* 0 - Asymptomatic (Fully active, able to carry on all predisease activities without restriction)
* 1 - Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)
* 2 - Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
* 3 - Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
* 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
* 5 - Death
Sunday, August 23, 2009
AUC and carboplatin dosing
Carboplatin dose (mg) = AUC x (CrCl in ml/min + 25)
CrCl (male) = ([140-age] x weight in kg)/(serum creatinine x 72)
CrCl (female) = CrCl (male) x 0.85
CrCl (male) = ([140-age] x weight in kg)/(serum creatinine x 72)
CrCl (female) = CrCl (male) x 0.85
Colon cancer
1. Synchronous
a. Colonoscopy
b. Chest/abdominal/pelvic CT
c. FBC, PLT, chemistry profile
d. CEA
e. KRAS
f. needle biopsy, if clinically indicated
g. PET scan only if potentially surgically curable M1 disease
2. Adjuvant
a. 5FU/leucovorin
- leucovorin 500mg/m2 given as 2h infusion and repeated weekly x 6; 5FU 500mg/m2 given bolus 1h after start of leucovorin and repeted 6 x weekly. Every 8 weeks for 4 cycles
- 5FU 370-400mg/m2 + leucovorin 200mg/m2 daily x 5d, every 28d x 6 cycles
b. Capecitabine 1250mg/m2 bd D1-14 every 3 weeks x 24 wks
c. FLOX
- 5FU 500mg/m2 IV bolus weekly x 6 + leucovorin 500mg/m2 IV weekly x 6, each 8 week cycle x 3 with oxaliplatin 85mg/m2 IV administered on weeks 1,3 and 5 of each 8 week cycle x 3
d. FOLFOX 4
oxaliplatin 85mg/m2 IV over 2h D1
leucovorin 400mg/m2 IV over 2h D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/,2 over 46-48 hr) continuous infusion
Repeat every 2 weeks
3. Advanced or metastatic disease
a. FOLFOX 4
Oxaliplatin 85mg.m2 IV over 2 hours D1
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
Followed on D 1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks
b. mFOLFOX 6
Oxaliplatin 85mg/m2 IV over 2 hours D1
Leucovorin 400mg/m2 IV over 2 hours D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks
c. CapeOX
Oxaliplatin 130mg/m2 D1
Capecitabine 850-1000mg/m2 bd for 14 days
Repeat every 3 weeks
d. FOLFIRI
(i)
Irinotecan 180mg/m2 IV over 30-120 minutes D1
Leucovorin 200mg/m2 IV infusion to match duration of irinotecan infusion, D1 & 2
Followed on D1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks
(ii)
Irinotecan 180mg/m2 IV over 30-120 min D1
Leucovorin 400mg/m2 IV infusion to match duration of irinotecan infusion D1
5FU 400mg/m2 IV bolus D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks
e. Bevacizumab + 5FU containing regimens
Bevacizumab5mg/kg IV every 2 weeks + 5FU and leucovorin/FOLFOX/FOLFIRI
Bevacizumab 7.5mg/kg IV every 3 weeks + CapeOX
f. Capecitabine 2000-2500mg/m2/day PO in 2 divided doses, D1-14 flw by 7 days rest/ Repeat every 3 weeks
g. Bolus or infusional 5FU/leucovorin
i. Roswell-Park regimen
Leucovorin 500mg/m2 IV over 2 hours D1/8/15/22/29/36
5FU 50mg/m2 IV bolus 1 hour after start of leucovorin, D1/8/15/22/29/36
Repeat every 8 weeks
ii. Biweekly
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion D1 & 2
Repeat every 2 weeks
iii. Simplified biweekly infusional 5FU/LV (sLV5FU2)
Leucovorin 400mg/m2 IV over 2 hours on D1 followed by 5FU bolus 400mg/m2 and then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46/48 h) continuous infusion
Repeat every 2 weeks
iv. Weekly
Leucovorin 20mg/m2 as 2 h infusion
5FU 500mg/m2 bolus administered 1h after LV infusion
Repeat every week
5FU 2600mg/m2 by 24h infusion plus leucovorin 500mg/m2
Repeat every week
h. FOLFOXIRI
Irinotecan 165mg/m2 IV D1, oxaliplatin 85mg/m2 D1
Leucovorin 400mg/m2 D1, fluorouracil 3200mg/m2 over 48h
Continuous infusion starting on D1
Repeat every 2 weeks
i. Irinotecan 300-350mg/m2 IV over 30-90 minutes D1 repeat every 3 wks
j. Cetuximab (KRAS wild type gene only) +/- irinotecan
Cetuximb 400mg/m2 1st infusion then 250mg/m2 IV weekly
Or
Cetuximab 500mg/m2 IV every 2 weeks
+/-
Irinotecan 300-350mg/m2 IV every 3 weeks
Or
Irinotecan 180mg/m2 IV every 2 weeks
Or
Irinotecan 125mg/m2 every week for 4 weeks
Every 6 weeks
k. Cetuximab (KRAS wild type gene only)
Cetuximab 400mg/m2 1st infusion then 250mg/m2 IV weekly
l. Panitumumab (KRAS wild type gene only)
Panitumumab 6mg/kg IV over 60 minutes every week
4. Surveillance
a. history and physical every 3-6 mo for 2y, then every 6 mo for total of 5y
b. CEA every 3-6 mo for 2y, then every 6 mo for a total of 5y for T2 or greater lesions
c. Chest/abdominal/pelvic CT annually x 3y for patients at high risk for recurrence
d. Colonoscopy in 1y except if no preoperative colonoscopy due to obstructing esion, colonoscopy in 3-6 mo: if advanced adenoma repeat in 1y then if no advanced adenoma repeat in 3y then every 5y
e. PET (serial CEA elevation)
f. Breast exam q1-3y btw ages 20-40, annual mammogram >40 yo, high risk = breast MRI and mammogram annually
g. Cervical CA, prostate CA screening
a. Colonoscopy
b. Chest/abdominal/pelvic CT
c. FBC, PLT, chemistry profile
d. CEA
e. KRAS
f. needle biopsy, if clinically indicated
g. PET scan only if potentially surgically curable M1 disease
2. Adjuvant
a. 5FU/leucovorin
- leucovorin 500mg/m2 given as 2h infusion and repeated weekly x 6; 5FU 500mg/m2 given bolus 1h after start of leucovorin and repeted 6 x weekly. Every 8 weeks for 4 cycles
- 5FU 370-400mg/m2 + leucovorin 200mg/m2 daily x 5d, every 28d x 6 cycles
b. Capecitabine 1250mg/m2 bd D1-14 every 3 weeks x 24 wks
c. FLOX
- 5FU 500mg/m2 IV bolus weekly x 6 + leucovorin 500mg/m2 IV weekly x 6, each 8 week cycle x 3 with oxaliplatin 85mg/m2 IV administered on weeks 1,3 and 5 of each 8 week cycle x 3
d. FOLFOX 4
oxaliplatin 85mg/m2 IV over 2h D1
leucovorin 400mg/m2 IV over 2h D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/,2 over 46-48 hr) continuous infusion
Repeat every 2 weeks
3. Advanced or metastatic disease
a. FOLFOX 4
Oxaliplatin 85mg.m2 IV over 2 hours D1
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
Followed on D 1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks
b. mFOLFOX 6
Oxaliplatin 85mg/m2 IV over 2 hours D1
Leucovorin 400mg/m2 IV over 2 hours D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks
c. CapeOX
Oxaliplatin 130mg/m2 D1
Capecitabine 850-1000mg/m2 bd for 14 days
Repeat every 3 weeks
d. FOLFIRI
(i)
Irinotecan 180mg/m2 IV over 30-120 minutes D1
Leucovorin 200mg/m2 IV infusion to match duration of irinotecan infusion, D1 & 2
Followed on D1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks
(ii)
Irinotecan 180mg/m2 IV over 30-120 min D1
Leucovorin 400mg/m2 IV infusion to match duration of irinotecan infusion D1
5FU 400mg/m2 IV bolus D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks
e. Bevacizumab + 5FU containing regimens
Bevacizumab5mg/kg IV every 2 weeks + 5FU and leucovorin/FOLFOX/FOLFIRI
Bevacizumab 7.5mg/kg IV every 3 weeks + CapeOX
f. Capecitabine 2000-2500mg/m2/day PO in 2 divided doses, D1-14 flw by 7 days rest/ Repeat every 3 weeks
g. Bolus or infusional 5FU/leucovorin
i. Roswell-Park regimen
Leucovorin 500mg/m2 IV over 2 hours D1/8/15/22/29/36
5FU 50mg/m2 IV bolus 1 hour after start of leucovorin, D1/8/15/22/29/36
Repeat every 8 weeks
ii. Biweekly
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion D1 & 2
Repeat every 2 weeks
iii. Simplified biweekly infusional 5FU/LV (sLV5FU2)
Leucovorin 400mg/m2 IV over 2 hours on D1 followed by 5FU bolus 400mg/m2 and then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46/48 h) continuous infusion
Repeat every 2 weeks
iv. Weekly
Leucovorin 20mg/m2 as 2 h infusion
5FU 500mg/m2 bolus administered 1h after LV infusion
Repeat every week
5FU 2600mg/m2 by 24h infusion plus leucovorin 500mg/m2
Repeat every week
h. FOLFOXIRI
Irinotecan 165mg/m2 IV D1, oxaliplatin 85mg/m2 D1
Leucovorin 400mg/m2 D1, fluorouracil 3200mg/m2 over 48h
Continuous infusion starting on D1
Repeat every 2 weeks
i. Irinotecan 300-350mg/m2 IV over 30-90 minutes D1 repeat every 3 wks
j. Cetuximab (KRAS wild type gene only) +/- irinotecan
Cetuximb 400mg/m2 1st infusion then 250mg/m2 IV weekly
Or
Cetuximab 500mg/m2 IV every 2 weeks
+/-
Irinotecan 300-350mg/m2 IV every 3 weeks
Or
Irinotecan 180mg/m2 IV every 2 weeks
Or
Irinotecan 125mg/m2 every week for 4 weeks
Every 6 weeks
k. Cetuximab (KRAS wild type gene only)
Cetuximab 400mg/m2 1st infusion then 250mg/m2 IV weekly
l. Panitumumab (KRAS wild type gene only)
Panitumumab 6mg/kg IV over 60 minutes every week
4. Surveillance
a. history and physical every 3-6 mo for 2y, then every 6 mo for total of 5y
b. CEA every 3-6 mo for 2y, then every 6 mo for a total of 5y for T2 or greater lesions
c. Chest/abdominal/pelvic CT annually x 3y for patients at high risk for recurrence
d. Colonoscopy in 1y except if no preoperative colonoscopy due to obstructing esion, colonoscopy in 3-6 mo: if advanced adenoma repeat in 1y then if no advanced adenoma repeat in 3y then every 5y
e. PET (serial CEA elevation)
f. Breast exam q1-3y btw ages 20-40, annual mammogram >40 yo, high risk = breast MRI and mammogram annually
g. Cervical CA, prostate CA screening
Breast cancer: metastatic disease
8. Metastatic disease
a. Preferred single agents
i. Anthracyclines:
- doxorubicin 60-75mg/m2 IV D1 cycled every 21 days or 20mg/m2 IV weekly
- epirubicin 60-90 mg/m2 IV D1 cycled every 21 days
- pegylated liposomal doxorubicin 50mg/m2 IV D1 cycled every 28 days
ii. Taxanes
- paclitaxel 175mg/m2 IV D1 cycled every 21 days or 80mg/m2 IV weekly
- docetaxel 60-100mg/m2 IV D1 cycled every 21 days or 40mg/m2 IV weekly for 6 wks followed by a 2 week rest then repeat
- albumin-bound paclitaxel 100mg/m2 or 150mg/m2 D1, 8 and 15 IV cycled every 28 days or 260mg/m2 IV cycled every 21 days
iii. Anti-metabolites
- capecitabine 1000-1250 mg/m2 PO bd D1-14 cycled every 21 days
- gemcitabine 800-11200mg/m2 IV D1, 8 and 15
iv. Other microtubule inhibitors
- vinorelbine 25mg/m2 IV weekly
b.Other single agents
- cyclophosphamide
- mitoxantrone
- cisplatin
- etoposide po
- vinblastine
- fluorouracil Cl
- ixabepilone
c. Preferred agents with Bevacizumab
- paclitaxel 90mg/m2 by 1h IV D1, 8 & 15
- bevacizumab 10mg/kg IV D1 & 15
- cycled every 28 days
d. Preferred chemotherapy combinations
- CAF
Cyclophasphamide 100mg/m2 PO D1-14
Doxorubicin 30mg/m2 IV D1 & 8
5FU 500mg/m2 IV D1 & 8
Cycled every 28 days
- FAC
5FU 500m/m2 IV D1 & 8 or D1 & 4
Doxorubicin 50mg/m2 IV D1
Cyclophosphamide 500mg/m2 IV D1
Cycled every 21 days
- FEC
Cyclophasmide 400mg/m2 IV D1 & 8
Epirubicin 50mg/m2 IV D1 & 8
5FU 500mg/m2 IV D1 & 8
Cycled every 28 days
- AC
Doxorubicin 60mg/m2 IV D1
Cyclophasphamide 600mg/m2 IV D1
Cycled every 21 days
- EC
Epirubicin 75mg/m2 IV D1
Cyclophosphamide 600mg/m2 IV D1
Cycled every 21 days
- AT
Doxorubicin 60mg/m2 IV D1 or 50mg/m2 IV D1
Paclitaxel 125-200 mg/m2 IV D1 or Docetaxel 75mg/m2 IV D1
Cycled every 21 days
- CMF
Cyclophosphamide 100mg/m2 PO D1-14
Methotrexate 40mg/m2 IV D1 & 8
5FU 600mg/m2 Iv D1 & *
Cycled every 28 days
- docetaxel/capecitabine
Docetaxel 75mg/m2 IV D1
Capecitabine 950mg/m2 PO bd 1-14
Cycled every 21 days
- GT
Paclitaxel 175mg/m2 IV D1
Gemcitabine 1250 mg/m2 IV D1 & 8 (following paclitaxel on D1)
Cycled every 21 days
e. Other combinations
- ixabepilone + capecitabine
Ixabepilone 40mg/m2 IV D1
Capecitabine 2000mg/m2 PO D1-14
Cycled every 21 days
f. Preferred first line agents for Her-2 positive disease: Trastuzumab 4 mg/kg IV D1 followed by 2mg/kg IV weekly or 8mg/kg IV D1 followed by 6mg/kg IV every 3 wks with:
- paclitaxel + carboplatin (PCH)
Carboplatin AUC of 6 IV D1
Paclitaxel 175mg/m2 IV D1
Cycled every 21 days
- weekly TCH chemotherapy
Paclitaxel 80mg/m2 IV D1, 8 & 15
Carboplatin AUC of 2 IV D1, 8 & 15
Cycled every 28 days
- paclitaxel 175mg/m2 IV D1 cycled every 21 days or 80-90mg/m2 IV weekly
- docetaxel 80-100mg/m2 IV D1 cycled every 21 days or 35mg/m2 IV infusion weekly
- vinorelbine 25mg/m2 IV weekly
- capecitabine 1000-1250mg/m2 PO bd D1-14 cycled every 21 days
g. Preferred agents for trastuzumab-exposed Her2-positive disease
- lapitinib 1250mg PO daily D1-21 + capecitabine 1000mg/m2 PO bd D1-14 cycled every 21 days
- trastuzumab + other first line agents
- trastuzumab + capecitabine
- trastuzumab + lapatinib (without cytotoxic therapy) 1000mg PO daily
(trastuzumab 4mg/kg IV D1 followed by 2mg/kg IV weekly or 8mg/kg IV D1 followed by 6mg/kg Iv every 3 wks)
a. Preferred single agents
i. Anthracyclines:
- doxorubicin 60-75mg/m2 IV D1 cycled every 21 days or 20mg/m2 IV weekly
- epirubicin 60-90 mg/m2 IV D1 cycled every 21 days
- pegylated liposomal doxorubicin 50mg/m2 IV D1 cycled every 28 days
ii. Taxanes
- paclitaxel 175mg/m2 IV D1 cycled every 21 days or 80mg/m2 IV weekly
- docetaxel 60-100mg/m2 IV D1 cycled every 21 days or 40mg/m2 IV weekly for 6 wks followed by a 2 week rest then repeat
- albumin-bound paclitaxel 100mg/m2 or 150mg/m2 D1, 8 and 15 IV cycled every 28 days or 260mg/m2 IV cycled every 21 days
iii. Anti-metabolites
- capecitabine 1000-1250 mg/m2 PO bd D1-14 cycled every 21 days
- gemcitabine 800-11200mg/m2 IV D1, 8 and 15
iv. Other microtubule inhibitors
- vinorelbine 25mg/m2 IV weekly
b.Other single agents
- cyclophosphamide
- mitoxantrone
- cisplatin
- etoposide po
- vinblastine
- fluorouracil Cl
- ixabepilone
c. Preferred agents with Bevacizumab
- paclitaxel 90mg/m2 by 1h IV D1, 8 & 15
- bevacizumab 10mg/kg IV D1 & 15
- cycled every 28 days
d. Preferred chemotherapy combinations
- CAF
Cyclophasphamide 100mg/m2 PO D1-14
Doxorubicin 30mg/m2 IV D1 & 8
5FU 500mg/m2 IV D1 & 8
Cycled every 28 days
- FAC
5FU 500m/m2 IV D1 & 8 or D1 & 4
Doxorubicin 50mg/m2 IV D1
Cyclophosphamide 500mg/m2 IV D1
Cycled every 21 days
- FEC
Cyclophasmide 400mg/m2 IV D1 & 8
Epirubicin 50mg/m2 IV D1 & 8
5FU 500mg/m2 IV D1 & 8
Cycled every 28 days
- AC
Doxorubicin 60mg/m2 IV D1
Cyclophasphamide 600mg/m2 IV D1
Cycled every 21 days
- EC
Epirubicin 75mg/m2 IV D1
Cyclophosphamide 600mg/m2 IV D1
Cycled every 21 days
- AT
Doxorubicin 60mg/m2 IV D1 or 50mg/m2 IV D1
Paclitaxel 125-200 mg/m2 IV D1 or Docetaxel 75mg/m2 IV D1
Cycled every 21 days
- CMF
Cyclophosphamide 100mg/m2 PO D1-14
Methotrexate 40mg/m2 IV D1 & 8
5FU 600mg/m2 Iv D1 & *
Cycled every 28 days
- docetaxel/capecitabine
Docetaxel 75mg/m2 IV D1
Capecitabine 950mg/m2 PO bd 1-14
Cycled every 21 days
- GT
Paclitaxel 175mg/m2 IV D1
Gemcitabine 1250 mg/m2 IV D1 & 8 (following paclitaxel on D1)
Cycled every 21 days
e. Other combinations
- ixabepilone + capecitabine
Ixabepilone 40mg/m2 IV D1
Capecitabine 2000mg/m2 PO D1-14
Cycled every 21 days
f. Preferred first line agents for Her-2 positive disease: Trastuzumab 4 mg/kg IV D1 followed by 2mg/kg IV weekly or 8mg/kg IV D1 followed by 6mg/kg IV every 3 wks with:
- paclitaxel + carboplatin (PCH)
Carboplatin AUC of 6 IV D1
Paclitaxel 175mg/m2 IV D1
Cycled every 21 days
- weekly TCH chemotherapy
Paclitaxel 80mg/m2 IV D1, 8 & 15
Carboplatin AUC of 2 IV D1, 8 & 15
Cycled every 28 days
- paclitaxel 175mg/m2 IV D1 cycled every 21 days or 80-90mg/m2 IV weekly
- docetaxel 80-100mg/m2 IV D1 cycled every 21 days or 35mg/m2 IV infusion weekly
- vinorelbine 25mg/m2 IV weekly
- capecitabine 1000-1250mg/m2 PO bd D1-14 cycled every 21 days
g. Preferred agents for trastuzumab-exposed Her2-positive disease
- lapitinib 1250mg PO daily D1-21 + capecitabine 1000mg/m2 PO bd D1-14 cycled every 21 days
- trastuzumab + other first line agents
- trastuzumab + capecitabine
- trastuzumab + lapatinib (without cytotoxic therapy) 1000mg PO daily
(trastuzumab 4mg/kg IV D1 followed by 2mg/kg IV weekly or 8mg/kg IV D1 followed by 6mg/kg Iv every 3 wks)
Saturday, August 22, 2009
Breast cancer: adjuvant and neoadjuvant chemotherapy regimes, adjuvant endocrine therapy
3. Non-trastuzumab containing adjuvant regimens (NCCN)
A. Preferred
a. TAC (docetaxel/doxorubicin/cyclophosphamide)
docetaxel 75mg/m2 iv D1
doxorubicin 50mg/m2 iv D1
cyclophosphamide 500mg/m2 IV D1
cycled every 21 days for 6 cycles (all cycles with filgrastim support)
b. Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h iv infusion day 1
cycled every 14 days for 4 cycles
all cycles with filgrastim support
c. AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
doxorubicin 60mg/m2 iv day 1
cyclophosphamide 600mg/m2 iv day 1
cycled every 21 days for 4 cycles
followed by paclitaxel 80mg/,2 by 1h IV infusion weekly for 12 wks
d. TC (docetaxel and cyclophosphamide)
docetaxel 75mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles
e. AC (doxorubicin/cyclophosphamide)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles
B. Others
a. FAC/CAF (fluorouracil/doxorubicin/cyclophosphamide)
i. FAC
5FU 500mg/m2 iv D1&8 or D1&4
Doxorubicin 50mg/m2 IV D1 or by 72h continuous infusion
Cyclophosphamide 500mg/m2 iv D1
Cycled every 21 days for 6 cycles
ii. CAF
cyclophosphamide 100mg/m2 iv D1
doxorubicin 30mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
Cycled every 28 days for 6 cycles
b. FEC/CEF (cyclophosphamide/epirubicin/fluorouracil)
i. FEC
cyclophosphamide 75mg/m2 PO D1-14
epirubicin 60mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
With cotrimoxazole support
Cycled every 28 days for 6 cycles
c. CMF (cyclophosphamide/methotrexae/fluorouracil)
Cyclophosphamide 100mg/m2 PO D1-14
Methotrexate 40mg/m2 iv D1&8
5FU 600mg/m2 IV D1&8
Cycled every 28 days for 6 cycles
d. AC followed by docetaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
followed by docetaxel 100mg/m2 IV on D1
cycled every 21 days for 4 cycles
e. AC followed by paclitaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by paclitaxel 175-225 mg/m2 by 3h IV infusion on D1
cycled every 21 days for 4 cycles
f. EC (epirubicin/cyclophosphamide)
epirubicin 100mg/m2 iv D1
cyclophosphamide 830mg/m2 IV D1
cycled every 21 days for 8 cycles
g. Dose dense ATC:- A followed by T followed by C (doxorubicin followed by paclitaxel followed by cyclophosphamide) every 2 weekly regimen with filgrastim support
doxorubicin 60mg/m2 IV D1 cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h IV D1 cycled every 14 days for 4 cycles
followed by cyclophosphamide 600mg/m2 IV D1 cycled every 14 days for 4 cycles
h. FEC followed by T (docetaxel)
5FU 500mg/m2 IV D1
Epirubicin 100mg/m2 IV D1
Cyclophosphamide 500mg/m2 D1
Cycled every 21 days for 3 cycles
Followed by docetaxel 100mg/m2 D1 cycled every 21 days for 3 cycles
4. Trastuzumab containing regimens
A. Preferred adjuvant
a. AC followed by T + concurrent tastuzumab (doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab, various schedules)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by
paclitaxel 80mg/m2 by 1h IV weekly for 12 wks OR paclitaxel 175mg/m2 by 3h IV D1 cycled every 21 days for 4 cycles
with trastuzumab 4mg/kg IV with first dose of paclitaxel
followed by
trastuzumab 2mg/kg IV weekly to complete 1y OR 6mg/kg iv every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)
b. Dose dense AC followed by paclitaxel chemotherapy (all cycles with filgrastim support)
AC as above but cycled every 14 days for 4 cycles
Followed by paclitaxel 175mg/m2 by 3h IV infusion D1 cycled every 14 days for 4 cycles
With trastuzumab 4mg/kg IV with first dose of paclitaxel
Followed by trastuzumab 2mg/kg IV weekly to complete 1y or 6mg/kg IV every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)
c. TCH (docetaxel, carboplatin, trastuzumab)
docetaxel 75mg/m2 IV D1
followed by carboplatin AUC 6 IV D1
cycled every 21 days for 6 cycles
with trastuzumab 4mg/kg wk 1 followed by 2mg/kg for 17 wks followed by 6mg/kg every 3 wks to complete 1 y
(cardiac monitoring at baseline,3,6,9 mo)
B. Other adjuvant
a. Docetaxel + trastuzumab followed by FEC (fluorouracil/epirubicin/cyclophosphamide)
docetaxel 100mg/m2 by 1h IV D1 cycled every 21 days for 3 cycles
with trastuzumab 4mg/kg IV with first dose of docetaxel D1 followed by 2mg/kg IV weekly to complete 9 wks
followed by
5FU 600mg/m2 D1
Epirubicin 60mg/m2 D1
Cyclophosphamide 600mg/m2 D1
Cycled every 21 days for 3 cycles
(cardiac monitoring at baseline, after last FEC cycle, at 12 and 36 mo after chemotherapy)
b. Chemotherapy followed by trastuzumab sequentially
Approved adjuvant chemotherapy regimen at least 4 cycles followed by trastuzumab 8mg/kg IV times 1 dose followed by trastuzumab 6mg/kg IV every 21days for 1 y
(cardiac monitoring at baseline,3,6,9 mo)
c. AC followed by docetaxel + trastuzumab
doxorubicin 60mg/m2 IV D1
cyclophosphamide 600mg/m2 D1
cycled every 21 days for 4 cycles
with
trastuzumab 4mg/kg IV wk one followed by 2mg/kg IV weekly for 11 weeks followed by 6mg/kg every 21 days to complete 1y of trastuzumab therapy
(cardiac monitoring at baseline,3,6,9 mo)
C. Neoadjuvant
a. T (paclitaxel) + trastuzumab followed by CEF + trastuzumab
trastuzumab 4mg/kg IV for 1 dose beginning just prior to first dose of pacitaxel
followed by trastuzumab 2mg/kg IV weekly for 23 weeks
paclitaxel 225mg/m2 by 24h IV infusion every 21 dys for 4 cycles (alternatively paclitaxel 80mg/m2 by 1h IV infusion weekly for 12 wks)
followed by
5FU 500mg/m2 on D1 and 4
Epirubicin 75mg/m2 on D1
Cyclophosphamide 500mg/m2 on D1
Cycled every 21 days for 4 cycles
7. Adjuvant endocrine therapy
a. Premenopausal
- tamoxifen for 2-3 y +/- ovarian suppression/ablation
- complete 5y tamoxifen or after postmenopausal aromatase inhibitor 5y
b. Menopause – prior bilateral oopherectomy, age >= 60y, age <60y and amenorrhoeic 12 mo in absence of chemotherapy/tamoxifen/toremifene/ovarian suppression and FSH & estradiol in postmenopausal range, if taking tamoxifen or toreifene and age<60y then FSH & oestradiol in postmenopausal range)
A. Preferred
a. TAC (docetaxel/doxorubicin/cyclophosphamide)
docetaxel 75mg/m2 iv D1
doxorubicin 50mg/m2 iv D1
cyclophosphamide 500mg/m2 IV D1
cycled every 21 days for 6 cycles (all cycles with filgrastim support)
b. Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h iv infusion day 1
cycled every 14 days for 4 cycles
all cycles with filgrastim support
c. AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
doxorubicin 60mg/m2 iv day 1
cyclophosphamide 600mg/m2 iv day 1
cycled every 21 days for 4 cycles
followed by paclitaxel 80mg/,2 by 1h IV infusion weekly for 12 wks
d. TC (docetaxel and cyclophosphamide)
docetaxel 75mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles
e. AC (doxorubicin/cyclophosphamide)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles
B. Others
a. FAC/CAF (fluorouracil/doxorubicin/cyclophosphamide)
i. FAC
5FU 500mg/m2 iv D1&8 or D1&4
Doxorubicin 50mg/m2 IV D1 or by 72h continuous infusion
Cyclophosphamide 500mg/m2 iv D1
Cycled every 21 days for 6 cycles
ii. CAF
cyclophosphamide 100mg/m2 iv D1
doxorubicin 30mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
Cycled every 28 days for 6 cycles
b. FEC/CEF (cyclophosphamide/epirubicin/fluorouracil)
i. FEC
cyclophosphamide 75mg/m2 PO D1-14
epirubicin 60mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
With cotrimoxazole support
Cycled every 28 days for 6 cycles
c. CMF (cyclophosphamide/methotrexae/fluorouracil)
Cyclophosphamide 100mg/m2 PO D1-14
Methotrexate 40mg/m2 iv D1&8
5FU 600mg/m2 IV D1&8
Cycled every 28 days for 6 cycles
d. AC followed by docetaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
followed by docetaxel 100mg/m2 IV on D1
cycled every 21 days for 4 cycles
e. AC followed by paclitaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by paclitaxel 175-225 mg/m2 by 3h IV infusion on D1
cycled every 21 days for 4 cycles
f. EC (epirubicin/cyclophosphamide)
epirubicin 100mg/m2 iv D1
cyclophosphamide 830mg/m2 IV D1
cycled every 21 days for 8 cycles
g. Dose dense ATC:- A followed by T followed by C (doxorubicin followed by paclitaxel followed by cyclophosphamide) every 2 weekly regimen with filgrastim support
doxorubicin 60mg/m2 IV D1 cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h IV D1 cycled every 14 days for 4 cycles
followed by cyclophosphamide 600mg/m2 IV D1 cycled every 14 days for 4 cycles
h. FEC followed by T (docetaxel)
5FU 500mg/m2 IV D1
Epirubicin 100mg/m2 IV D1
Cyclophosphamide 500mg/m2 D1
Cycled every 21 days for 3 cycles
Followed by docetaxel 100mg/m2 D1 cycled every 21 days for 3 cycles
4. Trastuzumab containing regimens
A. Preferred adjuvant
a. AC followed by T + concurrent tastuzumab (doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab, various schedules)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by
paclitaxel 80mg/m2 by 1h IV weekly for 12 wks OR paclitaxel 175mg/m2 by 3h IV D1 cycled every 21 days for 4 cycles
with trastuzumab 4mg/kg IV with first dose of paclitaxel
followed by
trastuzumab 2mg/kg IV weekly to complete 1y OR 6mg/kg iv every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)
b. Dose dense AC followed by paclitaxel chemotherapy (all cycles with filgrastim support)
AC as above but cycled every 14 days for 4 cycles
Followed by paclitaxel 175mg/m2 by 3h IV infusion D1 cycled every 14 days for 4 cycles
With trastuzumab 4mg/kg IV with first dose of paclitaxel
Followed by trastuzumab 2mg/kg IV weekly to complete 1y or 6mg/kg IV every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)
c. TCH (docetaxel, carboplatin, trastuzumab)
docetaxel 75mg/m2 IV D1
followed by carboplatin AUC 6 IV D1
cycled every 21 days for 6 cycles
with trastuzumab 4mg/kg wk 1 followed by 2mg/kg for 17 wks followed by 6mg/kg every 3 wks to complete 1 y
(cardiac monitoring at baseline,3,6,9 mo)
B. Other adjuvant
a. Docetaxel + trastuzumab followed by FEC (fluorouracil/epirubicin/cyclophosphamide)
docetaxel 100mg/m2 by 1h IV D1 cycled every 21 days for 3 cycles
with trastuzumab 4mg/kg IV with first dose of docetaxel D1 followed by 2mg/kg IV weekly to complete 9 wks
followed by
5FU 600mg/m2 D1
Epirubicin 60mg/m2 D1
Cyclophosphamide 600mg/m2 D1
Cycled every 21 days for 3 cycles
(cardiac monitoring at baseline, after last FEC cycle, at 12 and 36 mo after chemotherapy)
b. Chemotherapy followed by trastuzumab sequentially
Approved adjuvant chemotherapy regimen at least 4 cycles followed by trastuzumab 8mg/kg IV times 1 dose followed by trastuzumab 6mg/kg IV every 21days for 1 y
(cardiac monitoring at baseline,3,6,9 mo)
c. AC followed by docetaxel + trastuzumab
doxorubicin 60mg/m2 IV D1
cyclophosphamide 600mg/m2 D1
cycled every 21 days for 4 cycles
with
trastuzumab 4mg/kg IV wk one followed by 2mg/kg IV weekly for 11 weeks followed by 6mg/kg every 21 days to complete 1y of trastuzumab therapy
(cardiac monitoring at baseline,3,6,9 mo)
C. Neoadjuvant
a. T (paclitaxel) + trastuzumab followed by CEF + trastuzumab
trastuzumab 4mg/kg IV for 1 dose beginning just prior to first dose of pacitaxel
followed by trastuzumab 2mg/kg IV weekly for 23 weeks
paclitaxel 225mg/m2 by 24h IV infusion every 21 dys for 4 cycles (alternatively paclitaxel 80mg/m2 by 1h IV infusion weekly for 12 wks)
followed by
5FU 500mg/m2 on D1 and 4
Epirubicin 75mg/m2 on D1
Cyclophosphamide 500mg/m2 on D1
Cycled every 21 days for 4 cycles
7. Adjuvant endocrine therapy
a. Premenopausal
- tamoxifen for 2-3 y +/- ovarian suppression/ablation
- complete 5y tamoxifen or after postmenopausal aromatase inhibitor 5y
b. Menopause – prior bilateral oopherectomy, age >= 60y, age <60y and amenorrhoeic 12 mo in absence of chemotherapy/tamoxifen/toremifene/ovarian suppression and FSH & estradiol in postmenopausal range, if taking tamoxifen or toreifene and age<60y then FSH & oestradiol in postmenopausal range)
Breast cancer: background
1. Staging/investigation
a. bloods + LFT, ALP
b. diagnostic bilateral mammogram, ultrasound
c. determination of ER/PR/Her2 status
d. KIV breast MRI
e. bone scan (localized symptoms, elevated ALP, T3N1M0)
f. abdominal +/- pelvic CT/US/MRI (elevated ALP, abnormal LFT, abdominal symptoms, abnormal physical examination of abdomen or pelvis, T3N1M0)
g. chest imaging (if pulmonary symptoms present)
h. genetic counseling if high risk
i. tamoxifen: annual gynae assessment if uterus present
j. aromatase inhibitor/ovarian failure: BMD (also remember to give calcium and vit D tabs)
2. JH guidelines for metastatic breast CA
a. AC – Taxol – Gem/Cis – Femara – Xeloda
b. ECF, Epirubicin, 5FU, cyclophosphamide
c. Aromatase inhibitors (arimidex)
a. bloods + LFT, ALP
b. diagnostic bilateral mammogram, ultrasound
c. determination of ER/PR/Her2 status
d. KIV breast MRI
e. bone scan (localized symptoms, elevated ALP, T3N1M0)
f. abdominal +/- pelvic CT/US/MRI (elevated ALP, abnormal LFT, abdominal symptoms, abnormal physical examination of abdomen or pelvis, T3N1M0)
g. chest imaging (if pulmonary symptoms present)
h. genetic counseling if high risk
i. tamoxifen: annual gynae assessment if uterus present
j. aromatase inhibitor/ovarian failure: BMD (also remember to give calcium and vit D tabs)
2. JH guidelines for metastatic breast CA
a. AC – Taxol – Gem/Cis – Femara – Xeloda
b. ECF, Epirubicin, 5FU, cyclophosphamide
c. Aromatase inhibitors (arimidex)
Nasopharyngeal carcinoma (NPC)
1. Staging
a. Chest imaging
b. MRI with gadolinium of nasopharnx and base of skull to clavicles and/or CT with contrast or PET CT and CT with contrast
c. Dental evaluation
d. Speech and swallowing evaluation
e. Imaging for distant mets (chest, liver, bone) for WHO class 2-3/N2-3 disease (may include PET and/or CT
2. JH guidelines
a. Neoadjuvant
- 3 cycles of 3 weeks: D1 cisplatin 100mg/m2 and bleomycin 15mg then D2-5 bleomycin 12mg/m2
- 2-3 cycles of 3 weeks: D1 cisplatin 60mg/m2 and epirubicin 110mg/m2 D1
3. Treatment
a. T1, N0, M0 and T2a, N0, M0: definitive RT to nasopharyny and elective RT to neck
b. T1-T2a, N1-3; T2b-T4, any N:
Cisplatin 100mg/m2 on D1/22/43 of cisplatin 40mg/m2 every wk + RT (>= 70 Gy) to primary and gross nodal disease and bilateral neck: >= 50 Gy
= followed by=
Cisplatin 80 mg/m2 D1 + 5FU 1000mg/m2 Ca x 4 days, repeat every 4 wk x 3 courses
= KIV=
Neck dissection if residual tumour
c. Metastatic: Platinum based combination chemotherapy – if complete response, definitive RT to primary and neck
d. Unresectable T4b: PS0-1 concurrent cisplatin chemoRT or induction chemotherapy flw by chemoRT, PS2 definitive RT +/- concurrent systemic therapy, PS3 definitive RT or BSC = neck dissection if feasible and primary site controlled
4. Regimens
a. Chemoradiation followed by adjuvant chemotherapy: cisplatin + RT followed by cisplatin/5FU
b. Recurrent, unresectable or metastatic (incurable)
i. Combination therapy
- cisplatin/carboplatin + 5FU +/- cetuximab
- cisplatin or carboplatin + docetaxel or paclitaxel
- cisplatin/cetuximab
ii. Single agent: cisplatin, carboplatin, paclitaxel, docetaxel, 5FU, methotrexate, ifosfamide, bleomycin, gemcitabine (NPC), cetuximab
4. Follow up
a. Physical exam y1 q1-3mo, y2 q2-4 mo, y3-5 q4-6mo, >5y 6-12 mo
b. Post-treatment baseline imaging of primary and neck recommended within 6 mo of treatment, reimaging as indicated
c. Chest imaging as clinically indicated
d. TSH every 6-12 mo if neck irradiated
e. Speech, hearing and swallowing evaluation and rehab, dental evaluation
a. Chest imaging
b. MRI with gadolinium of nasopharnx and base of skull to clavicles and/or CT with contrast or PET CT and CT with contrast
c. Dental evaluation
d. Speech and swallowing evaluation
e. Imaging for distant mets (chest, liver, bone) for WHO class 2-3/N2-3 disease (may include PET and/or CT
2. JH guidelines
a. Neoadjuvant
- 3 cycles of 3 weeks: D1 cisplatin 100mg/m2 and bleomycin 15mg then D2-5 bleomycin 12mg/m2
- 2-3 cycles of 3 weeks: D1 cisplatin 60mg/m2 and epirubicin 110mg/m2 D1
3. Treatment
a. T1, N0, M0 and T2a, N0, M0: definitive RT to nasopharyny and elective RT to neck
b. T1-T2a, N1-3; T2b-T4, any N:
Cisplatin 100mg/m2 on D1/22/43 of cisplatin 40mg/m2 every wk + RT (>= 70 Gy) to primary and gross nodal disease and bilateral neck: >= 50 Gy
= followed by=
Cisplatin 80 mg/m2 D1 + 5FU 1000mg/m2 Ca x 4 days, repeat every 4 wk x 3 courses
= KIV=
Neck dissection if residual tumour
c. Metastatic: Platinum based combination chemotherapy – if complete response, definitive RT to primary and neck
d. Unresectable T4b: PS0-1 concurrent cisplatin chemoRT or induction chemotherapy flw by chemoRT, PS2 definitive RT +/- concurrent systemic therapy, PS3 definitive RT or BSC = neck dissection if feasible and primary site controlled
4. Regimens
a. Chemoradiation followed by adjuvant chemotherapy: cisplatin + RT followed by cisplatin/5FU
b. Recurrent, unresectable or metastatic (incurable)
i. Combination therapy
- cisplatin/carboplatin + 5FU +/- cetuximab
- cisplatin or carboplatin + docetaxel or paclitaxel
- cisplatin/cetuximab
ii. Single agent: cisplatin, carboplatin, paclitaxel, docetaxel, 5FU, methotrexate, ifosfamide, bleomycin, gemcitabine (NPC), cetuximab
4. Follow up
a. Physical exam y1 q1-3mo, y2 q2-4 mo, y3-5 q4-6mo, >5y 6-12 mo
b. Post-treatment baseline imaging of primary and neck recommended within 6 mo of treatment, reimaging as indicated
c. Chest imaging as clinically indicated
d. TSH every 6-12 mo if neck irradiated
e. Speech, hearing and swallowing evaluation and rehab, dental evaluation
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