afebrile neutropenia and neupogen

[mora224]

What are the benefits and risk, if any, to prophylactic neupogen for afebrile neutropenia?

I have stage IV invasive lobular bc with mets to ovaries and extensively to lymph nodes.  I am in the middle of a 6-8 cycle paclitaxel/carboplatin regiment with the understanding that more cycles will “buy more time.”  Six cycles is the norm; eight is pushing it.  Prior to my last chemo treatment I had marginal neutropenia –not unexpected– but the scheduled treatment went forward.  Well-meaning acquaintances with chemo experience say that I was not offered prophylactic neupogen strictly due to cost and insurance reimbursement considerations.  I read that neupogen can, in fact, double or triple the cost of chemo treatment.  My limited research finds, however, that prophylactic neupogen administration is not recommended in practice guidelines because outcomes are not improved (even though neutrophil recovery is improved).  My goal is to maximize the chemo cycles but I fear neutropenia could be a roadblock.  I am afebrile but have experienced infections in some very minor wounds.  Is there an argument for prophylactic neupogen?

[CCF-RN,MSN-rf]

Dear mora224:  The primary reason for using growth factors such as neupogen or neulasta is to be able to maintain the full dose and schedule of the chemotherapy regimen.  Some chemotherapy protocols are much more likely to result in low white blood cell counts that cause dose reductions or delays than others.  In these cases, and for older frailer patients, there may be an argument for prophylactic neupogen.  On the other hand, if the white blood cells continue to be adequate for continuation of therapy, then there is no role for neupogen. It would simply add cost (to you and or your insurance company) and provide no real benefit.  In these cases, if your white count were ever to drop low enough that the chemo would be dose reduced or delayed, the use of neupogen would likely be commenced with the next dose and continued throughout treatment.

[heidiho]

Dear Mora224:
  Although I can't compare my situation with yours, since virtually every BC case is different, I can certainly vouch for the benefits of Neulasta.
  I'm getting the dense-dose regimen (every 2 weeks instead of every 3, duration of 4 months instead of the usual 6, but same dose each cycle & same dose overall).  Therefore, I won't have that extra third week to get my WBCs up to par before the next treatment & would certainly develop life-threatening low white counts. I've only had two cycles so far, with the Neupogen shot 24 hours after each infusion ... but my WBCs are closely monitored every week.  My WBCs have actually gone above the normal count as soon as several days after the 1st injection. It is supposedly start regenerating your white cells about 3 days after the chemo does its damage.  Thus, I won't have to worry that much about getting infections.
  It's true that insurance is a big consideration in paying for  both Neupogen/Neulasta for WBC regeneration and Procrit for RBCs. (Although with the latter, RBCs do take a few weeks to replace themselves, but lower counts don't appear as imminently dangerous as low WBCs and resulting infections can be.)
  My advice is to touch base with your insurance company, and appeal if necessary, i.e., if your onc strongly recommends it. Some carriers will only approve the Neupogen/Neulasta in conjunction with bone marrow transplants (many HMOs fall in this category).  My company (New York, Medicaid) did approve it on recommendation of my doctor for the dose-dense.  Best wishes.