Elderly Vulnerable to Febrile Neutropenia Early in Chemotherapy

BOSTON—A review of more than 1,600 patients in the Oncology Practice Pattern Study found a 50% higher risk of febrile neutropenia for elderly patients than younger patients. Most incidents occurred during the first 21 days of chemotherapy, according to a presented at the third meeting of the International Society of Geriatric Oncology (SIOG abstract P-22). Based on the analysis, Vincent Caggiano, MD, medical director, Sutter Cancer Center, Sacramento, and his colleagues urged oncologists to consider giving prophylactic colony-stimulating factors (CSFs) during the first two chemotherapy cycles—especially among older patients who are more vulnerable to the complication.

"Age is the leading risk factor. We broke it at age 60, but if you go to age 70 or more, the risk is even higher," he told ONI. "We conclude that non-use of prophylactic CSFs is associated with an increased risk of febrile neutropenia."

The investigators retrospectively examined the medical records of 704 patients with non-Hodgkin’s lymphoma (NHL) and 913 patients with early-stage breast cancer. Of these, 211 patients (13%) had one or more hospitalizations for febrile neutropenia. All received chemotherapy between 1991 and 1999 at 16 oncology practices; 60% were under age 60 (median age, 57).

For all patients, febrile neutropenia was most likely to occur during the first two cycles, with the period of greatest hazard peaking midway through cycle 1. Half of all first neutropenic hospitalizations occurred by day 21 and slightly more than two thirds by the end of the second cycle.

Patients age 60 and above were significantly more likely to experience febrile neutropenia. They accounted for 61% of patients hospitalized with the complication, but only 39% of those who did not have an episode. Other significant risk factors were renal disease (9% of patients with febrile neutropenia vs 1.3% of those without) or cardiovascular disease (18.5% vs 7.9%, respectively).

The investigators also reported increased risk of febrile neutropenia when the planned average relative dose intensity exceeded 85% for early-stage breast cancer patients or 80% for NHL patients. The latter were more likely to be hospitalized for febrile neutropenia. NHL patients were only 44% of the total sample but accounted for 70% of febrile neutropenic episodes.

Prophylactic use of CSFs was rare, he said. No early use of CSF was recorded in 91% of patients with febrile neutropenia and in 92.1% of those without.

Dr. Caggiano concluded that "in elderly patient with comorbid conditions and other risk factors for febrile neutropenia, you have to strongly consider use of prophylactic CSFs during those first two cycles of chemotherapy, when there is the highest incidence."

The analysis received support from Amgen, Inc., Thousand Oaks, Calif, manufacturer of the CSFs filgrastim (Neu-pogen) and pegfilgrastim (Neulasta).