13© T O U C H B R I E F I N G S 2 0 0 8
Supportive Oncology
a report by
Gary H Lyman
Professor of Medicine, Division of Me...
14 E U R O P E A N O N C O L O G Y
Supportive Oncology
haematological toxicity, including neutropenic complications that
based on the type of cancer, chemotherapy regimen, patient-specific risk
factors and treatment intention, a formal risk...
16 E U R O P E A N O N C O L O G Y
Supportive Oncology
economic analyses have demonstrated that prophylactic myeloid
European Oncology Nursing
Society (EONS)
The European Oncology Nursing Society (EONS) has provided support
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Lyman managementofchemotherapy-induced

  1. 1. 13© T O U C H B R I E F I N G S 2 0 0 8 Supportive Oncology a report by Gary H Lyman Professor of Medicine, Division of Medical Oncology, and Director, Health Services and Outcomes Research, Duke University Myelosuppression, including chemotherapy-induced neutropenia and febrile neutropenia, is the major dose-limiting toxicity of cancer chemotherapy. The myeloid colony-stimulating factors have been shown to reduce the risk of febrile neutropenia and its complications. These agents are available globally and are utilised worldwide in oncology practice to support patients receiving cancer therapy. Clinical practice guidelines are available from several international professional organisations. Chemotherapy-induced Neutropenia Febrile neutropenia and its complications continue to be associated with substantial morbidity, mortality and cost.1,2 Haematological toxicity associated with cancer chemotherapy occurs most frequently during the initial cycles, but varies across patient populations and treatment programmes (see Figure 1).3–5 A number of studies have also indicated that chemotherapy-induced neutropenia is associated with improved treatment efficacy, presumably due to the delivered chemotherapy dose intensity.6,7 Neutropenic complications frequently result in subsequent reductions in chemotherapy dose intensity, compromising disease-free and overall survival in patients treated with curative intent.8–12 Reduced chemotherapy dose intensity appears to be more common among elderly or obese cancer patients and among certain racial and socioeconomic subgroups.11,13–18 Risk Factors for Chemotherapy-induced Neutropenia and Its Complications Neutropenic complications including febrile neutropenia, infection-related mortality and dose reductions and delays are more frequent among elderly cancer patients receiving chemotherapy.2,17,18 While the risk of cancer increases considerably among the elderly, increasing age is associated with a reduced marrow reserve and more frequent co-morbid medical conditions accompanied by declines in renal and hepatic function, increasing the risk of treatment-related complications.19–21 Other variables that increase the risk of neutropenic complications include the treatment regimen and certain patient characteristics such as functional status and medical co-morbidities. In order to more accurately predict the risk of neutropenic complications, multivariate risk models are undergoing extensive validation and may soon be available to assist clinical decision-making in oncology practice (see Figure 2).22 Colony-stimulating Factors The myeloid growth factors, and most notably granulocyte colony-stimulating factor (G-CSF), have demonstrated the ability to reduce the incidence and severity of neutropenia and febrile neutropenia while improving chemotherapy dose intensity.23–26 The long-acting myeloid growth factor pegfilgrastim appears to have several advantages including patient convenience, improved compliance and, potentially, greater potency.26,27 Multiple randomised controlled trials (RCTs) have consistently shown the efficacy and safety of G-CSF, which has recently been confirmed in a meta-analysis of RCTs in adult cancer patients receiving cancer chemotherapy.28 Significant reductions in the risk of febrile neutropenia were observed across studies for both solid tumour patients and those with non-Hodgkin’s lymphoma across adult age groups and all forms of G-CSF. Of note, a significant reduction in the risk of febrile neutropenia was observed across a broad range of baseline levels of risk ranging from 17 to 90%. As shown in Figure 3, the baseline risk of febrile neutropenia in the control arms of these trials ranges across the full spectrum of risk. In fact, a significant inverse relationship between the baseline risk of febrile neutropenia and the relative risk reduction with G-CSF was found (see Figure 3).28 This analysis also demonstrated a significant reduction in infection-related and early all-cause mortality. These observations are consistent with that of a Cochrane meta-analysis of therapeutic CSF in patients hospitalised with febrile neutropenia following cancer chemotherapy.29 The meta-analysis also confirmed the ability of these agents to sustain chemotherapy relative dose intensity averaging 95% in G-CSF patients compared with 88% in control study arms. While few studies have been adequately powered to study overall survival or second malignancies, no increase in mortality or risk of second malignancies has been observed in RCTs. Myeloid Growth Factor Use in the Elderly Cancer Patient The risk of cancer increases with increasing age. Patients 65 years of age and above account for some 60% of cancer diagnoses and as many as 70% of cancer deaths. Nevertheless, older patients able to tolerate standard chemotherapy regimens and schedules appear to derive nearly as much benefit from systemic chemotherapy as younger cancer patients.30–32 However, clearly, increasing age is a risk factor for Management of Chemotherapy-induced Neutropenia with Colony-stimulating Factors Gary H Lyman is a Professor of Medicine and Director of Health Services and Outcomes Research in the Division of Medical Oncology at Duke University. He is also a Senior Fellow at the Duke Center for Clinical Health Policy Research and a member of the Duke Comprehensive Cancer Center. His clinical focus is on the management of early-stage breast cancer and disease and treatment-related complications. Professor Lyman serves as a member of the Oncology Drug Advisory Committee to the US Food and Drug Administration (FDA) on new oncological agents. He is also active within the American Society of Clinical Oncology (ASCO), serving as a member of both the Health Services and Cancer Education Committees, chairing the Methodology Subcommittee and leading several clinical practice guideline panels, including the recent ASCO Guideline on The Prevention of Venous Thromboembolism in Patients with Cancer. Professor Lyman has published more than 300 articles and edited recent texts including Comprehensive Geriatric Oncology, Translational Therapeutic Strategies in Breast Cancer, Cancer Supportive Care, Advances in Therapeutic Strategies and The Oxford-American Hand Book of Oncology. Professor Lyman also serves as Editor in Chief of Cancer Investigation. E: gary.lyman@duke.edu Lyman_subbed.qxp 17/4/09 09:28 Page 13
  2. 2. 14 E U R O P E A N O N C O L O G Y Supportive Oncology haematological toxicity, including neutropenic complications that may result in a higher mortality in those hospitalised for febrile neutropenia.1 Greater reductions in chemotherapy dose intensity are also observed among elderly cancer patients with potentially compromised disease outcome.18,33–38 However, older patients appear to be nearly as responsive to the myeloid growth factors as younger patients.39,40 RCTs of prophylactic myeloid growth factors in older cancer patients have demonstrated a significant reduction in the risk of febrile neutropenia.34,37,41 The risk of febrile neutropenia among patients 65 years of age and older is twice that of younger patients in the first cycle.4,5 Nevertheless, practice pattern studies suggest that only a minority of elderly cancer patients receiving chemotherapy treatment receive a myeloid growth factor, with most receiving a reduced chemotherapy dose instead in order to reduce the risk of neutropenia.11,12,17,18 Clinical Practice Guidelines for the Myeloid Growth Factors Clinical practice guidelines for the use of the myeloid growth factors have been developed by various professional organisations, including the European Organisation for Research and Treatment of Cancer (EORTC), the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO).13,42–44 The NCCN guidelines differ in that they are largely based on a consensus process, whereas the EORTC and ASCO guidelines are based on an extensive evidence-based review (see Table 1). The various guideline panels reviewed results from the reported RCTs and meta-analyses of these trials. The EORTC has previously developed guidelines on the use of these agents specifically in the elderly.35 European Organisation for Research and Treatment of Cancer Guidelines The EORTC guidelines for the use of G-CSF recommend routine prophylactic use of G-CSF in those receiving a regimen with a 20% or greater risk of febrile neutropenia.42 The guidelines recommend an individual risk assessment in those receiving a regimen associated with a risk of between 10 and 20%, but advise against routine growth factor use when the risk is less than 10% (see Figure 4). Likewise, prophylactic G-CSF is recommended when dose-dense or dose-intense chemotherapy has been shown to have survival benefit. Finally, where a reduction in chemotherapy dose intensity may be associated with a poor outcome, consideration of G-CSF prophylaxis to maintain dose intensity is recommended. National Comprehensive Cancer Network Guidelines The myeloid growth factor guidelines from the NCCN have been updated annually since their generation in 2005.13,45 After an initial evaluation Figure 1: Risk of Neutropenic Complications in the First Cycle of Chemotherapy 0 0 20 40 60 80 100 120 0.5 1.0 1.5 2.0 2.5 Days to first febrile neutropenia episode Hazardrate 0 20 40 60 80 100 Breast cancer Non-small- cell lung cancer Small-cell lung cancer Colorectal cancer Non-Hodgkin’s lymphoma Hodgkin’s disease Ovarian cancer 58.4 73.5 50 57.4 71.4 74.2 62.5 52.8 61.5 57.1 54.5 46.076.5 80 FN FN or SN EventsincycleI,%(95%CI) Risk of neutropenic events in patients receiving cancer chemotherapy is greatest in the first cycle of treatment. A hazard plot for the initial episode of febrile neutropenia is shown from a study of patients with non-Hodgkin’s lymphoma receiving cyclophosphamide, doxorubicin, prednisone, vincristine (CHOP) chemotherapy.5 The bar graph represents the proportion (±95% confidence interval [CI]) of febrile neutropenia (blue bars) and severe or febrile neutropenia (purple bars) occurring in the first cycle of chemotherapy across several cancer types from a large US prospective observational study.3 FN = febrile neutropenia; SN = severe neutropenia. Figure 2: The Course of Neutropenia and Its Complications Pre-treatment blood cell counts Lymphocyte counts Haemoglobin level Lactate dehydrogenase level Bone marrow involvement Neutrophil count Prolonged neutropenia Monocyte count Platelet count Blood urea nitrogen level Glucose level Lactate dehydrogenase level Burden of illness Age Female sex Performance status Nutrition Body surface area Temperature Blood pressure Infection at intravenous site Pneumonia Antifungal prophylaxis No antibiotics Chemotherapy intensity Neutropenia Febrile neutropenia Complicated infection Bacteraemia Prolonged hospitalisation Death Figure 3: The Baseline Risk of Febrile Neutropenia in the Control Arms of Randomised Trials Included in the Recent Meta-analysis Ranges Across the Full Spectrum of Risk 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.2 0.4 0.6 0.8 1.0 Control risk of FN RelativeriskreductionofFN A significant inverse relationship was observed between the baseline risk of febrile neutropenia (FN) and the relative risk reduction with granulocyte colony-stimulating factor (G-CSF) across studies.28 Lyman_subbed.qxp 17/4/09 09:29 Page 14
  3. 3. 15 based on the type of cancer, chemotherapy regimen, patient-specific risk factors and treatment intention, a formal risk assessment is encouraged (see Figure 5). Like the EORTC guidelines, the NCCN guidelines recommend the use of G-CSF prophylaxis in cancer patients at 20% or greater risk of febrile neutropenia. If there are additional risk factors that place the patient at greater risk of febrile neutropenia or serious consequences, those receiving an intermediate-risk regimen in the range of 10–20% may be offered prophylactic G-CSF. The NCCN guidelines also recommend the use of CSFs to sustain or maintain treatment intensity in those with curable cancers. American Society of Clinical Oncology Guidelines While the original ASCO guidelines for the CSFs were published in 1994, the updated 2006 ASCO White Blood Cell Growth Factor Guideline also recommends the use of CSF prophylaxis when risk is approximately 20% or greater.44 Likewise, these agents are encouraged when special circumstances such as older age, co-morbid illnesses, previous febrile neutropenia and other risk factors for serious infection place a patient at an increased risk of febrile neutropenia and an equally effective regimen is not available. The principal evidence for the efficacy of the myeloid growth factors considered was based on the results of multiple RCTs and the recent meta-analysis of 17 RCTs of prophylactic G-CSF.28 Derivative products available with the guidelines include executive and patient summaries, a PowerPoint slide set and a worksheet to assist dissemination and application of the guidelines. These have been generated and are available at the ASCO website (www.asco.org). A comparison of the three guidelines based on a critical appraisal has recently been reported.43 Specific clinical content areas were extracted from each guideline and the comparative quality of the guidelines evaluated. While the NCCN guidelines are more concise and practical, the EORTC and ASCO guidelines were more rigorous. The recommendations from these guidelines are remarkably consistent for both primary and secondary prophylaxis with the CSFs. The guidelines are also similar in recommending consideration of their use in the elderly, sustaining chemotherapy dose intensity and individualised risk assessment based on patient-specific risk factors such as previous febrile neutropenia, prior chemotherapy, advanced stage, age of 65 years or above, poor performance, nutritional status, co-morbidities and low baseline blood counts. The quality of the guidelines is generally very good, with little difference in issues related to the scope and purpose, stakeholder involvement and applicability of the guidelines.40,43 The NCCN guidelines undergo a more explicit and thorough independent and external review. The ASCO and EORTC guidelines state individual panel member conflicts of interest, whereas the NCCN guidelines only reflect general potential panel conflicts. On the other hand, the NCCN guidelines are updated annually and the use of algorithms is helpful for comprehension and application. Cost and the Use of the Myeloid Growth Factors The decision of whether to use a CSF in chemotherapy patients should be based primarily on clinical indications guided by the recommendations discussed above. However, the cost of the myeloid growth factors raises economic considerations at the societal level that should be balanced against the reduction in costs of hospitalisation, any reduction in early mortality from infection and the potential effect of chemotherapy dose intensity on patient survival. The cost of hospitalisation for febrile neutropenia varies considerably, ranging from US$10,000 to US$20,000 per episode in most US studies.1,46,47 Economic analyses based on the efficacy demonstrated in RCTs and the trade-off between costs of growth factor use and the reduction in risk or duration of febrile neutropenia have provided estimates of overall treatment costs.48,49 While the results of these studies have not had a direct influence on the recommendations provided by clinical practice guidelines, the Figure 4: European Organisation for Research and Treatment of Cancer Patient Assessment Algorithm to Decide Prophylactic Granulocyte Colony-stimulating Factor Usage Step 1 Assess frequency of FN associated with the planned chemotherapy regimen Step 2 Assess factors that increase the frequency/risk of FN Step 3 Define the patient’s overall FN risk for planned chemotherapy regimen FN risk >20% Overall FN risk >20% Prophylactic G-CSF recommended G-CSF use not indicated Overall FN risk <20% High risk Age >65 years Increased risk Advanced disease (level I and II evidence) History of prior FN No antibiotic prophylaxis, no G-CSF use Other factors Poor performance and/or nutritional status (level III and IV evidence) Female gender Haemoglobin <12g/dl Liver, renal or cardiovascular disease FN risk <10%FN risk 10–20% G-CSF = granulocyte colony-stimulating factor; FN = febrile neutropenia. Source: Aapro et al., 2006.42 Figure 5: National Comprehensive Cancer Network Guidelines – Decision Tree for Primary Prophylaxis 1. Evaluate 2. Assess risk 3. Intervene Disease Use G-CSF Chemotherapy regimen Consider G-CSF No routine G-CSF Patient risk factors Treatment intent High (<20%) risk Intermediate (10–20%) risk Low (<10%) risk G-CSF = granulocyte colony-stimulating factor. Source: Lyman, 2005.45 E U R O P E A N O N C O L O G Y Management of Chemotherapy-induced Neutropenia with Colony-stimulating Factors Table 1: Critical Appraisal of Myeloid Growth Factor Guidelines ASCO 2006 (%) EORTC (%) NCCN (%) Category Domain Score Scope and purpose 100 100 100 Stakeholder involvement 42 50 42 Rigor of development 76 76 48 Clarity and presentation 92 83 100 Applicability 67 67 67 Editorial independence 67 67 33 Modified from Lyman GH, 2007.40 Lyman_subbed.qxp 22/5/09 09:41 Page 15
  4. 4. 16 E U R O P E A N O N C O L O G Y Supportive Oncology economic analyses have demonstrated that prophylactic myeloid growth factor use may reduce costs in many clinical settings. A recent study has estimated a net cost saving with primary prophylaxis with G- CSF at a threshold risk of febrile neutropenia of 20% or greater based on average US direct medical costs for hospitalisation for febrile neutropenia.48 The addition of indirect and out-of-pocket costs with febrile neutropenia to the analysis results in greater net cost savings with myeloid growth factors.50 The use of the myeloid growth factors used at the time of hospitalisation for febrile neutropenia may result in further cost savings by reducing the length of hospitalisation.50 Recent studies have demonstrated the potential clinical and economic value of targeting the myeloid growth factors towards patients at greatest risk based on accurate and valid predictive models.22 Conclusions Prophylaxis with the colony-stimulating agents represents an effective and reasonably cost-effective method to reduce the risk of febrile neutropenia in patients receiving cancer chemotherapy. Guidelines for the use of the myeloid growth factors from major professional organisations support their use when the risk of febrile neutropenia is 20% or greater and in a number of special circumstances, including the elderly or those with serious co-morbidities. While indications for the appropriate use of these agents have expanded, continued monitoring for any safety signals is essential. Efforts to define better strategies for identifying patients who are at an increased risk and are most likely to benefit from myeloid growth factor support are under way. ■ 1. Kuderer NM, Dale DC, Crawford J, et al., Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients, Cancer, 2006;106:2258–66. 2. Lyman GH, Kuderer NM, Epidemiology of febrile neutropenia, Support Cancer Ther, 2003;1:1–12. 3. Crawford J, Dale DC, Kuderer NM, et al., Risk and timing of neutropenic events in adult cancer patients receiving chemotherapy: the results of a prospective nationwide study of oncology practice, J Natl Compr Canc Netw, 2008l6:109–18. 4. Lyman GH, Delgado DJ, Risk and timing of hospitalization for febrile neutropenia in patients receiving CHOP, CHOP-R, or CNOP chemotherapy for intermediate-grade non-Hodgkin lymphoma, Cancer, 2003;98:2402–9. 5. Lyman GH, Morrison VA, Dale DC, et al., Risk of febrile neutropenia among patients with intermediate-grade non-Hodgkin’s lymphoma receiving CHOP chemotherapy, Leuk Lymphoma, 2003;44:2069–76. 6. Di Maio M, Gridelli C, Gallo C, et al., Chemotherapy-induced neutropenia and treatment efficacy in advanced non-small-cell lung cancer: a pooled analysis of three randomised trials, Lancet Oncol, 2005;6:669–77. 7. Crawford J, Armitage J, Balducci L et al: Myeloid growth factors. J Natl Compr Netw, 2009; 7: 64-83. 8. Bonneterre J, Roche H, Kerbrat P, et al., Epirubicin increases long-term survival in adjuvant chemotherapy of patients with poor-prognosis, node-positive, early breast cancer: 10-year follow-up results of the French Adjuvant Study Group 05 randomized trial, J Clin Oncol, 2005’23:2686–93. 9. Budman DR, Berry DA, Cirrincione CT, et al., Dose and dose intensity as determinants of outcome in the adjuvant treatment of breast cancer. The Cancer and Leukemia Group B, J Natl Cancer Inst, 1998;90:1205–11. 10. Chu E, DeVita V., Principles of Medical Oncology, 7th Edition, Philadelphia: Lippincott, 2006. 11. Lyman GH, Dale DC, Crawford J, Incidence and predictors of low dose-intensity in adjuvant breast cancer chemotherapy: a nationwide study of community practices, J Clin Oncol, 2003;21:4524–31. 12. Lyman GH, Dale DC, Friedberg J, et al., Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Hodgkin’s lymphoma: a nationwide study, J Clin Oncol, 2004;22:4302–11. 13. Crawford J, Althaus B, Armitage J, et al., Myeloid growth factors. Clinical practice guidelines in oncology, J Natl Compr Canc Netw, 2007;5:188–202. 14. Griggs JJ, Culakova E, Sorbero ME, et al., Social and racial differences in selection of breast cancer adjuvant chemotherapy regimens, J Clin Oncol, 2007;25:2522–7. 15. Griggs JJ, Culakova E, Sorbero ME, et al., Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy, J Clin Oncol, 2007;25: 277–84. 16. Griggs JJ, Sorbero ME, Lyman GH, Undertreatment of obese women receiving breast cancer chemotherapy, Arch Intern Med, 2005;165:1267–73. 17. Shayne M, Crawford J, Dale DC, et al., Predictors of reduced dose intensity in patients with early-stage breast cancer receiving adjuvant chemotherapy, Breast Cancer Res Treat, 2006;100:255–62. 18. Shayne M, Culakova E, Poniewierski MS, et al., Dose intensity and hematologic toxicity in older cancer patients receiving systemic chemotherapy, Cancer, 2007;110:1611–20. 19. Balducci L, Hardy CL, Anemia of Aging: A Model of Erythropoiesis in Cancer Patients, Cancer Control, 1998;5: 17–21. 20. Balducci L, Hardy CL, Lyman GH, Hemopoiesis and aging, Cancer Treat Res, 2005;124:109–34. 21. Balducci L, Yates J, General guidelines for the management of older patients with cancer, Oncology, 2000;14:221–7. 22. Lyman GH, Lyman CH, Agboola O, Risk models for predicting chemotherapy-induced neutropenia, Oncologist, 2005;10: 427–37. 23. Crawford J, Ozer H, Stoller R, et al., Reduction by granulocyte colony-stimulating factor of fever and neutropenia induced by chemotherapy in patients with small-cell lung cancer, N Engl J Med, 1991325:164–70. 24. Trillet-Lenoir V, Green J, Manegold C, et al., Recombinant granulocyte colony stimulating factor reduces the infectious complications of cytotoxic chemotherapy, Eur J Cancer, 1993;29A:319–24. 25. Komrokji RS, Lyman GH, The colony-stimulating factors: use to prevent and treat neutropenia and its complications, Expert Opin Biol Ther, 2004;4:1897–1910 26. Lyman GH, Pegfilgrastim: a granulocyte colony-stimulating factor with sustained duration of action, Expert Opin Biol Ther, 2005;5:1635–46. 27. Pinto L, Liu Z, Doan Q, et al., Comparison of pegfilgrastim with filgrastim on febrile neutropenia, grade IV neutropenia and bone pain: a meta-analysis of randomized controlled trials, Curr Med Res Opin, 2007;23:2283–95. 28. Kuderer NM, Dale DC, Crawford J, et al., Impact of primary prophylaxis with granulocyte colony-stimulating factor on febrile neutropenia and mortality in adult cancer patients receiving chemotherapy: a systematic review, J Clin Oncol, 2007;25: 3158-67. 29. Clark OA, Lyman GH, Castro AA, et al., Colony-stimulating factors for chemotherapy-induced febrile neutropenia: a meta-analysis of randomized controlled trials, J Clin Oncol, 2005;23:4198–214. 30. Elkin EB, Hurria A, Mitra N, et al., Adjuvant chemotherapy and survival in older women with hormone receptor-negative breast cancer: assessing outcome in a population-based, observational cohort, J Clin Oncol, 2006;24:2757–64. 31. Giordano SH, Duan Z, Kuo YF, et al., Use and outcomes of adjuvant chemotherapy in older women with breast cancer, J Clin Oncol, 2006;24:2750–56. 32. Sargent DJ, Goldberg RM, Jacobson SD, et al., A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients, N Engl J Med, 2001;345:1091–7. 33. Morrison VA, Picozzi V, Scott S, et al., The impact of age on delivered dose intensity and hospitalizations for febrile neutropenia in patients with intermediate-grade non-Hodgkin’s lymphoma receiving initial CHOP chemotherapy: a risk factor analysis, Clin Lymphoma, 2001;2:47–56. 34. Osby E, Hagberg H, Kvaloy S, et al., CHOP is superior to CNOP in elderly patients with aggressive lymphoma while outcome is unaffected by filgrastim treatment: results of a Nordic Lymphoma Group randomized trial, Blood, 2003;101:3840–48. 35. Repetto L, Biganzoli L, Koehne CH, et al., EORTC Cancer in the Elderly Task Force guidelines for the use of colony-stimulating factors in elderly patients with cancer, Eur J Cancer, 2003;39: 2264–72. 36. Rossini F, Prognosis of infections in elderly patients with haematological diseases, Support Care Cancer, 1996;4:46–50. 37. Zinzani PL, Storti S, Zaccaria A, et al., Elderly aggressive-histology non-Hodgkin’s lymphoma: first-line VNCOP-B regimen experience on 350 patients, Blood, 1999;94: 33–8. 38. Crivellari D, Bonetti M, Castiglione-Gertsch M, et al., Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breast cancer: the International Breast Cancer Study Group Trial VII, J Clin Oncol, 2000;18:1412–22. 39. Chatta GS, Price TH, Allen RC, et al., Effects of in vivo recombinant methionyl human granulocyte colony-stimulating factor on the neutrophil response and peripheral blood colony-forming cells in healthy young and elderly adult volunteers, Blood, 1994;84:2923–9. 40. Shank WA Jr, Balducci L, Recombinant hemopoietic growth factors: comparative hemopoietic response in younger and older subjects, J Am Geriatr Soc, 1992;40:151–4. 41. Doorduijn JK, van der Holt B, van Imhoff GW, et al., CHOP compared with CHOP plus granulocyte colony-stimulating factor in elderly patients with aggressive non-Hodgkin’s lymphoma, J Clin Oncol, 2003;21:3041–50. 42. Aapro MS, Cameron DA, Pettengell R, et al., EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphomas and solid tumours, Eur J Cancer, 2006;42:2433–53. 43. Lyman GH, Kleiner JM, Summary and comparison of myeloid growth factor guidelines in patients receiving cancer chemotherapy, J Natl Compr Canc Netw, 2007;5:217–28. 44. Smith TJ, Khatcheressian J, Lyman GH, et a., 2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline, J Clin Oncol, 24:3187-205, 2006 45. Lyman GH, Guidelines of the National Comprehensive Cancer Network on the use of myeloid growth factors with cancer chemotherapy: a review of the evidence, J Natl Compr Canc Netw, 2005;3:557–71. 46. Lyman GH, Kuderer N, Greene J, et al., The economics of febrile neutropenia: implications for the use of colony-stimulating factors, Eur J Cancer, 1998;34:1857–64. 47. Lyman GH, Kuderer NM, The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia, Crit Rev Oncol Hematol, 2004;50:129–46. 48. Eldar-Lissai A, Cosler LE, Culakova E, et al., Economic analysis of prophylactic pegfilgrastim in adult cancer patients receiving chemotherapy, Value Health, 2001;11:172–9. 49. Lyman GH, Lyman CG, Sanderson RA, et al., Decision analysis of hematopoietic growth factor use in patients receiving cancer chemotherapy, J Natl Cancer Inst, 1993;85:488–93. 50. Cosler LE, Calhoun EA, Agboola O, et al., Effects of indirect and additional direct costs on the risk threshold for prophylaxis with colony-stimulating factors in patients at risk for severe neutropenia from cancer chemotherapy, Pharmacotherapy, 2004;24:488–94. Lyman_subbed.qxp 17/4/09 09:30 Page 16
  5. 5. European Oncology Nursing Society (EONS) INTRODUCTION The European Oncology Nursing Society (EONS) has provided support to cancer nurses across Europe since 1984.The mission of EONS is to add value to the work of its individual members and national societies in delivering care to patients with cancer. It aims to assist in the pro- motion of healthy communities through influencing, research and edu- cation. The changing landscape of cancer management in relation to cancer treatments, new technologies, psychosocial care and health care provi- sion has meant a significant shift in the way nurses apply their clinical skills and knowledge in the workplace. However, the professional devel- opment and status of cancer nurses across Europe is not uniform and EONS strategic agenda (CARE) aims to address this inequality by working with oncology nurses through their national societies. STRATEGIC PRIORITIES Communication Communicating with and to oncology nurses across Europe remains a challenge. Developing diverse communication pathways is complex and EONS is committed to doing this by continuing to produce and distribute (through the national societies) a newsletter four times a year.The EONS website (part of Cancerworld) is an established forum for cancer nurses and EONS will be developing multi-language sections within the site as well as options for interactive forums to promote professional discussion, information and networking.The European Journal of Oncology Nursing continues to be one of the leading cancer journals and celebrated 10 years of publication in 2006. Political Agenda EONS is one of the professional cancer societies that form part of the umbrella organisation renamed ECCO in 2007 (European CanCer Organisation) previously known as FECS – Federation of European Cancer Societies.The organisation provides a collective political voice in Europe. EONS is also a member of the European Specialist Nurses Organisation (ESNO) which consists of associations from both European Nursing Specialist and Nursing Interest Groups.The organisation acts as a platform to represent nursing in the wider political forum. Research Promoting evidence based clinical practice through research has always been a core function of EONS.Various grants are distributed through EONS to promote and facilitate research initiatives. One of the priorities is to develop a European cancer nursing research network which will enable wider collaboration, participation and sharing of research evidence as well as build a body of research and development expertise. Education The themes as priorities in education are to develop cancer nurse educators to develop and accredit teaching programmes which have education quality standards as part of the review process. Inequality in accessing post-registration cancer nursing education exists across Europe.Alongside this work is the commitment to develop specialist education and leadership programmes which can be viewed in www.cancerworld.org/eons Notwithstanding the busy agenda the patient experience lies at the heart of the CARE Strategy. By utilising and working in collaboration with patients, EONS will continue to provide a unique contribution to the agenda of cancer care in Europe, whilst promoting the unique contribution of cancer nursing in this processs. For more information on EONS, please contact the secretariat at eons.secretariat@skynet.be CARE encompasses four bodies of work: C Communication A Activities for the Political agenda R Research E Education EONS_ad.qxp 17/4/09 09:32 Page 17