Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper

Cooksley, Tim; Font, Carme; Scotté, Florian; Escalante, Carmen P.; Johnson, Lindsay; Anderson, Ronald; Rapoport, Bernardo Leon

doi:10.1007/s00520-020-05906-y

Cited by 31 publications

(34 citation statements)

References 56 publications

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“…Unfortunately, we are unable to comment on appropriateness of these visits to the ED for diversion to the NCCHIC, secondary to the retrospective nature of this study. Further refinement and implementation of this type of model for acute unscheduled cancer care may help reduce ED visits and over-crowding, particularly important during the current COVID-19 pandemic [15].…”

Section: Discussionmentioning

confidence: 99%

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

Bischof

Bush

Shams

et al. 2021

Support Care Cancer

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Purpose Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC). Methods A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre-and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre-and post-periods. Results During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5). Conclusions This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

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Section: Discussionmentioning

confidence: 99%

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

Bischof

Bush

Shams

et al. 2021

Support Care Cancer

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“…Most published studies examined patients with fever and neutropenia prior to widespread use of rapid viral testing (e.g., for influenza and RSV). Notably, our study was conducted before the onset of the COVID-19 pandemic, so there were no COVID-positive patients in this sample [26]. The incidence of MRSA and Pseudomonas was low compared to other studies across the USA [7], but most patients received empiric antibiotic therapy appropriately per current guidelines because of the high risk for progression to fatal sepsis and mortality associated with these organisms [7,9,10].…”

Section: Discussionmentioning

confidence: 96%

Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study

Bhardwaj

Emmich

Knee

et al. 2021

Support Care Cancer

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Purpose The Multinational Association for Supportive Care in Cancer (MASCC) score is used to risk stratify outpatients with febrile neutropenia (FN). However, it is rarely used in hospital settings. We aimed to describe management, use of MASCC score, and outcomes among hospitalized patients with FN. Methods We conducted a retrospective cohort study of patients with cancer and FN. We collected patient demographics, cancer characteristics, microbiological profile, MASCC score, utilization of critical care therapies, documentation of goals of care (GOC), and inpatient deaths. Outcomes associated with low-(≥ 21) versus high-risk (< 21) MASCC scores are presented as absolute differences. Results Of 193 patients, few (2%, n = 3) had MASCC scores documented, but when calculated, 52% (n = 101) had a high-risk score (< 21). GOC were discussed in 12% (n = 24) of patients. Twenty one percent (n = 40) required intermediate/ICU level of care, and 12% (n = 23) died in the hospital. Those with a low-risk score were 33% less likely to require intermediate/ICU care (95% CI 23 to 44%) and 19% less likely to die in the hospital (95% CI 10% to 27%) compared to those with high-risk score. Conclusions MASCC score was rarely used for hospitalized patients with FN, but high-risk score was associated with worse outcomes. Education efforts to incorporate MASCC score into the workflow may help identify patients at high risk for complications and help clinicians admit these patients to a higher level of care (e.g., intermediate/ICU care) or guide them to initiate earlier GOC discussions.

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“…COVID-19 may mimic presentations of ICI-Pneumonitis and is a recent important addition to the differential diagnosis in patients with acute respiratory symptoms treated with ICI therapy (Cooksley et al, 2021).…”

Section: Acute Immune Checkpoint Inhibitor-mediated Pulmonary Emergenciesmentioning

confidence: 99%

Pulmonary Toxicities Associated With the Use of Immune Checkpoint Inhibitors: An Update From the Immuno-Oncology Subgroup of the Neutropenia, Infection & Myelosuppression Study Group of the Multinational Association for Supportive Care in Cancer

et al. 2021

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The development of immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment, with agents such as nivolumab, pembrolizumab, and cemiplimab targeting programmed cell death protein-1 (PD-1) and durvalumab, avelumab, and atezolizumab targeting PD-ligand 1 (PD-L1). Ipilimumab targets cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). These inhibitors have shown remarkable efficacy in melanoma, lung cancer, urothelial cancer, and a variety of solid tumors, either as single agents or in combination with other anticancer modalities. Additional indications are continuing to evolve. Checkpoint inhibitors are associated with less toxicity when compared to chemotherapy. These agents enhance the antitumor immune response and produce side- effects known as immune-related adverse events (irAEs). Although the incidence of immune checkpoint inhibitor pneumonitis (ICI-Pneumonitis) is relatively low, this complication is likely to cause the delay or cessation of immunotherapy and, in severe cases, may be associated with treatment-related mortality. The primary mechanism of ICI-Pneumonitis remains unclear, but it is believed to be associated with the immune dysregulation caused by ICIs. The development of irAEs may be related to increased T cell activity against cross-antigens expressed in tumor and normal tissues. Treatment with ICIs is associated with an increased number of activated alveolar T cells and reduced activity of the anti-inflammatory Treg phenotype, leading to dysregulation of T cell activity. This review discusses the pathogenesis of alveolar pneumonitis and the incidence, diagnosis, and clinical management of pulmonary toxicity, as well as the pulmonary complications of ICIs, either as monotherapy or in combination with other anticancer modalities, such as thoracic radiotherapy.

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Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper

Cited by 31 publications

References 56 publications

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study

Pulmonary Toxicities Associated With the Use of Immune Checkpoint Inhibitors: An Update From the Immuno-Oncology Subgroup of the Neutropenia, Infection & Myelosuppression Study Group of the Multinational Association for Supportive Care in Cancer

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