Supportive therapy in medical therapy of head and neck tumors

Abstract

Fever during neutropenia may be a symptom of severe life threatening infection, which must be treated immediately with antibiotics. If signs of infection persist, therapy must be modified. Diagnostic measures should not delay treatment. If the risk of febrile neutropenia after chemotherapy is ≥20%, then prophylactic therapy with G-CSF is standard of care. After protocols with a risk of febrile neutropenia of 10-20%, G-CSF is necessary, in patients older than 65 years or with severe comorbidity, open wounds, reduced general condition. Anemia in cancer patients must be diagnosed carefully, even preoperatively. Transfusions of red blood cells are indicated in Hb levels below 7-8 g/dl. Erythropoiesis stimulating agents (ESA) are recommended after chemotherapy only when hemoglobin levels are below 11 g/dl. The Hb-level must not be increased above 12 g/dl. Anemia with functional iron deficiency (transferrin saturation <20%) should be treated with intravenous iron, as oral iron is ineffective being not absorbed. Nausea or emesis following chemotherapy can be classified as minimal, low, moderate and high. The antiemetic prophylaxis should be escalated accordingly. In chemotherapy with low emetogenic potential steroids are sufficient, in the moderate level 5-HT3 receptor antagonists (setrons) are added, and in the highest level Aprepitant as third drug.

Keywords: G-CSF; anemia; antibiotic therapy; diarrhea; documented infection; erythropoiesis stimulating agents; febrile neutropenia; nausea and emesis after chemotherapy; neutropenia.

Table 1. Risk groups; risk of progression to a life-threatening infection depending on the overall duration of neutropenia

Table 2. Criteria of the low or standard risk group (medical complications considered serious and risk classification according to the “Multinational Association of Supportive Care in Cancer” MASCC [1])

Table 3. Probable initial pathogenic spectrum upon diagnosis

Table 4. Antiinfective drugs (alphabetical sorting refer to “Summary of Product Characteristics” (SmPC) and to labelling for different countries!)

Table 5. Antimycotics (alphabetical sorting; dosage in normal renal function refer to Summary of Product Characteristics (SmPC) and to labelling for different countries!)

Table 6. Diagnostic and therapeutic strategies (modification or amendment according to symptoms, clinical or microbiological finding in patients with neutropenia and fever)

Table 7. Examples of frequently used chemotherapy protocols with the risk of FN: high risk ≥20%, intermediate risk 10–20% or low risk <10% (EORTC guidelines 2010 [39], ASCO-guidelines 2006 [8] and NCCN [19])

Table 8. Risk factors of febrile neutropenia according National Comprehensive Cancer Network, NCCN 2010) [19], EORTC [16] and ASCO [8]

Table 9. Diagnostics in suspected anemia ov chronic disease (ACD), exclusion of additional causes of anemia

Table 10. Emetogenic potential of intravenously applicable antineoplastic substances; selected drugs, which are in use for head and neck tumors

Table 11. Emetogenic potential of orally applicable antineoplastic substances

Table 12. Antiemetic prophylaxis in chemotherapy on day 1 (acute phase) and days 2–4 (delayed phase ), according ASCO- and MASCC-Guidelines [58, 59]

Figure 1

Figure 2

Figure 3

Figure 4. Correlation between incidence of infections including febrile neutropenia and neutrophil recovery

Figure 5. This algorithm is a combined interpretation of the 2010 G-CSF guidelines of European Organisation for Research and Treatment of Cancer (EORTC) and American Society of Clinical Oncology (ASCO) [8, 39]. All of these organisations recommend that the physician should use their clinical judgement to assess FN risk as greater or less than 20% according to the estimated risk of expected neutropenic complications, based on the treatment regimen and patient-specific characteristics, including age ≥65 years and experience of FN in a previous chemotherapy cycle.

Figure 6. EORTC Guidelines for Erythropoietic Proteins in Anaemic Patients with Cancer Chemotherapy: 2011 Update