The Burdens of Cancer Therapy
Clinical and Economic Outcomes of Chemotherapy-Induced Mucositis W e read with great interest the article by Elting et al. describing the clinical and economic outcomes of patients with chemotherapyinduced mucositis. 1 Despite the limitation of a retrospective analysis, they have clearly demonstrated that patients with solid tumors who develop oral or gastrointestinal (GI) mucositis have an increased incidence of infection and infection-related mortality (resulting in excessive resource utilization) compared with patients who do not develop mucositis. One cannot help but wonder whether their results would have been even more striking had their data set been limited to patients with an absolute neutrophil count of Ο½ 500/L (the currently accepted definition of neutropenia) rather than Ο½ 1000/L. 2 Nevertheless, this study is an important step forward in our understanding of the burdens of cancer therapy. Although we agree with the authors' closing statement that there is a significant need for therapies to reduce the incidence and lessen the severity of mucositis, such measures remain distant. In the interim, their study raises some interesting issues.
The first is whether a high-risk subset of patients with solid tumors/neutropenia/mucositis can be identified early enough that they might benefit from antibacterial prophylaxis. Although the Infectious Diseases Society of America does not recommend routine antibacterial prophylaxis in neutropenic patients, it does so for high-risk patients with severe and prolonged neutropenia (generally patients with hematologic malignancies). 2 With the threefold increase in documented infections in patients with GI mucositis reported in the study by Elting et al. 1 , and a significant increase in infection-related morbidity and mortality, antibacterial prophylaxis in such patients might not only be justified, but desirable, and might reduce the incidence of documented infections substantially.
A second issue is the question of whether all patients who develop an infection need hospital-based therapy. The costs of hospital-based therapy for neutropenic patients with infection are high. Several risk prediction rules that identify "low-risk" febrile neutropenic patients recently have been developed and validated. 3,4 Several studies have demonstrated that low-risk patients can be safely treated with oral or parenteral antibiotic regimens without the need for hospital admission. 5 We believe this approach can reduce the economic burden associated with the hospital-based treatment of febrile neutropenic patients substantially.