Where Does Granulocyte Colony Stimulating Factor Use Stand Following Allogeneic Hematopoietic Stem Cell Transplant in 2012

WHERE DOES GRANULOCYTE COLONY STIMULATING FACTOR USE STAND FOLLOWING ALLOGENIC HEMATOPOIETIC STEM CELL TRANSPLANT IN 2012.

BACKGROUND:  Allogeneic hematopoietic stem cell transplantation (HSCT) is a life-saving measure for malignant hematologic disorders.   Infection during neutropenia, however, is a major cause of transplant related morbidity and mortality (TRM). The use of granulocyte colony stimulating factor (GCSF) following HSCT has become a standard of care in many institutions. Although several retrospective studies reported that it accelerates neutrophil recovery by 1-6 days, other meta analyses have failed to demonstrate any significant difference in the days of febrile neutropenia. The CIBMTR working group that reviewed outcomes of patients who received GCSF during HSCT found no benefit or risk in those with myeloid leukemia but no improvement in early TRM despite faster neutrophil recovery. Notably, there have been no standards published regarding its use or timing of use in this setting.

METHODS: First a review of the published literature on the use of GCSF in the HSCT setting was performed to summarize study findings and recommendations.  Second, a survey was undertaken of the use GCSF at 15 transplant centers. Questions included: timing of initiation, duration of therapy, and association with stem cell source and intensity of conditioning.   Finally, a cost analysis was performed using standard charges to estimate the cost of various GCSF regimens. 

RESULTS:  Thus far 8 of the 15 centers have responded.  The volume of transplants/center ranged from 126-519/year.   Use of GCSF is summarized in Table 1. 

Cost analysis:  the standard charge for GCSF is approx. $1.00/mcg and ranged from $300-800/dose.  Thus cost for GCSF regimens beginning on D0 vs. D+7 for treatment to D+14 could be  $4200-11200 vs $2100-5600.  These are compared to centers that do not utilize GCSF at all where the cost is $0. 

CONCLUSIONS:  Despite the lack of supportive data for the use of GCSF following HSCT,  several trials/analyses that reported no benefit in clinical outcomes, and in fact some reports of detrimental effect, the majority of responding transplant centers continue its use. Furthermore, timing for initiating GCSF varied from D0 to D+12 in those centers.  In the current environment of reducing healthcare costs, these findings suggest the need for reevaluation of its use.   

Table 1.

Institution #	Cords	RIC/nonmyeloablative BM/PBSC	Myeloablative BM/PBSC
1	D+1	Not used	Not used
2	D+1	D+7	D+7
3	D+7	D+7	D+7
4	D+1	Not used	Not used
5	D+1	Prn MD/clinical status	Prn MD/clinical status
6	D+5	D+5	D+12
7	Not used	Not used	Not used
8	D0	D+5	D0