Infusional 5-fluorouracil can be a pain in the neck: A case for repositioning displaced Hickman lines

5FU continuous infusion in heavily pretreated advanced breast cancer patients

BACKGROUND

Despite advances in the first- and secondline treatment of advanced breast cancer, optimal therapy thereafter remains controversial. Treatment of heavily pretreated patients is not standardized, often of low efficacy, and limited by comorbidity. In these patients, an effective treatment with low toxicity is needed.

PATIENTS AND METHODS

We retrospectively analyzed all metastatic breast cancer patients treated with 5-fluorouracil as continuous infusion (CI-5FU) with daily doses of 150-300 mg/m(2).

RESULTS

43 patients were treated with CI-5FU until disease progression. The median number of metastatic sites was 3. Most patients were heavily pretreated with a median of 3 palliative chemotherapies (range 1-11). 42 patients were evaluable for objective response; among them 5 (12%) showed a partial response (PR) and 6 (15%) showed stable disease (SD) lasting at least 6 months, leading to a clinical benefit (CB) rate (complete response + PR + SD ≥ 6 months) of 27%. The median time to progression of patients with CB was 10 months (range 3-22). Overall survival of all patients from the start of CI-5FU was 8 months (range 1-75) and from the time of first metastases 42 months (range 9-281). Toxicity was low even in patients with hepatic insufficiency.

CONCLUSION

CI-5FU showed a positive efficacy/toxicity ratio. Taking into account the high number of previous treatments, it results in a remarkable CB rate of 27%.

Optimizing the management of HER2-negative metastatic breast cancer with capecitabine (Xeloda)

Patients with metastatic breast cancer (MBC) require chemotherapy that improves outcomes without compromising quality of life. To achieve optimal outcomes with chemotherapy, treatment choices should be influenced by patient and disease characteristics, as well as patient preferences. Capecitabine (Xeloda; F. Hoffmann-La Roche, Basel, Switzerland) combined with docetaxel achieves significantly superior response rates, time to progression, and overall survival compared with single-agent docetaxel. With a manageable safety profile, capecitabine/docetaxel is a particularly appropriate option for younger, fitter patients with rapidly progressing disease and/or visceral metastases. In addition, studies show that dosing flexibility with capecitabine/docetaxel allows management of side effects without compromising efficacy. However, for older patients and those with comorbidities or more indolent disease, single-agent capecitabine may be more appropriate. Studies show that front-line capecitabine is a highly effective and well-tolerated alternative to standard intravenous treatments. The activity of capecitabine in the first-line treatment of MBC is underpinned by its consistently high activity in MBC. As an oral agent that causes minimal alopecia and myelosuppression, capecitabine has the potential to significantly improve patient quality of life and convenience. In summary, the treatment of MBC will always need to be individualized, but a large body of evidence indicates that capecitabine, whether alone or in combination, can be offered to women early in the disease course.

Implementation of capecitabine (Xeloda®) into a cancer centre: UK experience

Switching patients from intravenous 5-FU/LV to oral capecitabine (Xeloda) for the treatment of metastatic colorectal cancer is associated with a reduction in the need for hospitalisations to manage 5-FU-associated delivery and complications, with resulting healthcare savings. However, implementing oral therapy with capecitabine within a cancer centre in the UK has required a considerable change in attitude within healthcare services. The resulting need for patients to take an active role in their treatment, and the co-ordination and monitoring of such a service at home has raised issues for chemotherapy services. To enhance patient involvement and compliance with medication a patient guide was developed to educate, and support individuals and enable them to understand the rationale for treatment and when to seek help. In addition, patients are encouraged to monitor and record symptoms in a diary. This change in service focus has required an investment in time educating and informing patients, community health workers and hospital practitioners. This change has been co-ordinated through the chemotherapy outpatient clinic. Effective communication between hospital and home has been important in implementing oral chemotherapy. While the initial challenge of monitoring and educating patients receiving capecitabine has been met, the Primary Care team and cancer centre need to continue to assess side effects and patient compliance in order to improve knowledge of capecitabine among healthcare professionals and ensure safe practice.

Chemotherapy for metastatic breast cancer-report of a European expert panel

The anthracyclines doxorubicin and epirubicin, and the taxanes paclitaxel and docetaxel, are effective chemotherapeutic agents for the first-line and second-line treatment of metastatic breast cancer, and their clinical use is widespread. However, for women whose disease has progressed despite receiving these drugs, treatment options are limited. These women often have a good performance status, and may survive for many months or even years, so they should be given the opportunity to benefit from further chemotherapy. The goals of chemotherapy in these patients are to obtain maximum control of symptoms, prevent serious complications, and increase survival without diminishing quality of life. Several agents are used for this purpose, including fluorouracil, docetaxel (in patients who have already received paclitaxel), vinorelbine, and mitomycin c, but because data from controlled trials are limited, a standard regimen has not yet been established. Moreover, these agents may be inconvenient to administer and can be associated with adverse events requiring hospitalisation. Therefore, there is a clear need for additional therapeutic options for patients with metastatic breast cancer. Ideally, agents should have a convenient method of administration, eg, oral, and should be suitable for home-based rather than hospital-based therapy. Treatment should control disease in at least 20-30% of patients with an acceptable side-effect profile. Novel oral therapies have now been developed and are being used increasingly in patients whose disease has progressed following taxane therapy.

Answering patients' needs: oral alternatives to intravenous therapy

Metastatic colorectal cancer has traditionally been treated with i.v. 5-fluorouracil (5-FU), with or without leucovorin (LV). 5-FU is administered as either an i.v. bolus or a protracted infusion. Although schedules using the latter method offer efficacy benefits (objective response rate, time to disease progression), protracted infusion schedules are often associated with medical complications, inconvenience, high costs, and poor quality of life. Issues such as quality of life and convenience have influenced treatment decisions, but the availability of oral fluoropyrimidines represents a new development in this domain. Studies have confirmed that the majority of patients prefer oral to i.v. chemotherapy. Questionnaire-based studies have also demonstrated a preference for home-based rather than hospital-/clinic-based therapy. This preference was one of the driving forces behind the development of the oral fluoropyrimidines capecitabine (Xeloda) and uracil plus tegafur (UFT). Oral agents offer patients a more convenient treatment option that can be administered at home, providing patients with a greater sense of control over their therapy, while avoiding the medical complications and psychological distress associated with venous access. This article highlights some of the problems associated with i.v. therapy and reviews the available data on patient preference, including results of a recent, randomized, phase II study. It also provides a critical evaluation of the efficacy and safety profiles of the only two oral fluoropyrimidines approved for prescription, capecitabine and UFT/LV (UFT/LV not available in Germany and the U.S.), compared with those of two infused, 5-FU-based regimens. Finally, the results of an interactive debate exploring the opinions of approximately 400 oncologists on the issues of oral versus i.v. therapy are presented.