Limitations When Managing Chemo-Induced Myelosuppression

Jared Weiss, MD: Considering how well the myelosuppressive treatments work, such as G-CSF [granulocyte colony-stimulating factor] and ESAs [erythropoietin-stimulating agents], there’s a lot to be desired. Beginning with neutropenia, pegfilgrastim is the most commonly used, and it causes a lot of bone pain. When I give regimens with a high risk of febrile neutropenia and I give prophylactic pegfilgrastim, sometimes bone pain is the dominant effect in my patients’ quality of life, the thing that they talk to me about the most. My preventive measure is harming quality of life, and that’s of course a problem, and they don’t work completely. Some patients still have breakthrough events. The ESAs have a black box warning. They’re hard to give. Your patient must give consent that awful things can happen to them, you have to be part of a REMS [Risk Evaluation and Mitigation Strategy] program, they’re infrequently used in the United States. My opinion is that if we stick within the guidelines and indicated use, they probably should have a role, but in reality they don’t. Blood transfusions are problematic, not just in the COVID-19 era. Intermittently we have problems with adequate blood supply. You can have volume overload with a blood transfusion. You can have allergic reactions and all kinds of transfusion reactions, and it’s immunosuppressive to get somebody else’s blood. Then I don’t transfuse platelets or use TPO [thrombopoietin] mimetics that often in the care of small cell lung cancer. I don’t see bleeding that often in the care of small cell lung cancer. But I do often see dose reductions and dose delays; these can potentially harm treatment outcomes. They certainly cause patient anxiety, and they have financial costs associated with them. There remains a large unmet need.

Charu Aggarwal, MD, MPH: One of the main things that G-CSF and ESAs don’t meet is our needs around thrombocytopenia. There are many patients whose primary toxicity is platelets, especially patients who have been heavily pretreated tend to have more thrombocytopenia. And while we can support white [blood] cells and administer blood transfusions, we often can’t do that easily for somebody with a platelet count of 70,000 or 80,000 [per μL], where we don’t feel comfortable proceeding with chemotherapy, yet we don’t have something to offer them right away. That’s universal across all solid tumors, and I even see it in non–small cell lung cancer, especially in my patients receiving chemotherapeutic regimens such as gemcitabine.

Transcript edited for clarity.