Instead of competing on who can get the paper out first, let’s put the patients first. If we work together and encourage each other, we’re that much more likely to succeed.
—Scott C. Howard, MD
Recent developments in supportive care for children with cancer can be broken down into three categories: doing the simple things well, applying evidence-based medicine to daily practice, and extending the benefits to everyone, according to Scott C. Howard, MD, of St. Jude Children’s Research Hospital, Memphis.
At the 2014 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) International Symposium on Supportive Care in Cancer, Dr. Howard applied these principles to the management of febrile neutropenia in pediatric cancer patients.1
From Principle to Practice
“We know exactly what to do, yet there is often a gap in how we do it,” said Dr. Howard, a specialist in pediatric hematology-oncology. “For example, the number of lives saved by hand-washing are far more than almost anything we could imagine,” he said. However, in study after study, following the implementation of hand-washing programs, hand-washing practices improve only temporarily.
Within the realm of applying evidence-based medicine to daily practice, Dr. Howard outlined four important categories. First, it is important to establish a solid evidence base. “We know how to treat febrile neutropenia,” he said. Evidence guides the clinician in choice of antibiotics for patients with fever.
Secondly, there is the issue of education. “Just because we know what to do doesn’t mean we always do it,” explained Dr. Howard. New doctors, nurses, and pharmacists are constantly coming on board in need of continuous education. Finally, there are the matters of application and evaluation.
Reducing Morbidity and Mortality
According to Dr. Howard, the best way to reduce morbidity and mortality in patients with febrile neutropenia is by more rapid administration of the first dose of antibiotic.
The patient with 4,000 bacteria per microliter of blood typically presents with a fever. Because some bacteria double every half-hour, in 2 more hours, this patient will have 16 times the concentration of bacteria and will develop sepsis. Two hours after sepsis, if left untreated, the patient will go into septic shock, and 2 hours after septic shock the patient will die.
“We can do an ICU intervention,” explained Dr. Howard, “or we can catch the patient 6 hours earlier and not need an ICU intervention after all.” Such patients should be treated almost immediately, he stressed.
Causes of Treatment Failure
In order to effectively manage febrile neutropenia in pediatric cancer patients, the patient must get to a hospital. “We tell patients we want a phone call within 30 seconds and we want you there within 30 minutes,” said Dr. Howard. At St. Jude, if a patient calls ahead, the antibiotic is already prescribed and prepared when the patient arrives, he explained.
However, particularly in lower- and middle-income countries, a number of factors contribute to why children with febrile neutropenia never make it to the hospital. First, many individuals do not believe it is truly an emergency. “Some parents say, ‘The last time he got a fever we came 2 days later and he’s not dead. Now you’re telling us it’s an emergency?’” he explained.
“Since 10% to 20% of fevers are caused by bacteremia, four out of five times the patient won’t die; it’s not an emergency,” he continued. The problem lies in the inability to know upfront whether the fever is caused by bacteremia or something else (usually viral infections), he added.
Other reasons patients never make it to the hospital include conflicts with issues they deem as more important, as well as logistical issues, including distance to the hospital. “If it takes 12 hours to get to the hospital and you have bacteremia, that’s at least 6 hours too long,” Dr. Howard noted.
Sometimes, risks of travel exceed the risks of delayed management of febrile neutropenia. Toxic death from infection is a much more dire concern in lower- and middle-income countries than in high-income countries, he reiterated.
Extending Benefits to Everyone
According to Dr. Howard, extending the benefits to patients everywhere entails learning from mistakes and publishing the results, ensuring continuous quality improvement, and working together.
“We have people at this meeting from all over where the issues are similar, and I suspect that decision time, transport time, and antibiotic time are the three key components that should be measured in all countries—high income, middle income, and low income,” he said.
“Working together should be common practice and should involve recognizing and encouraging our colleagues, Dr. Howard suggested. “Instead of competing on who can get the paper out first, let’s put the patients first,” he said. “If we work together and encourage each other, we’re that much more likely to succeed.” ■
Disclosure: Dr. Howard reported no potential conflicts of interest.
1. Howard S: Supportive cancer care in children: Recent developments. Special Parallel Session: Global Development of Supportive Care. MASCC/ISOO International Symposium on Supportive Care in Cancer. Presented June 27, 2014.