Chemotherapy dose reduction protocols

[WifeampMum]

Hi all

This is a query for the wonderful PCUK nurses but I thought I'd post it here in case the answer is of wider interest.

As I mentioned on another thread today, my husband is on a regime of 6 months of Gemcitabine and it has been lowering his neutrophils and platelets. They were around 0.8 (neutrophils) and 75 (platelets) on day 14 of the first 3 cycles. The protocol that his oncologist has been following says that if the numbers are under 1 (neutrophils) or under 100 (platelets) treatment should be halted until the numbers rise. This has resulted in him missing Day 15 of the first 2 cycles.

We had a second opinion yesterday at another London hospital (different NHS Trust). It turns out that they use a different protocol and had my hubby been treated there he wouldn't have missed any day 15 treatments though the dosage would have been reduced.

It's set me wondering how the adoption of chemo protocols works in the NHS.

Please can a PCUK nurse explain?

Many thanks

W&M

[PCUK Nurse Chris]

Hi W&M,

Thank you for your post asking about hospital protocols on when to give chemotherapy. We are always glad to try to answer any queries that are forum users have.

In this circumstance it is difficult for us to comment on why individual NHS hospital trusts have variations in their guidance on when and when not to give chemotherapy.

I have forwarded your question onto some of the eminent clinicians that our charity works closely with to provide some clarity on this topic.

I hope that the replies will enlighten us all on how the difficult decisions on when and when not to give treatment are decided and how the protocols are formulated that help with these decisions.

Once I have more information on this topic I will post further updates

Kindest regards

Chris

Pancreatic cancer Nurse specialist

Support team

Pancreatic Cancer UK

[WifeampMum]

Thanks Chris, much appreciated. W&M

[Didge]

I know that with Rob there was a MDT meeting discussion on which chemo to use and differences of opinion. We were also told that chemo plans and dosage us an art not a science so I can only assume that there are many variations on what different teams think is best.

[WifeampMum]

Hi Didge,

I'm sure you are right but curiously, the published guidelines on dose reduction from the drug manufacturer match the protocol of our second opinion. I don't understand why one hospital follows what the drug manufacturer recommends and another doesn't.

In my husband's case this translated to having 2 treatments unnecessarily withheld, which is a rather discomforting thought.

[WifeampMum]

Although I'd still appreciate an answer to my query at the top of this thread, I thought I'd post an update on our experience.

My husband had an oncology clinic yesterday and his oncologist has now put him on the ESPAC4 protocol for Gemcitabine which means that he'll get the same protocol as is given at our second opinion hospital. We're very pleased about this 'though it's a shame that it didn't happen at the start of his treatment as it would have saved him missing two lots.

W&M

[PCUK Nurse Jeni]

Thanks W&M.

I think Chris was emailing this to a few clinicians - I can ask him if he has had any updates.

Kind regards,

Jeni.

Pancreatic Cancer Specialist Nurse,

Support Team.

[PCUK Nurse Chris]

Hello W and M and fellow forum users,

Sorry for the delay in getting a response to this post. I wanted to approach some clinicians to gauge their opinion on this topic.

In answer to your question I think this topic can be a little confusing and can be open to interpretation by different clinicians. Some practitioners would follow the policy of the second hospital and this is the policy adopted from many of the clinical trials using gemcitabine in pancreatic cancer. Looking at the summary of product characteristics (SPC) for gemcitabine it is also what is recommended in pancreatic cancer. However SPC’s can be confusing and may leave some room for individual judgement on prescribing.

The issue of dose delays and omissions with gemcitabine is a major one. Safety and prevention of toxicity when providing chemotherapy is very important but there may sometimes be over cautiousness exercised by clinicians. It is a delicate balancing act erring between optimising treatments and preventing harm to the patient. However patients would be entitled to ask the treating hospital why they are omitting treatments on the basis of blood results when the SPC suggests there should just be a dose reduction.

With regards to the adoption of chemotherapy protocols in the NHS this appears to be an open ended question with no blue print as yet for standardisation. Most protocols are those derived from clinical research studies that are then adapted depending on new data and the SPC of individual agents. Protocols should be fairly standard across the country but interpretation of dose modifications, delays and omissions will often come down to the judgement of the individual clinician prescribing the therapy.

I hope this goes in some way to answering your question and thank you for raising this topic for discussion.

Best regards

Chris

Pancreatic cancer nurse specialist

Support Team

Pancreatic Cancer UK

[WifeampMum]

Many thanks Chris for your helpful answer. I think in our oncologist's case she just made a mistake (it happens!) which has now been corrected.

I'm very interested in the point about the over-cautiousness practised by some clinicians which has reminded me of something I read recently. It put forward the idea that the clinician should be aware, from discussions with the patient, of how aggressively they want to be treated. I got the impression from the article that this doesn't happen enough at the moment, which is a pity.

KInd regards

W&M