Febrile Neutropenia - timely advice for the empowered patient

[alanbarlee]

(This article is reproduced from 'Cure Today', 30/11/18)

Researchers Identify Risk Factors of Chemotherapy Side Effect

Preventing febrile neutropenia is crucial because the body’s white blood cells help to fight infection.

BY KATIE KOSKO

PUBLISHED NOVEMBER 13, 2018

People being treated with chemotherapy are at risk of developing febrile neutropenia — a dangerously low white blood cell count, which increases their chance of serious infection. Researchers have identified factors related to the risk, according to study findings published in theJournal of the National Comprehensive Cancer Network.

The researchers determined that the timing and length of use for corticosteroids — medications that mimic the effects of the hormone cortisol — influences the likelihood of febrile neutropenia occurring in patients treated with chemotherapy.

“For febrile neutropenia it is important that patients at high risk are managed with prophylactic treatment,” lead author Chun Rebecca Chao, Ph.D., from Kaiser Permanente Southern California Department of Research & Evaluation, said in an interview with CURE. “The consequences (of febrile neutropenia) can be so severe and life-threatening, which requires hospitalization. It can also affect the chemotherapy schedule, which negatively affects the person’s cancer outcome.”

Researchers from Kaiser Permanente Southern California examined 15,971 patients who either had non-Hodgkin lymphoma, breast, lung, colorectal, ovarian or gastric cancer. All patients were treated with chemotherapy between 2000 and 2009. The researchers evaluated the relationship between several suspected risk factors, including radiation therapy; surgery prior to chemotherapy; oral corticosteroid use; oral and IV antibiotic use; and selected dermatologic and mucosal conditions, such as gastritis, dermatitis and psoriasis, and risk of febrile neutropenia.

More than 60 percent of patients had prior surgery and 44 percent had taken oral antibiotics. Radiation therapy was received by 6.6 percent and 2.6 percent of patients in the period prior to and concurrent with chemotherapy, respectively. And oral corticosteroid use was found in 5.6 percent of patients prior to chemotherapy.

During the first chemotherapy cycle, 4.3 percent of patients developed febrile neutropenia. Recent use of corticosteroids was associated with greatest risk of febrile neutropenia, long term use increased the risk further —two and three times the risk, respectively. Similarly, dermatologic and mucosal conditions and IV antibiotics before chemotherapy also proved for higher risk.

“Corticosteroid use is associated with quite higher risk of febrile neutropenia,” Chao said. “Corticosteroids are immunosuppressive drugs, and we know that immunosuppressive drugs are linked to risk of febrile neutropenia, but this study shows that it doesn’t require long-term use of corticosteroids. Even short-term use is still associated with double the risk.”

Preventing febrile neutropenia is crucial because the body’s white blood cells help to fight infection. “When you have low neutrophil counts in the body that means that while a person is on that treatment their body does not have defense against bacterial and fungal infections,” Chao said. “If the count is low enough, they can have very severe infections that can lead to sepsis, which is life-threatening.” The side effect can be treated with IV antibiotics and require a hospital stay until a patient’s counts rise.

It’s best for patients to advocate for themselves and initiate a conversation with their oncologist. “Patients need to understand what the chemotherapy agents do to their disease and also what they do to the rest of the body,” Chao said. “Patients should talk with their physician to choose a regimen that is most beneficial for them in terms of the goal of treating the cancer and managing quality of life.”

 

(Inserted comment: 'Neulasta' is a prophylactic medication that is relevant in this setting, and would be worth raising with your medical oncologist).

 

[Charles (Chuck) Maack]

Good information, Alan! Abiraterone Acetate/Zytiga requires 5mg Prednisone, a corticosteroid, twice daily.  For those prescribed this medication, or any medication requiring a corticosteroid, it would be important to have white blood cell counts checked regularly - and certainly if moving to chemotherapy after being prescribed a corticosteroid for any length of time previously or continuing to be so prescribed! 

[DavidW]

This is true. For the whole of 2017 I had 10 doses over 8 months of Cabazitaxel. My low cell numbers during that time  meant 3 visits to overnight hospital and numerous blood transfusions on a regular basis. I was discouraged from going out in crowds. The hospital visits were marked neutropenic and I had a private room to avoid other patients.  At one stage I had a BP of 60/40  (normally 160/140) so that meant a hospital night also. Apparently not all of us respond the same but for me a year after the Chemo stopped I cant walk without a walker or wheelchair because of peripheral neuropathy. My PSA dropped to nothing but quickly started to rise again.

I have just had my third dose of Lutetium - no side effect and  dropping PSA to 2. Empty pocket at $30,000 to date.

David W

[JimJimJimJim]

Neulasta is on the PBS if:

 

High risk

Conditions for supply are:

Authority Required
Chemotherapy-induced neutropenia

Clinical criteria:

Patient must be receiving chemotherapy with the intention of achieving a cure or a substantial remission,

AND

Patient must be at greater than 20% risk of developing febrile neutropenia; OR

Patient must be at substantial risk (greater than 20%) of prolonged severe neutropenia for more than or equal to seven days.

 

Blood counts a problem

Authority Required
Chemotherapy-induced neutropenia

Clinical criteria:

Patient must be receiving chemotherapy with the intention of achieving a cure or a substantial remission,

AND

Patient must have had a prior episode of febrile neutropenia; OR

Patient must have had a prior episode of prolonged severe neutropenia for more than or equal to seven days.

[Kezza2]

Great info - thanks Alan.   I was on abiraterone plus pred for 2 years before it failed.  Now,  I have had number 5 docetaxel a week ago, and take 2 x 4mg Dex twice a day on the day before chemo and the day after, then cut it back to 1 x 4mg twice a day for the next two days, before reverting to 2 x 5mg Pred per day for the rest of the cycle.  I also have a jab of Neulasta the day after chemo, because my neutrophill count was through the floor after the first chemo.  That said, I picked up a particularly nasty virus that is doing the rounds after chemo number 4, and now four weeks later and three courses of antibiotics I still cannot shake it.  PSA has dropped from 42 to 18 after 4 chemo sessions, so I guess it is working.  PSMA PET scans scheduled after next chemo, so here's hoping for a good outcome.

[John Murphy]

Very interesting Alan and Jim regarding Prednisolone and neutropenia. Thanks.

After Zytiga/Abiraterone, which only lasted for around 9 months I then had 10 courses of Docetaxel, which brought my PSA down but only lasted around 6 months before my PSA started to increase. Then came 31 treatments of Cabalitaxel, at intervals of mostly 3 weeks.

Prednisolone was also prescribed at 2 tablets of 5mg per day, apart from chemo days when I receive 25 mg. My MO is pretty relaxed about the dose rate so now I only take 2.5 mg per day. Bloods are done every three weeks (with a few longer intervals) and currently my PSA is around 0.25 and my white cell counts are just within the accepted range.  Apart from the usual side effects things appear to be OK. My latest PSMA etc scans look good.

 

[DavidW]

Hi to John Murphy 

i had ten doses of cabazitaxel and it left me with severe peripheral neuropathy now endured for twelve months with little change. Wheelchair and walking aids are now my life. How on earth you survived with so many  docataxel and cabazitaxel I’ll never  know. I’m now on  zoladex and prednisone and my third lutetium treatment- psa is two.Wekeep going as long as we can.

David W

[alanbarlee]

Hi Folks,

Here's a bit of additional news on Neulasta (pegfilgrastim): a lower cost biosimilar has recently been approved in USA and Europe.

The following comprises short extracts from a news release in 'Onc Live' (5/11/18):

 

"The FDA has granted an approval to pegfilgrastim-cbqv (CHS-1701; Udenyca), a pegfilgrastim (Neulasta) biosimilar, for patients with cancer receiving myelosuppressive chemotherapy, according to Coherus BioSciences, Inc, the manufacturer of the agent. The biosimilar was also granted approval by the European Commission for the same indication on September 21, 2018.

Pegfilgrastim-cbqv is a PEGylated growth colony-stimulating factor designed to decrease incidence of infection from febrile neutropenia associated with patients who have nonmyeloid malignancies receiving anti-cancer myelosuppressive therapy.

Regarding safety, the most common adverse events (≥5%) associated with pegfilgrastim compared with placebo, as seen in a randomized, double-blind, placebo-controlled study in patients with metastatic or non-metastatic breast cancer, are bone pain (31% vs 26%) and pain in extremity (9% vs 4%). In other studies, leukocytosis was reported in less than 1% of 932 patients with nonmyeloid malignancies treated with pegfilgrastim".

 

Alan