Myths About Chemotherapy Dr Anne Armstrong Consultant Medical

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 • • • 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 • • • The treatment is worse than the disease Chemotherapy is the last line of defence for cancer Hospital stays are needed to adminster chemotherapy y p a r e h cancer tbeat o A positive attitude is all you C need to m e h t u o b A Cancer is always painful s t Fac 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 • • 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 • 1980 s – many small trials had shown benefit of adjuvant chemotherapy but no agreed conclusions had been drawn • 1984 - 1 st 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: – – – 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 < 50 years Reduces annual RR by 50% and death by 30%

Recent decrease in UK and USA breast cancer mortality at ages 35 69 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: 3 x. FEC then 3 x. Docetaxol • 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

How to minimise chemotherapy toxicities: Nausea and Vomiting • 1980 s discovered that serotonin (5 HT) 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 5 HT 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 24 h 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 (p. CR) 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-Mac. Gregor 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