Many patients with metastatic disease ask how long we should do chemotherapy. This is astonishing since when we are diagnosed with diabetes or hypertension we usually would not ask the same question. Of course, for patients with metastatic disease we continue as long the chemotherapy works.
A lot of patients ask whether you can take a break from chemotherapy, particularly around the holidays or vacation times. Do you take a break from insulin or your high blood pressure medication? In the last two years, clinical trials have been conducted to answer exactly this question.
There is also a difference in treatment philosophies around the world. In Europe many oncologists feel if the tumor does not shrink anymore, it is time to stop chemotherapy completely. In the USA most oncologists treat until the tumor starts growing, assuming that no change in tumor is a good sign of control.
Interestingly, two studies in Europe have looked at patients with treatment holidays or with reduced treatment regimens. These studies were initiated to test whether when we can stop oxaliplatin to avoid neurotoxicity, only give 5-FU for a period of time, and then reintroduce oxaliplatin when the tumor starts growing again to give oxaliplatin the most time to work.
In the first of these studies, it was found that when you stop or hold oxaliplatin, you don’t jeopardize outcome to treatment if you still continue with maintenance therapy with 5-FU. It became also clear that the patients who did the best with this approach were the ones who had good control of disease and had good performance status. Based on this study, another follow up study was conducted to evaluate whether a real chemoholiday would be possible. This study was presented at ASCO last year and showed that a chemoholiday may be not a good idea for patients, particularly patients with stable disease, significant tumor volume, or cancer symptoms. For patients who had a great response and were doing well, stopping chemotherapy was not threatening, but ones with stable disease, large tumor volume, or symptoms did worse when treatment was stopped. We already know that for patients with a lot of disease and symptoms related to the cancer the best palliation is effective chemotherapy.
In my practice we skip a week or two or continue on a modified regimen in patients with great tumor shrinkage and overall good status. However in patients with great response and the chance of a curative resection, I don’t recommend a break because I try to get the patients to a point where we may be able to take the tumors out with the goal of curing the patient. We have learned over the last two years that we can hold oxaliplatin if the tumor seems to be controlled and resume when the tumor begins growing again, but in patients with symptoms associated with cancer such as pain or bleeding, I don’t stop oxaliplatin.
To completely stop chemotherapy has shown not to benefit patients, but in fact jeopardizes their outcome.
August 21, 2009 at 5:26 am, ritu said:
Dear Dr,
My father has gone thro 12 weeks ( 6 cycles) of Folfox 4+ erbitux therapy after his rectal resection . He did 6 weeks of the same regime before his surgery . he had a solitary 9mm nodule in the lung and minor lesions in liver ( the liver ones did not show metabolism on PET). He is 68years. What shold our further course of action be. He is not too keen on further therapy. He is in good health.Curently he is waiting for his next Pet scan to be done in three weeks
ritu
August 21, 2009 at 9:00 am, Heinz Josef Lenz said:
As you can imagine cant do specific treatment recommendations on cases i have not seen and evaluated myself, i would recommend to discuss the plan with your oncologists, it all depends are the liver lesions tumors or not, if not you may want to discuss to remove the lung lesion depending on how difficult it is. If the liver lesions are tumors, then it becomes for difficult and more chemotherapy may be the best way to go. sorry cant be more specific. HJL
December 08, 2010 at 11:00 am, Judy said:
Hi Dr. Lenz,
My husband has Stage IV rectal cancer that has spread to his liver and lungs. He was diagnosed almost a year ago and started his treatment in March of 2010 of chemo 5FU and radiation. It was thought he would have surgery to remove the tumor in his rectum and liver after he showed tumor shrinkage, but he has not so far. Drs decided he should continue with his chemo. His last cat scan and pet scan in august has showed alot of improvement with the tumors disappearing in liver and lungs, but some are still there but significantly smaller. His oncologist and cancer board has decided on no surgery, or cure, just to lengthen his life expectancy. He has developed nuerapathy and has problems with hands and feet. Is there anything besides Lyrica or B vitamins that can help him?? Is there a greater chance of cure if surgery is performed to remove the rectal tumor???