What do you think about your Chemo Protocol
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This INTRAHEPATIC CHOLANGIOCARCINOMA TREATMENT REGIMENS (Days 1 and 8: Cisplatin 25mg/m2 IV (1-hour infusion) followed by gemcitabine 1,000mg/m2 IV (0.5-hour infusion). ) do not have any positive effects.
Our patient 70 years lady patient has 5 chemos.
1. chemo 40 mg Cisplatin + 1200 mg gemcitabine
2 chemo 1200 mg gemcitabine
3 chemo 1200 mg gemcitabine
4 chemo 1200 mg gemcitabine
5 chemo 1200 mg gemcitabineThe CEA ab C19-9 tumor markers are increasing.
If The Oncologist will stop chemo, which treatments can be tried ?
Ali,
Regarding the ABC-02 trial,
Bridgewater, et al. published a really wonderful paper on cholangio in 2014. I have referenced it many times in projects I have worked on.
Regarding ABC-02 trial standard of care chemo (this is Gemzar (Gebcitabine) and Cisplatin.
Gemcitabine and Cisplatin systemic therapy is standard of care for non-resectable disease if the patient has a good performance status with a median survival of 11.2 months versus 7.7 (Bridgewater et al.,2014).
Here is the citation:
Bridgewater, J., Galle, P., Khan, S., Llovet, J., Park, J.W., Patel, T., Pawlik, T., & Gores, G. (2014). Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma. Journal of Hepatology, 60(6), 1268-1289. doi.org/10.1016/j.jhep.2014.01.021I hope this helps you.
-Karen
Ali…I understand he is buys, but as as your Mom’s physician he must answer questions as well. I may be that you need your Mom to give him permission to speak with you. In any case, you should have important questions clarified by him.
Hugs
MarionAli…there are many reasons for the colored ascities; however only her doctor can give you the explanation.
Hugs
Marionthank you very much Karen.
Is The ABC-02 trial effective. Does it cure ?
Lasix was given after cisplatin.She has Ascitic fluid (Ascites) in her abdomen. The Paracentesis procedure was performed four times. Ascitic fluid was yellow in three Paracentesis procedures.
But yesterday it is red and bloody.
What does red and bloody Ascites mean ? How can it be crue?
Here is some additional information that may help in understanding chemotherapy orders:
This link discusses how chemotherapy orders should be written to ensure safety.https://ctep.cancer.gov/protocolDevelopment/policies_nomenclature.htm
Here are some snippets of info from just one article that talks about dose reduction and dose delays and the reasoning behind the changes to the protocols. Although this article is from 2000, it has good information in it. I have also read many articles that discuss the effect of dose reducing or dose delaying chemotherapy and how this impacts the treatment of the cancer itself, i.e. poorer outcomes or disease free periods, or progression of the cancer. I feel though that providers are of course looking at the person as a whole, and you can’t give a full dose of chemotherapy if the patient’s body cannot tolerate it. Does this mean that a poorer outcome, or cancer progression may be the result? Possibly, but no one would want to give the full dose of chemotherapy to an individual to then have their kidneys stop working, or for their bone marrow to fail. I give oncologists a lot of credit…they are very skilled clinicians in deciding how best tosafely treat each individual person.
There are however a lot of supportive treatments that are given with chemotherapy to help the patient’s body to cope such as Neupogen to stimulate the bone marrow to produce white blood cells faster, or transfusions of packed red blood cells (RBCs) or Platelets.
“Treatment Delays
During the use of combination chemotherapeutic regimens for nonmyeloid malignancies, the standard response of physicians to the development of thrombocytopenia is dose reductions and/or delayed administration of the next cycle of chemotherapy (Table 2). This is also the response of treating physicians for patients receiving combined-modality therapy (chemotherapy and radiation therapy). In the study conducted by MacManus et al, thrombocytopenia forced the interruption of radiation therapy for 3 days or more in 98% (44/45) of patients, 27% (12/45) of whom had at least one measurement of platelet count < 25,000/µL.[2] In addition to treatment interruption, the planned radiation dose was reduced by > 10% in 51% of the cases, vs 11% of controls (radiation therapy only).
During myelosuppressive chemotherapy, the administration of subsequent cycles is routinely delayed until the platelet count has recovered to 100,000/µL, as mandated by almost all of the protocols for investigations of chemotherapeutic regimens seen in Table 2.[5,11,12,24-27] In these studies, treatment was delayed for 1 to 4 weeks if this platelet threshold was not reached.Dose Reductions
The practice of reducing doses in response to prolonged myelosuppression is demonstrated in the studies in Table 2. In the event of slow platelet recovery[11,24,26,27,29,30] or persistence of platelet counts < 50,000/µL [11,24,30-32] or even 75,000/µL to 100,000/µL,[22,27] chemotherapy was significantly deescalated, often by reducing drug doses by up to 50%
Thrombocytopenia in conjunction with neutropenia led to dose reductions in most patients who received more than three cycles of therapy”.-Karen
All information provided is my opinion only and is not to be used as medical advice. Please always consult with your prescribing physician for medical questions or issues.
Alikemal,
I should preface this post with the understanding that although a study may come out with a chemotherapy regimen for a specific cancer, there is much room for interpretation. Every oncologist will order differently, and this is not something that I can expound on as I am an oncology nurse. Hospitals also develop their own protocols.
In looking through the chemotherapy orders (or your very organized sheet!) what I see first is the protocol. This protocol appears to be roughly following the standard of care for biliary cancer based off the ABC-02 trial from 2010. Now I will go through the whole order sheet. I will attach the links to the New England Journal of Medicine (NEJM) where the ABC-02 study was published, and also Cancer Therapy Advisor so you may see where I sourced this information for you.1. The orders state that the chemotherapy administration will be on 1 and 8, every 21 days. (This would be one “cycle”). The ABC-02 trial was to give gemcitabine/cisplatin on days 1 and 8 every 3 weeks (so roughly 21 days). This treatment is to be given in 4 cycles per the study.
2. The order sheet says Cisplatin 30 mg/m2 and Gemcitabine 1000 mg/m2. The ABC-02 study and the Cancer Therapy Advisor list the doses as Cisplatin 25 mg/m2 and Gemcitabine 1000 mg/m2. Why the slight difference for your order sheet? Perhaps this is a case where the oncologist is ordering based on their knowledge base. You could always ask.
3. Numbers 5 and 6 in the list on the order sheet- Cisplatin 40 mg- The cisplatin orders state that this dose is to be 30 mg/m2. BSA is 1.48/m2 so 30mg x 1.48= 44.4 mg. Whoever mixed the chemo did 40 mg of Cisplatin even though the dose is technically 44.4. They chose to round down which I will explain in a bit. Gemcitabine 1000 mg/m2. 1.48 x 1000 = 1,480 mg. The given dose though is 1100 mg. Here again, the dose was decreased.
4. Numbers 1, 2, 3, 4. 1. Dekort I believe must be Decadron, a steroid and a pre-medication to prevent adverse reactions from the chemotherapy. 16 mg looks right to me. 2. My facility happens to give Ondansetron (Zofran) at 8 mg to prevent nausea (another premedication) 3. Benison or Avil, I have not heard of. As it says “antihistamine” on the sheet, I’m guessing this must be something like Benadryl, which I have given as a premedication for many things, including chemotherapy. I cannot remember giving this before Gemcitabine/Cisplatin, but I’m not saying this is wrong for it to be given. 4. Lasix 20 mg. Lasix (Furosemide) is a diuretic to help the body to diurese. The 1000 ml of saline is a kidney protectant as the Cisplatin is toxic to the kidneys. I have not given Lasix with Cisplatin before, but I certainly have pre and post hydrated with saline. Again, this must be oncologist specific per their knowledge base.
5. Number 7, Emend. This medication is an NK-1 antagonist, or a heavy duty anti-nausea medication that has been shown in studies to work very well to fight the kind of nausea that can occur with Cisplatin, which can be very severe. Cisplatin is what we call a “highly emetogenic” chemotherapy so precautions such as the administration of Emend will help to ward off this nausea/vomiting.
Now I will explain about dose reduction and speculate on why the entire 1-7 were given the first time, and not the second. Dose reduction is done for the safety of the patient. Your mother is 70, and perhaps she has some other illnesses (diabetes, heart disease, etc.). She may have underlying kidney or liver function issues…I do not know what her lab work would reveal or her health history. Oncologists will dose reduce to treat, but do as little harm to the body, which I suspect happened in this case. This is again why your mother most likely received Gemcitabine alone without the Cisplatin. Cisplatin can be especially harsh and cause the kidneys to struggle, and greatly affect the bone marrow and resultant lab results. (Platelet count can drop markedly, as well as the white blood cell count (WBC), hemoglobin/hematocrit, neutrophils, etc.). Neuropathy can occur too with the Cisplatin, and this will cause an oncologist to dose reduce or discontinue.
My advice would be to ask the oncologist any questions you may have, and look through the resources that I provide links for. Again, every oncologist orders differently and the information I have provided is my opinion based on experience, but I am not a physician.
Hopefully this will ease your mind, as it appears that the orders are very similar to the current standard of care treatment with some minor changes.-Karen D.
http://www.nejm.org/doi/full/10.1056/NEJMoa0908721#t=articleDiscussion
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