(Not so) special delivery

[Rich66]

More and more...despite the fascination with new molecules and synergies, there seems to be a lot to be said (and done) regarding delivery considerations.


Anyone asking their oncs about pre-med steroids undermining chemo (http://her2support.org/vbulletin/showthread.php?t=41877)?



Anyone talking about opiate alternatives or using Relistor (methylnaltrexone) (http://her2support.org/vbulletin/showthread.php?t=42074)in addition?


Anyone ever had their chemo discussed in terms of time of delivery? (i.e. chronotherapy) (http://her2support.org/vbulletin/showthread.php?t=41606)?


Anyone considering revisting a "failed" chemo via metronomic delivery (http://her2support.org/vbulletin/showthread.php?t=24729) or reversal strategies?


Considering the wide-ranging responses to therapies, I have to wonder how much is due to variations in delivery and use of "supportive" drugs that hamper efficacy. This might even play into the "we're not mice" issue. Delivery to mice in labs is precisely controlled. We, in contrast, arrange our delivery according to available time slots and convenience..not having an inkling it might matter, taking deleterious prophylactics that have benign alternatives. Some of this information has been out for years and yet the machine grinds on obliviously.
Sorry folks..say it like I see it. And I don't thing NCCN or SABC '09 is gonna "go there". Maybe those able to go there can bring these issues with them. Not that I'm not a fan of promising research. Just realizing the dire need to maximize, avoid undermining and avoid premature abandonment of tools that are within reach now. I'm thinking especially about people in this forum on the precipice as you read this. Are they really out of options? Maybe revisiting previous therapies in a different manner can pull them back off the ledge.
At a community level, I would appreciate acknowledgement, repudiation or support of these issues. This may seem like a negative rant but there are some very positive possibilities at the core.

[Rich66]

Heya folks..love to hear some thoughts.

[Carolyns]

Hi Rich,

I hope that you are doing well. I can say the Xeloda worked well for me for the longest period of time and that was pill form. But I haven't discussed these topcis with my doctor.

Pre-meds of steroids... only did that one time so I did not bring it up.

Opiate - so far I don't take pain pills.

TDM1 trial only allows for a dosing schedule of one time per three weeks.

I think that this is all very interesting but I know that right now a great deal of my doctor's resources are spent fighting insurance companies. We have so many Stage IV girls and it is getting tougher and tougher to get meds approved.

[schoolteacher]

Rich,

Thanks for this list of options. I have been wondering about the time of day when I take my Tomaxifen. I usually take it around 5 in the morning.

Amelia

[Rich66]

Speaking of insurance companies, it just occurred to me that bean counting insurance companies might be interested in delivery methods that don't undermine expensive drugs. A few different people here seem to have decided to skip steroids because of the way they made them feel. No reports of projectile vomiting..and they may have received the chemo without interference. How much does an insurance company get charged for pre-emptive IV Decadron? Would an insurance company prefer chemo was scheduled at the time of day most likely to work? Maybe oral equivalents in a metronomic/chrono-optimized fashion could save some $$.
Many ways to look at this.

Carolyn,
What was your Xeloda schedule? I have seen studies with colorectal cancer patients that showed biasing the dosage toward the evening is benficial. I suspect it's not specific to that cancer and more related to circadian issues. You may be able to benefit from it again if delivered metronomically with less "break".

In case folks feel I am splitting hairs on chronotherapy, consider (20+ year chrono-researcher) Hrushesky's human studies in Ovarian cancer where Doxorubicin was delivered in morning, Cisplatin at night. The second arm simply reversed the schedule. 5 year survival was 44% and 11% respectively.
Now there was a 33% who really drew the short straw. They probably should have stopped the trial early.

And toxicities are significantly reduced when drugs are given in an informed schedule. How much does it cost to transport, evaluate and hospitalize someone for febrile neutropenia and whatever else might come with that? Hey...bean counters are all ears at this point. I feel a powerpoint coming on. If I could just come up with a companion pie chart with hard data on avoided human suffering. Eh.

I have not found anything on chronotherapy of Tamoxifen or other anti-estrogens. But my uneducated hunch is that the endocrine system and relation to cancer is significantly circadian. It might be naive to think that because it's a daily pill that it doesn't matter when it's given. That's not what Xeloda suggests. Is there an endocrinoncologist in the house?

[Carolyns]

Hi Rich,

I took Xeloda in the morning w/ Tykerb and at night alone - twice per day. Two weeks on and one week of. We were going to move to one week on and one week off but I progressed before we could try that.

Thanks, Carolyn

[Rich66]

I'm hoping SABC attendees print the links (thread tools/print view) above and talk to some oncs. I honestly would go myself if it was remotely possible.

[Rich66]

Heya. Just imagining the hubbub at SABC about delivery issues. 'bout time...

[Rich66]

Ok..my tongue was firmly in cheek. But really..anyone walk upto an unsuspecting onc eating a chili dog and ask what they think about combining metronomic delivery with chronotherapy so as to reduce toxicity, increase effectiveness and avoid potentially harmful opiates and steroid premeds? (better know the Heimlich maneuver)

[Laurel]

Haven't been around in the past 2 weeks or so. At a convention and working hard. Loved this thread though! I think the steroids will be passe' soon enough, Rich, as the word spreads. If I were doing chemo presently, I would try a go without those nasty green pills. I hated decadron and it's effects!

Keep sounding the charge, Rich!

[Rich66]

Dunno..feel like I'm talking into the wall on these things.

[weety]

On the steroid pre-med situation--so fabulous that we have one more thing to worry about. I don't know what to think except too late now!

As for metronomic therapy--that's what I had with my TCH. My regimen looked like this:
Week 1: 1/2 taxotere, full carboplatin, herceptin
Week 2: 1/2 taxotere, herceptin
Week 3: herceptin only
(So TCH, then TH, then H only)
I was worried at times that this might have been inferior. Sounds like it was good to do it this way, though???

Edited to add: My onc seemed to think this was better for quite a few reasons. One was for fewer/less extreme side effects. She also seemed to think cancer cells were less likely to form resistence/protective mechanisms to a more constant flow of drugs. I can't remember the other reasons, but she really was all for it. I didn't question her much about it at the time.