Background: Patients with cancer must make frequent visits to the clinic not only for chemotherapy but also for the management of treatment-related adverse effects. Neutropenia, the most common dose-limiting toxicity of myelosuppressive chemotherapy, has substantial clinical and economic consequences. Colony-stimulating factors such as filgrastim and pegfilgrastim can reduce the incidence of neutropenia, but the clinic visits for these treatments can disrupt patients' routines and activities.

Findings in the baseline evaluation illustrate the need to improve supportive care--a key responsibility of oncology nurses.

The proactive use of granulocyte-colony-stimulating factors (G-CSFs) in patients with cancer treated with chemotherapy reduces the incidence of hospitalizations for febrile neutropenia (FN) as well as minimizes chemotherapy dose reductions and delays that could compromise treatment outcomes. In accordance with earlier economic analyses, the guidelines of the American Society of Clinical Oncology recommended the use of G-CSF in the fi rst cycle only with chemotherapy regimens associated with a 40% or greater risk of FN. However, more recent guidelines by the National Comprehensive Cancer Network (NCCN) recommended that the use of G-CSF in the fi rst cycle of chemotherapy be considered for patients at a 20% or higher risk of developing FN or other neutropenic complications. The results of a clinical trial, which led to NCCN's recommendations, are reviewed in this article. Patients with breast cancer were treated with single-agent docetaxel, a regimen that is associated with a risk of approximately 20% for developing FN. The use of pegfi lgrastim in all cycles of chemotherapy caused a signifi cantly lower incidence of FN, fewer hospitalizations as a result of FN, and lowered use of IV anti-infectives than placebo. Thus, when assessing patients before treatment, nurses should consider discussing with the multidisciplinary team the use of growth factor support even with moderately myelosuppressive chemotherapy regimens. Hematopoietic Support With Moderately Myelosuppressive Chemotherapy Regimens:A Nursing Perspective At a Glance ✦ The proactive use of granulocyte-colony-stimulating factors (G-CSFs) in patients with cancer treated with myelosuppressive chemotherapy reduces neutropenic complications and allows for delivery of chemotherapy at full dose and on schedule.✦ Recent economic analyses indicate that the cost of G-CSF is offset when the risk of febrile neutropenia is lower than 20%.✦ In clinical trials, benefi ts of G-CSF have been observed with moderately myelosuppressive regimens associated with a risk of febrile neutropenia of approximately 20%.Kelley Moore, RN, is vice president of clinical projects at Supportive Oncology Services, Inc., in Memphis, TN, and Debbie Crom, RN, is a research coordinator in the practice of Robert R. Carroll, MD, PA, in Gainesville, FL. No signifi cant fi nancial relationship to disclose.

Chemotherapy-related toxicities are common and often undertreated in routine cancer care. Initiatives to improve toxicity management in practices may not always be effective. Quality improvement programs must engage multiple disciplines of the healthcare team and sustain efforts to institute and maintain procedures that address practice needs. The Assessment, Information, and Management (AIM) Higher Initiative, a quality improvement program undertaken at 15 community oncology practices, was initiated to improve the AIM of chemotherapy-related toxicities in patients with cancer. AIM Higher focuses on improving five chemotherapy-related toxicities: neutropenia, anemia, depression and anxiety, diarrhea and constipation, and nausea and vomiting. Led by a nurse champion at each of the clinics, a variety of new procedures, processes, and tools were implemented to improve quality of care. Nurses and practice administrators can use the quality improvement processes to generate changes in procedures and practices.

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