Chapter 081. Principles of Cancer Treatment (Part 20)

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Transfusion of granulocytes has no role in the management of febrile neutropenia, owing to their exceedingly short half-life, mechanical fragility, and clinical syndromes of pulmonary compromise with leukostasis after their use. Instead, colony-stimulating factors (CSFs) are used to augment bone marrow production of PMNs. Early-acting factors such as IL-1, IL-3, and stem cell factor, have not been as useful clinically as late-acting, lineage-specific factors such as GCSF (granulocyte colony-stimulating factor) or GM-CSF (granulocyte- macrophage colony-stimulating factor), erythropoietin (EPO), thrombopoietin, IL6, and IL-11. CSFs may easily become overused in oncology practice. ...

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Chapter 081. Principles of Cancer Treatment (Part 20) Transfusion of granulocytes has no role in the management of febrile neutropenia, owing to their exceedingly short half-life, mechanical fragility, and clinical syndromes of pulmonary compromise with leukostasis after their use. Instead, colony-stimulating factors (CSFs) are used to augment bone marrow production of PMNs. Early-acting factors such as IL-1, IL-3, and stem cell factor, have not been as useful clinically as late-acting, lineage-specific factors such as G- CSF (granulocyte colony-stimulating factor) or GM-CSF (granulocyte- macrophage colony-stimulating factor), erythropoietin (EPO), thrombopoietin, IL- 6, and IL-11. CSFs may easily become overused in oncology practice. The settings in which their use has been proved effective are limited. G-CSF, GM-CSF, EPO,
and IL-11 are currently approved for use. The American Society of Clinical Oncology has developed practice guidelines for the use of G-CSF and GM-CSF (Table 81-3). Table 81-3 Indications for the Clinical Use of G-CSF or GM-CSF Preventive Uses With the first cycle of chemotherapy (so-called primary CSF administration) Not needed on a routine basis Use if the probability of febrile neutropenia is ≥20% Use if patient has preexisting neutropenia or active infection Age >65 treated for lymphoma with curative intent or other tumor treated by similar regimens Poor performance status
Extensive prior chemotherapy Dose-dense regimens in a clinical trial or with strong evidence of benefit With subsequent cycles if febrile neutropenia has previously occurred (so- called secondary CSF administration) Not needed after short duration neutropenia without fever Use if patient had febrile neutropenia in previous cycle Use if prolonged neutropenia (even without fever) delays therapy Therapeutic Uses Afebrile neutropenic patients No evidence of benefit Febrile neutropenic patients
No evidence of benefit May feel compelled to use in the face of clinical deterioration from sepsis, pneumonia, or fungal infection, but benefit unclear In bone marrow or peripheral blood stem cell transplantation Use to mobilize stem cells from marrow Use to hasten myeloid recovery In acute myeloid leukemia G-CSF of minor or no benefit GM-CSF of no benefit and may be harmful In myelodysplastic syndromes Not routinely beneficial
Use intermittently in subset with neutropenia and recurrent infection What Dose and Schedule Should Be Used? G-CSF: 5 µg/kg per day subcutaneously GM-CSF: 250 µg/m2 per day subcutaneously Peg-filgrastim: one dose of 6 mg 24 h after chemotherapy When Should Therapy Begin and End? When indicated, start 24–72 h after chemotherapy Continue until absolute neutrophil count is 10,000/µL Do not use concurrently with chemotherapy or radiation therapy Note: G-CSF, granulocyte colony-stimulating factor; GM-CSF, granulocyte-macrophage colony-stimulating factor.
Source: From the American Society of Clinical Oncology.