Advances in the Management of Chemotherapy-Induced Neutropenia - Episode 8
Breast oncologists discuss how they weigh the efficacy of anticancer treatment with the possibility of a treatment-related adverse event, like chemotherapy-induced neutropenia.
Hope S. Rugo, MD, FASCO: We’re really fortunate to be able to give growth factors to our patients because in some places around the world, people have to stop treatments if they have a lot of neutropenia.
In the curative setting, we all want to deliver the drugs with the schedule and the dose we had planned, and we rely on gross factors to help us do that. We manage bone pain from the growth factors and any kind of weird symptoms. I don’t know that we talked about how to prevent those, but we might mention them a little. One of the areas we still want to discuss is how we weigh the efficacies of the anticancer treatment. Do you choose a regimen vs the risk of CIN [chemotherapy-induced neutropenia]? How do you discuss that with your patients?What do you wish you had that we don’t have? What are our unmet needs? Tiffany?
Tiffany A. Traina, MD: The question around efficacy—goals of care are important, as well as which scenario are we talking about, early stage or advanced? Certainly, we’ve been blessed to see agents in the metastatic setting that have improved overall survival, and I’d like to be able to deliver those to my patients and support them in delivering those agents. I have a lower threshold to incorporate growth factors to be able to deliver effective therapy rather than sacrifice delivering a therapy that has lesser efficacy. We’ve seen in many studies that have had neutropenia and required dose modification that those agents still have efficacy at a reduced dose. That’s encouraging because some of our patients are disappointed when we talk about having a dose modification. We have to keep in mind what the goals of care are.
In terms of unmet needs, growth factors are still expensive, and some payers are regulating what we’re able to give or which modality we’re able to deliver for our patients. To have a great equalizer there would be wonderful to ensure that everybody has access to care. Route of administration is sometimes problematic. For example, having to come back for a subcutaneous injection the next day is inconvenient and not preferable for some of our patients who are needle phobic. Perhaps an easier route of administration, a more convenient timing or schedule of administration, would be great as well.
Hope S. Rugo, MD, FASCO: Other comments about that? We’re all using these all the time. Do you choose your treatments based on the risk of neutropenia in some patients, maybe in older patients? What do you wish we had that would work better? Rita?
Rita Nanda, MD: Generally, I don’t choose my regimen based on the risk of neutropenia. I choose the regimen based on efficacy and what I feel is appropriate for the patient. Then I make adjustments as needed. Just to follow-up on some of Tiffany’s comments, some of the issues around growth factor are absolutely insurance driven in what they’ll allow patients to receive. On-body administration, which prevents patients from driving back 2 to 3 hours to get a shot, has been really helpful, but not all insurance companies are covering that.
We also have a number of patients who are unwilling or unable to self-administer growth factor at home. Now that we’ve got these biosimilars, they’re what a lot of insurance companies are approving. For some patients, that’s not something we’re willing to do. Thinking about not just the needle-phobic patients but also the ones who don’t want to self-administer or aren’t comfortable with that, remain an issue. Things that can be given when they’re there in the infusion suite or with an on-body are obviously very convenient.
Getting back to the question you asked, Hope, I try to select the best regimen for a patient in regard to efficacy. But patients can’t always tolerate some regimens for all the reasons that have been mentioned: beat-up bone marrow, low counts, and marrow infiltration, which we see quite frequently in breast cancer. Sometimes, even though we want to give a particular therapy, we aren’t always able to.
Hope S. Rugo, MD, FASCO: Yeah, or maybe you need to change the schedule and dose as we talked about earlier.
Transcript edited for clarity.