A quarter of a century ago, the aim of cancer care was simply to cure the patient with little concern about the side effects of the treatment. But better understanding of the causes of side effects and development of better drugs to counteract chemotherapys side effects have helped lessen the adverse reactions to treatment.
Nausea and vomiting, the major side effect of cancer treatment, is frequently absent as new drugs are added to chemotherapy regimens. At the recent International Congress on Anti-Cancer Treatments in Paris, Richard Gralla, M.D., director of clinical research at the Columbia University-New York Hospital, noted during a session on lung cancer that "there were many different regimens presented here today, and 85% to 90% of them had little or no nausea. I think weve come a long way."
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But nausea and vomiting, so greatly dreaded by patients, is only one of a wide array of side effects for which remedies are being explored by researchers in this country and elsewhere.
In one of the most unusual approaches, the University of Texas M. D. Anderson Cancer Center, Houston, which has the largest outpatient clinic for cancer treatment in the world, has set up a collaboration between oncologists and specialists in internal medicine, headed by Robert Gagel, M.D., specifically to find ways around the side effects of cancer treatment.
Gagel said that strategies include not only dealing with immediate side effects, such as nausea and vomiting, but also with side effects that come up over the long term.
"I think [this] is an indication that cancer therapy is more successful now than it was even 10 to 15 years ago," Gagel said. "I think a lot of interesting things will be coming out in the next few years to get at some of these more subtle side effects of cancer and its therapy."
Fatigue
At the meeting, which was co-sponsored by M. D. Anderson and Hopital Pitie Salpetriere in Paris, a special session on the treatment of fatigue in cancer patients indicated that hemoglobin levels should probably be higher than previously thought to combat fatigue.
"From the patients perspective, I think we ought to do everything we can to maintain the hemoglobin at 12 g/dL, whereas we only used to worry when it fell to 8 or 9," said Jeffrey Crawford M.D., professor of medicine and director of clinical research at the Duke University Comprehensive Cancer Center, Durham, N.C.
He said blood transfusions can be used to raise the hemoglobin level, but it commonly falls back down again. The use of recombinant erythropoietin alfa, however, can keep the hemoglobin at a steadier level. It also probably would only be needed for two to four months. "Were not talking about a lifetime of [erythropoietin]," he said.
Infection
Strides also have been made to counter infection, another major side effect of immunosuppressive cancer treatment. Kenneth Rolston, M.D., head of the division of infectious diseases at M. D. Anderson, said that over the last 10 years the center has treated more than a thousand patients with febrile neutropenia out of the hospital to spare them the dangers of hospital-acquired infections.
"About 30% to 40% of our patients who come in with fever and neutropenia end up being treated as outpatients," Rolston said.
He said patients with solid tumors like breast cancer or sarcomas can often be treated briefly in the hospital, and then at home, or even entirely as outpatients. Frequently they can go home if they live within 30 miles, have a caretaker at home, and have a phone and transportation available.
A most important requirement in all cases, of course, is compliance. So far, so good, Rolston said. "Successful treatment in the low-risk febrile neutropenia setting has been 98% to 99%," he said. "I think every cancer center should take a look at this for low-risk patients." He added that outpatient care may not be appropriate for high-risk patients such as those with leukemia undergoing chemotherapy or for bone marrow transplant patients.
To prevent infections in those with central venous catheters, some hospitals are using new antibiotic-impregnated catheters, which were developed by Issam Raad, M.D., head of the section of infection control, and by Rabih Darouiche, M.D., of the Baylor College of Medicine.
Cardiomyopathy
There also are new strategies to deal with cardiomyopathy, a side effect of doxorubicin and other anthracyclines. Harry Gibbs, M.D., chief of the section of cardiology at M. D. Anderson, said that cardiomyopathy is more of a danger because now patients are living longer and coming in with second cancers after having been treated with an anthracycline for their first, or perhaps having had radiation therapy to the chest, which is another cardiomyopathy risk factor.
However, two approaches are being used to deal with the risk, he said. The first, started some years ago, is to give a drug like doxorubicin over 3 to 5 days, rather than as a bolus, or over 3 to 5 hours, as used to be done.
The other approach is to use the free radical oxygen scavenger drug dexrazoxane, which has been about equally as effective. In a study under way, both approaches will be used in the same patient to see if this toxic side effect, once as frequent as 10%, can be reduced even further than the present level, estimated to be 2% or less.
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