CANCER THERAPY AND SUPPORTIVE CARE

CASE STUDY
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 new
diagnosis of non-Hodgkins lymphoma. He had palpable axillary lymphadenopathy bilaterally and had an excisional axillary biopsy before the oncology referral.
Review of systems is essentially negative other than fatigue. Complete workup
shows a diffuse large B-cell non-Hodgkins lymphoma that is CD 20+. He has no
B symptoms and bone marrow biopsy is negative for disease.
WORKUP
Initial laboratory studies show: white blood cell count, 4100 cells/mm3; hemoglobin, 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 myocardial
infarction and a chest X ray that is clear except for mediastinal adenopathy. Multigated acquisition scanning shows ejection fraction of 72%. Computed tomography
scan shows inguinal, axillary, retroperitoneal, and mediastinal lymphadenopathy. All
other organs are within normal limits.
MEDICAL HISTORY
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. Past
surgical history is negative.
FAMILY HISTORY
He mentions a maternal history of hypercholesterolemia and paternal history of
hypertension, but has no other significant family history.
SOCIAL HISTORY
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 have
a 15-year-old daughter, who is in high school. He has a 4-year smoking history, but
quit approximately 35 years ago. He has wine with dinner approximately 3 times a
week and denies any illegal drug use. He describes himself as in excellent health and
exercises 4 times a week.
PHYSICAL EXAMINATION
On examination, the patient appears to be a well-developed, well-nourished,
Caucasian male in no acute distress. Karnofsky performance status is 90%. Vital signs
are as follows: blood pressure, 136/88 mm Hg; pulse, 84 beats/minute; respiratory
rate, 20 breaths/minute; temperature, 37.2C; and oxygen saturation, 98% on room
air. Head, ears, eyes, nose, throat examination: sclera anicteric; oral mucosa intact;
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extraocular movements intact; and

pupils are equal round and reactive to
light and accommodation. Patient has
no palpable cervical or supraclavicular
lymphadenopathy. On neurologic
examination, cranial nerves II-VII are
grossly intact. When the lymph nodes
are examined, there are palpable,
movable lymph nodes in the bilateral
axillae of approximately 2 to 3 cm.
There is 1 palpable groin node in the
left groin of approximately 2 cm, but
none on the right. The patients lungs
are clear to auscultation bilaterally.
On cardiac examination, his heart rate
and rhythm reveals no S3 or murmurs.
There is no peripheral edema. On
abdominal examination, the abdomen
is soft, nontender, nondistended, with
no hepatosplenomegaly and no other
palpable masses. Bowel sounds are present in all 4 quadrants and normoactive. Musculoskeletal examination
showed a strength of 5/5 and symmetry
in all major muscle groups of the upper
and lower extremities. Integumentary
examination showed a 2.5-cm incision
to left axilla with steri-strips intact,
ecchymosis, and a small amount of
serosanguinous drainage.
TREATMENT PLAN
The treatment plan for this
patient is to have 6 cycles of rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHOP)
once every 21 days. His medical insurance is Medicare with secondary gap
coverage. He has a Hickman catheter
placed. The physician has decided
that because of the patients good performance status and previous lack of
treatment, he will check the patients
counts on day 14 and assess the need
for growth factors in following cycles,
if necessary. The physician understands from the medical group that
the hospital outpatient center has had
past experience with Medicare denials
for growth factors administered in
cycle 1 when there is no history of
febrile neutropenia, normal baseline
white blood cells, and no other sup-

Vol. 4, No. 1

January 2006

CANCER THERAPY AND SUPPORTIVE CARE

portive documentation. Additionally,

the healthcare practice has found in
the past that many people with
Medicare cannot afford the out-ofpocket copayment.
TREATMENT COURSE
The patient is treated in the outpatient setting and has an uneventful
administration until day 12, when the
patient has a temperature of 38.6C and
shaking chills. He goes to the hospital
emergency room where routine laboratory studies show a white blood cell
count of 400 cells/mm3, hemoglobin
11.1 g/dL, and platelet count of
8800/mm3. Checking the patients vital
signs show a blood pressure of 100/62
mm Hg. The patient is started on intravenous (IV) fluids. A chest
X ray, urine culture, and sensitivity testing are obtained, in addition to blood
cultures peripherally and from each
Hickman lumen. Broad-spectrum
antibiotics are administered IV, and the
patient is admitted to the oncology unit.
The physician also starts daily growth
factors to be administered to an absolute
neutrophil count of 1500 cells/mm3.
DISCUSSION
It is not uncommon to base the use
of prophylactic growth factors on a
past bad experience of lack of reimbursement or to utilize the watch and
wait approach, particularly in light of
a good performance status and no pretreatment history. However, these are
the patients in whom we can a have a

Advanced Studies in Nursing

great impact on reducing regimenrelated morbidity and mortality with

appropriate use of prophylactic growth
factors from the first cycle of
chemotherapy. We can identify multiple risk factors in this patient before
his first cycle, including significant cardiac comorbidities, open axillary incision, central line, age, social exposure
to multiple organisms from his wife
and daughter, and, most significantly,
a baseline serum albumin of less than
3.5 g/dL and lactate dehydrogenase of
more than 460 IU/L. Studies have
shown that these pretreatment factors
are associated with a significantly elevated risk of febrile neutropenia.1,2
Additionally, studies have shown the
risk of febrile neutropenia is highest in
the first cycle of chemotherapy, lending significant risk to the watch and
wait approach.3-5 Given that this
patient has a potentially curable tumor,
dose reductions and delays have been
associated with suboptimal outcomes.
A better approach may have been to
start growth factors from cycle 1 and
ensure documentation of comorbidities
and risk factors. Use of a documented
risk assessment tool and a letter of medical necessity could help assure appropriate reimbursement. The cost of the
growth factors would be significantly less
than the cost of the hospital stay. It is
equally important that clinicians obtain
specifics about reported reimbursement
denials that may ultimately be a result of
the lack of supporting documentation,
inappropriate coding, or lack of aggres-

sive and appropriate appeals. The

patients secondary insurance would
most likely have covered the copayment.

REFERENCES
1. Intragumtornchai T, Sutheesophon J,
Sutcharitchan P, Swasdikul D. A predictive model for life-threatening neutropenia and febrile neutropenia after
the first course of CHOP chemotherapy in patients with aggressive nonHodgkins lymphoma. Leuk
Lymphoma. 2000;37:351-360.
2. Tompkins KA, Imrie KR. Neutropenic
events in patients receiving CHOP
chemotherapy for large cell nonHodgkins lymphoma: predicting who
is at risk [abstract 1427]. Blood.
2001;98(337a).
3. Crawford J, Wolff DA, Culakova E,
et al. First cycle risk of severe and
febrile neutropenia in cancer patients
receiving systemic chemotherapy:
results from a prospective nationwide
study [abstract]. Blood. 2004;
104:2210.
4. Gomez H, Hidalgo M, Casanova L,
et al. Risk factors for treatment-related
death in elderly patients with aggressive non-Hodgkins lymphoma: results
of a multivariate analysis. J Clin
Oncol. 1998;1:2065-2069.
5. Lyman GH, Morrison VA, Dale DC,
et al. Risk of febrile neutropenia
among patients with intermediategrade non-Hodgkins lymphoma
receiving CHOP chemotherapy. Leuk
Lymphoma. 2003;44:2069-2076.

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