Hope S. Rugo, MD, FASCO: One question for you all is how do you manage CIN [chemotherapy-induced neutropenia]? We’ve talked a lot about giving growth factors, but does it vary if a patient has had a fever or has consistently neutrophils of 200 vs 900 per mm3? Tiffany?

Tiffany A. Traina, MD: If a patient of mine has had a fever in the scenario of neutropenia, they’re still likely to be hospitalized. It certainly gives me pause for the next cycle, and if I haven’t used prophylactic growth factor already, I incorporate it at that point. I would try prophylactic growth factor and then, if I run into trouble again, entertain dose reduction and modification. I do think a fever significantly raises the bar in the setting of neutropenia.

We haven’t talked about the timing of the neutropenia. I find the relevance of checking a CBC [complete blood count] is only if I’m going to dose a patient that day. If their neutropenia is interfering with our ability to deliver a dose, that’s clinically significant. I advise my patients that if they develop a fever at any interval point between visits, then we need to know about it. We then check a CBC at that point, rather than the surveillance strategies of a midcycle CBC, where I just don’t know how to respond to that or react to it.

Hope S. Rugo, MD, FASCO: That’s a really interesting point, and it plays a role. We used to give prophylactic antibiotics all the time during the risky days, but I don’t think they do that as much anymore. Do you guys at all?

Rita Nanda, MD: No, I don’t really.

Hope S. Rugo, MD, FASCO: We tend not to see a lot of the big toxicities like mouth sores, etc. Certainly, if there are other toxicities, these patients may be at higher risk for developing more serious complications as well.

Hope S. Rugo, MD, FASCO: Do you think about giving radiation to bones that might cause neutropenia? For example, I see second opinions all the time where people have done global radiation to the pelvis, and I’m always trying to avoid that and do SBRT [stereotactic body radiation therapy] and things like that. What are your thoughts on that? Bill?

William J. Gradishar, MD: We certainly do not like to radiate the entire pelvis. That’s asking for trouble. The approach we use is to try to palliate the distinct area that’s causing the symptom rather than a large area. Of course, there are other bone marrow sources than just the pelvis, but that’s the big 1. We try to be a little more precise about where we use palliative radiation, as I’m sure all of you do. Sometimes you have no choice just because of the symptoms and some patients. That’s another cause for why their marrow gets tired out after awhile. Whether it’s chemotherapy or prior radiation therapy, they don’t have much reserve left.

Transcript edited for clarity.