Aapro, M.S., Bohlius, J., Cameron, D.A., Dal Lago, L., Donnelly, J.P., Kearney, N., . . . European Organisation for Research and Treatment of Cancer. (2011). 2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours. European Journal of Cancer, 47, 8–32.

The purpose of this article was to update existing guidelines for prophylactic granulocytye–colony-stimulating factor (G-CSF). The article focuses on patients receiving chemotherapy, not limited to one definition of febrile neutropenia (FN). No studies with pediatric patients or patients with leukemia were included.

This guideline resource used a process where articles were rated using the table listing below.

Level                Type of Evidence
A                        Evidence of type I or consistent findings from multiple studies of types II, III, or IV
B                       Evidence of types Ii, II, or IV and findings are generally consistent
C                       Evidence of types Ii, II, or IV, but findings are inconsistent
D                       Little or no systematic empirical evidence 

Information from papers included in meta-analyses were only used to answer questions not included in the meta-analyses. Publications available from Congress presentations previously included as abstracts were only used is they provided answers not yet presented. Authors were contacted if their abstracts were relevant and publications noted as missing or “in press” were included.

Regarding a search strategy, the MEDLINE, PreMEDLINE, EMBASE, and Cochrane Library databases were used.

Key words included antineoplastic agents, filgrastim, granulocyte–colony-stimulating factor, lenograstim, neoplasms, neutropenia, pegfilgrastim, and guideline

Articles were included if they were recent reviews, any primary papers deemed relevant, and meta-analyses subject to manual review. In addition to filgrastim and pegfilgrastim, two filgrastim biosimilar molicules, XMO2 and EP2006, daily G-CSFs have been approved in Europe. 

Articles were excluded if their studies included patients younger than age 18 years or patients with a diagnosis of leukemia.
 

• The phase of care is active chemotherapy treatment
• Applications is adult patients receiving chemotherapy.
   

Recommendations  Primary prophylactic G-CSF is recommended for patients at risk and should be started 24–72 hours following completion of the first cycle.

Step I:

• Assess frequency of FN associated with planned chemotherapy regimen, and reassess with each cycle.
• If FN risk is less than10%, G-CSF prophylaxis is not recommended. If FN risk is greater than 20%, prophylactic G-CSF is recommended.
• If FN risk 10%–20%,  proceed to step 2.

Step 2: 

• Assess for high risk: age older than 65 years.  
• Increased risk (level I, II evidence): Advanced disease, history of prior FN, no antibiotic prophylaxis, no G-CSF use
• Other factors (level III, IV evidence): Poor performance/nutritional status, female, Hgb < 12 g/dl, liver, renal, cardiovascular disease
• and then proceed to step 3

Step 3: 

• Define the patient’s overall FN risk for planned chemotherapy regimen.
• If overall FN risk is greater than 20%
• Secondary prophylaxis: Start G-CSF if neutropenic event occurred in previous cycle.

Provides percent risk for development of FN for some tumor types based on chemotherapy regimen. Identifies additional risk factors, but provides little guidance on how to use these to calculate an increase in risk that would warrant prophylactic G-CSF.
 

The article included results from an updated literature search to identify patient and chemotherapy regimen risk factors for developing FN, use of prophylactic G-CSF, G-CSF with existing FN, impact of overall FN risk on G-CSF use, and choice of G-CSF formulation. It was difficult to identify new information as recommendations were combined with existing recommendations.