Intermittent granulocyte colony-stimulating factor maintains dose intensity after ABVD therapy complicated by neutropenia

Introduction: Granulocyte Colony-Stimulating Factor (G-CSF) is commonly used to maintain dose intensity in patients receiving ABVD chemotherapy (doxorubicin, bleomycin, vinblastine and dacarbazine) for Hodgkin lymphoma. However, the need for growth factor support is unclear, with studies suggesting that dose intensity can be maintained without G-CSF. Moreover, G-CSF is expensive (pegfilgrastim: EUR 1540/cycle; 300 mu g filgrastim for 7 days: EUR 700/cycle) and is associated with side effects including bone pain and increased risk of bleomycin lung toxicity. Intermittent G-CSF may be an effective compromise, given that the effect of G-CSF on granulocyte precursors in vitro persists for 45 days after administration. After promising results of a pilot study, this schedule has been used subsequently in the majority of our patients receiving G-CSF as secondary prophylaxis for ABVD complicated by neutropenia. Methods: Retrospective analysis of the incidence of febrile neutropenia and treatment delay in a variety of different G-CSF schedules used as secondary prophylaxis in patients receiving ABVD. Results: 848 cycles in 85 consecutive patients were evaluated. Most patients (86%) received G-CSF, generally commenced prophylactically for neutropenia when cycle 1B was due. Intermittent G-CSF (typically given on days 4, 8 and 12) was used in 413 cycles compared with daily or pegylated G-CSF in 99 cycles. In patients receiving intermittent G-CSF, the median neutrophil count, across all cycles, was 7.3 x 109/L (range: 1.447.1) when the next scheduled chemotherapy was due. There were two cases of febrile neutropenia (0.45%) and no treatment delays. One patient developed possible bleomycin toxicity. Conclusions: Intermittent G-CSF is effective in maintaining dose intensity in patients receiving ABVD.