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  1. Kezza2

    Now for Docetaxel

    Well gentlemen, The time has come. I was on abiraterone + apelutimide trial for two years until that failed, and swapped to enzalutimide (Xtandi) but that only lasted three months, and now my PSA has more than doubled from 17 to 38 in 6 weeks, so it seems that docetaxel is next on the list. Having not had docetaxel previously I am not a candidate for the Lu177 trial unfortunately, so I am scheduled to start docetaxel in two weeks. I would appreciate any words of wisdom from the wise who have already been through this on side effects and how to avoid or minimise them, and what I may expect.
  2. Safety at home for patients on chemotherapy Chemotherapy (pronounced kee-mo-ther- a-pee) is a cancer treatment that uses drugs or medicines to kill cancer cells. It is sometimes just called ‘chemo’. Patients can have chemotherapy in different ways. Intravenous (IV) chemotherapy is given into the patient’s vein, and goes straight into their blood. Oral chemotherapy is given by mouth, as tablets, capsules or liquids that the patient swallows. Bush medicine Bush medicine could cause problems for patients having cancer treatment. Your patient should check with their doctor before using bush medicine. There are important safety measures that you should take while caring for patients who are having chemotherapy. You also need to educate your patients, and their families and carers, about safety. This section explains: how to protect yourself, and your patients’ families and carers, from chemotherapy drugs how to support patients who are taking oral chemotherapy at home what equipment you may need, like gloves and spill kits. 6 Chemotherapy safety Safety information for all chemotherapy patients Chemotherapy drugs kill cancer cells but can also damage normal cells. Each time your patient has chemotherapy, it can take up to seven days for the chemotherapy drugs to leave the body. During these seven days, chemotherapy drugs can be in the patient’s body fluids or waste products, including: blood urine (wee) vomit (spew) saliva (spit) semen vaginal secretions sweat stool/faeces (poo). If you accidentally touch any of these fluids, some of the chemotherapy drug could get into your body through your skin. You, and your patient’s family and carers, need to take special care to stay safe for the first seven days after each chemotherapy treatment. The information on the next pages explains how to do this. Important Women who are pregnant or breastfeeding should not touch: chemotherapy medication body fluids (wee, vomit, etc.) of someone having chemotherapy any bedding, clothing, or cleaning cloths with the above body fluids on them. Safety at home for patients on chemotherapy 7 Educate your patient About cleaning up spills If there is a spill of any body fluids (e.g. poo, wee, spew), put on rubber gloves and use a disposable cloth to clean up the spill straight away. Place the cloth in a plastic bag and tie it closed; then place that plastic bag into another plastic bag and tie it closed— this is called ‘double-bagging’. The plastic bag can then be placed in the normal household rubbish. Towels, linen or clothing that have body fluids on them should be machine washed separately in a hot or cold wash, on the longest washing cycle. They can then be dried outside. If there is a spill of body fluids on a bench top or floor, wear rubber gloves and wash it off with lots of water and detergent. About feeling sick and vomiting • It is a good idea to keep a plastic bowl or bag (without holes in it) handy for this. • A bowl used for vomiting, should not be used for anything else. • Wash the bowl out after each use. • Throw it away at the end of the chemotherapy treatment. About going to the toilet After going to the toilet, close the lid, and flush the toilet on full flush. This is so that fluids from the toilet don’t splash out. Men should sit down when using the toilet so there is no splashing. About having sex Your patient and their partner should always wear condoms when having sex in the first seven days after chemotherapy treatment. This is because low amounts of chemotherapy drugs may be passed in the semen or vaginal secretions. 8 Chemotherapy safety Safety information for patients taking oral chemotherapy at home You may need to care for patients taking oral chemotherapy at home. The patient may have to take tablets, capsules or liquid medicine. The information below explains how to do this safely. Make sure your patient knows how to take their oral chemotherapy drugs Most patients will have a written plan, telling them when to take their tablets. It’s a good idea for you to go through this with them to make sure they have understood this information. Make sure the patient knows they must take the oral chemotherapy exactly as their doctor or pharmacist has told them to. This includes taking it on the right day, at the right time, and with or without food, as directed. Check that your patient knows how to store their oral chemotherapy drugs safely It is important that your patient: • keeps the chemotherapy drugs in their original packaging • stores any chemotherapy drugs (tablets or liquids) as the doctor or pharmacist tells them to • stores them safely away from children or animals. Safety at home for patients on chemotherapy 9 Educate your patient How to handle oral chemotherapy drugs safely Your patient: Your patient can handle the oral chemotherapy drugs because the treatment is for them. After taking the drugs, they should wash their hands before touching anything else. You, and the patient’s family or carers You, and the patient’s family or carers, should never touch chemotherapy medicine with your bare hands. This is because some of the chemotherapy drug could be absorbed into your body through your skin. Sometimes you, or someone else, will need to touch chemotherapy drugs to help the patient to take them. You should always wear a pair of rubber gloves to touch or handle chemotherapy drugs. Wash your hands after taking off the gloves. How to take oral chemotherapy drugs safely Your patient should: • take the chemotherapy exactly as directed by their doctor or pharmacist (e.g. this may be with food or on an empty stomach)—it will say on the medicine label on the bottle • swallow the chemotherapy tablets or capsules whole—never crush, cut, chew or bite tablets, and do not open capsules • wash their hands after handling the chemotherapy tablet or capsule. Note: If the patient cannot swallow the tablets, talk to the doctor straight away. 10 Chemotherapy safety Important things to know What if my patient vomits after taking the chemotherapy? If your patient vomits straight after taking a dose of oral chemotherapy, they should not take a replacement dose but contact the treatment team for further advice. If they have been given anti-sickness tablets to stop nausea and vomiting, they should take this medicine as the doctor or pharmacist has instructed, even if they do not feel sick. If they have taken the anti-sickness medication and it does not stop them from vomiting, speak with the doctor about what to do. Make a note to tell the doctor or nurse from the treatment team about any missed or vomited doses. Important What if my patient forgets to take their chemotherapy tablets? • If your patient forgets to take a chemotherapy dose, they should take the next dose at the normal time, as prescribed. • Refer to the eviQ patient information sheet that they may have been given for further information. If the patient is unsure about what to do, speak with the doctor or clinic staff on the next working day. What if my patient has finished chemotherapy treatment but has some tablets left? Leftover chemotherapy capsules or tablets should be returned to the cancer clinic or pharmacy. If your patient is having chemotherapy treatment in hospital, they may see nursing staff wearing protective equipment. This is necessary for some types of chemotherapy administration. It is nothing to be frightened of. Safety at home for patients on chemotherapy 11 Useful equipment Gloves The best gloves to use are nitrile gloves, which are made from synthetic rubber and are resistant to chemotherapy. If you or your patient don’t have nitrile gloves, you can use: two pairs of disposable gloves, or a thick pair of rubber gloves that can be bought from the supermarket. Whichever gloves you use, they should only be used for cleaning up spills (see page 8), or for handling chemotherapy medication (see page 10). Home-made spill kit If your patient does not have a spill kit provided by the hospital, it is a good idea for them to keep a kit at home to clean up spills. It should include: incontinence pad/’inco sheet’ or disposable cloths gloves plastic apron vomit bag/bowl plastic bags. Important Be careful when removing gloves. Do not touch the outside of the gloves with your bare hands. Wash your hands after removing gloves. If using re-useable gloves, these gloves should be stored separately in a sealed plastic bag and thrown away at the end of treatment. With thanks to Cancer Institute NSW under Creative Commons Attribution 4. See also: Dealing with the risk of infection while on chemotherapy with Taxotere (docetaxel):
  3. Treatment of metastatic prostate cancer has changed recently. In the past doctors would use hormone therapy (ADT) at first, then wait until the disease was very progressed before giving chemotherapy with Taxotere (Docetaxel). The reason for the change? Professor Christopher Sweeney reported on a trial he led (CHAARTED). In CHAARTED, the researchers (an international team of medical oncologists) showed that starting BOTH chemotherapy and ADT at the beginning of treatment gave men a longer life. Members of your Executive Committee were invited to be the audience for an video interview of Christopher Sweeney and his Australian colleague, Professor Gavin Marx, by Anthony Lowe, PCFA CEO. Tony Maxwell, Alan Barlee and Nev Black and I were able to attend. (Paul Hobson had to miss out because of treatment.) Click on this sentence to see all of our videos on our YouTube channel. Note that most videos are in Playlists and you will have to click on each Playlist name to see the videos. Jim
  4. The opportunity There is a chance to have your voice heard on whether the drug Xtandi (enzalutamide) should be available on the PBS BEFORE chemotherapy. Timing Submissions are due Wednesday 8 February 2017, and no late submissions will be accepted. Enzalutamide on the PBS An important drug for men with advanced prostate cancer is Xtandi, also called enzalutamide. The first evidence that enzalutamide worked looked at using enzalutamide AFTER the chemotherapy drug docetaxel. A committee of experts looked at this evidence. They recommended that it was worth spending taxpayer money on. So, now men with advanced prostate cancer can get enzalutamide on the PBS at a low price, AFTER they have had chemotherapy with docetaxel. Some new evidence has arrived showing that enzalutamide works well BEFORE chemotherapy with docetaxel. The same committee of experts is now looking at this evidence to see if it is worth spending taxpayer money to put enzalutamide on the PBS for use BEFORE chemotherapy with docetaxel. This is the second time this has come up for consideration. The first time, the expert committee rejected the application: because the submission was focused on a claim of survival advantage, which was small and uncertain, rather than on outcomes that clinicians and patients considered to be of most value. The purpose of using enzalutamide earlier in the disease pathway would be: 1) to delay symptoms from developing and maintaining a better quality of life for longer in asymptomatic patients for whom placebo, or watchful waiting, is the appropriate comparator; and 2) delaying the toxicities of chemotherapy in symptomatic patients considered suitable for docetaxel. That committee has asked for public submissions for a new application. Enzalutamide BEFORE chemotherapy The first thing you should understand that enzalutamide is not a miracle cure. About half the men on the PREVAIL clinical trial were still alive three years after they started on enzalutamide. Some of the men who responded will have a much longer survival. I have met a man whose cancer has been kept at bay for 6 years so far on enzalutamide. But survival times pre-chemo and post-chemo are not different enough to convince the experts. What is most important about this drug is the quality of life it makes possible during that two or three years. Docetaxel chemotherapy vs enzalutamide side effects The first thing you should understand is the current first treatment at this stage - docetaxel chemotherapy. Many men report coping quite well with their docetaxel, finding the temporary hair loss and other side effects manageable. But some men have a terrible experience with the side effects. It is so bad for some men that they give up the treatment. And, about one man in four hundred dies from the treatment. On the other hand, enzalutamide treatment has far fewer reported side effects. Fatigue and hypertension were the most common. So, the first benefit of starting enzalutamide BEFORE chemotherapy is that a man can delay the start of the docetaxel chemotherapy. The PREVAIL clinical trial In the PREVAIL clinical trial of enzalutamide before chemotherapy, men had to: have metastatic prostate cancer, be castrate resistant, and have no, or few symptoms (like pain). Metastatic means that their prostate cancer had spread to other parts of their body. Castrate resistant means that the primary hormone therapy, with drugs like Zoladex, Lupron, and Eligard, was no longer able to keep the cancer in check by itself. In other words their PSA was rising, despite the hormone therapy keeping testosterone very low. Men in this trial on enzalutamide did not need to start chemotherapy, on average, for more than two years - 28 months. The control group of men had to start chemotherapy after 11 months. So men on enzalutamide had 17 MORE months at a higher quality of life. After 12 months of treatment, 65% of men treated with enzalutamide had scans which showed no progression of their cancer, compared to 14% of the control group. The trial was finished early when it became clear that the enzalutamide was far more effective. At that stage, 29% fewer men had died in the enzalutamide group. The enzalutamide group also had a longer time until the first skeletal-related event (that is, problems with their bones). Most prostate cancer metastases (about 89%) occur in bones. Of the men with metastases away from their bones, complete or partial soft-tissue response favoured enzalutamide 59% to 5%. Time until PSA started going up again also favoured enzalutamide. So did the number of men whose PSA dropped to at least half - 78% to 3%. Submissions The Prostate Cancer Foundation of Australia (PCFA) is making a submission on behalf of its members. Some individual members have told me that they are going to put in an individual submission. If you also wish to have your say, a couple of points: Firstly, while submission sounds grand, it is as easy as filling in a few boxes on a web page: Click on this sentence for the submission form. OR Here. Notes on the boxes on that page: Medicine to which this submission relates: Enzalutamide Date of PBAC meeting: March 2017 Note: This is when the board meets. It is not the due date for submissions which is Wednesday 8 February 2017. First declaration box: Nil (unless you work for the manufacturer, hold shares in the company, etc.) Second declaration box: Say what you are: man with this disease, partner, friend, doctor, etc. Say where you are in your disease: having the drug, missed out on the drug, expecting to be needing the drug in the future. What comments would you like the PBAC ...? • How does this condition/disease affect quality of life? • What would you most like to see from this treatment? Improved side effects? Slowing disease progression? More mobility? Other benefits? • If you have used or prescribed this new medicine, what was your experience of the beneficial effects? • If you have used or prescribed this new medicine, what side effects or toxicities did you experience or observe? • If you haven't used the new medicine yet, what are your expectations of it? • If you use other currently available therapies or medicines you use to manage your condition (or for prescribers, for your patient’s condition), what are the benefits and/ or the challenges? Where did you obtain the information that helped form your views on this treatment? ◦ I have been a patient on this medicine; ◦ Your doctor; ◦ Other patients stories/experiences ◦ Professional colleagues; ◦ Support networks: PCFA, Australian Advanced Prostate Cancer Support Group, JimJimJimJim ◦ Own research; ◦ Other patient resources; ◦ Direct experience as a health professional or carer; ◦ Other – please provide details. When your entry is complete be Very Careful not to press the wrong button. Tick: Agree to terms and conditions Click: Submit Click on this sentence for the submission form. Lets hope for a good result this time! Jim
  5. Having incurable cancer has caused Larry Axmaker to adjust his definition of "quality of life". Click here to read about how Larry defines "quality of life"
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