Abstract Acutely unwell cancer patients generally have longer lengths of stay, higher admission rates and higher mortality than non-cancer patients. There are an increasing number of acute cancer presentations that can be risk-assessed for care in an ambulatory emergency setting. This is essential for reducing pressures on Emergency Departments and delivering sustainable acute oncology care 1. Patients with neutropenic fever are a heterogeneous group with a minority developing clinically significant, potentially life-threatening complications 2. Assessing and identifying whether patients with febrile neutropenia are at high or low risk of developing severe infection and significant medical complications is important in order to personalize management and ensure optimal usage of healthcare resources 3. Variables used to do this include the clinical condition at febrile neutropenia presentation, the underlying malignancy and pre-existing medical co-morbidities. Risk assessment tools, such as the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE), have been developed to stratify adult patients with neutropenic fever. Management of patients with low-risk febrile neutropenia in an outpatient setting is proven to be safe and effective 4. There is significant heterogeneity in the modelling of outpatient low-risk febrile neutropenia management, reflecting the variation in pathways for the delivery of emergency oncology care. Intravenous and oral antibiotic therapy have been proven to be equally effective in patients with low-risk febrile neutropenia. Combined chemotherapy/immune checkpoint inhibitor therapy is increasingly standard of care for a range of cancers. The side effects of combination therapy reflect both additive and synergistic toxicities from chemotherapy and immune checkpoint inhibition, as well as the potential for immune-related adverse events. Febrile neutropenia is a common emergency presentation in patients treated with chemotherapy/immune checkpoint inhibitor therapy. One paper suggested triple negative breast cancer patients receiving neoadjuvant pembrolizumab in addition to carboplatin/paclitaxel followed by epirubicin/cyclophosphamide could have more severe presentations with febrile neutropenia illustrated by lower MASCC scores, higher National Early Warning Scores (NEWS2) and longer lengths of stay. This may necessitate greater caution in pathways for ambulatory management for this cohort 5. Immune checkpoint inhibitor-related neutropenia is a rare adverse event 6. Early recognition of immune checkpoint inhibitor-mediated neutropenia in patients treated with chemotherapy/immune checkpoint inhibitor therapy is challenging, with the vast majority driven by chemotherapy. Immune checkpoint inhibitor-mediated neutropenia should be considered in patients receiving combined chemotherapy/immune checkpoint inhibitor therapy when the timing of presentation is unanticipated, or there is a failure of neutrophil recovery with persistent severe neutropenia 10 days following systemic anti-cancer therapy administration. Modelling of ambulatory emergency oncology services, such as those for low-risk febrile neutropenia, will be dependent on local service deliveries and pathways, but are key for providing high-quality, personalized and sustainable emergency oncology care. Alongside ambulatory pathways, hospital-at-home programmes may be an increasingly important component of the delivery of acute cancer care. References 1. Cooksley T, Rice T. Emergency Oncology: Development, Current Position and Future Direction in the US and UK. Support Care Cancer 2017; 25: 3–7. 2. Klastersky J, Paesmans M. The Multinational Association for Supportive Care in Cancer (MASCC) risk score: 10 years of use for identifying low risk neutropenic cancer patients. Support Care Cancer 2013; 21: 1487–95. 3. Cooksley T, Holland M, Klastersky J. Ambulatory outpatient management of patients with low risk febrile neutropaenia. Acute Med 2015; 14: 178–81. 4. Teuffel O, Ethier M, Alibhal S et al. Outpatient management of cancer patients with febrile neutropenia: a systematic review and meta-analysis. Ann Oncol 2011; 22: 2358–65. 5. Weaver JMJ, Nagy B, Wilson C et al. Low-risk febrile neutropenia: does combined chemotherapy/immune checkpoint inhibitor necessitate a change in approach? Support Care Cancer 2025; 33:112. 6. Kroll MH, Rojas-Hernandez C, Yee C. Hematologic complications of immune checkpoint inhibitors. Blood 2022;139(25):3594–3604.
Tim Cooksley (Wed,) studied this question.