Bhana, N. (2007). Granulocyte colony-stimulating factors in the management of chemotherapy-induced neutropenia: Evidence based review. Current Opinion in Oncology, 19, 328–335.

The purpose of this study was to review the best current evidence for the efficacy of G-CSFs (filgrastim, pegfilgrastim, and lenograstim) for the primary and secondary prophylaxis of chemotherapy-induced neutropenia, specifically for the primary outcomes of incidence and risk of neutropenia, infections, and infection-induced mortality. Secondary aims include review of the best and current evidence for the efficacy of G-CSFs for the outcomes of duration of neutropenia, hospitalizations, and antibiotic therapy.

MEDLINE (1966 to date), EMBASE (1980 to date), the Cochrane Library, and the Odyssey databases were searched.
Key words included colony-stimulating factors, filgrastim, nuepogen, pegfilrastim, neulasta, lenograstim, granocyte, neutropenia, fever

Inclusion criteria:

• Randomized, controlled trials (RCTs) from the year 2000 and newer with more than 80 participants that investigated the named G-CSFs in comparison to placebo, other G-CSFs or no treatment, or in combination with antibiotics versus antibiotics alone for initiation of treatment (prior to neutropenia onset) or secondary prophylaxis during chemotherapy (minimum three-week follow-up (initiated during chemotherapy cycles following neutropenia of febrile neutropenia onset in a previous cyle).
• Data from meta-analyses, overviews of more than two studies, and systematic reviews of trial involving the named G-CSFs and where available, cost-effectiveness analyses of any of the studies meeting the inclusion criteria also were included.

Exclusion criteria:

• Non-English publications and studies published in abstract form only

Initially, 11 RCTs, two study overviews, four meta-analyses, and three economic analyses were reviewed. One RCT was excluded to bring the total to 10.

The inclusion criteria state that RCTs included in this review needed to have more than 80 participants, yet one study included had 49. In addition, the inclusion of three economic studies did not match the study aim of efficacy of use of G-CSFs for reduction of neutropenia and related complications. Two of these economic studies were analyses of two of the RCTs being evaluated for efficacy in neutropenia prevention/reduction. The third economic study did not have details about the trial disclosed.

• 20 studies were included in the total sample
• 7,409 subjects in total
• The sample range across studies was 49–1,823 subjects

The use of G-CSF is overall effective for the reduction of neutropenia, febrile neutropenia, associated infections, antibiotic use, and hospitalizations in various populations of adult patients with cancer. The use of pegfilgrastin is more effective than filgrastin in reducing the risk of febrile neutropenia and pegfilgrastin is as effective as filgrastin in reducing the duration of severe neutropenia.

In the pediatric population with cancer, use of G-CSFs is effective in reducing the risk of febrile neutropenia and associated hospitalizations, but is not effective in reducing infections.In older adult populations, G-CSFs were effective for reduced use of antibiotics but not for risk of febrile neutropenia.

Current trials show that G-CSFs are overall effective in reducing the risk of neutropenia, febrile neutropenia, and associated infections, hospitalizations, and antibiotic use for various populations of patients with cancer undergoing chemotherapeutic treatments.

Current American Society of Clinical Oncology recommendations promote the use of G-CSFs for patients receiving chemotherapeutic treatments that have a greater than 20% risk of inducing febrile neutropenia. Although this review found mixed results within the studies evaluated and the criteria for this review stated was not completely followed; overall findings do indicate that G-CSF continues to be an effective therapy in the reduction of neutropenic events and related sequelae.

Implications for nursing practice include understanding the use and effectiveness of administration of G-CSF, promoting its use, and continued monitoring for neutropenia, febrile neutropenia, and infections.