Taxotere, Carboplatin and Herceptin
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Omaz - so glad you mentioned it, I actually researched this (during my lovely early morning waking hours! LOL!) and found someone locally who looks really promising. I called him but he is out of town until tomorrow. This is high on my priority list. I need to ask my onc today for his ok, but I imagine he will be open to it. I have high hopes!!! Especially after hearing it worked for you!!! I'm also hoping he can work on my GI issues in general, and then throw in a couple sticks for my ringing ears. Why not try it all. At this point I'm open to anything and would love to not be stuffing all these meds into my body.
I've been taking my anti-nausea meds on schedule, especially since the heartburt arose (I had been trying to wean from them.) I'm wondering...should I still be needing the Zofran this far out? (Day 7 post) I will ask my onc this morning, but curious how long the rest of you took your anti-nausea meds post treatment.
BTW, just checked my temp...still running 99 F. I was surprised since I actually have a lot more energy compared to the weekend.
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DT - I was given Kytril pills for home use post chemo and took them every day for the first 10 days. I was minorly queasy all of those 10 days so I can't imagine how I would have felt without them.
I was given a scholarship at my cancer center for 12 acupunture sessions and 8 massage therapy sessions - I am starting next week. Hoping the acupunture gives some relief!
Also - I ran the 99 ish temp for the first 10 days as well.
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Thanks Relda!!!
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dance - my nausea lasted a long time, at least 10 days.0
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Thanks Omaz...sounds like Relda...very good to know! I thought perhaps I was overdoing the Zofran.
Here's a new question...how many of you developed lots of acne? I've got a ton all over my chin (I rarely ever break out). Do I just continue with my regular skin care...or is something else about to progress worse with this that I don't know about??? Ounce of prevention....
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dance - you may need to move on to another anti-nausea med also - I found that Zofran did not work for me. I switched to Compazine and took it for about 72 hours, around the clock. If you need something that is timed-release you may want to ask for a patch (Sancuso) which I think has worked well for some others. Something to consider when you get through all of this - not that you would be looking for another surgery - but I did have reflux surgery in '95. I did not have heartburn as a symptom at that time, I had chest pain and nausea all the time. I also had 8 cases of aspiration pneumonia in 5 years. None of the reflux meds controlled me and surgery was the last, but ultimately best, resort. I did not have any problems throughout chemo until the final couple of tx and OTC Zantac was enough to handle it.
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DanceT I control with diet as well as the Nutra flora in my yogurt daily and a daily acidophilus supplement. But I know my triggers are anything with animal fat. I eat very little red meat because of it. I stick to lower fat cheeses (sharp Cheddar will set things off but goat cheese won't). I never did drink coffee. I gave up soda before chemo because I found out I was osteopenic. I really think all that diet soda I used to drink caused. I feel like I can still eat tomato products but if I'm having an issue I need to stay away from that. I also find large portions will bloat me. Veggies can bloat me too but as long as it's not a big meal I'm not in any discomfort. Most important is reduce the stress.
If I want to feel pain all I have to do is eat a couple of pieces of bacon
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Dance - I got acne with my first 2 treatments, mostly around my mouth. Those deep painful ones that never came to a head. My onc said he had seen it before. I started washing my face twice a day. I added a 'clean and clear' product, something a little stronger, maybe a benzoyl. But I don't know if it helped at all. Thank goodness for cover-up foundation!
The rest of my treatments it subsided and I think my skin looked better than ever.
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Oh gosh, I just typed a long thing and lost it!!! Grrr....
Onc visit update: WBC definitely low. Result = 2 "low critical" with normal being 4.1 to 10.9. Plan is to wait and watch, be very cautious careful/isolate myself, etc. We could do Neulasta, etc., but we decided we want to watch the counts and see if they go lower/higher, etc. This will help us determine if my dosage was too high for my body...and if so, we can lower the chemo dose...yay! We could do prophylactic antibiotics, but again, decided not to, b/c it could worsen the big D or even scarier could cause C-diff. So I will be laying low and pretending I'm on a cruise ship with the Norovirus. I have lots of practice with that, LOL.
We will retest my counts on Thursday and proceed from there.
Was prescribed Protonix instead of prescrip Prilosec, doc says it is better. Also, he changed my mouthwash to the full "magic" type - Nystatin, Maalox, Lidocaine, Benadryl. I'm to swallow it, and it will also help with the reflux symptoms. I am also to start a probiotic since I can't stomach yogurt right now.
I feel good about our plan, think it is the right way to go...but I will admit...I'm scared about the next few days.
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Special K - I've considered that surgery...but even though I think I have reflux bad...wow, you trumped me big time. 8 cases of aspiration pnuemonia? Wow girl. So glad to hear the surgery worked for you. I'm keeping it as a possibility someday in my back pocket...uhhh...especially since learning about the bone loss from Lago!
Wendy thanks for the feedback on the acne. Doc said just to wash with a mild soap. I just don't want to do anything to make it worse.
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Dance - That's interesting. Maybe that is a new approach, to see if the dose is too much for the body based on WBC responess. I haven't read that before. For my onc neulasta wasn't a choice, I had to have it.0
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DT - I had a bad facial breakout after my first TX. I was horrified - it was tremendously upsetting. I was told by a friend to get Cetaphil and wash and dry VERY GENTLY. (I had been using harsh strong stuff and scrubbing.) I did that and it went away
I did call the onc very upset and insisted on an RX for my skin. But by the time I did that, it was turning the corner and I never did use it.And it never happened on any subsequent treatments, just the first one.
And - as a side bonus, chemo kills the top layer of skin cells (or something like that) and the result is like you had a facial. I have heard from many bc women that their skin is much improved after chemo, and mine certainly is. Fresher, smoother, dare I say younger looking? I sound like a commercial. LOL
So no scrubbing. GENTLE wash and PAT DRY.
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Dance...My WBC's dropped to just a point or two above being neutropenic after my 1st tx. I didn't do neulasta until my 2nd tx. It is GREAT, GREAT, GREAT that your MO is so proactive and that you are not afraid to call him/her with every symptom/concern!!!
Thanks for all of the info on the swelling. I guess I was concerned because it happened almost 3 weeks after treatment. I will let them know on Thursday...as it has went down a lot today. I was up going to the bathroom 4-5 times last night, so that is a good thing!!!
I had my first reflexology appointment today...oh it was so nice!!!! I didn't tell her anything (she did know that I had BC) but she hit on a few spots (kidneys, bladder, lymphatic system, adrenals, and my poor back) that were all spot on!!! I also had my last physical therapy appointment for my very mild LE!!! YAY!!!! Another chapter has closed!!!!
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Both my onc and MD Anderson said the national guidelines do not call for Neulasta prophylactically with TCH, b/c the risk of febrile neutropenia is not high enough. They only do it if an episode occurs. I questioned MD Anderson on it, and they said: "We don't use standard neulasta because it increases toxicities and there is not data that states that it is indicated unless a patient develops fever and neutropenia." I looked up the incidence of febrile neutropenia with TCH in the BCIR6 trials: 9.8%. NCCN has guidelines that describe chemo regimens by risk level:
low risk is < 10% febrile neutropenia - no growth factors advised
intermediate is 10 to 20% chance - consider growth factors based on treatment intention and balance of benefits vs. harm
high risk is > 20% - definitely do growth factors
I did read somewhere about dose modifications being made if your ANC goes to low...but I don't recall the details. I'm sure I'll be browsing this; will share if I find it again.
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Amy...uh-oh...I use a facial scrub (didn't notice the big breakout until today). Perhaps I antagonized it! Thank you for the Cetaphil tip...will have DH pick it up when he gets my scripts at CVS tonight! I will baby baby baby it from here on out...thank you...and hey...how long does the nice young (wow!) skin last, huh, huh???
Dougie's wife - do you know if your onc modified your dosage? Or did he just keep the same dose and do the Neulasta? I do LOVE my onc and his entire staff. They are so, so caring, he spends tons of time with me, talks to me in technical language b/c he knows I have a medical background...never ever talks down to me. Oh, I just love that guy!
Oh and Dougie'swife...be sure to ask them if it could be related to Herceptin/possible heart issue...I don't want to freak you out as it is most likely the Tax, but if you get heart damage from the Herceptin, it can't pump and hard and thus you end up with swelling in your legs. I just want to make sure all bases are covered for you! Congrats on finishing the PT and jealous about the reflexology!!!
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dancetrancer you might ask them about this:
"What is the Additional Important Safety Information associated with Herceptin?
Worsening of Low White Blood Cell Counts Due to ChemotherapyWorsening of low white blood cell counts to serious and life-threatening levels and associated fever were higher in patients taking Herceptin in combination with chemotherapy when compared with those who received chemotherapy alone..."
Also on the site "Low white and red blood cell counts" is one of the items listed under "What Are the Most Common Side Effects Associated with Herceptin?" source linky
My white counts were great all through chemo (had nuelasta all 6 times). 7 months later, while still doing Herceptin my PCP had me do a blood test for a rash I developed. He said my white counts were a little low but that was to be expected due to treatment.
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Nope, they never modified my dose. I just had my MUGA scan next week. They didn't call, so I'm assuming all is well. You should totally find a reflexologist!!! OMG...I had the BEST (TMI) poop ever!!!! After 5 months of either constipation or the big D, I actually went like a normal person!!! I have always had bathroom issues so this was SOOOO nice!!!! I have to laugh at myself over the things I get excited about now!!! LOL!!!
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Oh yes Lago, I know Herceptin lowers the count further. It's scary, isn't it? I think they just go by the hard numbers from the BCIR6 trial. Only 9.8% of the patients getting TCH developed febrile neutropenia. Not just neutropenia, but neutropenia with a high fever. They follow the data. Can't say I'm happy or unhappy about it, but if that is what MD Anderson said, I had to put faith in it. I definitely questioned it, but they were firm in their stance.
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dougieswife, I am CRACKING up!!! We need a poop train!!!
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LOL....The "Love Train" song just popped in my head!!!! (changing the words to "poop train" of course!!!!
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dance - in BCIRG006 it says "Hematopoietic growth factors were used at the discretion of treating physicians." so some must have gotten it.
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Interesting! I didn't look for that - good eye Omaz. I don't know where they get their stats from then (I thought it was from the trial). I just know they said it is not recommended per NCCN guidelines for TCH unless you have an incidence of febrile neutropenia and/or other risk factors.
Regarding the dose modification, I think I may have misunderstood my doc, the more I think about it. I'm going on only 3 hours of sleep, so I will need to re-discuss this with him Thursday!
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Hello! You guys won't believe it, but I'm feeling well. How about that? My reflux is completely controlled. I have no Big D. My thrush is completely gone (but continuing with the mouthwash). I am apparently trending towards the Big C (minimal activity on that front), but have started probiotics so hopeful this will prevent a worsening of my symptoms.
Soooo....if I hadn't had my bloodwork done yesterday, I'd have no clue that I have Grade 4 neutropenia! I figured out my ANC - absolute neutrophil count - (after re-listening to my meeting with my onc yesterday - thank goodness for taping it!). It is only 500. ANC < 500 is severe neutropenia, Grade IV. I'm freaking out about developing febrile neutropenia...but...knock on wood...fever still 99 F and under. I am following a neutropenic diet and extensive handwashing practices and have hermitized myself to the house.
And my onc did talk about potentially modifying my dose based upon what my numbers are tomorrow. I'm really questioning the dose modification, based up hearing what you guys had to say and reading stuff about using GSF factors to build WBC and prevent dose modifications...but I have been reading to try and find out if maybe there is more to the story???
So...it's been hard to find info, but I did find a study done using TC (no Herceptin) in ovarian cancer patients at the Cleveland Clinic. However, it was published in 2001. I know it's not breast cancer and doesn't include Herceptin, but I think you draw info from it about practice patterns, at least what they were in 2001...I think? It talked about GSF's and dose modification (T started at 60 mg/m2, C at 6 AUC). It's interesting b/c they did not use GSF's prophylactically (even though a high percent ended up with Gr IV neutropenia!) and then they didn't use them for subsequent treatments either (unless they actually developed actual neutropenic fever)...instead they modified the dose for those who had Gr IV neutropenia without fever. I was really surprised and stunned to read all of this. I'm not sure if I agree or not...I thought the whole point of GSF's was to prevent treatment delays and dose reductions due to severe neutropenia. I'm going to discuss this fully with my onc and also ask him to consult with MD Anderson to see what their protocol for dose modification vs GSF's is once you have had Gr IV neutropenia without fever. Comments?
I will attach a link to the full study (I haven't read past the part I'm posting - FYI!):
Treatment Plan
The initial chemotherapy doses were carboplatin, area under the
concentration-versus-time curve (AUC) of 6, and docetaxel, 60 mg/m2.
The carboplatin was infused over 30 minutes and the docetaxel, over 1
hour. Treatment was repeated every 21 days, assuming recovery from
toxicity of the previous cycle. A maximum of six cycles of therapy
were planned in patients responding to treatment or with no measurable
or nonmeasurable but assessable disease at the initiation of the
treatment program.
Standard antiemetics and hydration for carboplatin were employed.
Dexamethasone, 8 mg orally, was delivered twice a day, beginning 24
hours before chemotherapy and continuing for a total of five doses.15Bone marrow colony-stimulating agents were not routinely employed
in this trial but were permitted as clinically indicated in the
presence of neutropenic fever or sepsis. Patients were administered
prophylactic oral ciprofloxacin in the presence of grade 4 neutropenia
(without fever) if it was anticipated that the duration of neutropenia
would exceed 3 to 5 days.16 With subsequent courses, dose reductions
(see below), rather than prophylactic bone marrow colony-stimulating
factors, were employed as a strategy to prevent the recurrence of grade
4 neutropenia.Treatment Modifications
Treatment was to be delayed 1 week if the baseline laboratory
parameters had not been achieved at the time of scheduled retreatment.
If delay was required, subsequent therapy was to be delivered at a
reduced dose level (level 21; see below).
For patients experiencing any of the following toxicities, the dose of
therapy was also reduced one dose level (level 21). If a similar degree
of toxicity was experienced with any subsequent courses, the dose was
to be reduced by a second dose level (level 22).Toxicity Requiring Dose Modifications
The following indications of toxicity led to dose modification: (a)
nadir platelet count less than 60,000/mm3 , (b) nadir neutrophil count
less than 500/mm3, (c) nadir neutrophil count less than 1,000/mm3 and
with fever, or (d) any nonhematologic toxicity more than grade 2
(excluding emesis, anemia, and alopecia). Toxicity was graded on a
scale of 1 to 4 according to the National Cancer Institute Common
Toxicity Criteria.Treatment Dose Levels
Dose levels were as follows for carboplatin and docetaxel, respectively.
Initial dose level, AUC 6 and 60 mg/m2; level 21, AUC 5 and
50 mg/m2; level 22, AUC 4 and 40 mg/m2.0 -
dance - what neutropenic diet are you following? Not much can be done to increase WBC with diet. I wonder why so many of us receiving TCH had prophy Neulasta if the guidelines don't endorse it. Maybe our oncs have seen enough of what you are currently experiencing to just prescribe the drug regardless of the guidelines. I know at my center there were a few patients for whom Neulasta did not kick in and increase their counts and they were put on prophy antibiotics, and did the crowd avoidance/handwashing/etc.
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Oh, it's just to prevent infecting myself. All veggies cooked, eggs fully cooked, no cheeses like blue cheese, etc. It's not to build my WBC, I know I can't do anything for that (although I am trying to make sure I get enough protein, as that contributes to a lower immunity, from what I read.) Here's one that I'm using for some guidelines: http://www.library.umc.edu/pe-db/Neutropenic-Diet.pdf
The American Cancer society also has nutritional guidelines. http://www.cancer.org/acs/groups/cid/documents/webcontent/002903-pdf.pdf
I think you may be right about the docs not wanting to see their patients go through what I am going through/put them at that risk. I can't help but wonder if the incidence of febrile neutropenia with TCH is underreported...and that the NCCN guidelines are not based on enough accurate data regarding TCH risk...it's hard for me to believe NCCN and MD Anderson could be wrong? But gosh I'm really questioning whatever data they are looking at! I do know the risk of leukemia is raised with the use of GSF's...so that's what they mean by the risks of GSF and why they wish to avoid them unless indicated. But what if their data about incidence of febrile neutropenia with TCH is wrong??? Things that make you go hmmmmm....
And yes, I will be put on antibiotics I believe, if my counts aren't up by tomorrow. Looks like they do that if you levels are < 500 for 3 to 5 days.
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dance - I think it is entirely possible that the neutropenia accompanying TCH is underreported, but also possible that it is underreported because oncs are doing prophy Neulasta - one of those chicken and egg things! You are wise to cook the veggies and avoid food that may cause problems, and hopefully antibiotics will keep you safe, if needed. I am glad you are feeling better, this may be the pattern you follow - a bad week, followed by a couple of decent ones - you are doing 4tx?
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danceT I had read about that diet. Basically almost everything had to be cooked… no raw food. Even spiced I believe have to be cooked. No adding them after the cooking process.0
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I didn't get the neulasta shot after my first tx. It was only after my blood work came back at just a few point above being neutropenic did I get one with the next 5 tx's. I was told no raw foods (like sushi!!!) and to wash veggies and stuff really well. And hand sanitizer/good hand washing for everything.
I am actually very surprised that I didn't get sick (cold/flu/etc) with having a 6 yr. old in kindergarten. He actually didn't get sick at all this year like he normally does....with the exception of the day after my 1st tx he got a stomach bug that was going around the school.
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Special K, I totally agree with you!!! MD Anderson recommended 6 tx...but, they said if I end up only tolerating 3 or 4 that is better than nothing...so I'm running with that...already have it in my head I'm stopping at 4. LOL I think they just can't recommend anything that doesn't have a study behind it - and all the studies for TCH are X 6 (she said there are none for X 4). I'm reading between the lines (and thinking of taking the easier way out, esp since my tumor was so tiny).
I will tell you that this incidence has scared me so much that DH and I are thinking of stopping and going straight to Herceptin NOW. I'm not jumping to that conclusion just yet...but we have been discussing it. It makes you start to think about risk of dying from chemo vs risk of dying from cancer coming back...I can handle bad side effects (even though i complain a lot)...but fear of death...ahhhhhhhhhhhhh!!!!!!!! Neutropenic fever risk and death, honestly, is flipping me out.
Course you all know by now how I flip out and then eventually calm down. LOL So take it all with a grain of salt. We'll see how I'm feeling about all of this as the story unfolds...
Dougieswife - very interesting! thanks for sharing! I can't believe you didn't get sick...thank goodness your 6 year old stayed healthy for the most part. You are SO lucky you didn't get that bug!
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Wow, DT, you are on the scenic route too! I don't blame you for rethinking the whole thing. But at least you are thinking, rather than just reacting . You will do what is right for you. Hang in there. My onc give nuelasta automatically. Probably, because they saw too much nuetopenia. Hope you get better fast. Taking antibiotics won't help the D train!
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