Managing Neutropenia EffectivelyMay Improve Outcomes in ElderlyCancer Patients

MANHASSET, New York-Effectivemanagement of neutropeniamay give elderly patients the bestchance of cure, survival, or palliation,according to Stuart Lichtman, MD.Growth factors can be used to treatneutropenia, allowing for full deliveryof standard-dose chemotherapy, andthat may lead to better patient outcomes,said Dr. Lichtman, associateprofessor of clinical medicine, NYUSchool of Medicine, Division of Oncology,North Shore UniversityHospital, Manhasset, New York. Dr.Lichtman spoke at a satellite symposiumsponsored by Amgen and held inconjunction with the first annual GeriatricOncology Consortium multidisciplinaryconference.Optimal OutcomesWith effective strategies for managingmyelosuppression, elderly patientscan "look forward to a positiveoutcome with their treatment as muchas younger patients," Dr. Lichtmansaid.Maintaining the desired dose andschedule of chemotherapy may be veryimportant for optimal treatment outcome,as multiple investigations show.In one often-quoted study (J ClinOncol 4:295-305, 1986), lymphomapatients more than 65 years of age hadonly a 37% complete response rate toCHOP (cyclophosphamide [Cytoxan,Neosar]/doxorubicin HCl/vincristine[Oncovin]/prednisone)-based therapy;however, many elderly patients hadarbitrary dose reductions, based solelyon their age. Among elderly patientswho received full-dose chemotherapy, the complete response rate was52%, similar to that seen in youngerpatients.Recently, studies have proven benefitsof hematopoietic growth factorsupport in the elderly. Based on threerandomized studies of the elderly, includingtwo published in 2003, "it'spretty clear that...the growth factors doreduce neutropenia and neutropenicinfections, and it helps maintain doseintensity," Dr. Lichtman said. "However,we still have not been able toprove that the overall survival and distheease-free survival has been enhanced."Clearly, more prospective studiesof the role of growth factors in theelderly cancer population are needed.According to Dr. Lichtman, the GeriatricOncology Consortium is conductinga study to determine whetherprimary prophylaxis with pegylatedfilgrastim (Neulasta) can enhance chemotherapysafety and outcome.In 2002 at ASCO, researchersshowed that, in elderly patients withbreast cancer, pegfilgrastim shows safetyand efficacy similar to filgrastim(ASCO abstract 260). "In light of thestudies just published, I think this typeof clinical trial is even more important,because there are many unansweredquestions," Dr. Lichtman said.Dose-Dense Strategieson the RiseGrowth factors may also allow newerdose-dense chemotherapy regimensto be used in older patients. A recentbreast cancer trial (CALGB [Cancerand Leukemia Group B] 9741) showeddose-dense adjuvant chemotherapyimproved disease-free survival andoverall survival vs standard-dose chemotherapy;the treatment approach,which incorporates hematopoieticgrowth factors as part of the deliverystrategy, may be "feasible" for elderlycancer patients, Dr. Lichtman said."Older patients, in the next fewyears, are really going to be treatedmuch more commonly with the newdose-dense regimens which have recentlybeen published," Dr. Lichtmansaid. "It's going to be our job to selectpatients who are most appropriate forthese therapies."In addition, a German lymphomastudy group has shown that, specificallyin older patients, a 14-day CHOPregimen provided a better outcome vsstandard dose CHOP therapy (seestudy by Boccia et al, reported on page2 of this issue)."I don't think we are ready to goover completely to this kind of regimen,but certainly the feasibility ofthese new schedules is really going tobecome applicable to selected olderpatients," Dr. Lichtman said. "We havethe ability to minimize toxicity."