Febrile Neutropenia MASCC Score

MASCC explained

The Multinational Association for Supportive Care in Cancer score is a risk stratifying tool that helps with management of cancer patients under chemotherapy, when febrile neutropenia is suspected (at fever onset).

There are eight items in the score, acting as risk factors for adverse outcome:

There are other risk stratification tools, such as the Clinical Index of Stable Febrile Neutropenia (CISNE) score, that is able to discriminate between 3 levels of risk: low, intermediate and high.

Adverse outcome can be defined as any of the following conditions or events:

■ Hypotension (systolic blood pressure <90 mmHg);

■ Disseminated intravascular coagulation;

■ Admission to intensive care unit;

■ Arrhythmia or EKG changes requiring intervention;

■ Severe bleeding (requiring transfusion);

■ Respiratory failure (P_aO₂ <60 mmHg or need for mechanical ventilation);

■ Confusion or altered mental status;

■ Renal failure (requiring IV treatment or dialysis).

Score interpretation

The MASCC score determines patients at low risk of chemotherapy associated complications based on a cut off at 21 points. Each of the eight items in the score is awarded a number of points. The maximum score is 26.

Depending on the number of points they score, patients are classed in one of the two categories:

■ MASCC ≥21 is indicative of a low risk of febrile neutropenia. The patient can be treated as outpatient with oral antibiotics and there is a 91% chance of positive resolution without complications.

■ MASCC <21 is indicative of a high risk of febrile neutropenia. Patient needs to be admitted in hospital and treated with IV antibiotics. There is a 64% chance of resolution without adverse outcome or complications.

About the study

The MASCC model was created following a prospective multinational study by Klastersky et al. from 2000. Independent factors of febrile neutropenia were assessed (at fever onset) on a derivation cohort of 756 patients, with the aim to develop a risk-index score.

This was subsequently tested on a validation set, where the score showed a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%.

The conclusion was that this scoring system accurately identifies patient at low risk of complications and can help clinicians with malignancy management decisions.

Febrile neutropenia treatment

FN is the febrile complication of myelosuppressive chemotherapy and is considered a medical emergency. In 50% of cases an infection is detectable (neutropenic sepsis) and in 20% of patients, there is bacteremia.

Patients diagnosed with febrile neutropenia are treated with empirical antibiotics (until neutrophil count is recovered) and fever has gone down.

In low-risk cases a combination of oral amoxicillin-clavulanic acid and ciprofloxacin is used, while in more severe cases cephalosporins or carbapenems are recommended.

Original source

Klastersky J, Paesmans M, Rubenstein EB, Boyer M, Elting L, Feld R, Gallagher J, Herrstedt J, Rapoport B, Rolston K, Talcott J. The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol. 2000; 18(16):3038-51.

Validation

Uys A, Rapoport BL, Anderson R. Febrile neutropenia: a prospective study to validate the Multinational Association of Supportive Care of Cancer (MASCC) risk-index score. Support Care Cancer. 2004; 12(8):555-60.

Other references

1. Klastersky J, Paesmans M, Georgala A, Muanza F, Plehiers B, Dubreucq L, Lalami Y, Aoun M, Barette M. Outpatient oral antibiotics for febrile neutropenic cancer patients using a score predictive for complications. J Clin Oncol. 2006;24(25):4129-34.

2. Talcott JA, Finberg R, Mayer RJ, Goldman L. The medical course of cancer patients with fever and neutropenia. Clinical identification of a low-risk subgroup at presentation. Arch Intern Med. 1988; 148(12):2561-8.

3. Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR; Infectious Diseases Society of America. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of America. Clin Infect Dis. 2011; 52(4):e56-93.

4. Carmona-Bayonas A, Gómez J, González-Billalabeitia E, Canteras M, Navarrete A, Gonzálvez ML, Vicente V, Ayala de la Peña F. Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients. Br J Cancer. 2011; 105(5):612-7.