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Managing Chemotherapy Toxicities in GI CancersSeptember 30, 2008
Christine Brezden-Masley, MD PhD FRCPC
GI Chemotherapy Management | Sept 30, 2008 | 2 C. Brezden
Objectives
• To understand toxicities from– colorectal cancer therapy– gastric cancer therapy
• To manage toxicities from– colorectal cancer therapy– gastric cancer therapy
GI Chemotherapy Management | Sept 30, 2008 | 3 C. Brezden
Colorectal Cancer
• Adjuvant colorectal cancer– FOLFOX– Xeloda– Clinical trial:
• CRC2 – Stage 3 CRC: FOLFOX +/- Cetuximab (for RAS wt patients)
• CRC3 – Stage 2 CRC: 18q deletion: FOLFOX +/- Avastin
• CRC4 – Stage 2-3 Rectal cancer: FOLFOX +/- Avastin
GI Chemotherapy Management | Sept 30, 2008 | 4 C. Brezden
FOLFOX
• Dose-limiting cold-induced sensory peripheral neuropathy– Ask patients if are able to button shirt and write
• If so, but have tingling >14 days (into next cycle) then decrease dose of oxaliplatin 85 mg/m2 to 65 mg/m2
• If pain and significant paresthesia, cannot button shirt, cannot write – discontinue oxaliplatin and continue with FUFA
– Any prevention studies for neuropathy?
GI Chemotherapy Management | Sept 30, 2008 | 5 C. Brezden
CalMag Infusions
GI Chemotherapy Management | Sept 30, 2008 | 6 C. Brezden
2008 ASCO
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2008 ASCO
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Neuropathy
• CalMag– 2-3 tablets per day without food
• Stay warm
• Do not drink cold fluids
GI Chemotherapy Management | Sept 30, 2008 | 26 C. Brezden
Nausea and Vomiting
• FOLFOX– Hesketh 4
• FOLFIRI– Hesketh 4
• ECF/ECX– Hesketh 5
• Xeloda (Capecitabine)– Hesketh 2
GI Chemotherapy Management | Sept 30, 2008 | 27 C. Brezden
GI Chemotherapy Management | Sept 30, 2008 | 28 C. Brezden
Nausea and Vomiting
• Immediate– Zofran 8mg po BID– Decadron 8 mg po BID
• X 3 days with chemotherapy
• Delayed– Stemetil– Maxeran
GI Chemotherapy Management | Sept 30, 2008 | 29 C. Brezden
Delayed N/V
• IV hydration at home– CCAC daily IV hydration with NS 600ml/day
• Marinol/Nabilone (cannabinoid)
• Haldol
• Aprepitant– Cost
• Zyprexa (olanzapine)
GI Chemotherapy Management | Sept 30, 2008 | 30 C. Brezden
Diarrhea
• FOLFOX
• FOLFIRI– Imodium– Loperamide
• NO MAXIMUM for chemotherapy-induced diarrhea
• Ensure no C.Difficile (ischemic gut)– Somatostatin (100 mg sc x1)
GI Chemotherapy Management | Sept 30, 2008 | 31 C. Brezden
FOLFIRI
• Immediate diarrhea (during infusion)– SN38 active metabolite– Cholinergic response
• Treatment with Atropine 0.2 mg sc x1
• Morphine (cramping)
GI Chemotherapy Management | Sept 30, 2008 | 32 C. Brezden
Myelosuppression
• No role for primary prevention of GCSF– FOLFIRI>FOLFOX– ECF/ECX
• For CURATIVE intent– Can treat with GCSF – funding an issue– If private insurance – can use in advanced care to
push doses
GI Chemotherapy Management | Sept 30, 2008 | 33 C. Brezden
Myelosuppression
• If febrile neutropenia– Not difficult for Section 8 to fund
• FOLFOX and Gemcitabine– Thrombocytopenia
• If platelets <85 should dose-reduce• Educate patient about bleeding risk
• Anemia– Check for Fe stores – supplement– Role for ESAs?
GI Chemotherapy Management | Sept 30, 2008 | 34 C. Brezden
XELODA
• Hand-Foot Syndrome– Keep hands and feet moist with Udder cream– May reduce dose if continues (blistering and
desquamation and pain)
• Diarrhea
• Mucositis
GI Chemotherapy Management | Sept 30, 2008 | 35 C. Brezden
Mucositis
• Good oral hygeine critical– Baking soda rinses – ½ teaspoon of baking soda in
half glass of water daily 2-3x– If severe neutropenia – than mucositis usually
occurs• Nystatin (Nilstat) 500,000 Units po q4-6 hours (swish
and swallow)
• Tantum (ODB)
• Butlers/Blacksteins mouth wash
GI Chemotherapy Management | Sept 30, 2008 | 36 C. Brezden
DPD
• Dihydropyrimidine dehydrogenase (DPD)– Catabolic pathway of 5-FU
• Responsible for 85% of degradation of 5-FU
– 5-FU 5-FUTP 5-FdUMP (ACTIVE form)
• DPD deficiency– 3-5% population (polymorphisms as high as 8%)– Autosomal recessive
GI Chemotherapy Management | Sept 30, 2008 | 37 C. Brezden
DPD Deficiency
• DPD Deficiency Syndrome– Grade 4 neutropenia– Severe/fatal diarrhea– Mucositis/stomatitis– Rash
• Can happen after 1st or 2nd dose of 5-FU
• Treatment– Supportive care
GI Chemotherapy Management | Sept 30, 2008 | 38 C. Brezden
Clinical Pearls
• Shape your practice – you’re the boss
• Do not need to examine patient at each chemotherapy session – but need to– MONITOR ALL BLOODWORK– MONITOR SIDE-EFFECTS– ASK PATIENT HOW THEY’RE DOING
• FATIGUE/ENERGY
• APPETITE
• MOOD
GI Chemotherapy Management | Sept 30, 2008 | 39 C. Brezden
CLINICAL PEARLS
• NEED TO ASSESS PATIENT– Pain– New symptoms/signs
• Dehydration
• Neurologic
• Major organ involvement– Respiratory (r/o PE)
– Cardiac (electrolyte disturbances)
– Renal
– Hepatic (Ascites)
GI Chemotherapy Management | Sept 30, 2008 | 40 C. Brezden
Thanks
Questions?brezdenc@smh.toronto.on.ca