Same-Day Administration of Pegfilgrastim Following Myelosuppressive Chemotherapy: Practices and Rationale

Introduction: Granulocyte colony-stimulating factors such as pegfilgrastim (Neulasta^®) can reduce the incidence of febrile neutropenia, a life-threatening side effect of myelosuppressive chemotherapy. According to current FDA-approved prescribing information, pegfilgrastim should not be administered between 14 days before and 24 hours after administration of myelosuppressive chemotherapy. Previous research indicates that same- vs next-day administration of pegfilgrastim may be associated with worse patient outcomes, and current guidelines from both ASCO and NCCN recommend use of pegfilgrastim 1-3 days after chemotherapy. A recent health care claims database analysis has shown that same-day pegfilgrastim was administered in ~13% of chemotherapy cycles, but little is known about physician rationale for administering same-day pegfilgrastim. Here, we describe the results of a cross-sectional, web-based physician survey describing the practice- and patient-related factors that physicians report to have affected their decision to administer same-day pegfilgrastim.

Methods: Survey invitations were sent via e-mail to a sample of US medical oncologists, hematologists, and hematologist-oncologists who were enrolled in a national physician panel. Physicians who reported experience prescribing same-day pegfilgrastim within the last 6 months and provided informed consent were included. Physician reasons for prescribing same-day pegfilgrastim were assessed. The analysis was descriptive; summary statistics are presented.

Results: Of 17,478 physicians who were invited to participate, 386 were screened, and 186 (48%) reported administering same-day pegfilgrastim within the previous 6 months. A total of 183 physicians (47%) agreed to participate in the survey, and 151 (39%) completed the survey. Mean (SD) years in practice was 14.6 (8.2) years. Most physicians practiced in a private group practice (39%), at a cancer hospital/referral center (25%), or at other types of academic hospitals/clinics (23%). Physicians were relatively evenly distributed across the US and most (54%) practiced in towns with a population ≥250,000. Breast cancer and non-small cell lung cancer were the most common primary cancers in patients followed by the physicians.

Physicians estimated that ~41% of their patients received pegfilgrastim, and that among patients who received pegfilgrastim, ~32% received same-day pegfilgrastim, with ~43% of those patients receiving same-day pegfilgrastim across all chemotherapy cycles. 36% of physicians relied primarily on clinical judgment when deciding to administer same-day pegfilgrastim. The most common patient risk factors reported by physicians as moderately or very important when deciding to administer same-day pegfilgrastim were previous febrile neutropenia (78%), presence of infection or open wounds (70%), and poor ECOG performance status (67%). When asked to rank 7 different clinical and logistic reasons to administer same-day pegfilgrastim (with 1 being most important), "it was more practical for the patient" was the most important reason (mean rank = 3.0; SD = 1.7), and "it was more practical for the practice due to patient scheduling burden/load" was the least important (mean rank = 4.2; SD = 1.7). 85% of physicians reported travel distance for the patient/caregiver and 79% reported method or availability of transportation for the patient/caregiver as moderately or very important patient-related factors for same-day administration of pegfilgrastim. The most important administrative consideration for same-day administration of pegfilgrastim was burden of actual prophylactic administration of pegfilgrastim on the next day and follow-up (65% of physicians cited as moderately or very important).

Conclusions: Physicians rely primarily on clinical judgment when deciding whether to administer same-day pegfilgrastim, and clinical risk factors such as previous febrile neutropenia affect the decision to administer same-day pegfilgrastim. Additional physician considerations include patient/caregiver travel distance, method or availability of transportation, and burden of actual prophylactic administration of pegfilgrastim on the next day and follow-up. Continued education of patients and physicians on the potential risks of same-day pegfilgrastim administration could increase compliance and improve patient outcomes.