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extraocular movements intact; andpupils are equal round and reactive tolight and accommodation. Patient hasno palpable cervical or supraclavicularlymphadenopathy. On neurologicexamination, cranial nerves II-VII aregrossly intact. When the lymph nodesare examined, there are palpable,movable lymph nodes in the bilateralaxillae of approximately 2 to 3 cm.There is 1 palpable groin node in theleft groin of approximately 2 cm, butnone on the right. The patients lungsare clear to auscultation bilaterally.On cardiac examination, his heart rateand rhythm reveals no S3 or murmurs.There is no peripheral edema. Onabdominal examination, the abdomenis soft, nontender, nondistended, withno hepatosplenomegaly and no otherpalpable masses. Bowel sounds are pre-sent in all 4 quadrants and normoac-tive. Musculoskeletal examinationshowed a strength of 5/5 and symmetryin all major muscle groups of the upperand lower extremities. Integumentaryexamination showed a 2.5-cm incisionto left axilla with steri-strips intact,ecchymosis, and a small amount ofserosanguinous drainage.

TREATMENT PLAN

The treatment plan for thispatient is to have 6 cycles of ritux-imab, cyclophosphamide, doxoru-bicin, and prednisone (R-CHOP)once every 21 days. His medical insur-ance is Medicare with secondary gapcoverage. He has a Hickman catheterplaced. The physician has decidedthat because of the patients good per-formance status and previous lack oftreatment, he will check the patients

counts on day 14 and assess the needfor growth factors in following cycles,if necessary. The physician under-stands from the medical group thatthe hospital outpatient center has hadpast experience with Medicare denialsfor growth factors administered incycle 1 when there is no history offebrile neutropenia, normal baselinewhite blood cells, and no other sup-

12 Vol. 4, No. 1

January 2006

CANCER THERAPY AND SUPPORTIVE CARE

65-YEAR-OLD MAN WITH NON-HODGKINS LYMPHOMA

Tina Maluso-Bolton, RN, MSN, NP

BACKGROUND

A 65-year-old male presented to a hospital-based outpatient clinic with a newdiagnosis of non-Hodgkins lymphoma. He had palpable axillary lymphadenopa-thy bilaterally and had an excisional axillary biopsy before the oncology referral.Review of systems is essentially negative other than fatigue. Complete workupshows a diffuse large B-cell non-Hodgkins lymphoma that is CD 20+. He has noB symptoms and bone marrow biopsy is negative for disease.

WORKUP

Initial laboratory studies show: white blood cell count, 4100 cells/mm3; hemo-globin, 11.2 g/dL; hematocrit, 37%; platelet count, 152 000/mm3; albumin, 3.1 g/dL;lactate dehydrogenase, 490 IU/L; blood urea nitrogen, 20 mg/dL; creatinine, 1 mg/dL;sodium, 136 mEq/L; potassium, 3.8 mEq/L; glucose, 132 mg/dL; magnesium,1.8 mEq/L; calcium, 8 mg/dL; total bilirubin, 0.9 mol/L.

Full workup shows an electrocardiogram with evidence of old inferior myocardialinfarction and a chest X ray that is clear except for mediastinal adenopathy. Multi-gated acquisition scanning shows ejection fraction of 72%. Computed tomographyscan shows inguinal, axillary, retroperitoneal, and mediastinal lymphadenopathy. Allother organs are within normal limits.

MEDICALHISTORY

The patients medical history is positive for a mild heart attack 2 years ago. He

is taking an 8-mg aspirin tablet and -blocker daily, in addition to multivitamins. Pastsurgical history is negative.

FAMILYHISTORY

He mentions a maternal history of hypercholesterolemia and paternal history ofhypertension, but has no other significant family history.

SOCIALHISTORY

The patient has been married for 15 years to his second wife who is aged 53 years.She is an elementary school teacher, and the patient is a retired principal. They havea 15-year-old daughter, who is in high school. He has a 4-year smoking history, butquit approximately 35 years ago. He has wine with dinner approximately 3 times aweek and denies any illegal drug use. He describes himself as in excellent health andexercises 4 times a week.

PHYSICALEXAMINATION

On examination, the patient appears to be a well-developed, well-nourished,Caucasian male in no acute distress. Karnofsky performance status is 90%. Vital signsare as follows: blood pressure, 136/88 mm Hg; pulse, 84 beats/minute; respiratoryrate, 20 breaths/minute; temperature, 37.2C; and oxygen saturation, 98% on roomair. Head, ears, eyes, nose, throat examination: sclera anicteric; oral mucosa intact;

CASE STUDY

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portive documentation. Additionally,the healthcare practice has found inthe past that many people withMedicare cannot afford the out-of-pocket copayment.

TREATMENT COURSE

The patient is treated in the outpa-tient setting and has an uneventfuladministration until day 12, when thepatient has a temperature of 38.6C andshaking chills. He goes to the hospitalemergency room where routine labora-tory studies show a white blood cellcount of 400 cells/mm3, hemoglobin11.1 g/dL, and platelet count of8800/mm3. Checking the patients vitalsigns show a blood pressure of 100/62mm Hg. The patient is started on intra-venous (IV) fluids. A chestX ray, urine culture, and sensitivity test-ing are obtained, in addition to bloodcultures peripherally and from eachHickman lumen. Broad-spectrumantibiotics are administered IV, and thepatient is admitted to the oncology unit.The physician also starts daily growthfactors to be administered to an absoluteneutrophil count of 1500 cells/mm3.

DISCUSSION

It is not uncommon to base the useof prophylactic growth factors on apast bad experience of lack of reim-bursement or to utilize the watch andwait approach, particularly in light ofa good performance status and no pre-treatment history. However, these arethe patients in whom we can a have a

great impact on reducing regimen-related morbidity and mortality withappropriate use of prophylactic growthfactors from the first cycle ofchemotherapy. We can identify multi-ple risk factors in this patient beforehis first cycle, including significant car-diac comorbidities, open axillary inci-sion, central line, age, social exposureto multiple organisms from his wifeand daughter, and, most significantly,a baseline serum albumin of less than3.5 g/dL and lactate dehydrogenase ofmore than 460 IU/L. Studies haveshown that these pretreatment factorsare associated with a significantly ele-vated risk of febrile neutropenia.1,2

Additionally, studies have shown therisk of febrile neutropenia is highest inthe first cycle of chemotherapy, lend-ing significant risk to the watch andwait approach.3-5 Given that thispatient has a potentially curable tumor,dose reductions and delays have beenassociated with suboptimal outcomes.

A better approach may have been tostart growth factors from cycle 1 andensure documentation of comorbiditiesand risk factors. Use of a documentedrisk assessment tool and a letter of med-

ical necessity could help assure appropri-ate reimbursement. The cost of thegrowth factors would be significantly lessthan the cost of the hospital stay. It isequally important that clinicians obtainspecifics about reported reimbursementdenials that may ultimately be a result ofthe lack of supporting documentation,inappropriate coding, or lack of aggres-

sive and appropriate appeals. Thepatients secondary insurance wouldmost likely have covered the copayment.

REFERENCES

1. Intragumtornchai T, Sutheesophon J,Sutcharitchan P, Swasdikul D. A pre-dictive model for life-threatening neu-tropenia and febrile neutropenia afterthe first course of CHOP chemothera-py in patients with aggressive non-Hodgkins lymphoma. LeukLymphoma. 2000;37:351-360.

2. Tompkins KA, Imrie KR. Neutropenicevents in patients receiving CHOPchemotherapy for large cell non-Hodgkins lymphoma: predicting whois at risk [abstract 1427]. Blood.2001;98(337a).

3. Crawford J, Wolff DA, Culakova E,et al. First cycle risk of severe andfebrile neutropenia in cancer patientsreceiving systemic chemotherapy:results from a prospective nationwidestudy [abstract]. Blood. 2004;104:2210.

4. Gomez H, Hidalgo M, Casanova L,et al. Risk factors for treatment-relateddeath in elderly patients with aggres-sive non-Hodgkins lymphoma: resultsof a multivariate analysis.J ClinOncol. 1998;1:2065-2069.

5. Lyman GH, Morrison VA, Dale DC,et al. Risk of febrile neutropeniaamong patients with intermediate-

grade non-Hodgkins lymphomareceiving CHOP chemotherapy. LeukLymphoma. 2003;44:2069-2076.

CANCER THERAPY AND SUPPORTIVE CARE