The Myeloid Growth Factors guidelines in this month's issue are in some ways a paradigm for successful guidelines—guidelines that support clinical decision-making. The algorithm comes down to the level of actual administration, with specific thresholds for beginning, dosages, and stopping. This granularity is possible, of course, because of the extraordinary number of trials meticulously designed to answer specific drug-related questions. For example, Frankfurt and Tallman's article on using these agents in leukemia describes trials that have investigated not only the efficacy of these stimulating factors but also their potential deleterious effects. I'm reassured to learn from Lyman and Kleiner of the consistency found across 3 well-known guidelines for these agents.
A major recommendation in all 3 guidelines is that growth factors be initiated for primary prophylaxis if the expected rate of febrile neutropenia is 20%. This new threshold varies considerably from the initial American Society of Clinical Oncology (ASCO) guidelines in 1994, which used a 40% threshold. The new mark is based on results from several randomized clinical trials and meta-analyses that confirm the efficacy of these agents in significantly diminishing the incidence of febrile neutropenia at this level.
In what will likely become a major issue for guidelines developers in the future, economic considerations emerged in these discussions. Although NCCN and ASCO state that decisions were based on proven clinical benefit, both groups acknowledge the potentially large economic impact that using these agents may have—both their capacity to save in-hospital expenses and the financial burden they could impose if...
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Rodger J. Winn is the Editor-in-Chief of JNCCN. He is Clinical Consultant at the National Quality Forum, and his past positions include Associate Professor of Clinical Medicine at The University of Texas M. D. Anderson Cancer Center. Dr. Winn received his medical degree from Jefferson Medical College of Philadelphia. His postgraduate training includes an internship and residency at Jefferson Medical College, and he also completed a medical oncology fellowship at Memorial Sloan-Kettering Cancer Center in New York. He is board certified in internal medicine and holds subspecialty certification in oncology.