Timing of Primary Prophylaxis G-CSF Use during Chemotherapy in Elderly Patients with NHL

Background: Febrile neutropenia (FN) and hospitalizations for infection are serious potential complications of myelosuppressive chemotherapy (chemo) treatment in cancer patients. Primary prophylactic G-CSF (PPG) is often used to decrease incidence of FN in patients at high risk. Due to the potential for G-CSF to stimulate neutrophil precursors at the same time as myelosuppression from chemotherapy, it is recommended that G-C SF be administered 24 hours after chemo administration. In addition, several studies showed that use of G-CSF on the same day as chemo may result in worse FN outcomes. Data are limited describing practice patterns of PPG timing relative to chemo administration in elderly patients with non-Hodgkin's lymphoma (NHL), overall and by agent.

Methods: The study population included non-HMO enrollees in the 20% Medicare sample with Parts A and B coverage who had NHL and initiated the first course of chemo between July 1, 2007, and November 30, 2011. PPG was defined as G-CSF initiated during days 0-5 of the first cycle, with day 0 the start of the chemo course. In patients with PPG, type of agent prescribed [Filgrastim (FIL), Sargramostim (SAR), or Pegfilgrastim(PEG)], timing of PPG initiation relative to chemo start date overall and by agent, and duration of prophylactic use (for the daily use agents FIL and SAR) were examined. Counts and percentages were estimated.

Results: The study cohort included 13,402 patients with NHL; 2690 (20.1%) received PPG. In these patients, the most common PPG agent used was PEG (2471; 91.9%) followed by FIL (171; 6.4%) and SAR (48; 1.8%). The median [interquartile range] of course duration (in days) for the daily use agents was 3.5 [2, 5] for FIL and 3 [1.5, 5] for SAR. Overall, first G-CSF use within the prophylactic period peaked on the day after chemo initiation (day 1, 47.3%) and steadily decreased from day 2 (22%) to day 5 (4%). About 5% of patients received PPG on the same day as chemo (day 0). Patterns were similar by agent type (Figure). More PPG with FIL than with PEG was used on days 4 and 5.

Conclusion: Use of prophylactic growth factor support is the recommended standard of care for patients at high risk of neutropenic infection. Consistent with the recommendations, PPG began most often on the day after chemo initiation regardless of agent type and more PPG with FIL started on day 4 or 5 after chemo initiation.

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Note: Ten or fewer patients with SAR on days 0, 3-5. Results are not shown.