Poonawalla, I.B., Piller, L.B., Lairson, D.R., Chan, W., & Du, X.L. (2016). Impact of hematopoietic growth factors on blood transfusion needs, incidence of neutropenia, and overall survival among elderly advanced ovarian cancer patients treated with chemotherapy. International Journal of Gynecological Cancer, 26, 95–103. 

To determine the effectives of an erythropoietin-stimulating agent (ESA) and granulocyte–colony-stimulating factor (G-CSF) in reducing blood transfusion needs and neutropenia incidence in community-dwelling older adults with ovarian cancer

Woman aged older than 65 years diagnosed with stage III–IV epithelial ovarian cancer (from January 2000–December 2009) were identified as having received chemotherapy by procedure codes in Medicare within nine months of diagnosis. Cox models were used for analysis and included time-dependent covariates. ESAs and G-CSFs were identified by Healthcare Common Procedure Coding System codes for epoetin-alfa/darbepoetin-alfa and filgrastim/pegfilgrastim. Blood transfusion need was measured from the time of diagnosis to first Medicare claim indicating the receipt of blood transfusion. Neutropenia incidence was measured from the time of the first chemotherapy administration to the first claim of neutropenia. Patients who did not receive a blood transfusion or did not develop neutropenia were censored at the date of death or last date in Medicare claims (i.e., December 31, 2010), whichever occurred first. Overall survival was measured from the time of first chemotherapy administration until death or the end of the follow-up period (December 31, 2011). Patients not experiencing the event (death) by this date were censored.

• N = 5,572   
• AGE = Older than 65 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Stage III–IV epithelial ovarian cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: Sociodemographics

• SITE: Multi-site   
• SETTING TYPE: Not specified

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

Retrospective cohort study using SEER Medicare linked database

• Cox Model
• Kaplan-Meier curves
• Propensity scores
• Logistic regression model
• Propensity score distribution plots

ESAa were effective in reducing blood transfusion need. G-CSFs were effective in lowering neutropenia incidence and were associated with improved survival in older adults with ovarian cancer. The interaction between ESA time and CSF time was significant (p = 0.0001).

The findings demonstrated that using epoetin-alfa or darbepoetin-alfa effectively lowers the blood transfusion needs by 48%–78% in patients receiving chemotherapy, which is comparable to prior randomized trials of patients with gynecologic and ovarian cancer. The use of a G-CSF was associated with a longer survival compared to those who received at least three doses of a G-CSF. The findings showed that patients who received fewer than three prophylactic G-CSF administrations did not experience better outcomes.

• Risk of bias (no random assignment)
• Findings not generalizable
• No ability to look at laboratory data that triggered the use of ESAs and G-CSFs
• No ability to look at intensity of chemotherapy
• Potential risk of ESAs or G-CSFs in relation to thrombocytopenia and bleeding events

This was a good study; however, it had a very focused patient population and may not be reproducible in the younger population. In addition, no information was provided regarding adverse events related to the use of ESAs or G-CSFs. Prior studies have shown a possible higher risk for mortality with the use of ESAs and G-CSFs. It is important to continue to look at established guidelines (Oncology Nursing Society, American Society for Clinical Oncology, National Comprehensive Cancer Network, Food and Drug Administration) for the use of ESAs and G-CSFs in the cancer population.