Balancing the benefits and costs of colony-stimulating factors: a current perspective

Neutropenia is the most common dose-limiting toxicity associated with cancer chemotherapy. Neutropenic complications, including febrile neutropenia, occur in a substantial proportion of patients with chemotherapy-induced neutropenia. Although neutropenia and its complications can be reduced with colony-stimulating factors (CSFs), it is not considered cost-effective to administer them prophylactically to all patients. The current American Society of Clinical Oncology guidelines recommend primary prophylaxis with the CSFs in patients receiving chemotherapy regimens that produce febrile neutropenia in 40% or more of those treated. This recommendation was supported by an early economic analysis based on a decision model incorporating hospital cost data to determine the risk threshold for the cost-saving use of the CSFs. Updating this model to include current estimates of hospitalization costs, indirect costs such as productivity losses, and out-of-pocket patient expenses reduced the risk threshold for cost savings with CSF to 18%. Recent efforts have focused on identifying individual patient characteristics that might be used to target prophylactic CSF in patients who are at greatest risk. Should such factors be identified and validated, assessing each patient's individual risk for neutropenic complications may prove to be a better strategy for the cost-effective use of the CSFs than the risk threshold approach. Preliminary results suggest that the targeted application of CSF support based on a risk model may improve the associated cost savings.