Understanding ASCO’s Recommendations for Managing Febrile Neutropenia, with Christopher Flowers, MD

January 14, 2013
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In this podcast, we discuss ASCO’s recommendations for managing a symptom of cancer and cancer treatment called febrile neutropenia. This podcast is led by Dr. Christopher Flowers, who is an associate professor at the Winship Cancer Institute in the Department of Hematology/Oncology at Emory University in Atlanta.



ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology known as ASCO, the world's professional leading organization for doctors that care for people with cancer.

In today's podcast, we'll discuss ASCO's recommendations for managing a symptom of cancer and cancer treatment called febrile neutropenia. This podcast will be led by Dr. Christopher Flowers, who is an associate professor at the Winship Cancer Institute in the department of hematology oncology at Emory University in Atlanta. ASCO would like to thank Dr. Flowers for discussing this topic.

Dr. Flowers: Welcome to this ASCO clinical practice guideline podcast on the outpatient management of febrile neutropenia. I'm Christopher Flowers, an Associate Professor at the Winship Cancer Institute in the department of hematology/oncology at Emory University in Atlanta, and I'd like to walk you through the management and the issues associated with neutropenic fever or febrile neutropenic episodes.

Neutropenia is a state when 1 particular part of the white blood cell count, the neutrophils, is low. And this is something that happens relatively commonly in patients who have disease that involves their bone marrow or in other ways, suppress their neutrophil count, or in patients of any type who are undergoing chemotherapy and have their white blood cell count suppressed.

So the neutrophils are one sub-population of the white blood cells that are routinely measured in a CBC or a complete blood cell count when there is a differential performed. This is something that you can ask your doctor about whenever you get blood counts drawn. If you look at the laboratory values that you receive, you will commonly see the white blood cell count listed as W-B-C. But, the neutrophils are one sub-group of those white blood cell counts, and you will either need to perform calculations using the percentage of neutrophils, sometimes called ANC or absolute neutrophil count to determine what the total number of neutrophils is at that time. You can also ask your physician or the nurses to help you perform that calculation.

As part of the American Society of Clinical Oncology Clinical Practice Guideline, I helped to lead a task force that was engaged in trying to identify who are the patients at highest and lowest risk of developing febrile neutropenia or developing a fever during the time when the white blood cell count is low. And then, helping to identify among those patients who are patients that need to go into the hospital for management when there's the occurrence of a febrile neutropenic episode, and who are patients that might be managed as outpatients. The routine and typical management of febrile neutropenic episodes, or anytime that the white blood cell count is low or the neutrophil count is low, would be to be admitted to the hospital and to receive inpatient intravenous antibiotics until the neutrophil count comes up and until the fever resolves.

This new ASCO Clinical Practice Guideline aims to identify patients who might be at sufficiently low risk, that instead of going into the hospital to be managed for a febrile neutropenic episode, they can engage in management in the outpatient setting. We further go on to help your doctors to try to identify who are the patients that might need to have antibiotics to help prevent from one of these episodes to occur. The ways that we guide your doctors in this are trying to identify patients who are expected to have profound neutropenia, which is defined as having a neutrophil count that is expected to be below 100 and likely to last for more than 7 days. This commonly incurs an intensive chemotherapy regimen, like those that are given to patients with leukemia or lymphoma or to patients who are undergoing stem cell transplant or other dose-intensive chemotherapy sessions. In this setting, patients should be considered for use of prophylaxis with antibiotics to prevent the neutropenia from developing into a more serious infection.

When you are in the outpatient setting and undergoing an intensive chemotherapy regimen, this is something you should discuss with your doctors, about when it might be appropriate to have an antibiotic to prevent against having a more serious infection during this setting. In addition, we help to describe the kinds of hygiene and guidelines for handwashing practices to reduce exposures to contact, respiratory hygiene that you should use to help to reduce your exposure to droplet transmissions, and these are additional things that you should talk about with your doctors and the nursing staff. We also recommend that all patients, for whom it is appropriate, to receive seasonal influenza vaccination for anyone who's undergoing management of a malignancy and for all family and all household contacts every year during flu season, as this is an immunization that changes from year to year. We recommend that the influenza immunization be given using a particular type of vaccine called a trivalent inactivated vaccine.

In addition, we looked at what happens when a patient develops neutropenia and is at risk for developing a fever, which patients should be managed in the outpatient setting. Because medical complications can occur in up to 11% of patients who fall into a lower risk category, we considered inpatient treatment as the appropriate standard for managing a febrile neutropenic episode in nearly all patients. For selected patients, however, when fever occurs with neutropenia, it can happen in the outpatient setting. There are now well-developed and validated indices to help to identify patients who might be at sufficiently low risk. One called the MASCC score or M-A-S-C-C score, and another called Talcott's Rules can help to identify patients who are at sufficiently low risk, that they might be managed safely outside of the hospital with an oral antibiotic regimen.

These regimens are what is called empirical antibiotics, meaning that we are giving antibiotics to help prevent a serious infection knowing that there is fever, but not having yet identified what that infection is. In this setting where we see a fever among patients who have neutropenia, there are a number of tests that need to be performed. The first are tests that involve looking for sources for those infections. Things like blood cultures, urine cultures, on some occasions, sputum cultures, chest X-ray, and other imaging evaluation may be useful to help to try and identify patients who have some source of occult infection. In addition, other tests may be performed down the road, either in the inpatient or outpatient setting to identify patients who may have an infection.

Among patients who have a fever and have no identified source of infection, about 40% of the time, an infection is never identified. And when the white blood cell count comes up and the neutropenia resolves, the fevers typically go away. During that period of time though, while patients are neutropenia, it is important to continue antimicrobial prophylaxis with antibiotics. At any point in time if patients fall into a category where they need to come into the hospital or certain situations arise, like the fever persists or other situations occur, like the kidney function worsens, or there are other complications, like when the blood pressure drops, an individual may need to come into the hospital immediately. If you're being managed in the outpatient setting with a fever and with neutropenia, it will require very close contact with your doctor. Patients who are identified at low risk and identified for outpatient management need to be observed at least for 4 hours when they're first identified and started on antibiotics. And if stable, they can continue management in the outpatient setting.

The types of patients for whom outpatient management might be appropriate are those who live within 1 hour or less than 30 miles from the clinic or hospital where they receive their care. Settings where the patient's primary care physician or primary oncologist agrees to management in the outpatient setting and can see the patient very regularly. Patients who are able to comply with these kind of logistic requirements, like frequent clinic visits and have a family member or caregiver who's at home 24-hours a day and can bring the patient into the hospital immediately, if necessary. In order to consider this type of outpatient management, an individual must have 24-hour a day access to a telephone and to transportation to get into the hospital immediately and should be compliant with all treatment protocols up to that point in the management. I hope that this guideline discussion has been helpful to you in decision making about the management of your cancer. Further discussion should occur with your doctor about your specific management. Thank you for your attention.

ASCO: Thank you, Dr. Flowers.


More information on managing febrile neutropenia and other symptoms of cancer and cancer treatment can be found at www.Cancer.Net. Cancer.Net is supported by the Conquer Cancer Foundation, which is working to create a world free from the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients worldwide, and supporting initiatives to ensure that all people have access to high-quality cancer care. Thank you for listening to this Cancer.Net podcast.