Volume 5, Number 8 for health professionals who care for cancer patients August 2002 Available on website www.bccancer.bc.ca I NSIDE THIS ISSUE Amifostine (Undesignated Indication approval New Treatment Policy 2002/03 required for each patient) radiation protection Benefit Drug List – Amifostine, Interferon, for radical radiotherapy. (Note: requires Valrubicin approval from Health Canada Special Access Protocol Update – GIFUA, GUBVAL, Programme) (UHNRAMI) UHNRAMI, MYHDC, USMAJIFN Interferon (Undesignated Indication approval Cancer Management Manual required for each patient) for adjuvant therapy Pre-Printed Order Update – of high risk malignant melanoma (USMAJIFN) Patient Education Update - LHRH Agonists, ZD Valrubicin (Class II) for BCG-refractory 1839 (Iressa®) bladder Tis in patients unfit for cystectomy Drug Update - ZD 1839 (Iressa®), (GUBVAL) Hyaluronidase (Wydase®) Focus on the Sequence of Administration of These new indications are now added to the benefit Rituximab and CHOP list. If applicable, a Class II form or Undesignated Cancer Drug Manual - Interferon alpha Indication application must be completed and Provincial Systemic Therapy Program Policies - submitted to the Provincial Systemic Therapy Policy on Extravasation of Chemotherapy Program before the drug will be dispensed at a Library/Cancer Information Centre regional cancer centre or reimbursed to a Continuing Education - BC Cancer Agency community hospital. Annual Cancer Conference, Canadian Association of Nurses in Oncology Conference Susan O’Reilly, MB, FRCPC Provincial Systemic Program Leader FAX request form and IN TOUCH phone list are provided if additional information is needed. The current Benefit Drug List, Class II forms Undesignated Indication application forms are NEW TREATMENT POLICY 2002/3 available on the BC Cancer Agency website The Provincial Systemic Therapy Program of the (www.bccancer.bc.ca) under Health Professionals BC Cancer Agency is pleased to announce the Info, Chemotherapy Protocols, Frequently Used funding of a number of new treatment programs. Forms. These programs will be implemented once the relevant treatment protocols, patient education PROTOCOL UPDATE materials and pre-printed orders have been INDEX to BC Cancer Agency Protocol developed by the Provincial Tumour Groups, the Summaries revised monthly (includes tumour Provincial Pharmacy and the Regional Cancer group, protocol code, indication, drugs, last revision Centres. For more details, please see under Benefit date and version). Protocol codes for treatments Drug List and Protocol Update of this and the July requiring “Undesignated Indication” approval prior issue of the Systemic Therapy Update. to use are prefixed with the letter U. GIFUA revised (treatment cycle lengthened to 6 BENEFIT DRUG LIST weeks): Curative combined modality therapy The following new programs have been funded by for carcinoma of the anal canal using the Provincial Systemic Therapy Program effective mitomycin, infusional fluorouracil and radiation 1 August 2002: therapy British Columbia Cancer Agency ♦ Provincial Systemic Therapy Program Update ♦ Vol. 5 No. 8 2002 2 GUBVAL new: Intravesical valrubicin for Patient information handouts for cancer drugs are BCG-refractory bladder Tis in patients unfit for available on the BC Cancer Agency website cystectomy (www.bccancer.bc.ca) under Health Professionals UHNRAMI new (Undesignated Indication Info, Drug Database. approval required for each patient): Radiation protection for radical radiotherapy of head and DRUG UPDATE neck tumours using amifostine (Note: requires ZD 1839 (Iressa®) is an oral antineoplastic agent approval from Health Canada Special Access that has not been marketed but is being studied in Programme) various types of cancers, including non-small cell MYHDC revised (ciprofloxacin and filgrastim lung cancer. The main mechanism of action is the treatments): Single dose cyclophosphamide selective inhibition of tyrosine kinase at the priming therapy for multiple myeloma prior to epidermal growth factor receptor. Supply of ZD autologous stem cell transplant 1839 may be obtained through the Health Canada USMAJIFN new (Undesignated Indication Special Access Programme but it is not a BCCA approval required for each patient): Adjuvant Benefit Drug. therapy of high-risk malignant melanoma with high dose interferon (HDIFN) ∝-2b (Note: for Hyaluronidase (Wydase®) is no longer nursing issues related to this protocol, please available in Canada. This is traditionally used in contact 604-877 6098 local 2623). the management in the extravasation of vinca alkaloids. There are some suggestions that normal saline in various quantities may be injected to the Protocols are available on the BC Cancer Agency extravasation site to dilute the vesicant.1,2 However, website (www.bccancer.bc.ca) under Health based on the current evidence available, the Professionals Info, Chemotherapy Protocols. American Society of Health-System Pharmacy cannot recommend a pharmacologic alternative to CANCER MANAGEMENT MANUAL hyaluronidase3 and patients should be managed with The Cancer Management Manual is available are the usual nonpharmacologic measures as outlined in available on the BC Cancer Agency website the BC Cancer Agency Systemic Therapy Policy on (www.bccancer.bc.ca) under Health Professionals the Prevention and Management of Extravasation of Info, Cancer Management Guidelines. Chemotherapy (Policy III-20) (available on the BC Cancer Agency website www.bccancer.bc.ca under PRE-PRINTED ORDER UPDATE Health Professionals Info, Chemotherapy Protocols, Pre-printed orders should always be checked with Policies and Procedures) the most current BC Cancer Agency protocol summaries. The BC Cancer Agency Vancouver References Centre has prepared chemotherapy pre-printed 1. Robert T. Dorr, PhD. Personal communication. Professor of orders, which can be used as a guide for reference. Pharmacology, Arizona Cancer Center, Tucson, Arizona;11 An index to the orders can be obtained by Fax-back. April 2002. 2. Scuderi N, Onesti M. Antitumor agents: extravasation, management, and surgical treatment. Ann Plast Surg PATIENT EDUCATION UPDATE 1994;32(1):39-44. LHRH Agonists The patient information handouts 3. American Society of Health-System Pharmacists. for Buserelin, Goserelin and Leuprolide have been Hyaluronidase Injection—Product Unavailable. 3 April 2002. Available from revised to reflect the current formulation of these http://www.ashp.org/shortage/hyaluronidase.html#ref. products. Accessed 5 April, 2002. ZD 1839 (Iressa®) A new patient information FOCUS ON THE SEQUENCE OF ADMINISTRATION handout is now available. OF RITUXIMAB AND CHOP Rituximab plus CHOP (LYCHOP-R) protocol is indicated in the treatment of previously untreated British Columbia Cancer Agency ♦ Provincial Systemic Therapy Program Update ♦ Vol. 5 No. 8 2002 3 advanced stage diffuse large B-cell lymphoma, autocrine/paracrine loop and results in down-regulation of Bcl- using cyclophosphamide, doxorubicin, vincristine, 2 and sensitization to cytotoxic drugs. Cancer Res 2001;61(13):5137-44. prednisone (CHOP) and rituximab. Based on the 6. Ghetie MA, Bright H, Vitetta ES. Homodimers but not preliminary report from the Groupe d'Etude des monomers of Rituxan (chimeric anti-CD20) induce apoptosis in Lymphomes de l'Adulte (GELA),1 the protocol was human B-lymphoma cells and synergize with a initially implemented in March 2001 and allowed chemotherapeutic agent and an immunotoxin. Blood either CHOP or rituximab to be given first, as long 2001;97(5):1392-8. as they were within 72 hours of each other. With more details available after the full report Nancy Coady was published in January 2002,2 the protocol was Pharmacy CON Educator revised in February 2002 to specify that CHOP Vancouver Island Centre should be given on Day 1 and rituximab on Day 1 or 2 whenever possible, but no later than 72 hours Reviewed by Joseph Connors, after CHOP. This change was made to reflect the Chair, Lymphoma Tumour Group current knowledge on the concurrent use of these BCCA drugs, as published by the GELA group.2 Until additional information about the sequencing CANCER DRUG MANUAL of the drugs in CHOP-R becomes available it is Interferon alpha monograph for healthcare important that we mimic the original administration professionals has been revised to reflect the current procedure and timing as closely as possible when pharmaceutical and dosing information of Intron A®. using this potentially curative chemotherapy. An The Cancer Drug Manual is available on the BC Cancer additional advantage of this sequence in Agency website www.bccancer.bc.ca/cdm/. administration is the beneficial effect of prednisone on the infusion-related adverse events common with PROVINCIAL SYSTEMIC THERAPY the first dose of rituximab. The protocol was PROGRAM POLICIES revised to reflect this benefit, specifying that the prednisone dose for that day should be taken on the Policy on Extravasation of Chemotherapy morning of the rituximab infusion. Finally, there The BC Cancer Agency Systemic Therapy Policy are emerging in vitro data that suggest that on the Prevention and Management of rituximab may sensitize lymphoma cells to Extravasation of Chemotherapy (Policy III-20) has cytotoxic agents, although the clinical significance been revised to reflect the following changes: of these findings and their implications for drug change in the preferred route of administration sequencing and timing are yet to be established.3-6 of vinblastine (see Drug Update section