Systematic Review of Emerging Models of Cancer Care: Implications for the Health Industry
Journal of Integrative Oncology
In selected patients diagnosed with Breast Cancer (BC), adjuvant chemotherapy might reduce local and systemic recurrence risk, as well as cancer death rate. The combination of Docetaxel and Cyclophosphamide (TC) is a wellrecognized effective adjuvant chemotherapy regimen. Nonetheless, a considerable high rate of febrile neutropenia (FN) is associated with this regimen. We sought to investigate hematologic toxicity associated with adjuvant TC in a non-selected, "real world" cohort of BC
... Methods: We reviewed the electronic medical records of patients who presented to the Oncology Center from Hospital Sírio-Libanês (HSL) and Instituto do Câncer do Estado de Sao Paulo (ICESP). Patients included in the analysis received adjuvant chemotherapy with TC regimen after definitive breast surgery. Results: 95 patients with were included in our analysis. Median age was 55.5 years. All patients had a good performance status (either ECOG 0 or 1), and the great majority had no comorbidities. Most patients received 4 cycles of chemotherapy (80%). Data on granulocyte colony stimulating factor (G-CSF) administration was available in 85 patients from our cohort. G-CSF was used as primary prophylaxis in 31 patients, and as secondary prophylaxis in 13 patients, following a prior episode of febrile neutropenia. Overall, fifteen women (15.8%) had a documented FN episode. Among women who received G-CSF as primary prophylaxis, the rate of FN was 6.45% (2 patients). In contrast, among patients who did not receive primary prophylaxis with G-CSF, FN rate was considerably higher, namely 24.07% (13 patients). Patients who received primary prophylaxis with G-CSF had a statistically significant lower risk of experiencing a FN episode (p=0.049). Conclusion: Febrile Neutropenia rate in this group of non-selected BC patients was higher than previous reported on randomized controlled trials that evaluated adjuvant TC regimen in the same dosing and schedule as used in our cohort. Primary prophylaxis with G-CSF was associated with a statistically significant lower risk of FN and should be considered in the management of patients who receive this chemotherapy combination. The P4 model, predictive, preventive, personalized, and participative, directly relates to the rapid learning health systems  . The goal of P4 is to transform medicine to focus on wellness, rather than disease. Systems approaches to disease, emerging technologies, and analytical tools guide the way for P4 medicine  . The five challenges that exist with the rapid learning and P4 models are: 1) collecting data properly with accurate information; 2) creating an environment of data sharing; 3) overcoming technical obstacles such as uniformity, incentives, oncology research complexity, and quantity of data; 4) implementing a health IT system that promotes meaningful use, directly related to step 6 with the Integrated Practice Unit Model discussed in the next section; and 5) understanding the role of government agencies like the National Institutes of Health (NIH), Centers for Medicare and Medicaid Services (CMS), and the Food and Drug Administration (FDA)  .