Nausea and Vomiting after Chemotherapy for Breast Cancer: New ASCO Guidelines on Prevention

Nausea and vomiting are perhaps the most unpleasant potential side effects of chemotherapy for breast cancer. Last week the American Society of Clinical Oncology (ASCO) updated its practice guidelines for the prevention of nausea and vomiting. Today, we'll highlight the latest recommendations.

Links to the new guidelines published in the Journal of Clinical Oncology, a DoctorsChannel.com video about the update and a Los Angeles Times story on the start of preventative medication may be found on the Aloxi (palonosetron) page of our website.

Adriamycin/Cytoxan and Ellence/Cytoxan combinations have a high risk

The ASCO guidelines classify chemotherapy drugs and combinations according to the likelihood that they may cause nausea and vomiting. Individually, Adriamycin (doxorubicin), Ellence (epirubicin) and lower dose Cytoxan (cyclophosphamide) are considered to have a moderate risk of causing nausea and vomiting. Under the new guidelines, the Adriamycin/Cytoxan and Ellence/Cytoxan combinations are considered to have a high risk, meaning they are very likely to cause nausea and vomiting.

Three drug combination for chemotherapy with a high risk

For chemotherapy drugs with a high risk of causing nausea and vomiting, such as the combinations above, Platinol (cisplatin) and high dose Cytoxan, the guidelines recommend a three drug combination:

EMEND (aprepitant) or EMEND for Injection (fosaprepitant) . Because EMEND for Injection is administered for 1 day rather than 3, it may be preferable.

plus

Aloxi (palonosetron). If Aloxi is not available, Kytril (granisetron) or Zofran (odansetron) may be substituted.

plus

dexamthasone.

Two drug combination for chemotherapy with a moderate risk

For chemotherapy with a moderate risk of causing nausea and vomiting, such as Camptosar (irinotecan), Paraplatin (carboplatin) or Adriamycin, Ellence or low dose Cytoxan alone, the ASCO recommends a two drug combination of dexamethasone plus Aloxi. The report notes that there is "moderate evidence" suggesting that EMEND may add benefit.

One drug for chemotherapy with a low risk

For chemotherapy with a low risk of causing nausea and vomiting, such as Taxotere (docetaxel), 5-FU (fluorouracil), Gemzar (Gemcitabine), methotrexate, Torisel (temsirolimus) and Ixempra (ixabepilone), the ASCO recommends a single dose of dexamethasone.

According to an October 3 article in the Los Angeles Times, it's not unusual to start taking medication to prevent nausea before the start of chemo.

A September 26 What to Know guide from ASCO provides a patient-friendly summary of the ASCO guidelines, including a classification of chemotherapy drugs by risk of nausea and vomiting.

At LATESTBreastCancer.com, we'll continue to follow research on the prevention of nausea and vomiting related to chemotherapy for breast cancer. Any new developments will be added to the treatment pages of our website and highlighted here. Please stay tuned.

Breast Cancer News (8/8): Aloxi for nausea

Nausea and vomiting are perhaps the most unpleasant potential side-effects of chemotherapy to treat breast cancer. This year, several studies have shown Aloxi (palonosetron) to be effective in the prevention of chemotherapy-induced nausea and vomiting for breast cancer patients. All of the studies discussed today may be found on the Aloxi page of the LATESTBreastCancer.com website.

Single dose of Aloxi plus dexamethasone for moderately emetogenic chemotherapy

A May 2011 study in the Italian journal Tumori examined the effectiveness of Aloxi to control nausea and vomiting associated with moderately emetogenic chemotherapy, meaning chemotherapy with a moderate risk of vomiting. A single IV administration of Aloxi (.25 mg) plus dexamethasone (8 mg) before the administration of chemotherapy adequately controlled nausea and vomiting "during the entire period of emetic risk."

Aloxi plus dexamethasone for repeated cycles of Platinol, AC or EC chemotherapy

An August 2011 Japanese phase III study in Supportive Care in Cancer tested Aloxi with repeated cycles of Platinol (highly emetogenic), Adriamycin/Cytoxan (AC) and Ellence/Cytoxan (EC) chemotherapy combinations. Aloxi (.75 mg) was administered 30 minutes prior to chemotherapy. Dexamethasone was administered on days 1 through 3. The authors found an "extraordinary safety profile and maintenance of efficacy . . . throughout repeated chemotherapy cycles."

Two studies show Aloxi to be superior to other, similar drugs

Biologically, Aloxi is a 5-hydroxytryptamine receptor antagonist (5-HT(3) RA). It blocks the action of seratonin at 5-HT(3) receptors in the central nervous system and gastrointestinal tract. Other 5-HT(3) RAs are available for the supression of nausea and vomiting. Two recent studies found Aloxi to be superior to other 5-HT(3) RAs.

A May study in Supportive Care in Cancer compared Aloxi to other 5-HT(3) RAs in breast cancer patients treated with Cytoxan based chemotherapy and lung cancer patients on Paraplatin (carboplatin) or Platinol (cisplatin). The patients on Aloxi had a "significantly lower risk" of nausea and vomiting associated with hospital admission compared to those treated with other 5-HT(3) RAs.

Similarly, a June 2011 study in Expert Reviews of Pharmacoeconomics & Outcomes Research compared different 5-HT RAs in combination with aprepitant/fosaprepitant and dexamethasone for highly emetogenic chemotherapy. Patients on Aloxi had a lower risk of uncontrolled nausea and vomiting events than patients on other 5-HT(3) RAs.

At LATESTBreastCancer.com, we'll continue to add the latest news and research on medications to treat side effects to our database and website. Please stay tuned.

The Breast Cancer News Daily Update: May 6

It's Friday. Today we'll cover the morning breast cancer news and highlight the noteworthy abstracts from medical research publications we added to our database this week.

First the news.

This morning, The Telegraph (UK) reported that tamoxifen only reduces risk of breast cancer in about half of the women who take it for breast cancer prevention.

The screening mammography discussion continued today with a Reuters story about the impact of the US Preventative Services Task force recommendation against mammograms for women in their 40s on minority women. According to the report, "minority women are more likely to develop breast cancer in their forties than white women."

In prognostic testing, Irish and American researchers compared the OncotypeDX test to the PAM50 test. According to the story in Medical News Today, the tests predicted similar risk for those with high and low risk. For those with intermediate risk, the PAM50 identified more patients who would not benefit from chemotherapy.

Also in prognostic testing, French researchers reported that baseline circulating tumor cell (CTC) counts are prognostic at baseline for metastatic patients, and that CTC changes during treatment, "may be an early indicator of chemotherapy efficiency."

This week, we added a few interesting abstracts from breast cancer research medical publications to our database.

Researchers in Chicago reviewed hospital and emergency room admission records to see which 5-HT(3) RA class drugs for chemotherapy-related nausea and vomiting were most effective. They concluded that breast cancer patients on cyclophosphamide-based chemotherapy had "a significantly lower risk" of hospital-related nausea and vomiting if they started and continued taking palonosetron (brand name Aloxi).

The Annals of Plastic Surgery published a study that found "nearly 1 in 5" healthy breasts removed during a contralateral prophylactic mastectomy contained a malignant or pre-malignant lesion. Risk factors for finding a malignancy in a healthy breast included "a lobular histology in the original specimen" and patient age over 54.

In the UK, a study in The British Journal of Cancer found clinical benefit in continuing trastuzumab (brand name Herceptin) beyond disease progression in patients with locally advanced or metastatic HER2 positive disease.

Please check back Sunday evening for a recap of the weekend breast cancer news. As always, at LATESTBreastCancer.com we welcome any and all feedback. We want to know what interests you most.