Managing Chemotherapy Toxicities in GI Cancers September 30, 2008 Christine Brezden-Masley, MD PhD...

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


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


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?


CalMag Infusions


2008 ASCO

GI Chemotherapy Management | Sept 30, 2008 | 7 C. Brezden2008 ASCO


2008 ASCO


Neuropathy

• CalMag– 2-3 tablets per day without food

• Stay warm

• Do not drink cold fluids


Nausea and Vomiting

• FOLFOX– Hesketh 4

• FOLFIRI– Hesketh 4

• ECF/ECX– Hesketh 5

• Xeloda (Capecitabine)– Hesketh 2


Nausea and Vomiting

• Immediate– Zofran 8mg po BID– Decadron 8 mg po BID

• X 3 days with chemotherapy

• Delayed– Stemetil– Maxeran


Delayed N/V

• IV hydration at home– CCAC daily IV hydration with NS 600ml/day

• Marinol/Nabilone (cannabinoid)

• Haldol

• Aprepitant– Cost

• Zyprexa (olanzapine)


Diarrhea

• FOLFOX

• FOLFIRI– Imodium– Loperamide

• NO MAXIMUM for chemotherapy-induced diarrhea

• Ensure no C.Difficile (ischemic gut)– Somatostatin (100 mg sc x1)


FOLFIRI

• Immediate diarrhea (during infusion)– SN38 active metabolite– Cholinergic response

• Treatment with Atropine 0.2 mg sc x1

• Morphine (cramping)


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


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?


XELODA

• Hand-Foot Syndrome– Keep hands and feet moist with Udder cream– May reduce dose if continues (blistering and

desquamation and pain)

• Diarrhea

• Mucositis


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


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


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


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


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)


Thanks

[email protected]

Managing Chemotherapy Toxicities in GI Cancers September 30, 2008 Christine Brezden-Masley, MD PhD...

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