Myelosuppression: A Report from the 2007 ONS Annual Congress

Cancer Connect

Introduction

Myelosuppression was an important topic at the 2007 Oncology Nursing Society Congress. Two satellite symposia, two instructional sessions, and three abstracts addressed various facets of myelosuppression in cancer patients.1-10

Anemia

The satellite symposium on anemia included presentations on dosing erythropoietic agents, iron management, anemia in hematologic malignancies, perioperative anemia, and safety issues in using erythropoietic agents.6,9-12 Recent results of studies of intravenous (IV) iron indicate that hemoglobin response with IV iron is superior to no iron and to oral iron. Specific criteria for determining whether or not IV iron is needed and the advantages and disadvantages of the three common iron formulations were presented.

The presentation on safety issues received a great deal of attention. This presentation addressed the findings of recent published and unpublished studies testing the effects of erythropoietin stimulating agents (ESA) in cancer and chronic kidney disease and the resulting FDA-mandated changes to the package inserts for ESAs. These studies raised concern about thromboembolic events and shortened duration of survival with erythropoietic agents in cancer when the agents were used outside the approved indication for decreasing transfusion use, higher than recommended hemoglobin targets were established, and higher than recommended hemoglobin levels were used at the initiation of therapy. The safety message embedded in this symposium focused on a hemoglobin of 12 g/dL as the maximum level to be achieved in patients with chemotherapy-induced anemia where the goal is to decrease transfusion use.10

The anemia content presented in the myelosuppresion symposium focused on more general issues but did address the use of iron supplementation (oral or IV).3 June Eilers, PhD, RN, BC, CS and Luisa Rounds, BSN, RN presented the results of their literature review on bloodless interventions.2 This evidence-based practice project identified blood conservation and bloodless interventions, including cell salvage, aprotinin, colloids, growth factors, tranexamic acid, and the overlap autogenous tissue (OAT) patch. The rationale for the project included a discussion of the history of blood shortages for allogeneic transfusion, concerns about blood-transmitted illness, cultural and religious concerns or restrictions on the use of blood, and a general challenge to assumptions underlying the use of blood products. Suggested uses of the information in this review were presented including an evidence-based guide to selection of interventions for managing chemotherapy-induced anemia.

Thrombocytopenia

Thrombocytopenia has received much less attention in the research and clinical literature than either anemia or neutropenia. Kimberly Noonan, RN, NP, AOCN, from the Dana Farber Cancer Institute discussed chemotherapy-induced thrombocytopenia at a satellite symposium. Kimberly Noonans presentation addressed several important issues such as the need to recognize that commonly used drugs can contribute to drug-induced thrombocytopenia when platelets are destroyed by drug specific antibodies.7 Additional concerns in addressing thrombocytopenia include phenomena such as alloimmunization, bleeding, infection, heparin use, mismatch with ABO type, graft versus host disease, and disseminated intravascular coagulation (DIC). Thrombopoietins and platelet growth factors are being developed and tested for use in chemotherapy-induced thrombocytopenia.

Neutropenia

The high level of interest in neutropenia among the attendees was evident in the number of abstracts and instructional sessions devoted to this topic. Topics included treatment, cancer, and personal risk factors for neutropenia, criteria for evaluating the severity of neutropenia (absolute neutrophil count level), the contribution of the disease process in hematologic malignancies versus the myelosuppressive effects of chemotherapy or whole body radiation treatment, and the impact of neutropenia and febrile neutropenia on function, and quality of life.3 The economic impact of neutropenia was also discussed. Unlike anemia where prophylaxis is not one of the dosing options, granulocyte-colony stimulating factors (G-CSF), such as filgrastim or pegfilgrastim, are used prophylactically to maintain an acceptable level of white cells. Cautions in the use of white cell growth factors include the need to deliver an adequate dose, avoid administering G-CSF the same day as chemotherapy, and challenges in monitoring outpatients for neutropenia, febrile neutropenia, and infection.4,5

Conclusion

Myelosuppression is a dose-limiting factor in cancer treatment and can progress to the level of being an oncologic emergency with infection (neutropenia), bleeding (thrombocytopenia) or cardiac problems (anemia). At this point, neutropenia is the only one of the three components of myelosuppression where prophylactic strategies are accepted, although they are by no means free of controversy. Neutropenia can cause treatment delays, dose reductions, and premature cessation of chemotherapy. When neutropenia progresses to infection, hospitalization may be required and there is debate over who should be hospitalized as well as the appropriate course for treating infection.4,13,14

Myelosuppression remains an important issue in systemic therapy of cancer. Issues around the prevention, detection, and management of neutropenia with and without fever cross practice settings and cancer patient populations and represent a major challenge to all members of the patient care team.

References

1.Bolton TM. Chemotherapy-induced anemia. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

2.Eilers J, Rounds L. Blood transfusion or not: A literature review of bloodless interventions to treat cancer related anemia. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007, Abstract #2318.

3.Friese CR. Chemotherapy-induced neutropenia. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

4.Gardner A. Neutropenic fevers. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

5.Moore S. Sepsis. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

6.Nail LM. Anemia in hematologic malignancies. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

7.Noonan K. Chemotherapy-induced thrombocytopenia. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

8.Shelburne N, Wedrow L, Bugos K. Care of immunocompromised patients with hematologic disorders. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

9.Stanley KJ. Perioperative anemia. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

10.Stanley KJ. Safety issues when using erythropoietic agents. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

11.Stricker CT. Flexible dosing of erythropoietic agents. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

12.Stricker CT. Iron management. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

13.Leibovici L, Paul M, Cullen M, et al. Antibiotic prophylaxis in neutropenic patients: new evidence, practical decisions. Cancer. 2006;107(8):1743-51.

14.Lo N, Cullen M. Antibiotic prophylaxis in chemotherapy-induced neutropenia: time to reconsider. Hematol Oncol. 2006;24(3):120-5.

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