The American Society of Clinical Oncology (ASCO) released an update to their guideline, Recommendations for the Use of White Blood Cell Growth Factors. This update replaces the previous version, published in 2015.
For this guideline update, a literature review analyzed evidence data published between September 1, 2014 and August 22, 2025. The studies reviewed in the literature search focused on the safety and efficacy of new CSFs, including biosimilars of pegfilgrastim and filgrastim, and a pair of novel agents: eflapegrastim and efbemalenograstim.
Today, we are taking a look at how the recommendations included in the 2026 update compare to the previous recommendations from the 2015 version.
Guidelines Referenced:
- Recommendations for the Use of White Blood Cell Growth Factors
- July 2015
- Full Text
Major Changes and Key Takeaways (2015–2026)
The following table reflects the updates added in the 2025 update and compares them to the recommendations included in the 2015 version. To view the complete guideline, along with the full recommendations themselves, view the full-text versions using the links featured above.
Some noteworthy takeaways include the recommendation regarding primary prophylaxis of febrile neutropenia with a CSF was expanded from one to three recommendations on risk factors and availability and affordability.
Additionally, the inclusion of eflapegrastim to the included selection of preferred CSF for prophylaxis or treatment of febrile neutropenia, differs from the 2015 version. With that addition, the guideline still maintains that the choice agent depends on the clinical situation along with convenience and cost.
The 2015 guideline had also yet to integrate evidence GRADE tables. This is the first ASCO Use of White Blood Cell Growth Factor guideline update to do so.
Comparison of Recommendations
| Item | 2015 Guideline | 2026 Guideline |
|---|---|---|
| Primary Prophylaxis | Primary prophylaxis with a CSF starting with the first cycle and continuing through subsequent cycles of chemotherapy is recommended in patients who have an approximately 20% or higher risk for febrile neutropenia on the basis of patient-, disease-, and treatment-related factors. Primary CSF prophylaxis should also be given in patients receiving dose-dense chemotherapy when considered appropriate. Consideration should be given to alternative, equally effective, and safe chemotherapy regimens not requiring CSF support when available. | Patients should be offered primary prophylaxis with a granulocyte colony-stimulating factor (G-CSF) when the risk of febrile neutropenia, secondary to a chemotherapy regimen, is equal to or greater than approximately 20%, unless an alternative chemotherapy regimen with comparable efficacy and safety that does not require G-CSF is available Among patients who receive chemotherapy with a lower risk of febrile neutropenia, primary prophylaxis with a G-CSF should be offered if a patient is at high risk of complications from febrile neutropenia based on age, comorbidities, or disease characteristics and no alternative chemotherapy regimen with comparable efficacy and safety that does not require G-CSF is available. If G-CSF is not affordable or available, antibiotic prophylaxis may be offered. |
| Seconday Prophlaxis | Secondary prohylaxis with CSFs is recommended for patients who experience a netropenic complication from a previous cycle of chemotherapy (for which primary prophylaxis was not recieved), in which a reduced dose or treatment delay may compromise disease-free or overall survival or treatment outcome. In many clinical situations, dose reduction or delay may be reasonable alternative. | Secondary prophylaxis with a CSF is recommended for patients who experienced a neutropenic complication from a previous cycle of chemotherapy (for which primary prophylaxis was not received), in which a reduced dose or treatment delay may compromise cure rates or survival outcomes. In many clinical situations, dose reduction or delay may be a reasonable alternative or additional strategy. |
| CSFs for the Treatment of Febrile Neutropenia | CSFs should not be routinely used for patients with neutropenia who are afebrile. CSFs should not be routinely used as adjunctive treatment with antibiotic therapy for patients with fever and neutropenia. However, CSFs should be considered in patients with fever and neutropenia who are at high risk for infection-associated complications. High-risk features, include expected prolonged (>10 days) and profound (<0.1 x 10⁹/L) neutropenia, age older than 65 years, uncontrolled primary disease, pneumonia, hypotension and multiorgan dysfunction (sepsis syndrome), invasive fungal infection, or being hospitalized at the time of the development of fever. | A CSF should not be routinely used for patients with neutropenia who are afebrile. A CSF should not be routinely used as adjunctive treatment with antibiotic therapy for patients with fever and neutropenia. A CSF may be offered in patients with fever and neutropenia who are at high risk for infection-associated complications or who have prognostic factors that are predictive of poor clinical outcomes. |
| CSFs as Adjuncts to Progenitor-Cell Transplantation | CSFs may be used alone, after chemotherapy, or in combination with plerixafor to mobilize peripheral-blood progenitor cells (PBPCs). Choice of mobilization strategey depends in part on type of cancer and type of transplantation. CSFS should be administered after autologous stem cell transplantation to reduce the duration of severe neutropenia. CSFs may be administered after allogenic stem cell transplantaion to reduce the duration of severe neutropenia. | A CSF should be used alone, after chemotherapy, or in combination with a CXCR4 inhibitor (plerixafor or motixafortide), to mobilize peripheral-blood progenitor cells. Choice of mobilization strategy depends in part on the type of cancer and type of transplantation. A CSF should be administered after autologous SCT to reduce the duration of severe neutropenia. A CSF may be administered after allogeneic SCT to reduce the duration of severe neutropenia. |
| CSFs in Patients Recieving Concomitant Chemotherapy and Radiation Therapy | CSFs should be avoided in patients recieving concomitant chemotherapy and radiation therapy, particularly involving the mediastinum. In the absence of chemotherapy, theraputic use of CSFs may be considered in patients receiving radiation therapy alone if prolonged delays secondary to netropenia are expected. | CSFs are not recommended in patients receiving concomitant chemotherapy and radiation therapy, particularly involving the mediastinum. There is little evidence regarding use of CSFs in patients receiving radiation therapy alone. |
| Preference of CSF for Prophylaxis or Treatment of Febrile Neutropenia | Pegfilgrastim, filgrastime, tbo-filgrastim, and filgrastim-sndz (and other biosimilars, as they become available) can be used for the prevention of treatment-related febrile neutropenia. The choice of agent depends on convenience, cost, and the clinical situation. There have been no further data comparing G-SCF and GM-CSF since the 2006 update therefore there is no charge in the recommendation regarding their therapeutic equivalency. | Filgrastim, pegfilgrastim, eflapegrastim, and biosimilars can be used for prophylaxis or treatment of febrile neutropenia. The choice of agent depends on cost, patient convenience, availability, accessibility, health system context, disease subtype, and treatment regimen. |
Initiation, Duration, and Administration of CSFs
| Item | 2015 Guideline | 2026 Guideline |
|---|---|---|
| Filgrastim, Including Biosimilars | Filgrastim should be started 1 to 3 days after the administration of myelotoxic chemotherapy. In the setting of high-dose therapy and autologous stem-cell rescue, filgrastim can be started 1 to 5 days after administration of high-dose therapy. Filgrastim should be continued until reaching an absolute neutrophil count (ANC) of at least 2 to 3 x 10⁹/L. For PBPC mobilization, filgrastim should be started at least 4 days before the first leukapheresis procedure and continued until the last leukapheresis. In adults, the recommended filgrastim dose is 5 μg/kg per day for all clinical settings other than PBPC mobilzation. In the setting of PBPC mobilization, a dose of 10 μg/kg per day may be preferable. The preferred route of filgrastim administration is subcutaneous. Filgrastim-sndz: Same as for filgrastim. Tbo-filgrastim: Tbo-filgrastim should be started 1 to 3 days after the administration of myelotoxic chemotherapy. In adults, the recommended tbo-filgrastim dose is 5 μg/kg per day. The preferred route of tbo-filgrastime adminstration is subcutaneous. | Filgrastim should be started 24-72 hours after the administration of myelotoxic chemotherapy. In the setting of high-dose therapy and autologous stem-cell rescue, filgrastim can be started 1-5 days after administration of high-dose therapy. For peripheral blood progenitor cell mobilization, filgrastim should be started at least 4 days before the first leukapheresis procedure and continued until the last leukapheresis. In adults, the recommended filgrastim dose is 5 μg/kg once per day for all clinical settings other than peripheral blood stem-cell mobilization. In the setting of peripheral blood stem-cell mobilization, a dose of 10 μg/kg once per day may be preferable. The preferred route of filgrastim administration is subcutaneous. |
| Pegfilgrastim, Including Biosimilars | 6 mg should be given once 1 to 3 days after chemotherapy if at all possible. Because some patients will not be able to return for a dose of pegfilgrastim as a result of distance or immobility, for instance, alternative to consider may include self-administered filgrastim or tbo-filgrastim, or same-day pegfilgrastim, recognizing that although same-day pegfilgrastim is not as effective as later pegfilgrastim, it is better than no pegfilgrastim. Pegfilgrastim is also available in a time auto-inject device that delivers 6mg of pegfilgrastim subcutaneously, 27 hours after it is placed on the skin and activated. Pegfilgrastim is not currently indicated for stem-cell mobilization. The 6 mg formulation should not be used in infants, children, or small adolescents who weigh less than 45 kg. | Pegfilgrastim 6 mg should be given once per chemotherapy cycle, 24-72 hours after chemotherapy. Pegfilgrastim is also available in a timed auto-inject device that delivers 6 mg of pegfilgrastim subcutaneously, 27 hours after it is placed on the skin and activated. Pegfilgrastim is not currently indicated for stem-cell mobilization. The 6-mg formulation should not be used in infants, children, or small adolescents who weigh <45 kg. |
| Eflapegrastimxnst | Not addressed. | Eflapegrastim-xnst 13.2 mg should be given once per chemotherapy cycle, approximately 24 hours after chemotherapy. The route of administration is subcutaneous. Eflapegrastim-xnst is not currently indicated for stem-cell mobilization. |
| Sargramostim | Because GM-CSF has been liscensed specifically for use in mobilization and after transplantation of autologous PBPCs, after autologous or allogeneic bone marrow transplantation, and for AML, the manufacturer's instructions for administration are limited to those clinical settings. GM-CSF should be initiated on the day of bone marrow infusion and not less than 24 hours after the last chemotherapy and 12 hours after the most recent radiotherapy. GM-CSF should be continued until an ANC greated than 1.5 x 10⁹/L for 3 consecutive days is obtained. The drug should be discontinued early or the dose reduced by 50% if the ANC increases to greated than 20 x 10⁹/L. The recommended dose for adults is 250 μg/m² per day. | Because sargramostim (GM-CSF) has been licensed specifically for use in mobilization and after transplantation of autologous PBPCs, after autologous or allogeneic bone marrow transplantation, and for AML, the manufacturer's instructions for administration are limited to those clinical settings. GM-CSF should be initiated on the day of bone marrow infusion, not <24 hours after the last chemotherapy, and 12 hours after the most recent radiotherapy. GM-CSF should be continued until an ANC >1.5 × 10⁹/L for 3 consecutive days. The drug should be discontinued early or the dose reduced by 50% if the ANC increases to > 20 × 10⁹L. The recommended dose for adults is 250 μg/m² once per day. |
Check out other clinical practice guidelines published by ASCO and sign up for alerts and stay informed on the latest published guidelines and articles.