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Journal of Clinical Oncology, Vol 24, No 7 (March 1), 2006: pp. 1222-1223 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.0054
In Reply:Pediatric Oncology and Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands As stated in the conclusion of our article,1 we completely agree with Dr Lyman that this risk assessment strategy needs further confirmation and validation in a multicenter setting before it can be implemented into daily clinical oncologic practice. Dr Lyman criticizes the fact that children as well as adults were included in our study. The design of the protocol allowed all patients treated with chemotherapy for a malignancy in our University Medical Center to be classified in the risk assessment when admitted from home with febrile neutropenia, regardless of age or febrile neutropenic episode number. The diversity of our study population and the use of objective risk assessment parameters underscore the strength of this clinical observation and imply a potential broad applicability. Together, these data support the exploration of this risk assessment strategy with important clinical managerial potential of outpatients. In several studies thus far, retrospectively identified risk factors for either high- or low-risk patients are reported.2,3 However, it is not positive whether these parameters can actually be used in today's practice. The risk prediction model of Santolaya et al4 has shown to be helpful in discriminating between children with high or low risk for invasive bacterial infection. Data comparing morbidity and mortality of adult versus pediatric cancer patients have been published. In 1997, results from European Organisation for Research and Treatment of Cancer studies, which were performed between 1986 and 1994 and analyzing 2,321 adults and 759 children, showed that the incidence of bacteremia was similar (adults v children), but the incidence of clinically documented infection was less frequent in children (adults v children). Death from infections was reported to be 4% in adults and 1% in children.5 In a recent study of 12,446 pediatric patients treated between 1995 and 2002, the mortality rate was 3%.2 This suggests that the differences between morbidity and mortality in pediatric and adult populations are not large. However, a direct comparison between the morbidity and mortality of adult versus pediatric patients in the outpatient setting is lacking. We analyzed our data not per patient but per febrile neutropenic episode. As stated in the Discussion, to prove statistical independence of data obtained from subsequent episodes in one patient is difficult. However, no statistical dependence was found between subsequent febrile neutropenic episodes in single patients. In the cost analysis, Dutch standard prices were used, which, in general, are lower than the US prices. However, we are convinced that the ratio of the costs of the experimental protocol to the costs of the standard treatment is generalizable to the US situation. In addition, the costs of interleukin-8 assays were assessed based on true resources used and time invested and, thus, provide a realistic estimation of the societal costs. Although the seemingly low percentage of bacteremia in our study may be a consequence of the inclusion of only outpatients, comparable studies enrolling outpatients have reported similar incidences of bacteremia at febrile neutropenic presentations.4,6 In conclusion, we described for the first time a new managerial option for a selected subpopulation of febrile neutropenic cancer patients. Confirmation of these study results is essential before the approach of withholding antibiotics can be incorporated into daily clinical practice. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Nijhuis CO, Kamps WA, Daenen SM, et al: Feasibility of withholding antibiotics in selected febrile neutropenic cancer patients. J Clin Oncol 23:7437-7444, 2005 2. Basu SK, Fernandez ID, Fisher SG, et al: Length of stay and mortality associated with febrile neutropenia among children with cancer. J Clin Oncol 23:7958-7966, 2005 3. Ammann RA, Hirt A, Luthy AR, et al: Identification of children presenting with fever in chemotherapy-induced neutropenia at low risk for severe bacterial infection. Med Pediatr Oncol 41:436-443, 2003[CrossRef][Medline] 4. Santolaya ME, Alvarez AM, Aviles CL, et al: Prospective evaluation of a model of prediction of invasive bacterial infection risk among children with cancer, fever, and neutropenia. Clin Infect Dis 35:678-683, 2002[CrossRef][Medline] 5. Hann I, Viscoli C, Paesmans M, et al: A comparison of outcome from febrile neutropenic episodes in children compared with adults: Results from four EORTC studies—International Antimicrobial Therapy Cooperative Group (IATCG) of the European Organization for Research and Treatment of Cancer (EORTC). Br J Haematol 99:580-588, 1997[CrossRef][Medline] 6. Freifeld A, Marchigiani D, Walsh T, et al: A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 341:305-311, 1999
Related Correspondence
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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