Validation of the Clinical Index of Stable Febrile Neutropenia (CISNE) model in febrile neutropenia patients visiting the emergency department. Can it guide emergency physicians to a reasonable decision on outpatient vs. inpatient treatment?

Abstract

Advances in oncology have enabled physicians to treat low-risk febrile neutropenia (FN) in outpatient settings. This study was aimed to explore the usefulness of the CISNE model and identify better triage in the emergency setting. This is a retrospective cohort study on 400 adult FN patients presenting to the Emergency Department of National Cancer Center, Korea from January 2010 to December 2016. All had been treated with cytotoxic chemotherapy for solid tumors in the previous 30 days. The primary outcome was the frequency of any serious complications during the duration of illness. Apparently stable patients numbered 299 (74.8%) of 400, and the remainder comprised clinically unstable patients. The stable patients fell into three cohorts according to the risk scores: CISNE I (low risk), 56 patients (18.7%); CISNE II (intermediate), 124 (41.5%) and CISNE III (high), 119 (39.8%). The primary outcome occurred in 10.7%, 19.4% and 33.6%, respectively, according to the cohort. Compared with the Multinational Association of Supportive Care in Cancer Risk Index Score (MASCC RIS), CISNE I stratum had significantly lower sensitivity (0.22 vs. 0.95 of MASCC low risk) but higher specificity (0.91 vs. 0.17) to predict zero occurrence of the primary outcome. The CISNE model was useful for identifying low-risk FN patients for outpatient treatment. The combination of the CISNE and MASCC RIS may help emergency physicians cope with FN more confidently.

Comparison of CISNE and MASCC Score in Predicting Complications on Post Chemotherapy Febrile Neutropenia

“…Two previous studies have analyzed the performance of CISNE scores in patients with solid malignancies. Research by Koppaka et al [11] also showed that CISNE scores had an AUROC of 0.846, whereas in Moon et al [7], CISNE scores had an AUROC of only 0.66. In our study, the population of solid malignancies was dominated by headneck malignancies, whereas previous studies showed head-neck malignancies in only 5% of populations.…”

“…Furthermore, the types of solid tumor in this study differed from the types of solid tumor in previous studies. In a study by Bayonas et al [2] and Moon et al, [7] the majority of solid tumor were breast cancer.…”

“…This study was the rst study to assess CISNE and MASCC score performance based on malignancy type. Previous studies by Koppaka et al [11] and Moon et al [7] were only conducted on patients with solid malignancy. Other research by Bayonas et al [2] was conducted on patients with solid malignancy in 90% of cases.…”

“…However, several studies have been conducted to assess the performances of CISNE scores, and the results remain controversial. [2,[6][7][8][9][10] Further study comparing CISNE score with MASCC score based on tumor type is still needed to assess the role of each score in predicting complications and therefore reducing mortality.…”

Is Outpatient Treatment for Low-Risk Febrile Neutropenic Cancer Patients Associated With Increased Treatment Failure or Mortality?

“…Various tools are available for risk stratification in adult patients with neutropenic fever, including the Clinical Index of Stable Febrile Neutropenia score, the Multinational Association for Supportive Care in Cancer risk index, and Infectious Diseases Society of America Risk Criteria. 4 However, there is currently no pediatric scoring tool to identify low-risk patients amenable to outpatient management, leading to significant variation in local practice patterns. 5 Although these findings suggest no difference in outcomes for inpatient versus outpatient treatment of low-risk patients, identifying optimal candidates for outpatient management is necessary.…”