Chemotherapy

This content has been reviewed and approved by

Daniel P. Petrylak, MD
Associate Professor of Medicine
Director, Genitourinary Oncology Program
Columbia University Medical Center

Is chemotherapy helpful in patients with hormone-refractory prostate cancer? 

Question: I am in a lot of pain from hormone-refractory prostate cancer. My oncologist wants me to go on chemotherapy. Will it help me live longer?

Answer: Until the last few years, single-agent chemotherapy has never been shown to prolong survival time in cases of hormone-refractory metastatic prostate cancer. Recently, however, Taxotere^® (docetaxel) and low-dose prednisone have been shown in two large randomized controlled trials to improve overall survival time and decrease bone pain. A recent update of a randomized trial comparing either weekly or every 3 weeks of docetaxel to mitoxantrone and prednisone demonstrated a superior 3-year survival time for every 3 weeks of docetaxel compared to mitoxantrone.

Does chemotherapy help improve the quality of life in patients with hormone-refractory prostate cancer? 

Question: I am in a lot of pain from hormone-refractory prostate cancer. My oncologist wants me to go on chemotherapy. Will it help relieve my symptoms?

Answer: Yes. Before the use of Taxotere^® (docetaxel) and prednisone, the combination of Novantrone^® (mitoxantrone, another chemotherapeutic drug) and prednisone showed a definite improvement in the quality of life compared with prednisone alone. Docetaxel combinations further improve quality of life as well as showing a survival difference.

How often is Taxotere^® (docetaxel) and prednisone given? 

Question: I was recently told by my doctor that I needed docetaxel and prednisone for my metastatic prostate cancer. How are these drugs given?

Answer: Prednisone is given at a relatively low dose by mouth of 10 milligrams in one dose or 5 milligrams two times daily continuously. The docetaxel is generally given once every 3 weeks intravenously.

How long does the chemotherapy take?

Question: I was recently told by my doctor that I needed Taxotere^® (docetaxel) and prednisone for my metastatic prostate cancer, which has become refractory to hormones. How long will the treatments take?

Answer: Usually 1 to 1½ hours, including giving the premedications.

How long is Taxotere^® (docetaxel) and prednisone continued?

Question: I was recently told by my doctor that I needed docetaxel and prednisone for my metastatic prostate cancer, which has become refractory to hormones. How long or how many cycles will I need?

Answer: It will usually take three cycles (6 weeks) to see if it is working. If it is not working, your oncologist may suggest other treatments. If it is not working, your oncologist may suggest other treatments. If it is working, it can be given for several cycles before a chemotherapy rest is needed or until it is no longer effective.

What is the longest time you have seen Taxotere^® (docetaxel) and prednisone work? 

Question: I just began docetaxel and prednisone and am interested as to how long you have seen it work.

Answer: I have had some patients who have been on and off this therapy for as long as 4 years, with good symptom control, and I have clearly seen an improvement in their survival time. Seventeen percent of patients treated with an every 3 week regimen of docetaxel are alive at 3 years, compared to 12 percent treated with every 3 weeks of mitoxantrone.

How long a difference in survival time does Taxotere^® (docetaxel) and prednisone make?

Question: If I decide to take docetaxel and prednisone as my oncologist recommends, how much longer can I expect to live?

Answer: The two phase III randomized controlled trials recently published indicate a median of 2 to 2½ months survival time difference over the control arm of mitoxantrone and prednisone. The latter drugs previously were the accepted standard of treatment for hormone-refractory prostate cancer. These drugs were shown to improve quality of life over the prednisone-alone arm, but did not improve survival time.

Docetaxel and prednisone are the first chemotherapy combination that has ever been shown to make a survival time difference in metastatic prostate cancer in a phase III trial. Remember, however, that a number of patients can do a lot better than the median.

Why bother taking Taxotere^® (docetaxel) and prednisone?

Question: A 2 to 2½ month survival time difference for docetaxel and prednisone does not sound like a large one. What can taking it mean to me?

Answer: These survival time differences can be reported as a median, or as a hazard ratio. The median survival time means that half of the patients live past a particular point in time and half do not. The median survival time measures survival at a given point in time.The hazard ratio is the reduction in the risk of death over time.
 
Although the median survival time of docetaxel treated patients was 18 months, more importantly the reduction in the risk of death in the docetaxel studies over the entire observation period was 20 percent to 24 percent. This is a comparable risk reduction for those patients treated with chemotherapy for metastatic breast or lung cancer.

It is very difficult to determine how any individuals will respond to this combination. We've still not identified the factors responsible for better survival time with docetaxel treatment. We have seen patients even in the worst of performance statuses respond well and for a long time. Again 17 percent of patients treated with an every 3 week regimen of docetaxel are alive at 3 years compared with 13 percent treated with mitoxantrone.

Would you take Taxotere^® (docetaxel) and prednisone if you had metastatic prostate cancer? 

Question: What has your experience been with docetaxel and prednisone? Would you take it?

Answer: I feel that this is a reasonably easy treatment to take, even for elderly men and men who, although ill, want a chance to live longer and with a better quality of life. I have seen many patients who I feel have benefited for much longer than 2 to 2½ months. I, therefore, would try it, depending on my desire to live. One can always discontinue this chemotherapy if it is not helping quality of life or if it is too toxic.

What are the side effects of Taxotere^® (docetaxel) and prednisone? 

Question: I was recently told by my oncologist to start chemotherapy with docetaxel and prednisone. I'm very sensitive to medication. What bad reactions can I expect?

Answer: There is a long list of possible toxicities and side effects. The most common ones are fatigue and muscle and joint aches, hair loss, low blood counts, with the possibility of infections as well as edema (swelling of your ankles and legs), nausea and vomiting, and tingling and numbness of your fingers and/or feet. Allergic reactions have also been described.

Are the side effects from Taxotere^® (docetaxel) and prednisone controllable?

Question: What can you do to control the side effects and toxicities from docetaxel and prednisone?

Answer: For the most part, there are a wide variety of supportive medications to help prevent or alleviate most of the common side effects. Your doctor can also give you either a dose reduction or a chemotherapy vacation or rest until your body recovers from the side effects. This is especially useful if you are responding to these treatments. He or she can give you diuretics to also remove excess fluid that may result from docetaxel treatment.

What are the supportive treatments that are available for nausea and vomiting?

Question: I heard that chemotherapy can cause nausea and vomiting. What can be done to prevent or treat it?

Answer: There are a number of drugs that are very effective in preventing nausea and vomiting in the vast majority of patients. Some of these drugs include Aloxi^® (palonosetron); Zofran^® (ondansetron); Kytril^® (granisetron); and Anzamet^® (dolasetron). Doctors generally combine them with steroids, such as dexamethasone. Taxotere^® (docetaxel) infrequently causes this problem.

How often and what kind of allergic reactions do patients have and how can they be prevented or treated?

Question: One of my friends with prostate cancer got very short of breath when taking Taxotere^® (docetaxel). What are the allergic reactions for this drug and how are they prevented or treated?

Answer: The allergic reactions are generally preventable by taking dexamethasone beginning the night before your treatment on a schedule given to you by your oncologist. It is generally continued for several hours after your treatment has been completed. Severe reactions are very rare. Usually the treatment is stopped and more steroids, antihistamines, and other drugs will control the reaction. The chemotherapy can usually be restarted at a slower rate without further problems. Some patients are not able to continue their treatments, however.

What can be done to prevent and treat infections?

Question: I have heard that you can get infections as a result of chemotherapy. How is this prevented and treated?

Answer: There is a class of drugs called colony-stimulating factors that can be given after your chemotherapy. These are very effective in preventing low white blood cell counts and infections. If you get a fever while on chemotherapy, it is important to call your doctor immediately as aggressive antibiotic therapy will most likely be prescribed to treat a presumed bacterial infection, especially if you have a low white blood cell (WBC) count.

What are the drugs that are given to help prevent low white blood cell counts?

Question: What are the names of the drugs that are used to prevent low white blood cell counts?

Answer: There are two short-acting drugs, Neupogen^® (G-CSF) and Leukine^® (GM-CSF). These drugs are given subcutaneously by injection (under the skin), usually for several days after the chemotherapy.

There is a long-lasting drug, Neulasta^® (pegylated G-CSF) that is usually given subcutaneously the day after your chemotherapy and lasts for up to 2 weeks to prevent low white blood cell counts.

What are the side effects of these white blood cell stimulators?

Question: What side effects can I expect if my doctor gives me one of the medications to help prevent low WBCs?

Answer: Neupogen^® (filgrastim): Common reactions are bone and musculoskeletal pain, as well as injection site reaction. Nausea, headache, and increased white count can also occur. Leukine^® (sargramostim): Similar side effects as well as low-grade fever. Neulasta^® (pegfilgrastim): Similar side effects to filgrastim.

What treatments are available to prevent or treat fatigue and tiredness from anemia? 

Question: I have been on chemotherapy for 3 months and feel very tired and easily fatigued. My doctor says I have become anemic from the chemotherapy. What can be done to treat or help prevent these effects?

Answer: There are two medications available to treat anemia (low red blood cell count). Anemia is a major cause of feeling tired and/or fatigued. Procrit^® (epoetin alfa) is either given subcutaneously three times a week or one time a week. Aranesp^® (darbepoetin alfa) is given subcutaneously in different doses weekly, biweekly, or every 3 weeks, depending upon your needs and your oncologist's treatment plan.

What are the side effects of Procrit^® (epoetin alfa) and Aranesp^® (darbepoetin alfa)? 

Question: I have been told that going on an RBC stimulating drug (darbepoetin alfa or epoetin alfa) will help treat my anemia. What side effects can I expect?

Answer: These drugs are usually very well tolerated. Severe high blood pressure can occur, and this needs to be monitored before treatment is given. Other reactions include headache, and muscle and joint pains. There also may be an increased risk of blood clots in those treated with erythropoietin. The U.S. Food and Drug Administration and Medicare have recently lowered the target hemoglobin levels, and now recommend that erythropoietin not be administered to patients with a hemoglobin level greater than 10.

Are there other treatments for fatigue and tiredness? 

Question: I continue to be tired and fatigued even after treatment with a RBC stimulator. I'm told that I have only a minimal anemia. What else can I do?

Answer: Prednisone, anxiety, and other factors can affect your sleep cycle. It is important to get enough rest to have energy. It may help to take prednisone only in the morning, or if divided doses, no later than 6 p.m., depending upon your bedtime. A mild sleeping pill may be helpful as well.

Antianxiety medications are frequently useful. (A number of them also control the hot flushes and sweats that inhibit a good sleep). A healthy diet and exercise regimen help promote more energy and better sleep. Sometimes a short nap will be energizing.

There are other stimulants, such as Provigil^® (modafinil), nicotine, Dexedrine^® (dextroamphetamine), and Ritalin^® (methylphenidate), which may be helpful. These need to be discussed with your physician.

How are the muscle and joint pains associated with Taxotere^® (docetaxel) and prednisone treated? 

Question: I have been on 6 months of docetaxel and prednisone and now have moderately uncomfortable muscle and joint aches. What can be done to alleviate these symptoms?

Answer: Frequently nonsteroidal antiinflammatory drugs, Tylenol, or other analgesics give good or complete relief. A "vacation" or rest from chemotherapy may be needed if this side effect becomes too severe.

Can hair loss be prevented? 

Question: I'm 52 years old and am going to start on Taxotere^® (docetaxel). I would like to keep my hair. Is there anything I can do to prevent hair loss?

Answer: Most men are usually not too concerned with this side effect. We used to put ice on the scalp to decrease the blood flow (and therefore the amount of chemotherapy going to the hair follicles), however, this treatment has been, by and large, given up due to its ineffectiveness.

How can the numbness, tingling, and burning of the hands and feet be prevented or treated? 

Question: I have been taking Taxotere^® (docetaxel) and prednisone for 4 months with a good PSA decrease; however, I have numbness, tingling, and burning of the hands and feet. What can be done to prevent this from getting worse or to make it go away?

Answer: There is nothing available at this time to prevent this side effect. There are drugs that have been helpful in some patients to help decrease the symptoms. These include Neurontin^® (gabapentin) and possibly a new drug on the marked called Lyrica (pregabalin). Chemotherapy dose reduction or holiday may be very helpful in some cases.

How is chemotherapy (Taxotere^® [docetaxel] and prednisone) induced swelling treated? 

Question: I have noticed that my feet are swollen and I've gained 10 pounds while on docetaxel and prednisone. What can be done at this point in time?

Answer: Diuretics (water pills), leg elevation, dose reduction, or chemotherapy rest are generally the modalities used. If you have been on lower doses of premedication with dexamethasone, increasing the dose and/or duration of dexamethasone can be helpful. It is important that you carefully monitor your weight during treatment because this can be an early sign of fluid retention.

Do diabetics have to take any special precautions when on chemotherapy and prednisone? 

Question: I am an adult onset diabetic who takes oral medication for control of my blood sugar. Is there anything special I need to do while on chemotherapy and prednisone treatments?

Answer: Blood sugars can be raised on prednisone, and the dexamethasone premedication can cause higher levels of blood sugar, therefore your primary care doctor and/or oncologist, as well as yourself and family, must be aware of this. You need to be monitored more frequently and possibly treated differently than you have in the past. Be aware that your blood sugar can fluctuate more, especially if given more medication to treat your high blood sugar, as blood sugars can suddenly decrease and you can become hypoglycemic. You need to be aware of the symptoms and signs of both low and high sugar and how these levels of blood sugar are treated.