Febrile Neutropenia Nomogram Flags Serious Complication Risk

Simple calculation may help identify chemotherapy patients at high risk of developing serious complications of febrile neutropenia

medwireNews: Researchers have developed a nomogram and online calculator to predict the likelihood of serious complications in patients receiving emergency care for clinically stable chemotherapy-related febrile neutropenia (FN).

The team applied the Clinical Index of Stable Febrile Neutropenia (CISNE) prognostication classification to 1133 FINITE study participants undergoing mild–moderate intensity chemotherapy for solid tumours who had no serious complications within 3 hours of FN diagnosis.

“CISNE seeks to decrease the uncertainty linked to the diminished inflammatory response due to immunosuppression, which undermines the clinician’s ability to detect complications early on”, explain Alberto Carmona-Bayonas, from Hospital Universitario Morales Meseguer in Murcia, Spain, and co-investigators.

Patients were awarded points for an ECOG performance status of 2 or higher; a diagnosis of chronic obstructive pulmonary disease or chronic cardiovascular disease; mucositis of grade 2 or higher; a low monocyte count (<200/mm3) and stress-induced hyperglycaemia.

Overall, 13.4% of the patients developed serious complications and 1.8% died. A nomogram score of 116 points or higher – translating to at least a 13% risk of serious complications – significantly predicted the likelihood of complications with a corrected concordance index of 0.855.

The nomogram was then tested in a second group of 296 patients in the University of Salamanca Hospital registry who sought emergency care for fever and neutropenia; a CISNE score of 116 points or above gave a significant concordance index of 0.831.

At this cutoff, the nomogram was 66% sensitive and 83% specific for the prediction of serious complications in the validation group, with positive and negative predictive values of 48% and 91%, respectively.

The team believes that the CISNE nomogram, when applied as a two-step process in tandem with exclusion criteria for early release after admittance for neutropenia, is a “safe method” for assessing risk of serious complications in this population because it aims to keep patients in hospital until apparent FN stability is confirmed.

“Therefore, the results of our study are mainly applicable to avoid early discharge of patients with cancer beginning in-patient therapy”, the researchers write in the British Journal of Cancer.

While acknowledging the need for clinical trial testing of their nomogram, the investigators conclude: “In light of our data, we suggest that patients experiencing seemingly stable episodes with a CISNE nomogram score ≥116 points (equivalent to a risk of serious complications ≥13%) should not be sent home until they have proven to be truly stable and blood cultures have been examined.”

But they add: “[W]e emphasise that this nomogram should not be used so much to select low-risk patients for direct outpatient treatment. “

Reference

Fonseca PJ, Carmona-Bayonas A, García IM, et al. A nomogram for predicting complications in patients with solid tumours and seemingly stable febrile neutropenia. Br J Cancer 2016; Advance online publication 17 May. doi: 10.1038/bjc.2016.118

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