Use of prophylactic growth factors and antimicrobials in elderly patients with cancer: a review of the Medicare database

Abstract

Purpose Growth factors and antimicrobials can reduce complications of chemotherapy-induced myelosuppression. Their prophylactic use in elderly patients is important given the associated comorbidity in this age group. There is a developing trend by payers to include supportive care agents in chemotherapy care bundles, which could affect clinical practice. We examined whether the febrile neutropenia (FN) risk categories can be used to describe utilization in the Centers for Medicare & Medicaid fee-for-service system in older adults. Methods We conducted a retrospective cohort study using the Medicare 20% sample data to describe growth factor and antimicrobial use patterns in patients receiving chemotherapy for breast cancer, lung cancer, and non-Hodgkin lymphoma (NHL). Results The highest percentage of patients receiving granulocyte colony-stimulating factor (GCSF) within the first 5 days of a chemotherapy cycle were on high-FN-risk regimens, particularly for cycle 1 (73.7%, breast cancer; 61.5%, NHL) and cycle 2 (75.9%, breast cancer; 77.5%, NHL). Chemotherapy regimens for lung cancer are less myelotoxic, and growth factor use was more likely with latter cycles. Antibiotic use was lower at 15% within a cycle and appeared to be in response to complications. Conclusion Practitioners use GCSF and antibiotics for elderly patients treated with potentially toxic chemotherapy, while comorbidity burden plays a role for patients treated with less myelotoxic regimens. The complexity of these choices in clinical practice should be considered in the proposed reimbursement changes being piloted by Medicare and private insurance companies seeking treatment cost reductions, as altered use could affect safety and efficacy.

Patterns of granulocyte colony–stimulating factor prophylaxis in patients with cancer receiving myelosuppressive chemotherapy

“…Our results are consistent with prior studies that reported suboptimal use of prophylactic G-CSF [24,25]. Ramsey [25].…”

“…Our results are consistent with prior studies that reported suboptimal use of prophylactic G-CSF [ 24 , 25 ]. Ramsey and colleagues linked the Western Washington State Surveillance, Epidemiology, and End Results (SEER) registry data with data from 4 major insurers (Medicare, Medicaid, Premera Blue Cross, and Regence Blue Shield) for patients treated for breast cancer, non-small cell lung cancer, and colorectal cancer from 2002 to 2005 [ 24 ].…”

“…Our results are consistent with prior studies that reported suboptimal use of prophylactic G-CSF [24,25]. Ramsey [25]. In their study, prophylactic G-CSF use among patients receiving intermediate FN risk chemotherapy was 10% for breast cancer and 20% for lung cancer patients.…”

“…They observed prophylactic G-CSF use of 33% and 10% among patients receiving high risk FN chemotherapy and intermediate FN risk chemotherapy, respectively. In a retrospective cohort study using a 20% Medicare sample from 2007 to 2011, Sosa and colleagues observed that 74% of breast cancer patients and 62% of NHL patients receiving high FN risk chemotherapy received prophylactic G-CSF in the first cycle [ 25 ]. In their study, prophylactic G-CSF use among patients receiving intermediate FN risk chemotherapy was 10% for breast cancer and 20% for lung cancer patients.…”

A Survey of Oncologists’ Perceptions and Opinions Regarding the Use of Granulocyte Colony-Stimulating Factors

“…In the USA, the real-world use of G-CSF among patients at high risk of FN does not reflect the recommendations of national guidelines. G-CSF prophylaxis is observed in 17 to 74% of patients receiving chemotherapy regimens associated with high risk of FN, suggesting underutilization of an important preventive measure [14][15][16]. There is a paucity of information regarding the decision-making process employed by oncologists in determining the use of G-CSF prophylaxis for appropriate patients.…”