Two leaders in the management of ES-SCLC provide an overview of chemotherapy-induced myelosuppression including key risk factors and its effect on patient outcomes.
Martin Dietrich, MD, PhD: Hello. I’m Dr Martin Dietrich from Florida Cancer Specialists & Research Institute in Orlando Florida.
Edgardo Santos, MD, FACP: My name is Dr Edgardo Santos from Florida Precision Oncology and GenesisCare in Aventura Florida. I’m a medical oncologist. Martin, it’s nice to see you.
Martin Dietrich, MD, PhD: Good to see you too.
Edgardo Santos, MD, FACP: Thank you. We’re here during ASCO [American Society of Clinical Oncology Annual Meeting] with so many data in oncology. Let me ask you this question about chemotherapy-induced myelosuppression: how frequent is this problem in extensive-disease small cell lung cancer?
Martin Dietrich, MD, PhD: Myelosuppression is 1 of the biggest problems and biggest needs for supportive care in small cell lung cancer. We’re seeing neutropenia in the rates of 70% or 80%. Both of us practice in Florida, in a geriatric population, so it’s almost a ubiquitous problem affecting both white and red cell lineages.
Edgardo Santos, MD, FACP: Martin, are there any risk factors that predispose the patient to developing chemotherapy-induced myelosuppression? What do you think about those important risk factors while seeing a patient in your clinic?
Martin Dietrich, MD, PhD: Several risk factors are present. Obviously, 1 is age. We’re seeing predisposition there. Bone marrow infiltration, if present, will probably be less frequent in small cell lung cancer. We can think about pretreatment. There are other bone marrow conditions that may be preexistent in an older-patient population: kidney dysfunction, EPO [erythropoietin] deficiency, and others. There are many predisposing factors in a real-world population that would enhance the concern of myelosuppression.
Edgardo Santos, MD, FACP: In oncology, we have several treatments for patients with cancer. We’re going to discuss more about the treatments for extensive-stage small-cell lung cancer. What kind of therapy comes to mind when you know that you need to be more proactive because you already foresee the possibility of chemotherapy in myelosuppression? What therapy regimens come to mind right away?
Martin Dietrich, MD, PhD: Typically, the doublets are at the top of our minds when we treat extensive-stage small cell lung cancer. Any of the regimens are aggressive and extensive, typically given over several days. Carboplatin or cisplatin have slightly different involvements with the bone marrow, but we typically see significant myelosuppression regardless. Etoposide [Toposar] and topotecan [Hycamtin] are very suppressive regimens that require growth factor supports, frequently and are oftentimes prophylactic, with an anticipated risk far above 20%¾more in the range of 80%. We’re seeing these parts. They have mostly predisposed patients to a concern of infection, hospitalization, possible sepsis, and worse outcomes. On the other hand, they’ve also affected quality of life with a significant amount of anemia, need for transfusions, low energy, shortness of breath, and the presence of preexisting conditions¾which are already prevalent in the small cell population¾ that will be aggravated by additional suppression of the bone marrow and anemia.
Dr Santos, in your patient population, what impact do you see of myelosuppression on your patients? How does it affect your treatments? How does it affect your patients in general?
Edgardo Santos, MD, FACP: When the patient is exposed to a myelosuppressive regimen, and they develop neutropenia, there’s a serious consideration. You can develop neutropenia grade 1 or 2, no problem, but when the patient starts to get grade 3 with some symptoms or grade 4, especially with a fever, that’s an emergency situation. The patient needs to be admitted to the hospital. If the patient doesn’t have an infection, the patient can easily get back to the regimen. The patient could develop a serious infection that could become fatal, an outcome that we don’t want, or the infection will certainly cause a delay on therapy. If there’s no way to prevent that, then we have to reduce the dose sometimes. As you know, Martin, when we do dose reduction in therapy, we lose efficacy¾ several clinical trials have shown that. Dose reduction is something we prefer to avoid unless it’s extremely necessary. Certainly, the issue of neutropenia will bring a serious issue for the patient in several aspects.
Martin Dietrich, MD, PhD: One of the most frequent emergencies that we see in medical oncology is the patient that comes into the hospital with neutropenic fever, with all the downstream effects happening.
Edgardo Santos, MD, FACP: Exactly.
Transcript edited for clarity.