1Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, UK; 2Cancer Research Campaign Department, University of Glasgow, and Beatson Oncology Centre, Glasgow, UK; 3University Hospital Gasthuisberg, Leuven, Belgium; 4MD Anderson Cancer Center, Houston, TX, USA; 5Istituto Nazionale Tumori, Milan, Italy; 6Department of Medical Oncology, Royal Prince Alfred Hospital, Camperdown, Australia; 7Department DOncologie Medicale, Center Claudius Regaud, Toulouse, France; 8F. Hoffmann-La Roche Ltd, Basel, Switzerland; 9Russian Research Center, Moscow, Russia; 10Medizinische Universitätsklinik, Knappschaftskrankenhaus, Bochum, Germany; 11Department of Oncology, Box Hill Hospital, Melbourne, Australia; 12Ottawa Regional Cancer Center, Ottawa, Canada; 13Developmental Therapeutics and Gastroenterology Oncology, Lombardi Cancer Center, Washington, DC, USA; 14Servicio de Oncologia, Hospital Gregorio Marañón, Madrid, Spain; 15Oncologia Medica, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy; 16Department of Gastroenterology, Hospital Ambroise Pare, Boulogne, France; 17Biological Sciences Division, University of Chicago, Chicago, IL, USA
Received 2 May 2001; revised 26 September 2001; accepted 10 October 2001.
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Abstract |
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To evaluate the safety profile of capecitabine using data from a large, well-characterized population of patients with metastatic colorectal cancer treated in two phase III studies. In these trials, capecitabine achieved significantly superior response rates, equivalent time to disease progression and equivalent survival compared with 5-fluorouracil (5-FU)/leucovorin.
Patients and methods
Patients (n = 1207) were randomized to either oral capecitabine (1250 mg/m2 twice daily, on days 114 every 21 days) or intravenous (i.v.) bolus 5-FU/leucovorin (Mayo Clinic regimen).
Results
Capecitabine demonstrated a safety profile superior to that of 5-FU/leucovorin, with a significantly lower incidence of diarrhea, stomatitis, nausea, alopecia and grade 3 or 4 neutropenia leading to significantly fewer neutropenic fever/sepsis cases and fewer hospitalizations. All patients in the capecitabine group received a starting dose of 1250 mg/m2 twice daily and the majority (66%) did not require dose modification for adverse events. In the 5-FU/leucovorin group, 58% of patients did not require dose reduction for toxicities. The capecitabine dose-modification scheme reduced the recurrence of key toxicities without compromising efficacy. In both treatment arms, patients with moderate renal impairment at baseline (estimated creatinine clearance 3050 ml/min) experienced a higher incidence of grade 3 or 4 toxicities. This increase was more pronounced with 5-FU/leucovorin.
Conclusions
Capecitabine is at least as effective, better tolerated and more convenient than i.v. 5-FU/leucovorin as treatment for patients with metastatic colorectal cancer. Analysis of data from two large phase III trials demonstrates that efficacy is not compromised in patients requiring a dose reduction for adverse events. The phase III data and an additional pharmacokinetic study support a lower starting dose in patients with moderate renal impairment at baseline (calculated creatinine clearance 3050 ml/min) and a contra-indication in patients with severely impaired creatinine clearance at baseline (<30 ml/min). For patients with normal or mildly impaired renal function at baseline, the standard starting dose is well tolerated. The incidence and severity of adverse events in patients with moderate renal impairment at baseline who were treated with 5-FU/leucovorin was more pronounced, indicating that capecitabine provides a better-tolerated alternative.
Key words: capecitabine, colorectal cancer, fluoropyrimidine, tolerability
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Introduction |
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Capecitabine has been investigated extensively in clinical trials. Capecitabine monotherapy is an established treatment option for patients with anthracycline- and taxane-pretreated metastatic breast cancer [4, 5] and is active in patients with metastatic colorectal cancer [68]. Two large, phase III trials have demonstrated that as first-line therapy for metastatic colorectal cancer, capecitabine achieves significantly superior response rates, equivalent time to disease progression and equivalent survival compared with 5-FU/leucovorin [7, 8]. A prospectively planned, integrated analysis of the efficacy and safety data from these trials was conducted to obtain information on a large patient population (>1200). The results of the integrated analysis confirmed the results of the individual trials [9].
All phase II/III capecitabine trials have included a scheme for dose modification, including both treatment interruption and dose reduction, in the event of toxicities classified as grade 2 or higher [according to National Cancer Institute of Canada Common Toxicity Criteria (NCIC CTC)] [4]. The goal of treatment interruption and dose modification is to prevent development of more severe toxicities and to avoid the recurrence of toxicities, while maintaining efficacy at an individually adjusted dose level.
The integrated analysis of the two phase III trials in metastatic colorectal cancer has provided an opportunity to retrospectively assess the impact of the capecitabine dose-modification scheme in a large, well-characterized population of patients with metastatic colorectal cancer. This paper reviews in detail the safety profile of capecitabine, and compares the incidence and timing of dose modification and its impact on safety and efficacy in patients treated with capecitabine or 5-FU/leucovorin. The impact of moderate or severe renal impairment at baseline, defined using the Cockcroft and Gault formula [10], is also compared in the two treatment groups. In addition, the impact of age on the safety profile of capecitabine is assessed and capecitabine dosing recommendations are provided.
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Patients and methods |
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Assessment of safety
The population for safety assessment included all patients who received at least one dose of study medication. Toxicities were assessed and recorded at every visit and graded (grade 14) according to NCIC CTC (version 1.0). Handfoot syndrome was graded 13 [4]. Grade 1 was defined as numbness, dysesthesia/paresthesia, tingling, painless swelling or erythema not disrupting normal activities; grade 2 was defined as painful erythema with swelling or disruption of daily activities; and grade 3 was defined as moist desquamation, ulceration, blistering, severe pain or any symptoms leading to inability to perform daily activities.
Assessment of the impact of the dose-modification scheme
The capecitabine dose-modification scheme was applied if patients experienced grade 24 toxicities (Table 1). In the 5-FU/leucovorin treatment group, the dose of leucovorin was not modified and the dose of 5-FU was escalated or reduced depending upon the occurrence and severity of toxicities in the preceding treatment cycle (Table 2). Dose modification was not required for toxicities that were considered unlikely to become serious or life-threatening (e.g. alopecia or altered taste) or for anemia, as this could be effectively managed with red blood cell transfusions.
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Pharmacokinetic study
A population pharmacokinetic study was performed in patients receiving capecitabine. Blood samples were taken during study weeks 4 and 10, within 0.51.5 h, 1.53.0 h and 35 h after drug administration. Patients who vomited within 2 h of ingesting capecitabine were excluded from the pharmacokinetic analysis. Patients were also excluded if blood samples were unavailable or if the time of drug administration or blood sampling was unclear or improperly documented. The pharmacokinetics of capecitabine and its key metabolites 5'-deoxy-5-fluorouridine (5'-DFUR), 5-FU and -fluoro-ß-alanine (FBAL) were compared in retrospectively defined patient subgroups.
Impact of renal impairment and age on safety
The effect of renal function and age at baseline on the safety profile of capecitabine was also evaluated in the safety population. The incidences of grade 3 or 4 adverse events were retrospectively analyzed in patient subpopulations grouped by age and baseline creatinine clearance. Creatinine clearance was calculated according to the formula of Cockroft and Gault [10], based on sex, age, unadjusted body weight and serum creatinine concentration: for females, creatinine clearance (ml/min) = [(140-age) x weight (kg) x 0.85]/[72 x serum creatinine (mg/dl)] or [(140-age) x weight (kg) x 0.85]/[0.81 x serum creatinine (µmol/l)]. For males, creatinine clearance (ml/min) = [(140-age) x weight (kg)]/[72 x serum creatinine (mg/dl)] or [(140-age) x weight (kg)]/[0.81 x serum creatinine (µmol/l)].
Renal function was classified as normal (>80 ml/min), mildly impaired (5180 ml/min), moderately impaired (3050 ml/min) or severely impaired (<30 ml/min).
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Results |
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The demographic and baseline characteristics of patients in the two groups were well balanced in terms of median age [64 years (range 2386) in the capecitabine group and 63 years (range 2487) in the 5-FU/leucovorin group], Karnofsky Performance status (median of 90% in both groups), and proportion of patients who had received prior adjuvant treatment (23% and 25% for capecitabine and 5-FU/leucovorin, respectively). The predominant metastatic sites were liver (72% and 73% of patients, respectively) and lung (12% and 14% of patients, respectively).
Safety profile
Table 3 shows the distribution of treatment-related adverse events occurring in >5% of patients in either of the two treatment arms. Diarrhea, stomatitis, neutropenia leading to medical intervention, nausea and alopecia occurred significantly more frequently in the 5-FU/leucovorin arm (P <0.001), while handfoot syndrome occurred more frequently in the capecitabine arm (P <0.001). The majority of treatment-related adverse events in both treatment arms were graded as mild to moderate in intensity. Grade 3 adverse events were more common in the capecitabine group than the 5-FU/leucovorin group (38.1% compared with 34.1%, respectively; P = 0.16), due primarily to grade 3 handfoot syndrome. However, grade 4 adverse events were more common with 5-FU/leucovorin (3.0% and 5.1%, respectively; P = 0.078), due primarily to neutropenia-related complications and diarrhea. The most frequent grade 3 or 4 treatment-related adverse events in patients receiving 5-FU/leucovorin were diarrhea (grade 3, 10.3%; grade 4, 1.9%) and stomatitis (grade 3, 14.2%; grade 4, 0.5%). In patients receiving capecitabine, handfoot syndrome (grade 3, 17.1%; grade 4, not applicable) and diarrhea (grade 3, 11.6%; grade 4, 1.5%) were the most commonly occurring grade 3 or 4 treatment-related adverse events (Figure 1). The incidence of grade 3 or 4 treatment-related adverse events during the first treatment cycle was significantly higher in patients receiving 5-FU/leucovorin than in those receiving capecitabine (22.6% compared with 9.1%, respectively; P <0.001).
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Dose modification and its impact on safety
The median duration of treatment was 4.5 months (range 0.016.6 months) in the capecitabine group and 4.6 months (range 0.111.9 months) in the 5-FU/leucovorin arm. Fewer patients in the capecitabine group required dose modification for adverse events than in the 5-FU/leucovorin group (33.9% compared with 42.2%; P = 0.0037) (Table 5). In addition, dose modifications for toxicities occurred later in the capecitabine group than in the 5-FU/leucovorin group. The median time to first-level dose reduction (reduction to 75% of the baseline capecitabine dose or 7080% of baseline 5-FU dose) was 2.5 months in the capecitabine group compared with 1.2 months in the 5-FU/leucovorin group. The median time to second-level dose reduction (reduction to 50% of the baseline capecitabine dose or 4964% of baseline 5-FU/leucovorin dose) was 3.6 months in the capecitabine group and 3.2 months in the 5-FU/leucovorin group. The baseline demographic characteristics of the patients requiring capecitabine dose modification were similar to those of patients not requiring dose modification for adverse events.
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The adverse events most commonly leading to treatment interruption or dose reduction were handfoot syndrome (182 patients) and diarrhea (96 patients) in the capecitabine group, and stomatitis (135 patients) and diarrhea (91 patients) in the 5-FU/leucovorin group. The capecitabine dose-modification scheme was effective in managing the three key adverse events characteristics of infused fluoropyrimidines (diarrhea, handfoot syndrome and stomatitis). Following dose reduction for diarrhea (89 patients), 14 patients experienced further grade 2 and seven patients experienced further grade 3 or 4 diarrhea (Figure 2A). Following dose reduction for handfoot syndrome (138 patients), 25 patients experienced a grade 2 recurrence and 20 patients experienced a grade 3 recurrence (Figure 2B). None of the patients receiving capecitabine ex-perienced grade 4 stomatitis; following dose modification for grade 2 or 3 stomatitis (30 patients), there was no further grade 3 stomatitis and six patients (20%) experienced a grade 2 recurrence (Figure 2C).
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Hospitalizations and treatment withdrawals
Hospitalizations for treatment-related adverse events were significantly less common in patients treated with capecitabine compared with 5-FU/leucovorin (11.6% compared with 18.0%, respectively; P <0.005). Overall, there were 76 hospitalizations for treatment-related adverse events in the capecitabine group compared with 113 hospitalizations for treatment-related adverse events with 5-FU/leucovorin. Hospitalization for stomatitis (one case compared with 21 cases) and neutropenic fever/sepsis (one case compared with 17 cases) was significantly less common in patients receiving capecitabine (Figure 3). In the capecitabine group, only two patients required hospitalization for handfoot syndrome, for <24 h in one patient and <8 h in the other.
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Impact of baseline renal function on safety
The distribution of patients with renal impairment at baseline, calculated according to the formula of Cockroft and Gault [10], was similar in the two treatment arms (Table 7). Since all patients had a baseline serum creatinine value <1.5 x upper normal limit, in accordance with the study inclusion criteria, the principal factors contributing to impaired calculated creatinine clearance were older age, lower body weight and borderline serum creatinine. Approximately 45% of patients had normal renal function (defined as calculated creatinine clearance >80 ml/min) at baseline, a further 45% had mild renal impairment (creatinine clearance 5180 ml/min) and only 10% had moderate renal impairment (creatinine clearance 3050 ml/min). In both the capecitabine and the 5-FU/leucovorin treatment arms, the incidence of grade 3 or 4 adverse events was higher in patients with moderate renal impairment (creatinine clearance 3050 ml/min) than in those with normal renal function. Among patients receiving capecitabine, the incidence of dose reduction was 44% in those with moderate renal impairment compared with 32% and 33% in patients with mildly impaired and normal renal function, respectively (Table 7). More patients with moderate renal impairment were withdrawn from capecitabine therapy (not significant), with most withdrawals occurring in the first two treatment cycles. The principal cause of treatment withdrawal was diarrhea. In patients with mild renal impairment at baseline, capecitabine at its standard starting dose showed an acceptable tolerability profile. Dose recommendations based on creatinine clearance at baseline are presented in the Discussion.
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The objective response rate to capecitabine in the subgroup of patients with moderately impaired renal function (24%) was similar to that achieved in patients with normal or mildly impaired renal function (25% and 27%, respectively) (Table 7). In contrast, response rates in patients with moderately impaired renal function receiving 5-FU/leucovorin were lower (10%) than in patients with normal or mildly impaired renal function (16% and 19%, respectively), indicating that the efficacy of 5-FU/leucovorin was reduced in patients with moderate renal impairment.
Impact of age on the safety profile of capecitabine
The data from the retrospective analysis indicated that in patients with moderately impaired creatinine clearance at baseline there was an increased risk of toxicity. Since one of the most important factors influencing creatinine clearance is age, a further subpopulation analysis was conducted, grouping patients in 5-year age categories. The safety results for capecitabine according to age are shown in Table 8. There was an increased incidence of grade 3 or 4 adverse events, particularly gastrointestinal toxicities, in patients aged 80 years or older receiving capecitabine, whereas differences were modest in the younger age categories. Since age and renal function are strongly correlated, Cox regression analyses were performed to further investigate the relationship between age, baseline creatinine clearance and the safety profile of capecitabine. A univariate Cox regression analysis demonstrated that both age (P = 0.04) and creatinine clearance (P = 0.05) have a statistically significant impact on the safety profile of capecitabine. However, a multivariate Cox regression analysis adjusting for creatinine clearance showed that age does not have an additional, statistically significant, independent im-pact (P = 0.72) on the safety profile of capecitabine. This analysis indicates that the less favorable safety profile of capecitabine in older patients is due primarily to age-related impairment of renal function.
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Discussion |
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Capecitabine at its recommended dose of 1250 mg/m2 twice daily on days 114 followed by a 7-day rest period was well tolerated and the majority of patients (66%) did not require dose modification. Furthermore, the lower incidence and later onset of adverse events requiring dose modification with capecitabine indicate that patients receiving capecitabine who experience disease progression early in the treatment period are more likely to be spared unnecessary toxicity than patients receiving 5-FU/leucovorin.
In patients requiring dose modification, the full dose of capecitabine was administered for a median of 11 weeks before the first dose modification. In contrast, there was a significantly higher incidence of dose modification in the 5-FU/leucovorin group, and patients requiring dose modification received a median of only 5 weeks of therapy at the full dose of 5-FU/leucovorin. As capecitabine is an oral agent, the dose can be titrated at the first appearance of a moderate toxicity, thus reducing the likelihood of development of more serious toxicities. Furthermore, the twice-daily dosing schedule provides numerous opportunities per cycle to interrupt therapy or reduce the dose after administration of the first dose. Analyses of the integrated data from the phase III trials in colorectal cancer have confirmed that the capecitabine dose-modification scheme is a key component of the treatment regimen, and was effective in preventing the recurrence of severe toxicities during the treatment period.
Most importantly, the efficacy of capecitabine was maintained in patients requiring dose modification. All patients started treatment at the full standard starting dose and, where needed, doses were adjusted to the individuals tolerable dose. There was no increase in the risk of disease progression or death in capecitabine-treated patients requiring dose modification for adverse events compared with those who did not require dose modification. However, the risk of disease progression following dose reduction in the 5-FU/leucovorin group was increased by 12%, and by 30% in patients requiring a second-level dose reduction (not statistically significant).
In a retrospectively conducted subpopulation analysis of the safety data according to calculated creatinine clearance, the safety profile in the subpopulation of patients with moderate renal impairment at baseline was quantitatively different from that seen in patients with normal renal function. There were more adverse events, particularly during the early stages of treatment, leading to more dose reductions. This effect was seen in both treatment arms.
The results of the subpopulation safety analysis suggested that in patients with moderately impaired renal function, a reduced starting dose may be prudent. Consequently, data from an additional pharmacokinetic trial of capecitabine in patients with solid tumors were analyzed to identify the most appropriate starting dose of capecitabine for these patients [11]. This study included patients with normal renal function and patients with mild, moderate or severe renal impairment. Unlike the phase III clinical trials, serum creatinine >1.5 x upper normal limit at baseline did not preclude inclusion in the study. The results indicated that baseline creatinine clearance had no effect on the pharmacokinetics of intact drug and 5-FU. However, moderate impairment of creatinine clearance in-creased the AUC of the key metabolite 5'-DFUR, the immediate precursor to 5-FU, by 35% compared with the subgroup of patients with normal renal function. This increase in systemic exposure to 5'-DFUR may explain the increased incidence of clinically relevant adverse events in patients with moderate renal impairment at baselines because 5'-DFUR plasma concentrations reflect the tissue exposure to 5-FU most closely. These pharmacokinetic findings, together with the safety analysis of the clinical database, support the recommendation that in patients with moderate renal impairment, the starting dose should be reduced to 75% of the standard starting dose, thus aiming for similar systemic exposure in patients with moderate renal impairment as in patients with normal renal function receiving the standard starting dose. Furthermore, data from the pharmacokinetic study showed that in patients with severe renal impairment, the toxicity profile of capecitabine was even more pronounced. This led to a contra-indication for capecitabine in patients with severe renal impairment at baseline. However, there was no evidence of direct nephrotoxicity with capecitabine.
It is important to note that patients with moderate renal impairment currently do not have a safer treatment option than capecitabine, as in the present study 5-FU/leucovorin resulted in an increase in toxicity of a similar or higher magnitude. There was a higher incidence of grade 3 or 4 treatment-related adverse events, and the incidence of stomatitis was almost doubled in patients with moderate renal impairment who received 5-FU/leucovorin. More than half of the patients with moderate renal impairment required 5-FU dose reduction. Furthermore, efficacy was substantially reduced in these patients. In contrast, response rates to capecitabine were similar in subgroups of patients with moderately impaired, mildly impaired or normal renal function. It is likely that, as with capecitabine and 5-FU/leucovorin, other oral fluoropyrimidines will show more pronounced toxicities in patients with moderate renal impairment. The increased exposure to 5-FU in patients with moderate renal impairment treated with eniluracil, and the associated increase in toxicity, led to the initiation of a number of trials investigating lower starting doses of eniluracil in patients with moderate renal impairment [12]. Patients with severe renal impairment may be ineligible for treatment with other oral fluoropyrimidines.
In patients with mild renal impairment at baseline, the safety profile was similar to that observed in patients with normal renal function. Therefore in these patients capecitabine treatment should be initiated at the standard dose (1250 mg/m2 twice daily). Careful monitoring is advised, with prompt treatment interruption and dose reduction in the event of a grade 2 or higher toxicity, as detailed in the standard capecitabine dose-modification scheme.
Creatinine clearance and age are highly correlated, and therefore the safety data from the phase III colorectal cancer trials were analyzed according to 5-year age intervals. The safety profile of capecitabine was found to be notably poorer in patients aged over 80 years, with a higher incidence of grade 3 or 4 gastrointestinal events. However, a multivariate Cox regression analysis demonstrated that age did not have an additional, statistically significant impact on the safety profile of capecitabine over and above creatinine clearance. It was concluded, therefore, that the decreased tolerability of capecitabine in older patients was caused primarily by an age-related decline in renal function, as evident from calculated creatinine clearance, whereas serum creatinine was still within normal limits.
Another pharmacokinetic study showed that in patients with mild to moderate hepatic dysfunction at baseline due to liver metastases, both the AUC0 and Cmax of capecitabine were increased by 50% compared with values for patients with normal hepatic function [13]. However, there were no significant differences in the pharmacokinetic parameters of the main capecitabine metabolites (5'-DFUR, 5-FU and FBAL) between the patient groups. It was concluded, therefore, that there is no need for a priori adjustment of the dose in patients with mild to moderate hepatic dysfunction, although caution should be exercised when administering capecitabine to these patients.
Capecitabine has a number of features that potentially contribute to its favorable safety profile. Its unique mechanism of activation results in the generation of 5-FU preferentially in tumor tissue, minimizing systemic exposure to 5-FU [3]. In addition the chemical structure of capecitabine prevents direct release of 5-FU into the gastrointestinal tract. The data from the phase III trials in patients with colorectal cancer confirm that the standard starting dose of capecitabine (1250 mg/m2 twice daily, days 114 followed by a 7-day rest period) is well tolerated by the majority of patients. Based on these data and analysis of the pharmacokinetic trial in patients with impaired renal function at baseline, a lower starting dose (950 mg/m2 twice daily, days 114 followed by a 7-day rest period) is recommended for patients with moderate renal impairment (baseline creatinine clearance 3050 ml/min, calculated according to the formula of Cockroft and Gault [10]).
Patient education is essential for anyone receiving cytotoxic chemotherapy in an outpatient setting. Patients receiving capecitabine should be educated to recognize side-effects and their severity. It is important that patients interrupt treatment upon the development of a moderate or more severe toxicity, and, if necessary, contact their physician or nurse for further advice. Patients should be reassured that efficacy will not be compromised if treatment is interrupted or modified, since patients may otherwise be reluctant to report adverse events and risk treatment interruption. This is partly because of a fear that efficacy may be reduced if treatment is interrupted or the dose is reduced. Patient follow-up procedures can help to ensure optimal management of adverse events, particularly in patients receiving capecitabine for the first time.
Capecitabine is a convenient, effective and well-tolerated agent for the treatment of patients with breast and colorectal cancer. For these indications, capecitabine provides a valuable outpatient treatment option. These analyses have shown that the current capecitabine dose-modification scheme is effective in the management of adverse events. Future trials will investigate the impact of capecitabine dose reduction to 75% of the baseline dose at the first occurrence of a grade 2 toxicity, which may further improve the safety profile of capecitabine.
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Footnotes |
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References |
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