A novel approach to maintain planned dose chemotherapy on time: a decision-making tool to improve patient care

Studies of primary prophylaxis of febrile neutropenia with recombinant gran ulocyte colony-stimulating factor (r-metHuG-CSF, filgrastim), administered to all patients starting with the initial course of chemotherapy, have demo nstrated an economic advantage over a wide range of settings. In these anal yses, the threshold risk for febrile neutropenia at which a cost saving is realised is inversely related to the direct medical costs of hospitalisatio n. Clinical practice guidelines for the use of filgrastim have been develop ed based on these observations. Recent studies incorporating indirect insti tutional costs have demonstrated that cost savings can be achieved at subst antially lower febrile neutropenia risk thresholds than previously estimate d. Despite the demonstrated efficacy of filgrastim in primary prophylaxis, its value may be further enhanced through the appropriate selection of pati ents for such therapy and a better understanding of the importance of susta ining dose intensity in specific malignancies. Clinical prediction models c apable of identifying individuals at high risk for neutropenic complication s yield further reductions in febrile neutropenia risk thresholds and treat ment costs in patients receiving cancer chemotherapy. Prediction models can also be used to evaluate the cost-effectiveness or cost-efficiency of filg rastim use. Such a model has recently been developed and validated and is d escribed here which incorporates both baseline clinical characteristics as well as the results of the first cycle of chemotherapy in patients with ear ly-stage breast cancer. A cost-effectiveness ratio of US$ 34 297 (Euro 32 0 02)dagger per year of life saved (YLS) was calculated based on dose-respons e assumptions derived from a previously reported adjuvant breast cancer tri al studying the impact of dose reduction on disease-free survival. This fig ure is comparable with accepted cost-effectiveness ratios for other interve ntions, e.g. US$ 45 000/LYS (Euro 41 989) for renal dialysis for patients w ith end-stage renal disease. The cost-effectiveness of filgrastim was evide nt over a wide range of clinical and cost assumptions. Clinical prediction models permit rational and cost-effective selection of patients for filgras tim support. Current guidelines should be re-evaluated in light of new info rmation available on both the total cost of febrile neutropenia, as well as the cost-effectiveness of these agents in specific clinical situations. (C ) 2000 Elsevier Science Ltd. All rights reserved.