Download Myths About Chemotherapy

Myths About Chemotherapy
Dr Anne Armstrong
Consultant Medical Oncologist and Honorary Senior Lecturer
The Christie Hospital NHS Foundation Trust and The University of
Manchester
Myths About Chemotherapy
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The treatment is worse than the disease
Chemotherapy is the last line of defence for cancer
Hospital stays are needed to adminster chemotherapy
A positive attitude is all you need to beat cancer
Cancer is always painful
Everyone with the same kind of cancer gets the same kind of
treatment
Chemotherapy always causes vomiting
Chemotherapy wreaks havoc on the immune system
Chemotherapy stops you carrying out normal activities
Once chemotherapy is started it cannot be stopped until the
course is completed
Myths About Chemotherapy
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•
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The treatment is worse than the disease
Chemotherapy is the last line of defence for cancer
Hospital stays are needed to adminster chemotherapy
A positive attitude is all you need to beat cancer
Cancer is always painful
Everyone with the same kind of cancer gets the same kind of
treatment
Chemotherapy always causes vomiting
Chemotherapy wreaks havoc on the immune system
Chemotherapy stops you carrying out normal activities
Once chemotherapy is started it cannot be stopped until the
course is completed
Facts About Chemotherapy
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What we use chemotherapy for
Why we use it
How we manage toxicities
Evidence on inter-ethnic differences to chemotherapy
toxicities and response
Why we use chemotherapy
For early breast cancer the aim of chemotherapy is to :
increase the chance of cure
For secondary (metastatic) breast cancer the aim of
chemotherapy is to:
maximise both quality and quantity of life
Why We Use Chemotherapy for Early Breast
Cancer: the Early Breast Cancer Trialists’
Collaborative Group (EBCTCG) Overview
• 1980s – many small trials had shown benefit of adjuvant
chemotherapy but no agreed conclusions had been drawn
• 1984- 1st EBCTCG met to allow meta-analysis of adjuvant
tamoxifen/ chemotherapy trials
• 1989- extended to all treatments for early breast cancer
EBCTCG overview: Chemotherapy for Early
Breast Cancer
• 1988 – 31 trials of 11,000 patients and 3500 deaths,
mortality reduced with chemotherapy p<0.00001
• Subsequent overviews have shown that
chemotherapy:
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Chemotherapy better than no chemo
Drug combinations are better than a single drug
Shorter durations (3-6/12) =vt to longer
Proportional benefits of CT same for N+/NAdjuvant chemotherapy more effective < 50years
Reduces annual RR by 50% and death by 30%
Recent decrease in UK and USA breast
cancer mortality at ages 3569 years
CTx
ETx
Screening
How do we tell who needs chemotherapy
for early breast cancer?
How do we tell who needs chemotherapy for
early breast cancer?: Adjuvant! Online
Treat 100 women to save 1 life
How do we tell who needs chemotherapy
for early breast cancer?: Adjuvant! Online
Treat 3.5 women to save 1 life
How to administer chemotherapy safely
and appropriately
Side Effects of Chemotherapy for
Early Breast Cancer
Short Term Risks
• Risk of infection
• Nausea and vomiting
• Hair/nail loss
• Sore mouth
• Diarrhoea
• Constipation
• Fatigue
• Muscle and Joint Pain
• Fluid retention
• Rashes
• Allergic Reactions
• Nerve damage
Late Risks
• Loss of fertility and premature
menopause
• Damage to the heart
• Risk of second cancer
Unnecessary Dose Reductions Should
be Avoided
The best way to give chemotherapy for early breast cancer is the correct
dose at the correct time
How to Administer Chemotherapy
Safely: Choosing the correct regimen
• Young, fit Patients: 3xFEC then 3xDocetaxol
• More elderly or patients with co-morbidities: FEC then weekly
Pacitaxol or weekly paclitaxol
• Patients with cardiac disease: TC
How to Administer Chemotherapy Safely:
Managing Toxicities
All patients are reviewed prior to each dose of
chemotherapy to ensure
– Well enough for next dose
– There were no undue toxicities with last dose of
chemotherapy
Assessing Chemotherapy Toxicities: CTC
Grading
Adverse event
Nausea
1
2
3
4
Loss of appetite
Oral intake
decreased
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Vomiting
1-2 episodes in 24
hrs
3-5 episodes in
24 hrs
Inadequate
oral caloric or
fluid intake –
hospitalisation
indicated
>= 6 episodes
in 24 hrs
Stomatitis/oral
mucositis
Asymptomatic or
mild symptoms
Moderate pain:
not interfering
with oral intake
Diarrhoea
Increase of < 4 stools
per day
Increase of 4-6
stools per day
Constipation
Occasional or
intermittent
symptoms
Alopecia
Hair loss of up to
50%.Wig/camouflage
not required
Persistent
symptoms with
regular use of
laxatives
Hair loss of
>50%. A
wig/camouflage
necessary if
patient desires
Severe pain:
interfering
with oral
intake
Increase of
>=7 stools per
day or
incontinence
or
hospitalisation
indicated
Manual
evacuation
indicated
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Life
threatening
consequences
Lifethreatening
consequences
Lifethreatening
consequences
Lifethreatening
consequences
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How to minimise chemotherapy toxicities:
Nausea and Vomiting
• 1980s discovered that serotonin (5HT) was partially responsible
for chemotherapy-induced N&V
• Subsequent development of drugs that block serotonin
revolutionised oncologists ability to give emetogenic
chemotherapy
• All patients give combination 5HT antagonists, steroids with
their chemotherapy
• For the odd patient who experiences N&V despite the above a
new class of drugs, which block neurokinin receptors are added
• Nausea and vomiting after chemotherapy is manageable
How to minimise chemotherapy toxicities:
Infection
• Chemotherapy attacks fast growing cells – eg cancer cells, hair
follicles, gut, bone-marrow
• Low white cells put patients at risk of potentially life
threatening infections
• All patients commencing chemotherapy are given access to a
24h hotline for urgent advice
• Risk of hospitalisation with a temperature and low white cell
counts is 1 in 5
• All patients having FEC or FEC-T are given G-CSF injections
which halves the risk of infection
How to minimise chemotherapy
toxicities: Hair Loss
Scalp cooling can be used for
some chemotherapy regimens
and reduces the risk of hair loss
How to minimise chemotherapy toxicities:
Fertility After a Diagnosis of Breast Cancer
• Chemotherapy ages ovaries & can lead to early menopause and infertility
• In GMCCN a Fertility Preservation Service was set up in 2007 to allow
implementation of the NICE guideline 2004
• Women under 40 with a cancer diagnosis are seen within 7 days of referral
by specialist in reproductive medicine
• IVF/fertility preservation techniques available if <40, healthy BMI, no
children
• Referral pathway for breast cancer allows prompt oncology input around
time of diagnosis
Inter-ethnic differences in chemotherapy
toxicities and efficacy
Inter-Ethnic Differences: How Important
are they in Breast Cancer Treatment?
• Black women have a lower incidence of breast cancer and an
inferior outcome to white women
• Likely to be multi-factorial including women from some
minority groups presenting with a more advanced stage
• In USA women from ethnic minorities less likely to receive
XRT, CTx and ETx
• In UK MDT working and the NHS may minimise the disparities
in care seen in some countries
Inter-Ethnic Differences: How Important are
they in toxicities from Cancer Treatment?
• Giving chemotherapy at the right dose at the right time
ensures optimal outcomes
• (Some) recovery from chemotherapy toxicities is needed
before the next dose can be administered safely
• Most chemotherapy studies are performed in the West on
white women which account for only 10% of worlds
population
• Little is known about racial differences in treatment related
toxicities
Inter-Ethnic Differences: How Important are
they in toxicities from Cancer Treatment?
Han et al., EJC 2011
Methods
• Data from 5 international centres (330♀) for EBC using FEC
• Toxicities across Caucasian, African American, Asian, Hispanic
patients compared
Results
• Asian women had a higher rate of GIII haematological
toxicities than other groups
• Non-haematological toxicities very low
• No significant differences in dose intensity across the groups
Inter-Ethnic Differences: How Important are
they in toxicities from Cancer Treatment?
Han et al., EJC 2011
Inter-Ethnic Differences: How Important
are they for efficacy of chemotherapy?
Methods
• 2074 patients EBC Rx neo-adjuvant chemotherapy
• Ix response rate (pCR) to pre-surgical chemotherapy
Results
• No differences across racial subgroups
• (12% black, 14% Hispanic, 12% white, 11.5% other)
• More data is needed, but data there is, is reassuring
Chavez-MacGregor et al., Cancer 2010
Conclusions
• Chemotherapy reduces risk of breast cancer deaths &
recurrence
• For some women the benefits of chemotherapy do not
outweigh the risks
• Aim of oncological care is to
– provide enough information to women to make informed decisions
about chemotherapy
– manage side effects from chemotherapy to allow safe AND optimal
administration of chemotherapy
• There is evidence of racial differences to chemotherapy
toxicities
• More research is needed that includes women from ethnic
minorities
• Survival from breast cancer continues to improve