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ASCO Updates Guidelines for Use of Colony-Stimulating Factors

Changes include addition of tbo-filgrastim and filgrastim-sndz

The 2006 American Society of Clinical Oncology guidelines on the use of hematopoietic colony-stimulating factors (CSFs) have been updated, according to a special article published online in the Journal of Clinical Oncology.

Thomas J. Smith, MD, of the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center in Baltimore, and colleagues conducted a systematic review of the literature and updated the 2006 American Society of Clinical Oncology guidelines on the use of hematopoietic CSFs.

According to the authors, changes to prior recommendations include the addition of tbo-filgrastim and filgrastim-sndz; in older patients with diffuse aggressive lymphoma, the recommendation regarding routine CSF use was moderated; and recommendations in favor of high-dose chemotherapy in urothelial cancer and against routine dose-dense chemotherapy in lymphoma were added. Recommendations regarding CSF use in acute myeloid leukemia or myelodysplastic syndromes in adults were not addressed. Prophylactic use of CSFs is warranted to reduce the risk of febrile neutropenia when no other equally effective and safe CSF-free regimen is available. Primary prophylaxis is recommended for those at high risk of febrile neutropenia.

“ASCO guidelines are developed for implementation across health settings,” the authors write. “Barriers to implementation include the need to increase awareness of the guideline recommendations among front-line practitioners and survivors of cancer and caregivers and also to provide adequate services in the face of limited resources.”

Key points in the new recommendations include the following:

  • Primary prophylaxis with a CSF starting with the first cycle and continuing through subsequent cycles of chemotherapy is recommended in patients who have an approximately 20% or higher risk for febrile neutropenia based on patient-, disease- and treatment-related factors. Primary CSF prophylaxis should also be administered in patients receiving dose-dense chemotherapy when considered appropriate.
  • Secondary prophylaxis with a CSF is recommended for patients who experienced a neutropenic complication from a prior cycle of chemotherapy (for which primary prophylaxis was not received), in which a reduced dose or treatment delay may compromise disease-free or overall survival or the treatment outcome. In many clinical situations, dose reduction or delay may be a reasonable alternative.
  • CSFs should not be routinely used for patients with neutropenia who are afebrile.
  • Dose-dense regimens with CSF support should be used only if supported by convincing efficacy data or within an appropriately designed clinical trial.
  • CSFs may be used alone, after chemotherapy, or in combination with plerixafor to mobilize peripheral-blood progenitor cells.
  • CSFs should be administered after autologous stem-cell transplantation to reduce the duration of severe neutropenia.
  • CSFs may be administered after allogeneic stem-cell transplantation to reduce the duration of severe neutropenia.
  • Prophylactic CSFs for patients 65 years of age or older with diffuse aggressive lymphoma treated with curative chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) should be considered, particularly in the presence of comorbidities.
  • The use of CSFs in pediatric patients will almost always be guided by clinical protocols. As in adults, the use of CSFs is reasonable as primary prophylaxis for pediatric patients with a high likelihood of febrile neutropenia.
  • For pediatric indications in which dose-intense chemotherapy is known to have a survival benefit, such as Ewing sarcoma, CSFs should be used to enable the administration of these regimens.
  • CSFs should not be used in pediatric patients with nonrelapsed acute lymphoblastic leukemia or nonrelapsed acute myeloid leukemia who do not have an infection.
  • Pegfilgrastim, filgrastim, tbo-filgrastim, and filgrastim-sndz (and other biosimilars, as they become available) can be used for the prevention of treatment-related febrile neutropenia. The choice of agent depends on convenience, cost, and clinical situation.
  • Current recommendations for the management of patients exposed to lethal doses of total-body radiotherapy, but not doses high enough to lead to certain death resulting from injury to other organs, include the prompt administration of CSFs or pegylated granulocyte CSFs.

Sources: Medical Xpress; July 14, 2015; and JCO; July 13, 2015.


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