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290
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 11, 2015. For personal use only. No other uses without permission. . All rights
Campto® effective and flexible chemotherapy for advanced colorectal cancer
always be discussed with the individual. symptom control, performance status and
The continuing assessment of treatment- quality of life (Scheithauer et al, 1993).
related side effects and correct manage- From 2000 new chemotherapy agents used
ment is essential in determining the after, or in combination with, 5-FU have
acceptability of palliative chemotherapy. been introduced, giving oncologists and
Poor performance status (World Health individuals more scope to personalize
Organization (WHO) grade 3 or 4, Table treatment regimens.
1) low serum albumin, high alkaline phos- Massacesi et al (2002) have published
phatase and liver involvement are indepen- outcomes from an observational study that
dent predictors of progression. Low serum looked at predictors of 5-FU failure. With
albumin, high glutamyl transferase and this data oncologists are better able to pro-
high carcino-embryonic antigen are predic- file patients that may have a predisposition
tors for poor survival. Patients with these to 5-FU failure and thus consider alterna-
markers are less likely to benefit from tive agents or no chemotherapy at all,
chemotherapy (Fountzilas et al, 1996). depending on patient choice (Massacesi et
al, 2002).
5-fluorouracil and folinic acid Controversy exists around the world as
Up until the mid 1990s, 5-fluorouracil (5- to the optimal 5-FU regimen. This is an
FU) was the only active drug available in important issue when evaluating the results
the management of colorectal cancer. A of clinical trials conducted with various 5-
combination of 5-FU with a biochemical FU regimens as the standard arm (Cassidy,
modulator, such as folinic acid (FA), was 2001). Clinical trials conducted or led from
the standard treatment for advanced colo- the USA tend to use the bolus 5-FU regi-
rectal cancer, increasing survival by about mens. In Europe infusional regimens
3–6 months, as well as improving both (Table 2) are generally preferred and used
as standard therapy. Current evidence sug-
Table 1. World Health Organization (WHO) performance gests that 5-FU administered in an infu-
status sional form (at least 24 hours duration)
doubles response rate, increases median
WHO grade Characteristics
survival and reduces toxicity over bolus
0 Able to carry out all normal activity without restriction regimens (Meta-Analysis Group in
1 Restricted in physically strenuous activity but Cancer, 1998).
ambulatory and able to carry out light work The toxicities of infusional 5-FU with or
2 Ambulatory and capable of all self-care but unable to without FA (Table 2) are usually manage-
carry out any work; up and about more than 50% of able and both regimens are well tolerated,
waking hours with minimal disruption to functional sta-
3 Capable only of limited self-care; confined to bed or tus. Educating individuals about common
chair more than 50% of waking hours side effects and prompt management can
4 Completely disabled; cannot carry out any self-care;
reduce the grade of toxicity. Both regimens
totally confined to bed or chair require an indwelling central or peripheral
line and individuals must be made aware of
(WHO, 1979)
the limitations of living with an indwelling
line and of potential complications. These
Table 2. Infusional 5-FU regimens for the treatment of can range from clots, infection and
advanced colorectal cancer phlebitis, to the breaking of lines, which
can delay treatment. Oral 5-FU pro-drugs
Method of are now emerging that have been shown to
Regimen administration Common side effects have similar efficacy to bolus 5-FU (Hoff,
de Gramont Infused over 48 hours Mucositis, neutropenia, 2000) but without the complications asso-
(5-FU/FA) every 2 weeks nausea and vomiting, ciated with line insertion. There is much
(usually requires diarrhoea, plantar palmar debate about the optimum duration of
indwelling central or erythrodysaethesia (hand and
peripheral line) foot syndrome) and fatigue
chemotherapy. Common practice is to
vary between 12 and 24 weeks or until
disease progression.
Lokich Continuous infusion Mucositis, neutropenia,
(5-FU) (requires ambulatory nausea and vomiting,
It has been shown that in advanced dis-
pump and indwelling diarrhoea, plantar palmar ease, starting chemotherapy early, before
central or peripheral erythrodysaethesia (hand and clinical deterioration, can improve response
line) foot syndrome) and fatigue rate of treatment and overall survival by
5-FU=5-fluorouracil, FA=folinic acid (NHS Clinical Outcomes Group, 1997) 3–6 months without any adverse effect on
quality of life (Scheithauer et al, 1993).
292
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 11, 2015. For personal use only. No other uses without permission. . All rights
Campto® effective and flexible chemotherapy for advanced colorectal cancer
Acute cholinergic syndrome ● Short lasting S/C injection of atropine sulphate 0.25 mg
Defined as early diarrhoea, ● Never life threatening Subsequent injections should be administered
sweating, abdominal cramps, ● Unpleasant for the individual before each cycle
lacrimation, myositis, salivation, ● Treatable and preventable
visual disturbances, malaise ● Should not led to treatment
and decrease in blood pressure discontinuation
Occurs within 24 hours
of treatment administration
Early diarrhoea Treatment should be with atropine and not
Watery loose stools occurring Loperamide
within first 24 hours of
treatment administration
Nausea and vomiting ● Controllable with effective Pre-treatment infusion:
Can occur after each anti-emetic therapy. IV bolus granisetron 3 mg or ondansetron 8 mg
administration of treatment ● Usually administered IV IV bolus dexamethasone 8 mg
before each cycle. Day 2: Oral dexamethasone 4 mg three times daily
● Oral treatment to take home Day 3: Oral dexamethasone 4 mg twice daily
Day 4: Oral dexamethasone 4 mg once daily
Domperidone or metoclopramide as required
Delayed diarrhoea ● Usually short lived As soon as delayed diarrhoea occurs the individual
Occurring >24 hours after (12–72 hours) must take 2 loperamide capsules,
treatment administration ● Most common dose-limiting then take 2 capsules every 2 hours for 12 hours
Predictable at around 5 days toxicity of Campto treatment If diarrhoea persists patients should keep taking
after administration ● Education of patient and staff capsules every 2 hours until there has been
in the appropriate management no diarrhoea for 12 hours
can reduce severity An individual must inform the hospital
● Severe grade 3–4* diarrhoea ● if diarrhoea persists after 24 hours on
seen in 13% of individuals loperamide capsules
treated first-line ● if they have a temperature as well as diarrhoea
(combination) and in ● if they have nausea and vomiting
20% of individuals treated as well as diarrhoea
second-line (single agent) Antibiotic therapy will need to be commenced
after 24 hours of diarrhoea
If diarrhoea has not settled after 48 hours despite
medication an individual will need to be seen at
hospital to ensure they are not dehydrated or have
a bowel infection.
Patients should be given a prescription for
loperamide, and may also be given a prescription
for an oral fluoroquinolone, when they leave hospital.
Patients should be given instructions on their use
and physician contact details, and be advised
to contact their physician if they experience
prolonged diarrhoea, with or without fever
Neutropenia ● Second most dose-limiting Weekly blood counts recommended
Median day to nadir is 8 days toxicity Treatment delay if blood counts have not
● Non-cumulative recovered to local policy satisfactory values
● Febrile neutropenia in 1–2% of
patients treated first line
(combination) and in 5% treated
second line (single agent)
Alopecia ● Reversible when treatment is Education of patient as to incidence
Occurs gradually as cycles discontinued Provision of a wig if desired
continue ● Grade 1–2† occurs in 51% of
individuals treated first line
(combination) and in >90%
treated second line
(single agent)
*Grade 3 diarrhoea – increase of ≥7 stools/day or need for parental support for dehydration. Grade 4 diarrhoea – physiological consequences
requiring intensive care or haemodynamic collapse, †Grade 1 alopecia – mild hair loss. Grade 2 alopecia – pronounced hair loss, S/C=subcuta-
neous, IV=intravenous, (Adapted from Aventis Pharma, 2003)
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 11, 2015. For personal use only. No other uses without permission. . All rights
Campto® effective and flexible chemotherapy for advanced colorectal cancer
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 11, 2015. For personal use only. No other uses without permission. . All rights
Campto® effective and flexible chemotherapy for advanced colorectal cancer
‘Quality of life in overall survival and improvement in qual- informed choice and give consent.
cancer care is ity of life against the potential treatment Information on quality of life outcomes
toxicities (Simmonds, 2000). can assist in the decision-making process.
increasingly
There is evidence of significant variation
recognized as a Oncology team in the management and outcomes of col-
valuable The management of patients with colorec- orectal cancer nationally and internation-
supplement to tal cancer is multifaceted, including ally (Cancer Research Campaign, 1999).
tumour response treatment, symptom management, and Current guidelines (The Association of
and survival emotional and psychosocial support. Coloproctology of Great Britain and
The multidisciplinary team encompasses Ireland, 2001) advocate the use of
data... ’
oncologist, radiographers, chemotherapy chemotherapy in advanced and recurrent
nurse, specialist nurses, trials team, dieti- disease. Whether the decision is to treat
cians, medical social worker and rehabilita- or palliate in order to extend life in
tion team. The general management advanced or recurrent disease, quality of
recommendations given earlier for Campto life issues should be the main focus.
can also be applied to other agents (Box 1). Quality of life in cancer care is increas-
The pathway of care for an individual ingly recognized as a valuable supplement
with colorectal cancer is continually to tumour response and survival data, pro-
moving between primary, secondary and viding the individual’s perspective on
tertiary care settings, increased communi- therapies and evaluating whether small
cation and the sharing of information can gains in life span come at too high a cost.
only improve the whole package of care Taking into account the individual’s
to the individual resulting in improved assessment of quality of life during treat-
outcomes. ment might give a different perception of
With the increased used of ambulatory toxicity and efficacy than that of the clini-
chemotherapy in advanced colorectal can- cian. The nurse has a practical role in
cer, increased links have been established assessing the ongoing quality of life with
with the primary health-care team, who individual patients throughout any treat-
can be responsible for the disconnection of ment regimen during his/her nursing
infusers and the care of central and periph- assessment and is in a prime position to
eral lines. The oncology team must ensure support patients in decisions about treat-
that district nurses are kept up to date in ment continuation or discontinuation.
the management of individuals receiving
ambulatory chemotherapy and practice Future
using local guidelines, as well as providing Fluoropyrimidine-based therapies have
support and advice. been the main component of first-line
Over recent years, individuals with treatment for individuals with colorectal
advanced colorectal cancer have seen an cancer. With the current data showing sig-
increase in overall survival, with the use of nificantly prolonged survival when indi-
palliative chemotherapy and the availabil- viduals are treated with first-line Campto
ity of new agents. But that survival is, on combined with infusional 5-FU/FA, first-
average, about 18 months (Douillard et al, line Campto based regimens should be
2000), therefore, liaison with local pallia- offered as a first-line treatment in
tive care teams is advisable early on, to advanced colorectal cancer.
ensure good palliation of symptoms and Phase I and II trials are currently
psychosocial support. underway exploring the value of combin-
ing Campto with other oral 5-FU pro-
Implications for nurses drugs It may be that Campto in
In considering the cure/care dichotomy combination with 5-FU/FA, or an oral 5-
in advanced colorectal cancer emphasis FU pro-drug, in the adjuvant setting will
must be placed on individual care and opti- prove of greater use in the treatment of
mal quality of life. Families, nurses and colorectal cancer than 5-FU/FA alone.
other health-care professionals share an
interest in maximizing positive outcomes Summary
of any treatment intervention by support- In recent years new cytotoxic agents have
ing the patient in making the best decision become available for the treatment of
for their particular situation. The oncology colorectal cancer, hopefully, during the
nurse is in an ideal position to help the next few years, the use of different com-
individual obtain information about vari- binations of these agents will be seen in
ous treatment options in order to make an both the adjuvant and palliative setting,
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 11, 2015. For personal use only. No other uses without permission. . All rights