Draft NICE guidance calls for improved prevention and management of common complication of cancer treatment
NICE, the healthcare guidance body is today (16 February) opening a consultation on its guideline which aims to address shortcomings in the prevention and management of neutropenic sepsis, an increasingly common and potentially fatal complication of cancer treatment, in children, young people and adults with cancer.
Systemic therapies, particularly chemotherapy, to treat cancer have a risk of damaging bone marrow cells. This can suppress the bone marrow's ability to produce a type of white blood cell known as a neutrophil, thereby affecting the body's capacity to respond to infection. When neutropenic, patients are vulnerable to invasive infection which can potentially cause overwhelming sepsis and death. In clinical practice the terms febrile neutropenia and neutropenic sepsis are used interchangeably in this patient group and recommendations within this guideline use the term "neutropenic sepsis" to indicate the full range of severity of illness.
Neutropenic sepsis is common, resulting in hundreds of hospital admissions every month and potentially causing the deaths of over 1 in 500 people diagnosed with cancer - approximately two each day. The total number of deaths from neutropenic sepsis in England and Wales has more than doubled over the last 10 years from around 300 in 2001 to around 700 in 2011. It is also the second most common reason for hospital admission among children and young people with cancer, with approximately 4000 episodes occurring annually in the UK.
Despite the recognition of neutropenic sepsis as a potentially fatal complication of cancer treatment, there is evidence that the number of deaths from neutropenic sepsis is increasing at a faster rate than the number of cancers being diagnosed. Recent reports from the National Confidential Enquiry into Patient Outcome and Death (Systemic anti-cancer therapy: for better for worse?)  and the National Chemotherapy Advisory Group (Chemotherapy services in England: ensuring quality and safety)  highlighted problems with the management of neutropenic sepsis in adults. These included the need for systems for urgent assessment and trust-level policies for dealing with neutropenic fever, variation in the provision of information on treatment of side effects and access to 24-hour telephone advice. There is also evidence of national variation in the use of primary and secondary prophylaxis, risk stratification in episodes of neutropenic sepsis, oral or intravenous antibiotics, bone marrow growth factors, and in- or outpatient management policies.
Draft key priorities for implementation include:
- Provide patients undergoing anti-cancer treatment and their carers with written and verbal information before starting and throughout treatment on:
- neutropenic sepsis
- how and when to contact 24-hour specialist oncology advice and access emergency care.
- Treat suspected neutropenic sepsis as an acute medical emergency and offer antibiotic therapy immediately.
- Diagnose neutropenic sepsis in patients with a temperature higher than 38°C and a neutrophil count lower than 0.5 x 109/litre.
- A member of the oncology team should assess the patient's risk of septic complications as soon as possible and within 48 hours of presentation to secondary or tertiary care, basing the risk assessment on presentation features and using a validated risk scoring system1.
Christine Carson, Programme Director, Centre for Clinical Practice at NICE said: "Chemotherapy is most commonly given in a day-case or outpatient setting so most episodes of obvious sepsis, and fever in a person with potential sepsis, present in the community. Neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment. However, there is evidence of dramatic variation throughout England and Wales regarding its definition, prevention, diagnosis and treatment. This picture is complicated by the fact that patients with suspected neutropenic sepsis may present to a variety of healthcare settings including primary care, emergency departments and hospital wards. Healthcare professionals within these settings are often unfamiliar with the management and potentially life threatening complications of neutropenic sepsis and have varying levels of expertise within this field. All of these factors highlight the need for an evidence based guideline to influence and unify practice in order to reduce the number of unnecessary deaths and improve outcomes for patients with cancer presenting with this important complication of anti-cancer treatments. The draft guideline is now open for consultation and we would welcome comment from stakeholders."
Stakeholders have until 28 March 2012 to comment on the recommendations in the draft guideline. Organisations can register as stakeholders at any time during the development of the guideline and comments must be submitted via the NICE website. Until the final guideline is published, recommendations could change depending on feedback received during the development of this guideline.
Notes to Editors
1. Validated risk scoring systems include the Multinational Association for Supportive Care in Cancer (MASCC) risk index for adults (aged 18 years and over) (Klastersky J, Paesmans M, Rubenstein EB et al.  The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients [Journal of Clinical Oncology 18: 3038-51]) and the modified Alexander rule for children (aged under 18) (Dommett R, Geary J, Freeman S et al.  Successful introduction and audit of a step-down oral antibiotic strategy for low risk paediatric febrile neutropaenia in a UK, multicentre, shared care setting [European Journal of Cancer 45: 2843-9]).
About the draft guideline
2. The draft guideline on the prevention and management of neutropenic sepsis in cancer patients is available from the NICE website at: http://guidance.nice.org.uk/CG/Wave23/11
3. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.
4. NICE produces guidance in three areas of health:
- public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
- clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
5. NICE produces standards for patient care:
- quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
- Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
6. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.
This page was last updated: 16 February 2012