Low-dose chemotherapy - 1259572

Hi watu, I hope you're feeling alright.

I'm all for less drug. I'll ask one of the doctors to comment.

I am not aware of any data indicating the lowering the dose of gemcitabine for lung cancer improves outcome. There have been a variety of studies in pancreatic cancer looking at different durations of infusions, but it's not clear even there that there were any advantages to the alternative regimens.

Formally, the dose indication in the US is 1250mg/m2 days 1 and 8 of a 3 week regimen. I, and many US oncologists do prefer a dose of 1000mg/m2, again on days 1 and 8. But I don't reduce the dose because I believe that efficacy will be higher; I reduce it because 1250mg/m2 is hard for most patients to tolerate.

I just wanted to say that I agree completely with Dr. Weiss. I know of no high quality data to support increased efficacy with lower dose gemcitabine. I also give a lower dose than the FDA-approved one in the clear majority of patients, but that's because the 1250 mg/m2 dose is infeasible for administering on the intended schedule in the real world.

-Dr. West

Dr. Weiss and Dr. West -- do you use Gemcitabine often as 2nd line therapy for elderly patients ? (my mom is 79 and performance # approx. 2.5) Taxol would prob. have the best efficacy, the would most likely be much too harsh for my mother, and she would definitely loose her hair, correct ?

I thought I had read somewhere where a study showed that a 1000 mg dose didn't show very good results, but a little higher dose would.

What is it that patients can;t tolerate if the dose would be 1250 mg ? the blood counts issues ?

I would say that there are not significant differences in side effects overall among the agents that would be more commonly given as a single agent. Gemcitabine is certainly as drug that is often well tolerated, and it's uncommon to lose hair (even then, it's usually more thinning than significant hair loss). However, the response rate is low, under 5%, and there is no survival benefit -- and the question of dose hasn't been studied well enough to say that a higher dose will provide a significant survival benefit. Higher dose is definitely associated with a higher risk of low blood counts complicating attempts to treat on a regular schedule.

The only agents that have a proven survival benefit in patients who have received prior chemotherapy are Taxotere (docetaxel), Alimta (pemetrexed), and Tarceva (erlotinib). Though you could use gemcitabine as second line therapy, I don't favor it over the agents that have a proven benefit. Knowing that we have no evidence of it significantly improving outcomes in patients who have received prior chemotherapy, I generally recommend it as a later line of treatment only in patients who have had good responses to several lines of prior chemotherapy and still have a good performance status -- such patients are the ones most likely to have an unusually favorable result from gemcitabine.

Good luck.

-Dr. West

Dr .. I was diagnosed last May with Adenocarcinoma Non Small Cell stage 2A.
Due to involvement of a lymph node. Wedge resection and lymph nodes removed. I had 4 rounds of Amilta ? And Cisplatin. I had local recurrence after the chemo in lymph nodes in mid chest. No other areas . That was only app 9 months after original diagnosis. I will now have 6 wks radiation daily and 4 rounds. Possible Dr said 6 rounds.The chemo Taxol/ carboplatin low dose .. Is low dose chemo less like to help the radiation work rastherbthanbs regular dose ? ZI have asked your advice before and it us so appreciated...Thank you all for all the help...you give everyone... and thanks for any replies. M. M

Sorry my question to try above is the medications etc pretty standard for local reinsurance re stage 2A..I have heard success rates are good. Which I am happy about though. Thank you. M M

HI Merilee,

Low dose is pretty standard with radiation. There really isn't a standard of care for recurrent curative treatment but your plan sounds typical of what oncologists do that's been curative. Chemo doses are very often lessened for radiation because radiation can cause the chemo to be more potent and have worrying side effects. Original diagnosed curitive treatment with low dose chemo and concurrent standard rounds of radiation very often have curitive results, better so than full doses done separately.
The research show 4 rounds of chemo are as effective as 6 but many oncs give 6 rounds if the person can withstand is and many can. So it's kind of like a little more might get that last cancer cell but there really isn't any proof and many oncs feel it's not worth the side effects. These decisions come in the realm of more art than science.

I look forward to hearing lots of good news and few to no bumps in the road :)
Janine

Exposure to high level of radiation can cause serious health problems while the low dose rate radiation have been shown to have less side effects than the normal one. There are many studies that show low dose is some degree a protective effect against the other causes of cancer.