Volume 3, Number 6 for health professionals who care for cancer patients June 2000 were intended for patients who are treated as I NSIDE THIS ISSUE inpatient for the first two of five daily treatments. It . Alert! – GUEP Pre-printed Order must be ensured that the full 5 days of Misinterpretation, LUCAV, LUALTE, LUALTL chemotherapy is given, not just the final three days. Pre-printed Order Error Note that both GUEP and GUBEP protocols are . Protocol Update – BRAVCAP, BRAVTRAP, five-day treatments. GUVIP2, HNFUA, LYCDA, SCHYPCAL, UBRAVTR The GUEP pre-printed orders have been revised to . Cancer Management Manual – Genitourinary, prevent potential misinterpretation and treatment Lymphoma, Nutritional Care error. Other pre-printed orders are being reviewed . Pre-Printed Order Update – Lymphoma New to identify if similar potential for misinterpretation Patient Consultation, GUMVAC, LUCAV, exists. LUALTE, LUALTL, LYECV, LYACOP6, LYACOP12, LYCOPA LUCAV, LUALTE, LUALTL Pre-printed . Drug Update – Dacarbazine, Flutamide, Oral Orders Error The Vancouver Cancer Centre pre- Phosphate, Thalidomide, Trastuzumab printed orders (last revised 8 March) for these (Herceptin®) protocols, titled LUCAV, LUALTE-CAV, . Continuing Education – Canadian Association th LUALTL-CAV, respectively, contain a significant of Nurses in Oncology 12 Annual Conference, error. There is a statement that the chemotherapy is BCCA Annual Clinical Cancer Conference Days 1-3. This should be a Day 1 dose only. Comments to the Editor – Scent-free Workplace Please discard all previous versions and replace with new versions dated 26 May 2000. FAX request form and IN TOUCH phone list are provided if additional information is needed. PROTOCOL UPDATE Protocol codes for treatments requiring ALERT! “Undesignated Indication” approval prior to use are It has come to our attention that one pre-printed prefixed with the letter U. order has the potential to be misinterpreted and . INDEX to BCCA Protocol Summaries three others contain a significant error. It is essential revised monthly (includes tumour group, that all chemotherapy treatments, with or without protocol code, indication, drugs, last revision pre-printed orders, should always be checked with date and version) the most current BCCA protocol summaries. BRAVCAP revised (starting dose modification for elderly, poor performance status or heavily GUEP Pre-printed Order Misinterpretation pretreated added; dose modifications for hand- There is a potential for serious misinterpretation of and-foot syndrome revised): Therapy of the pre-printed orders for the etoposide-cisplatin metastatic breast cancer using capecitabine protocol for germ cell cancers of the testis (GUEP). BRAVTRAP revised (serious infusion reaction warning added, dose modification for hepatic The GUEP pre-printed orders from Fraser Valley dysfunction clarified): Therapy of metastatic Cancer Centre or Cancer Centre of Southern breast cancer using trastuzumab and paclitaxel Interior (last revised October 1998, 24 June 1999) . GUVIP2 revised (etoposide infusion time revised): Nonseminoma consolidation/salvage British Columbia Cancer Agency Provincial Systemic Therapy Program Update Vol. 3 No. 6 2000 Website version http://cancercentre.com/communities/communication.cfm 2 protocol using etoposide, cisplatin, ifosfamide, . LUALTL revised (pre-printed order titled MESNA LUALTL-CAV): Treatment of limited stage . HNFUA revised (maximum dose of mitomycin small cell lung cancer alternating changed): Combined modality therapy for cyclophosphamide, doxorubicin and vincristine advanced head and neck cancer using (CAV) with etoposide and cisplatin (EP) plus mitomycin, fluorouracil and radiation therapy early thoracic irradiation . LYCDA reformatted: Treatment of hairy cell . LYACOP12 revised: Treatment of lymphoma leukemia with cladribine with doxorubicin, cyclophosphamide, . SCHYPCAL revised (Pharmascience vincristine and prednisone Phosphate Solution changed to Phosphate . LYACOP6 revised: Treatment of lymphoma Novartis® tablets for oral phosphate): with doxorubicin, cyclophosphamide, Guidelines for the diagnosis and management of vincristine and prednisone for 6 weeks malignancy related hypercalcemia . LYCDA: Treatment of hairy cell leukemia with . UBRAVTR revised (serious infusion reaction cladribine warning added): Therapy of metastatic breast . LYCOPA revised: Treatment of lymphoma cancer using trastuzumab with doxorubicin, vincristine and cyclophosphamide CANCER MANAGEMENT MANUAL UPDATE . LYECV revised: Etoposide/cyclophosphamide Genitourinary Tumour Group has revised the consolidation for lymphoma section on medical castration. Lymphoma new patient consultation (pre- printed order entitled LymphNP orders) revised Lymphoma Tumour Group has revised the . LYRITUX new: Treatment of lymphoma with entire section on lymphoma. rituximab . VASACDEV: Vascular access device/ right Nutritional Services has revised the entire atrial catheter insertion for BMT service section on nutritional care. An index to the orders can be obtained by Fax-back. PRE-PRINTED ORDER UPDATE Pre-printed orders should always be checked with DRUG UPDATE the most current BCCA protocol summaries. The Dacarbazine 600-mg size vials (Faulding) are Vancouver Cancer Centre has prepared the now available on BCHS contract and reimbursable following chemotherapy pre-printed orders, which via the usual CON billing process, effective 27 can used as a guide for reference: April 2000. Some doses will exceed 600 mg and it . BRAVDOC: Palliative therapy for metastatic is clinically acceptable to combine the Faulding breast cancer using docetaxel (Taxotere) 600-mg vial with the Bayer 200-mg vial in order to . Febrile neutropenia: Febrile neutropenia reduce wastage. Both brands are reimbursable by orders for BMT service the BCCA. GIIR: Second-line palliative treatment of fluorouracil-refractory metastatic colorectal Flutamide is a non-steroidal antiandrogen used in cancer using irinotecan prostate cancer. For CON hospitals, which are not . GUMVAC revised: MVAC for Transitional on BCHS contract, flutamide is reimbursed at a Cell Cancers maximum of $1.35 per tablet for a BCCA approved . LUCAV revised: Treatment of extensive small indication since 21 February, 2000. Maximal cell lung cancer with cyclophosphamide, androgen blockade is not a BCCA GU Tumour doxorubicin and vincristine (CAV) Group policy and flutamide will not be funded for . LUALTE revised (pre-printed order titled this use. LUALTE-CAV): Alternating CAV/EP for extensive stage small cell lung cancer (standard) Oral Phosphate for outpatient management of malignancy related hypercalcemia is now available British Columbia Cancer Agency Provincial Systemic Therapy Program Update Vol. 3 No. 6 2000 3 as Phosphate Novartis® 500-mg effervescent do not apply in Canada. However, Canadian health tablets. This can be substituted for Pharmascience® professionals should ensure their patients are fully Phosphate Solution, which was previously the only informed of the potential risks of using this drug. oral phosphate product available. The BCCA guidelines for the diagnosis and management of 1. Singhal S, Mehta J, Desikan R et al. Antitumor activity of thalidomide in refractory multiple myeloma. N Engl J Med malignancy related hypercalcemia has been revised 1999;341:1565-71 to reflect this information. Trastuzumab (Herceptin®) is a monoclonal Thalidomide is an oral agent with antiangiogenic, antibody for the treatment of metastatic breast immunomodulatory, and anti-inflammatory cancer in patients whose tumours over express the activities. It has been shown to have some HER2 protein. Since its approval for use in late 1 antitumour activity in refractory multiple myeloma 1998 in the US, trastuzumab has been associated and has been used for this indication in a number of with infusion-related reactions (i.e., occurring patients in BC since 1999. Thalidomide has also within 24 hours of infusion) that were more severe been used in a limited number of other malignant than those seen during the clinical trials. Thus far, conditions. 62 cases (3 per 1000 patients) of serious infusion- related reactions have been reported, with 15 Use of thalidomide requires approval from both fatalities (4 per 10,000 patients). The onset of BCCA as an Undesignated Indication and the symptoms was mostly associated with the first Special Access Program (SAP) of Health Canada. infusion, and reactions include dyspnea, The lavender section of the CPS (Compendium of hypotension, wheezing, bronchospasm, tachycardia, Pharmaceutical Specialties) provides detailed oxygen desaturation, respiratory distress, and rarely, information on how to obtain SAP approval. Once allergic-like reactions. The time between the approved by Health Canada, SAP will authorise the infusion reactions and death varied from a few manufacturer (Celgene Corporation, New Jersey) to hours to 6 days. Patients who are experiencing release a one-month supply of thalidomide to the dyspnea at rest due to pulmonary metastases and requesting physician for treatment of the specified other pulmonary/cardiac conditions may be at patient. The purchasing facility must provide a increased risk of a fatal infusion reaction. Serious purchase order number to Celgene. The cost of reactions can be treated with discontinuation of thalidomide is US $98.40 per bottle of thirty 50-mg infusion and supportive measures such as oxygen, capsules and will be reimbursed by BCCA provided beta-agonists and corticosteroids, until resolution of that Undesignated