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.