Are cancer patients getting enough chemo?

[Hebbie]

Are cancer patients getting enough chemo?

Study: Side effects prevent some from receiving full treatment

The Associated Press

Updated: 9:38 a.m. ET June 01, 2004; WASHINGTON -

It’s a worrisome finding: About a third of patients with potentially curable breast cancer aren’t getting full-strength doses of chemotherapy because of side effects or other problems.

Now researchers are preparing to find out whether this inadvertent chemo-lite is common with other cancers, too — and how much the dose can dip before patients’ chances of survival are harmed.

“This is not just a breast cancer problem,” predicts Dr. Gary Lyman of the University of Rochester Medical Center, who is leading some of the research.

“We’re very concerned about it,” adds Dr. Larry Norton, deputy physician-in-chief for breast cancer at Memorial Sloan-Kettering Cancer Center.

Under-dosing a problem

Norton’s own research shows that undergoing breast cancer chemotherapy every two weeks instead of every three can improve survival by 30 percent. That means skipping chemo sessions or lowering doses has ominous implications.

What could the toll be?

“The bottom line is nobody knows,” says Dr. Howard Ozer, with the Oklahoma University Cancer Center, who is heading an effort by the American Society of Clinical Oncology to examine some of the issues. “It has not been recognized that this (under-dosing) is a problem.”

Strict scientific studies set the “dose intensity” for different chemotherapy cocktails — the proper dose plus how often it must be given.

But community oncologists often don’t stick to those recommendations as rigorously as do researchers, and Lyman’s breast cancer data provides the best picture of that so far. He reviewed medical records for more than 20,000 breast cancer patients who underwent post-surgery chemotherapy.

Lyman found that more than half received less than 85 percent of the recommended dose intensity that is considered the minimum for optimal treatment. For a quarter of patients, the problem was postponing chemo sessions; for the rest, it was dosage cuts, presumably because of side effects.

Many of those women were treated in the mid-1990s, before a shift to some easier-to-tolerate chemotherapy agents. So Lyman is examining records from 10,000 women treated since 2000 — and is finding some improvement, with about a third of patients now undertreated. He plans to report this at a cancer meeting later this year.

Still, that’s worse than the 5 percent to 10 percent of patients that Lyman and some other researchers believe truly cannot tolerate full-strength dosing despite today’s improved medications to counter side effects.

No one knows how often patients with other cancers are under-dosed, although a much smaller study suggests half of those with non-Hodgkin’s lymphoma are.

To help answer the question, Lyman has begun a registry tracking patients from 100 community-based oncology practices nationwide as they receive chemo for breast, lung, ovarian and colorectal cancers and lymphoma. About 3,000 patients are enrolled so far.

Vulnerable to infections

This time, he’ll also check why chemo is postponed or cut — gathering details on side effects, and whether some skipping is due to physician disagreement over proper dosing or simply the patient’s ill-informed desire for a break.

“I’ve had patients say to me, ’I’d like to skip a week to take an exam or a trip,”’ Sloan-Kettering’s Norton says. “I can’t force you to get treatment on time, but I sure can encourage you.”

Lyman’s work is funded by Amgen Inc., which makes one of the treatments for the common chemotherapy side effect neutropenia, a loss of white blood cells that leaves patients vulnerable to infection.

Drugs that spur white blood cell production can prevent neutropenia so chemo won’t have to be cut or delayed, but they’re too expensive for routine use. In June, Ozer and colleagues at the American Society for Clinical Oncology will finalize guidelines to help determine who is at high enough risk of neutropenia to receive such drugs protectively.

And Ozer is helping to plan a study of five cancers similar to Lyman’s registry — but that also will attempt to determine at what level does dips in doses cause real harm.

What side effects must be tackled to prevent under-dosing will be cancer-specific, because different chemotherapies are used for each, cautions Dr. James Doroshow of the National Cancer Institute.

Genetic tests within a few years could decrease concern about under-dosing, by allowing doctors to tailor patients’ chemo dose in ways now impossible, Doroshow says.

Until then, Norton and Lyman advise cancer patients to talk candidly with their doctors about ways to ease side effects without cutting chemo doses.

© 2004 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed

[john]

This line is discouraging:

Drugs that spur white blood cell production can prevent neutropenia so chemo won’t have to be cut or delayed, but they’re too expensive for routine use. In June, Ozer and colleagues at the American Society for Clinical Oncology will finalize guidelines to help determine who is at high enough risk of neutropenia to receive such drugs protectivel

So

1) they're saying people are underdosed

2) We have drugs to treat side effects so they can get the optimum dose

3) But they're TOO EXPENSIVE

What is the price of a life anyway? It also sounds penny wise and pound foolish. If the chemo is not effective at a low dose then it is wasting money, so if they give the drugs to boost the cell counts, then it is actually saving money.

[Elaine]

John

Would you happen to know the names of these drugs?

elaine

[john]

Elaine,

I think neupogen or Neulasta (pegfilgrastim) is used for white blood cells. I think these are the same as GM-CSF and G-CSF (colony stimulating factor)

EPO type drugs are used for red blood cells (Procrit, EPOgen, Aranesp). There are two types of EPO drugs, one is supposed to work slightly better, but I don't know off had what they are.

For platlets a transfusion is usually given but there is a drug called Neumega.

[Addie]

John...you said it....

What is the price of a life anyway? It also sounds penny wise and pound foolish.

I just got my first Neulasta shot last week and was told I will get one following the third day of chemo at every cycle now. My Onc apparently gives it routinely...especially for someone like me with an already compromised immune system.

Expensive? Maybe....but treatment is expensive in general! I'm also getting a DAILY amifostine shot before radiation. I wonder what that baby is costing?

I was told that while I'm undergoing radiation, my chemo doses will be slightly reduced...from (as I recall the nurse saying) 170 mgs. to about 130-140 mgs? Of course I was concerned and asked her if what I was getting was STILL gonna give the cancer a decent "whack" and she raised her eyebrows and said, "Oh, yeah!!" This next cycle, I am going to reconfirm that with my Onc too.

I presume with the effects of radiation added, the key is to make sure that I'm tolerating the treatments well enough NOT to interrupt them and of course, that is MY goal too! But I don't want the dose cut IF I can tolerate it at the higher level...you know?

The whole notion of underdosing is disturbing. Given a choice, NONE of us want to feel sick, nauseated, in pain or otherwise affected by treatment....but heck, given a choice none of us would choose cancer either, would we?

The point though, is to obtain treatment that gives us the BEST shot at beating this disease...and if I had a doctor that seemed sort of wishy-washy about aggressive treatment OR using what is available to offset side effects (like Neulasta or anti-nausea meds, steroids, whatever) I think I'd be looking for a new doctor!

Sometimes we don't know what a person can tolerate until we test it out a bit....right? I wouldn't want a doctor to presume I was a wuss and couldn't take the full treatment if the dosage I was given was going to reduce my odds of survival or cure. I think that choice ought to be mine!

[john]

Addie,

I think you misunderstood. I think doctors should use the Neulasta and anything that can help.

The ARTICLE said we do not use it routinely because it is too expensive.

I think that is crap and people should push for the drugs (EPO, neulasta, ethyol, anti-nausea etc)

Take care and glad you are getting the "expensive" drugs.

John

[Addie]

No, John....I understood it just fine and I AGREE with you, that YES....these drugs should be used. I may have gotten off on a tangent that made my meaning unclear....but I agree with you totally that if these drugs are available and work, they should be used!

I was just saying that my own Onc DOES use them and I'm glad. I wish everyone's Onc did!! I can understand reducing a chemo dose a little while a patient is undergoihg radiation too....but again, I still say the individual's tolerance for treatment has to be part of the equation. My Onc has told me he feels I have a pretty "strong constitution"....so it's my feeling that unless or until I have a clear reaction, that he's going to treat me aggressively...which is what I want. The amount that he reduced my chemo when radiation started wasn't too significant...and for all I know, he may up it again since I'm tolerating it all just fine.

Sorry I wasn't more clear John...but I agree with your take on this completely.

[john]

Addie,

No problems! Yes it is good to see patients are getting all the help and drugs that are needed.

I hope your posts help people fight for what they want

God bless,

John