the day after their infusion.

Hope S. Rugo, MD, FASCO: You can do manual screening if you’re flying, so that works OK, but the on-body device is interesting. Doctors would often give different amounts of pegfilgrastim if people didn’t need the full dose, but with the on-body device, we can’t do that. Additionally, I’ve had a very overweight patient for whom I don’t think a drug was delivered. She kept getting profound neutropenia, and then as soon as we switched to the injection, on day 2 it went away. I’m sure it was a delivery issue, which is unique to patient size and things like that.

Transcript edited for clarity.