Managing Neutropenia EffectivelyMay Improve Outcomes in ElderlyCancer Patients

MANHASSET, New York-Effective management of neutropenia may give elderly patients the best chance of cure, survival, or palliation, according to Stuart Lichtman, MD. Growth factors can be used to treat neutropenia, allowing for full delivery of standard-dose chemotherapy, and that may lead to better patient outcomes, said Dr. Lichtman, associate professor of clinical medicine, NYU School of Medicine, Division of Oncology, North Shore University Hospital, Manhasset, New York. Dr. Lichtman spoke at a satellite symposium sponsored by Amgen and held in conjunction with the first annual Geriatric Oncology Consortium multidisciplinary conference. Optimal Outcomes With effective strategies for managing myelosuppression, elderly patients can "look forward to a positive outcome with their treatment as much as younger patients," Dr. Lichtman said. Maintaining the desired dose and schedule of chemotherapy may be very important for optimal treatment outcome, as multiple investigations show. In one often-quoted study (J Clin Oncol 4:295-305, 1986), lymphomapatients more than 65 years of age had only a 37% complete response rate to CHOP (cyclophosphamide [Cytoxan, Neosar]/doxorubicin HCl/vincristine [Oncovin]/prednisone)-based therapy; however, many elderly patients had arbitrary dose reductions, based solely on their age. Among elderly patients who received full-dose chemotherapy, the complete response rate was 52%, similar to that seen in younger patients. Recently, studies have proven benefits of hematopoietic growth factor support in the elderly. Based on three randomized studies of the elderly, including two published in 2003, "it's pretty clear that...the growth factors do reduce neutropenia and neutropenic infections, and it helps maintain dose intensity," Dr. Lichtman said. "However, we still have not been able to prove that the overall survival and distheease- free survival has been enhanced." Clearly, more prospective studies of the role of growth factors in the elderly cancer population are needed. According to Dr. Lichtman, the Geriatric Oncology Consortium is conducting a study to determine whether primary prophylaxis with pegylated filgrastim(Drug information on filgrastim) (Neulasta) can enhance chemotherapy safety and outcome. In 2002 at ASCO, researchers showed that, in elderly patients with breast cancer, pegfilgrastim shows safety and efficacy similar to filgrastim (ASCO abstract 260). "In light of the studies just published, I think this type of clinical trial is even more important, because there are many unanswered questions," Dr. Lichtman said. Dose-Dense Strategies on the Rise Growth factors may also allow newer dose-dense chemotherapy regimens to be used in older patients. A recent breast cancer trial (CALGB [Cancer and Leukemia Group B] 9741) showed dose-dense adjuvant chemotherapy improved disease-free survival and overall survival vs standard-dose chemotherapy; the treatment approach, which incorporates hematopoietic growth factors as part of the deliverystrategy, may be "feasible" for elderly cancer patients, Dr. Lichtman said. "Older patients, in the next few years, are really going to be treated much more commonly with the new dose-dense regimens which have recently been published," Dr. Lichtman said. "It's going to be our job to selectpatients who are most appropriate for these therapies." In addition, a German lymphoma study group has shown that, specifically in older patients, a 14-day CHOP regimen provided a better outcome vs standard dose CHOP therapy (see study by Boccia et al, reported on page2 of this issue). "I don't think we are ready to go over completely to this kind of regimen, but certainly the feasibility of these new schedules is really going to become applicable to selected older patients," Dr. Lichtman said. "We have the ability to minimize toxicity."