Thames Valley Thames Valley Chemotherapy Regimens Lung Cancer Thames Valley Notes from the editor These regimens are available on the Network website www.tvcn.org.uk. Any correspondence about the regimens should be addressed to: Sally Coutts, Cancer Pharmacist, Thames Valley email: [email protected] Tel: 01865 857158 to leave a message Acknowledgements These regimens have been compiled by the Network Pharmacy Group in collaboration with the Lung TSSG with key contributions from Dr Nick Bates, Consultant Oncologist, ORH Dr Paul Rogers, Consultant Oncologist, RBFT Dr Joss Adams, Consultant Oncologist, RBFT Sally Punter, formerly Oncology Pharmacist, ORH Sandra Harding Brown, formerly Specialist Principal Pharmacist Oncology, ORH Alison Ashman, formerly Lead Pharmacist Thames Valley Cancer Network © Thames Valley Cancer Network. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Network Chemotherapy Protocols – Lung Cancer 2 Thames Valley Thames Valley Chemotherapy Regimens Lung Cancer Network Chemotherapy regimens used in the management of Lung Cancer Date published: March 2015 Date of review: March 2017 Chemotherapy Regimens Name of protocol Indication Page List of amendments to this version 5 Notes 6 ACE Small Cell lung 7 CAV Small Cell lung 9 Carboplatin Etoposide Small cell lung 11 Cisplatin (75) Etoposide (100) Small cell lung 13 Cisplatin (60) Etoposide(120) Small cell lung 15 Topotecan oral Small cell lung 17 Afatnib Non small cell lung 19 Cisplatin (50) Etoposide (50) Non small cell lung 21 Cisplatin Vinorelbine with concurrent RT Non small cell lung 23 Gemcitabine Cisplatin i Non small cell lung 25 Cisplatin 40 RT Non small cell lung 27 Crizotinib Non small cell lung cancer 29 Docetaxel 75 Non small cell lung 31 Docetaxel (75) Cisplatin (75) Non small cell lung 33 Docetaxel (75) Carboplatin Non small cell lung 35 Erlotinib Non small cell lung 37 Gefitinib Non small cell lung 39 Gemcitabine (1200) Carboplatin Non small cell lung and small cell lung 41 Gemcitabine (1000) Non small cell lung 43 Paclitaxel weekly NSCLC 45 Vinorelbine (25) Carboplatin Non small cell lung 47 Vinorelbine (25) Cisplatin (80) Non small cell lung 49 Vinorelbine Non small cell lung 51 Vinorelbine (oral) Non small cell lung 52 Chemotherapy regimens – Lung Cancer 3 Thames Valley Name of protocol NamePage of protocol NameIndication of protocol Vinorelbine elderly (oral) Non small cell lung 54 Vinorelbine (oral) Cisplatin Non small cell lung 56 Vinorelbine (oral) Carboplatin Non small cell lung 57 Carboplatin Pemetrexed Non small cell lung, Mesothelioma 59 Cisplatin Pemetrexed Non small cell lung, Mesothelioma 61 Pemetrexed maintenance Non small cell lung 63 Pre and post hydration regimens 65 Common toxicity criteria 66 Chemotherapy regimens – Lung Cancer 4 Thames Valley List of amendments in this version Regimen type: Lung Tumours Date due for review: March 2017 Previous Version number: 3.3 This version number: 3.4 Table 1 Amendments Page Amendment Made/ asked by Table 2 New protocols to be approved and checked by TSSG included in this version Name of regimen Indication Reason / Proposer Pemetrexed weekly NSCLC Dr Adams Chemotherapy regimens – Lung Cancer 5 Thames Valley Notes 1. There is variation in practice in the administration of etoposide. In some hospitals this is only given intravenously; in others it is given intravenously on day 1 and orally on days 2 and 3. The reason for using oral administration is lack of chemotherapy suite time. The absorption of oral etoposide is known to be erratic, with reduced efficacy in some patients, and severe toxicity in others and is not recommended. Chemotherapy resources should be reallocated to allow intravenous administration of etoposide in all appropriate patients. 2. Combinations of paclitaxel, docetaxel, gemcitabine or vinorelbine with a platinum have been recommended by NICE for first line chemotherapy in NSCLC. All four of the new drugs are in use across across the network. 3. NICE has recommended Pemetrexed for malignant mesothelioma for some groups of patients and first line treatment of NSCLC with adenocarcinoma and large cell undifferentiated carcinoma. 4. These protocols are likely to change as new evidence becomes available. Please ensure you are using the most up to date version of the protocols (as published on the TVCN website). Chemotherapy regimens – Lung Cancer 6 Thames Valley ACE (SCLC) Indication: Has been used as first line treatment for SCLC but platinum/etoposide is preferred People with small-cell lung cancer should have treatment initiated within 2 weeks of the pathological diagnosis. (NICE) DRUG REGIMEN 2 Day 1 DOXORUBICIN 40mg/ IV bolus 2 CYCLOPHOSPHAMIDE 600mg/m IV bolus 2 ETOPOSIDE 100mg/m infusion in 1000ml sodium chloride 0.9% over 60 minutes Day 2 ETOPOSIDE 100mg/m2 infusion in 1000ml sodium chloride 0.9% over 60 minutes Day 3 ETOPOSIDE 100mg/m2 infusion in 1000ml sodium chloride 0.9% over 60 minutes NB Day 2 and 3 etoposide can be given orally ETOPOSIDE 200mg/m2 PO but is not recommended as oral absorption is variable (it may cause reduced efficacy or severe toxicity in patients), the intravenous route is preferred, however for logistical reasons the oral route may be necessary. Cycle Frequency: Every 21 days Number of cycles: Usually 6 (subject to tolerance and response) DOSE MODIFICATIONS Doxorubicin: Dose reduce in severe renal impairment. Bilirubin 20-50micromol/L give 50% dose Bilirubin 51-85micromol/L give 25% dose Bilirubin >85micromol/L omit If AST is 2-3 x ULN give 75% dose If AST is >3 x ULN give 50% dose Maximum cumulative dose = 450 mg/m2 (in normal cardiac function) = 400 mg/m2 (in patients with cardiac dysfunction or exposed to mediastinal irradiation) Etoposide: CrCl >50ml/min give 100% dose CrCl 15-50ml/min give 75% dose CrCl <15ml/min give 50% dose Bilirubin 26-51micromol/L or AST 60-180u/L give 50% dose Bilirubin >51micromol/L or AST >180u/L Clinical decision ACE Lung TSSG Chair Authorisation: Page 1 of 2 Published: March 2015 Version 3.4 Date: Review: March 2017 Chemotherapy regimens – Lung Cancer 7 Thames Valley Cyclophosphamide: GFR >20ml/min give 100% dose GFR 10-20ml/min give 75% dose GFR <10ml/min give 50% dose INVESTIGATIONS Routine Blood test 1) Blood results required before chemotherapy administration Give Discuss Hb x g/dL ≥10 < 10 Plt x 109/L ≥100 < 100 Neutrophils x 109/L ≥1.5 < 1.5 Liver function tests (LFT) Serum Creatinine 2) Non urgent blood tests Tests relating to disease response/progression ECG (possibly ECHO) required if patient has preexisting cardiac disease (Doxorubicin) CONCURRENT MEDICATION ANTIEMETIC POLICY High emetic risk day 1 Low emetic risk days 2 and 3 ADVERSE EFFECTS / REGIMEN SPECIFIC COMPLICATIONS Cyclophosphamide may irritate bladder, drink copious volumes of water. Cardiotoxicity – Monitor cardiac function to minimise the risk of anthracycline induced cardiac failure. Doxorubicin may be stopped in future cycles if signs of cardiotoxicity e.g. cardiac arrhythmias, pericardial effusion, tachycardia with fatigue. REFERENCES 1. Aisner J et al. Cancer Treat Rep 1982; 66: 221 230 2. Daniels, S. and S. Gabriel, Dosage adjustment for cytotoxics in renal impairment and hepatic impairment. 2009, The North London Cancer Network. ACE Lung TSSG Chair Authorisation: Page 2 of 2 Published: March 2015 Version 3.4 Date: Review: March 2017 Chemotherapy regimens – Lung Cancer 8 Thames Valley CAV (SCLC) Indication: First line treatment for SCLC in patients not able to tolerate platinum and etoposide (e.g. performance status of 3). Can also be used as second line treatment after relapse. People with small-cell lung cancer should have treatment initiated within 2 weeks of the pathological diagnosis. (NICE) DRUG REGIMEN 2 Day 1 VINCRISTINE 1.3mg/m (max. 2 mg) in 50ml sodium chloride 0.9% IV over 10 mins DOXORUBICIN 40mg/m2 IV bolus CYCLOPHOSPHAMIDE 750 mg/m2 IV bolus Cycle Frequency: Every 21 days Number of cycles: Usually 6 (subject to tolerance and response) DOSE MODIFICATIONS Vincristine: If patient complains of tingling of fingers and/or toes, discuss. Bilirubin 25-51micromol/L or AST 60-180u/L give 50% dose Bilirubin >51micromol/L and normal AST give 50% dose Bilirubin >51micromol/L and AST >180u/L omit Doxorubicin: Dose reduce in severe renal impairment. Bilirubin 20-50micromol/L give 50% dose Bilirubin 51-85micromol/L give 25% dose Bilirubin >85micromol/L omit If AST is 2-3 x ULN give 75% dose If AST is >3 x ULN give 50% dose Maximum cumulative dose = 450 mg/m2 (in normal cardiac function) = 400 mg/m2(in patients with cardiac dysfunction or exposed to mediastinal irradiation) Cyclophosphamide: GFR >20ml/min give 100% dose GFR 10-20ml/min give 75% dose GFR <10ml/min give 50% dose CAV Lung TSSG Chair Authorisation: Page 1 of 2 Published: March 2015 Version 3.4 Date: Review: March 2017 Chemotherapy regimens – Lung Cancer 9 Thames Valley INVESTIGATIONS Routine Blood test 1) Blood results required before chemotherapy administration Give Discuss Hb x g/dL ≥10 < 10 Plt x 109/L ≥100 < 100 Neutrophils x 109/L ≥1.5 < 1.5 Liver function tests (LFT) Serum Creatinine 2) Non urgent blood tests Tests relating to disease response/progression ECG (possibly ECHO) required if patients has pre- existing cardiac disease (Doxorubicin) CONCURRENT MEDICATION ANTIEMETIC POLICY High emetic risk ADVERSE EFFECTS / REGIMEN SPECIFIC COMPLICATIONS Cardiotoxicity – Monitor cardiac function to minimise the risk of anthracycline induced cardiac failure. Doxorubicin may be stopped in future cycles if signs of cardiotoxicity e.g. cardiac arrhythmias, pericardial effusion, tachycardia with fatigue. Cyclophosphamide may irritate bladder, drink copious volumes of water. REFERENCES 1. Greco FA et al. Am J Med 1979; 66: 625 630. 2. Roth BJ et al. J Clin Oncol 1992; 10: 282291 3. Daniels, S. and S. Gabriel, Dosage adjustment for cytotoxics in renal impairment and hepatic impairment.