New Directions in Chemotherapy-Induced Neutropenia - Episode 10
To address the impact of chemotherapy-induced neutropenia on the delivery of chemotherapy to patients, Dr John Fox discusses how health plans are best supporting members.
John Fox, MD, MHA: CIN [chemotherapy-induced neutropenia] affects how chemotherapy is delivered in several ways. First, if patients develop febrile neutropenia, it can delay their treatment because of hospitalization or waiting for the neutrophil count to recover. Especially if this is being used in the presurgical setting, this can result in the delay of surgery, which causes distress for patients and families alike. For patients who have a complex medical history, it may also change the regimen that’s being delivered. For example, for patients who are at high risk but have no medical comorbidities, dose-dense AC [doxorubicin, cyclophosphamide]is a common adjuvant treatment for breast cancer. But for patients who may have chronic disease, such as renal disease or heart failure, providers may choose a standard-dose AC [doxorubicin, cyclophosphamide] or docetaxel or paclitaxel as alternatives because of the high risk of febrile neutropenia.
And lastly, CIN can also affect how patients are treated. For patients who are getting primary prophylaxis who develop CIN or febrile neutropenia, those patients may have to switch therapies or have a dose reduction, whereas those patients who aren’t on prophylactic therapy who develop CIN will subsequently get secondary prophylaxis.
Different health plans have different mechanisms or strategies or even philosophies on how we should be managing drugs as prophylaxis against CIN. At the health plan that I most recently worked with, there were no prior authorizations in place. We left the decision on primary or secondary prophylaxis to the providers. On the other hand, many health plans have prior authorization processes in place to, as I referred to earlier, ensure that the right patients are getting treatment and that we’re not overusing this treatment. A prior authorization for some plans could be to label; it could be for primary prophylaxis in patients who have greater than 20% risk of developing CIN. Other plans have a more generous prior authorization criteria and allow patients to access these therapies for regimens that have a 10% to 19% risk of CIN. That could include patients who are on moderate-risk therapies who have other comorbidities, including a prior history of CIN.