In my practice, almost every day patients ask me how long we continue doing chemotherapy? These are patients with metastatic disease who think that chemotherapy is only given for a very specific time.
I often ask them if they had diabetes or hypertension how long would they expect to take medication for that disease, and there is no hesitation answering that you take it for a long time, if not forever. So I try to explain that we give chemotherapy as long it works and is tolerated.
Patients always wonder if they can be give a break or change to a less toxic regimen to make it easier. Interestingly, two studies in Europe have looked at patients with treatment holidays or with a kind of reduced treatment regimens. These studies were initiated to test whether we could stop oxaliplatin to avoid neurotoxicity, only give 5-FU, and then reintroduce oxaliplatin when the tumor starts growing in order to give oxaliplatin the best time to work.
In the first of these studies, it was found that when you stop or hold oxaliplatin you don’t jeopardize treatment outcome because you continue with 5-FU maintenance therapy. It became also clear that the patients who did the best with this approach were the ones who had good control of disease and good performance status.
Based on this study, another follow up study was conducted to evaluate whether a real chemoholiday with no chemotherapy at all would be possible. This study was presented at ASCO last year and showed that a chemoholiday may be not a good idea for all patients, particularly patients with stable disease, significant tumor volume, or symptoms. For patients who had a great response and were doing well stopping chemotherapy was not threatening, but those 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. I think it is absolutely ok to skip a week or two or to 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.
In other words if a patient has multiple liver metastases and they are shrinking, I would not stop in the middle of it and give a chemoholiday. I would continue treatment to see if the tumors shrink or disappear so we are able to perform a tumor resection.
However we always are willing to accommodate special requests like an extra week for special trips, family events, holidays, since one or even two weeks will not threaten with any downsides.
May 01, 2009 at 3:56 pm, Judy Wells said:
You don’t mention non-toxic remedies such as diet, supplements, or other in your article. During the break from chemo, wouldn’t a focus on these other activities to strengthen the immune system and support energy levels be a good idea?
May 01, 2009 at 5:03 pm, heinz josef lenz said:
there are interesting data on western diet, aspirin, exercise etc can reduce risk for recurrence hjl
May 01, 2009 at 7:24 pm, j.d. said:
“I often ask them if they had diabetes or hypertension how long would they expect to take medication for that disease, and there is no hesitation answering that you take it for a long time, if not forever. So I try to explain that we give chemotherapy as long it works and is tolerated.”
Why would this logic not apply to a patient who has had the tumors resected? I guess the question really is: how does one know when it’s time to stop adjuvant chemo?
The rate of recurrence for stage 4 resected patients is very high, so would it not make sense for patients in this group to keep taking chemo for a long time, just like in the palliative setting?
May 01, 2009 at 11:07 pm, heinz josef lenz said:
there is rationale for chemo the questions how long and not forever. However in high risk patients we have given maintenance therapies. however difficult and goes beyond an online discussion. HJL
June 16, 2009 at 1:51 pm, john said:
Dr. Lenz,
Thank you for this blog. I’m not sure if it is too late to comment on the chemo holiday post. In 2008 I was diagnosed with a recurrence in my supraclavicular and axillary lymph nodes. After 10 treatments of Folfiri and Avastin plus 33 IMRT radiation treatments, my oncologist put me on a chemo holiday for 8 months. My CEA stayed low but I was just diagnosed with 32 lung nodules and pelvic lymph node involvement. I am back on Folfiri and Avastin. I am now thinking that if I had been on a maintenance dosage rather than taking a long chemo break, I would be in much better shape today.
June 16, 2009 at 8:12 pm, Heinz-Josef Lenz said:
not sure about that you seem to do very well overall i am only afraid to do chemo if there is a lot of disease left. in your case it seems to be no evidence so there is a role of vacation…..i doubt that maintenance could have prevented this occurence of the disease. HJL