Overuse and underuse of pegfilgrastim for primary prophylaxis of febrile neutropenia

Abstract

Introduction Guidelines recommend pegfilgrastim for primary prophylaxis of febrile neutropenia after highly myelosuppressive chemotherapy. While deviations from guidelines could result in overuse and increased costs, underuse is also a concern and could compromise quality of care. Our objectives were to evaluate guideline adherence and quantify the extent to which physician heterogeneity may influence pegfilgrastim use. Methods We randomly sampled 550 patients from a retrospective cohort of those who received infusions at an academic cancer center between 1 September 2013 and 1 September 2014. Electronic medical and drug dispensing records provided information on patient characteristics, chemotherapy characteristics, prescribing physician, and pegfilgrastim administration. Results We included 154 patients treated by 25 physicians. About half of patients were male and mean age was 61.3 years. Forty (26.1%) patients had no febrile neutropenia risk factors, 62 (40.5%) had one, and 51 (33.3%) had two or more. Thirty patients (19.5%) received pegfilgrastim, of which 12 (40%) received palliative chemotherapy. Nine (60%) of 15 patients on a regimen with a febrile neutropenia risk ≥ 20% received pegfilgrastim. Pegfilgrastim use significantly varied by cancer type (p < 0.01), chemotherapy regimen (p < 0.001), and regimen febrile neutropenia risk (p < 0.001). Multivariable analysis reaffirmed the association between chemotherapy regimen febrile neutropenia risk ≥ 20% and pegfilgrastim use (odds ratio (OR) = 10.1, 95% confidence interval (CI): 1.6-62.7) and suggested that 31% (95% CI: 8%-71%) of the variation in use was attributable to physician characteristics. Conclusion Pegfilgrastim was potentially overused for palliative chemotherapy and underused for chemotherapy regimens with febrile neutropenia risk ≥ 20%. Successful interventions to modify prescribing practices likely require an understanding of the relationship between specific physician characteristics and pegfilgrastim use.

Appropriateness of using granulocyte colony-stimulating factor (G-CSF) for primary prophylaxis of febrile neutropenia in solid tumors

“…Likewise, in a study conducted by Zullo et al in the United States, nine out of 15 patients who were treated with a chemotherapy regimen with high FN risk did not receive G-CSF. 21 This is while all patients with high FN risk in our study received prophylactic G-CSF. Of note, G-CSF was administered to 60 (62%) patients with no indication and over utilization was a more important inconsistency with the guideline recommendations in our study.…”

Febrile neutropenia prophylaxis, G-CSF physician preferences: discrete-choice experiment

“…A retrospective study assessed pegfilgrastim use in four outpatient sites of the Lifespan Comprehensive Cancer Centre (USA). 17 The study found that pegfilgrastim, predominantly as primary prophylaxis, was prescribed when the chemotherapy used had a risk of FN of ≥20%. Interestingly, filgrastim was rarely used.…”

“…In fact, various studies have shown that G-CSFs tend to be overused in patients administered low-risk chemotherapies (risk of FN <10% or 10%-20%) and underused in those on high-risk regimens (risk of FN >20%). [17][18][19] Indeed, the use of G-CSFs in clinical practice, as primary and secondary prophylaxes, is driven by various factors including the convenience and cost of G-CSFs, availability of biosimilars and the clinical evidence for the benefit of G-CSFs. 14 A better understanding of the factors that influence the choice of G-CSF will allow optimisation of G-CSF use in clinical practice and consequently improve FN management in patients with cancer .…”

Improved risk prediction of chemotherapy‐induced neutropenia—model development and validation with real‐world data

“…Significant underuse of G‐CSFs in high‐ and intermediate‐risk regimens, and overuse in low‐risk regimens, have been reported both in the EU 4,5 and in the US 6‐8 . G‐CSFs contribute also significantly to increased healthcare costs 9 .…”