Shane D. Scott

Delivering adjuvant chemotherapy to women with early-stage breast carcinoma: Current patterns of care

Variations in practice patterns are markers for the quality of patient care in general medicine, but little is known about variation in care delivered to cancer patients. This studys purpose was to describe chemotherapy use, variations in chemotherapy delivery, and the incidence of complications in community practice settings.

Dose Conversion from Recombinant Human Erythropoietin to Darbepoetin alfa: Recommendations From Clinical Studies

Recombinant human erythropoietin (r‐HuEPO, epoetin alfa), is an established and effective treatment for anemia associated with both chronic kidney disease (CKD) and cancer and has improved the management of anemia over alternatives such as transfusion. Darbepoetin alfa is a new erythropoietic agent with a 3‐fold longer half‐life and increased in vivo potency relative to r‐HuEPO. These properties allow patients to be treated with longer dosing intervals than with r‐HuEPO. Relative potency between r‐HuEPO and darbepoetin alfa is not a fixed relationship but is dependent on several factors. Clinical study results suggest that greater relative potency differences are seen between r‐HuEPO and darbepoetin alfa when the dosing intervals are longer and when r‐HuEPO dose requirements are higher. Although 200 U of r‐HuEPO contains the same peptide mass as 1 μg of darbepoetin alfa, a fixed ratio of 200:1 does not necessarily predict an appropriate dose conversion between the two drugs across the entire spectrum of dose ranges. When converting patients with CKD from r‐HuEPO to darbepoetin alfa, dosing should be based on relevant clinical data. Appropriate guidance for conversion of patients with CKD from r‐HuEPO to darbepoetin alfa is provided in the approved United States package insert for darbepoetin alfa. In patients who are prescribed darbepoetin alfa, either by conversion from r‐HuEPO or as de novo treatment, therapy should begin according to recommendations in the package insert, after which, doses should be titrated individually according to each patients hemoglobin response. Dosing data from oncology clinical studies, although not necessarily applicable to CKD, indicate similar potency ratios between r‐HuEPO and darbepoetin alfa, and in addition affirm the finding that, as the interval between doses of darbepoetin alfa is increased, hemoglobin response is maintained.

Population-based assessment of hospitalizations for neutropenia from chemotherapy in older adults with non-Hodgkin's lymphoma (United States).

ObjectiveTo study neutropenia hospitalization (NH) incidence and risk factors in a population-based sample of older adults with non-Hodgkin’s lymphoma (NHL) and evaluate the validity of inferences from Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases.MethodsNHL cases receiving first-course chemotherapy were identified from Iowa SEER-Medicare. Survival methods evaluated NH risk factors. Medical record and Medicare claims data on chemotherapy and NH were compared.ResultsOf 761 subjects, 165 (21.7%, 95% CI: 18.8, 24.6) were hospitalized for neutropenia. Of those hospitalized, 41% were hospitalized in cycle 1 and 22% in cycle 2. Significant multivariable risk factors for NH were diffuse large cell histology, renal disease, Charlson comorbidity index, and anthracycline chemotherapy but not patient age. Medicare and medical records agreed on month of chemotherapy initiation 95% of the time and chemotherapy type 95% of the time. ICD-9 code 288.0 sensitivity for NH was 80%.ConclusionsNeutropenia hospitalizations were common in the first 2 chemotherapy cycles, especially among older adults with comorbidity. Findings conflict with a prior medical records study in which age was a risk factor for NH and dose intensity a negative confounder. Valid inferences about age effects on chemotherapy toxicity require more clinical detail than is available in administrative data.

Factors associated with early termination of CHOP therapy and the impact on survival among patients with chemosensitive intermediate-grade non-Hodgkin's lymphoma.

BACKGROUND Six to eight cycles of CHOP therapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) is standard for intermediate-grade non-Hodgkins lymphoma (NHL) but is associated with toxicity that may cause premature termination of therapy. METHODS We studied factors associated with premature termination of CHOP therapy (receiving fewer than 6 cycles) and the relationship of premature termination with survival. Subjects consisted of a population-based sample of Iowa residents with intermediate-grade NHL who were planned to receive > or = 6 or more cycles of CHOP and who were chemosensitive (ie, achieved a documented partial or complete response to CHOP). RESULTS In a comparison with patients 18-59 years of age, the odds of premature termination of CHOP therapy was 2.6 (95% CI, 0.7-9.2) for those aged 60-74 and 6.2 (95% CI, 1.7-23.3) for those aged > or = 75. Patients with cycle 1 febrile neutropenia hospitalization (FNH) were 4.4 times (95% CI, 1.4-13.8) more likely to terminate CHOP prematurely than those without cycle 1 FNH. Among patients aged 60-74, but not those aged > or = 75, premature termination appeared to be associated with decreased 5-year survival (hazard ratio [HR] = 6.0; 95% CI, 2.4-15.2) compared with those completing CHOP therapy (HR = 2.1; 95% CI, 1.0-4.2). Findings for overall survival were similar. CONCLUSIONS First-cycle FNH and age > or = 60 years were associated with premature termination of CHOP therapy. The association of premature termination with survival among chemosensitive patients differed by age.

Information Gained From Linking Seer Cancer Registry Data to State-level Hospital Discharge Abstracts

Objectives.Our goal was to link patients from the Iowa Surveillance, Epidemiology, and End Results (SEER) Registry to their respective inpatient discharge abstracts from an Iowa Health Care Cost and Utilization Project (HCUP)–formatted database and evaluate whether this linkage provides information related to cancer treatment variation. Methods.Computer algorithms linked patients from the Iowa SEER Registry to discharge abstracts using 5 variables consistently defined between the databases (hospital identification, date of birth, admission date, discharge date, and zip code). Abstracts were reviewed for validity, and links not passing face validity were excluded. Subjects.Our sample contained 7,296 patients with early-stage breast cancer (I, IIa, IIb) with surgery from the Iowa SEER Registry from 1989 through 1994 with contacts only with Iowa hospitals. Results.Inpatient discharges abstracts were linked to 86.4% of the patients in our sample. More than 96% of the linked discharges for Medicare patients had a corresponding Medicare claim. Over 45% of the linked patients were not covered by Medicare. Comorbidity indexes were comparable to other published sources. Significant differences in diagnosis, comorbidities, and treatment were found across third-party payers. Conclusions.This linkage provides a valuable source of comorbidity and insurance data and perhaps the only source of secondary clinical information for the uninsured. This linkage is best suited for cancers requiring inpatient stays for treatment and for those states where border crossing for treatment is low.

Effect of clinical characteristics on neutropenia-related inpatient costs among newly diagnosed non-Hodgkin's lymphoma cases during first-course chemotherapy.

Study Objective. To estimate the costs of hospitalization for neutropenia among chemotherapy‐treated patients with newly diagnosed non‐Hodgkins lymphoma and to assess baseline patient factors associated with these costs.

Pharmacoeconomics and considerations for injectable products: focus on colony-stimulating factors.

OBJECTIVE: To discuss clinical data on the utility of 2 colony-stimulating factors (CSFs), filgrastim and pegfilgrastim, in reducing the risk and incidence of neutropenic complications with chemotherapy. DATA SOURCES: This article reviews the data from the clinical studies for both pegfilgrastim and filgrastim. Additionally, data from large, population-based retrospective analyses on the clinical and economic consequences of chemotherapy-induced neutropenia (CIN) are reviewed. CONCLUSIONS: CIN remains an undertreated condition despite the evidence of its danger. Pivotal trials show that CSFs like pegfilgrastim and filgrastim are safe and effective in reducing both the incidence and duration of CIN and febrile neutropenia in patients who have been treated with myelosuppressive chemotherapy. Approximately 11 daily injections of filgrastim per chemotherapy cycle are required to achieve this clinical end point. Pegfilgrastim provides all the clinical benefits of daily filgrastim for managing CIN with a single dose per chemotherapy cycle.