Use of hematopoietic colony-stimulating factors: the American Society of Clinical Oncology survey. The Health Services Research Committee of the American Society of Clinical Oncology.

PURPOSE: Dissemination of use of the hematopoietic colony-stimulating factors (CSFs) is unprecedented in oncology, with almost all physicians having experience with granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) shortly after the drugs received Food and Drug Administration (FDA) approval in 1991. The American Society of Clinical Oncology (ASCO) Health Services Research Committee sought to assess patterns of use of CSFs before dissemination of its first-ever publication of ASCO guidelines. METHODS: A questionnaire describing clinical scenarios was mailed to American oncologists and hematologists who practice medical oncology. In each scenario, the physician was asked whether he would prefer to use a CSF to prevent or treat neutropenia. RESULTS: The response rate to the mailed survey was 49% (N = 475). Most physicians preferred to use CSFs for secondary prophylaxis in patients receiving chemotherapy at rates of 44% to 85%, rather than reduce doses. Patterns of use did not differ for palliative, curative, or adjuvant chemotherapy. While the majority of CSF patterns of care were similar to those recommended in the ASCO guidelines, more than half of the physicians chose to use CSFs in the treatment of febrile neutropenia, an area not supported in the subsequent guidelines. In general, physicians at academic medical centers and in Health Maintenance Organization (HMO) practices were more likely to prefer dose-reduction strategies over addition of CSFs, while fee-for-service physicians preferred the opposite strategies. CONCLUSION: Variations in CSF preferences for use were related to differences in clinical characteristics (history of afebrile v febrile neutropenia), drug characteristics (G-CSF or GM-CSF), and physician practice characteristics (HMO or fee-for-service setting). However, before dissemination of the guidelines, the majority of American oncologists preferred strategies that were subsequently included in the ASCO CSF guidelines. CSF guidelines would be most likely to reduce CSF use for treatment of afebrile and uncomplicated febrile neutropenia.

Justification and implementation of an oncology pharmacist practitioner in an HMO setting.

The role of an oncology pharmacist practitioner in an outpatient clinic is described. The clinic provides cancer treatment and follow-up to approximately 60 to 80 patients per day. The hospital pharmacy department, the director of the medical oncology service, and the oncology nurse specialist presented a proposal to the clinic administration for the employment of a full-time pharmacist. Previously, the clinic nursing staff prepared all chemotherapeutic agents. The oncology pharmacist now prepares between 35 to 75 chemotherapy drug doses per day. As a result, nurses are able to devote more time to direct patient care. Through the application of inventory management, clinic drug costs have been reduced. In addition, patients undergoing chemotherapy no longer have to wait for their prescriptions since the oncology pharmacist calls them to the outpatient pharmacy. A valuable service has been introduced tht not only benefits the clinic personnel, but also assures that the patients receive the highest standards of care.

Antipyretic effects of indomethacin in liver metastases of solid tumors.

Six cases of fever in patients with dominant hepatic metastases from a variety of solid tumors are presented. The elevated temperature in each case was due to the malignant process itself without evidence of infection. After failure to control fever with various antipyretics and antibiotics, indomethacin promptly controlled fever in all six patients. Prior reports of antipyresis from indomethacin in hematologic malignancies and solid tumors are reviewed. Both the mechanism of fever due to the malignant process itself and the possible mechanism of indomethacin's antipyretic effect are presented. The major thrust of this report is the clinical usefulness of indomethacin for the management of liver metastases with uncontrollable fever.