Scalp cooling device to reduce hair loss during chemotherapy

Hair loss during chemotherapy can be a huge psychological and physical blow to a lady. Today, we tried the Paxman scalp cooling device on two of our chemotherapy patients. This device leads to vasoconstriction of the scalp vessels and reduces hair loss during chemo.

Studies done using the device report a 70% reduction in hair loss with Paclitaxel based chemotherapy ( used for breast cancer, ovarian cancer) and a 30% reduction in hair loss with adriamycin (used for breast cancer) based chemotherapy.

 

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Operative Video of Chemoport Insertion

Chemoport is a vascular access device which helps in administering chemotherapy with relative ease. The port device is anchored to the upper part of the chest and the catheter is usually placed in one of the large veins.

 

Advantages of a port:

  • Needle is inserted in the port system and not the vein. This avoid puncturing of the vein and complications like thrombophlebitis, which are very common in patients where chemotherapy is given through a peripheral line.
  • In many patients it is difficult to insert an IV line as their veins are either very thin or deep seated. Chemoport are kept in the subcutaneous plane and they are easily felt. This results in a safer and more efficient access than an IV line.
  • Chemotherapy medications can sometimes extravasate through a peripheral IV line (cannula) and cause permanent damage to the tissue and skin. Such events are very rare with a port.
  • Chemoports can be utilized for delivering chemotherapy, IV fluids, blood, medications. It can also be used for drawing labs and injecting contrasts during PET/CT
  • A port needle can remain in situ for upto 7 days, if handled properly whereas an IV line usually needs to be changed after 3-4 days.
  • Chemoports can be kept for 2-3 years and they are quite handy in patients who require prolonged chemotherapy sessions. IV lines are temporary and need to be inserted every time a procedure is to be carried out.

Disadvantages of a port:

  • Chemoport should be flushed every four weeks to prevent it from getting blocked
  • Chemoport placement requires a  minor surgical procedure; IV access does not.

Both chemoports and IV lines are associated with certain risks but the incidence of the complications is quite low:

  • Infection
  • Occlusion or blockage of line
  • Dislodgement of port or line
  • Damage to the port

 

In our Breast Cancer unit, we encourage patients to get a chemoport inserted for chemotherapy as it makes their life easier. Another reason for advocating chemoports in breast cancer patients is that the ipsilateral arm (same side as the breast cancer) cannot be used for IV access, as it increases the risk of lymphedema in them.

 

 

Endopredict vs Oncotype Dx for Breast Cancer

A new test, called EndoPredict, can predict the risk of a woman’s breast cancer spreading within 10 years of diagnosis more accurately than the current Oncotype Dx test. Also, research found that the results can be made available more quickly.
 
A study, published in the Journal of the National Cancer Institute, compared EndoPredict with Oncotype DX. Both tests can predict whether breast cancer will spread in women with oestrogen receptor positive, HER2 negative (ER+/HER2-) disease. This is a sub-type of breast cancer that accounts for about two-thirds of all cases.
 
The new EndoPredict test analyses eight different genes found in a sample of a patient’s tumour. This information, as well as the size of the patient’s tumour and their nodal status – whether the cancer has spread from the breast to their lymph nodes – are then used to determine the patient’s risk of their breast cancer spreading in the next 10 years.
 
An ‘EPclin’ score categorises patients into low- and high-risk groups. Patients placed in the high-risk group would be recommended to have chemotherapy, but those in the low-risk group could be spared this treatment – and the debilitating side effects associated with it.
 
In the study it was found that EndoPredict was more accurate and the results were available faster as compared to the conventional Oncotype Dx test.
 
Points to remember:
1. EndoPredict is meant for early breast cancers which are ER, PR positive (same as Oncotype Dx)
2. It analyses 8 genes as compared to 21 in Onctoype Dx

AMRIT for Indian Breast Cancer Patients

In my previous posts, I have highlighted the misery of poor Indian breast cancer patients who test positive for HER 2 neu. These cancers are usually aggressive and need to be treated with targeted agents like Herceptin. The problem is that each dose of Herceptin costs close to 50-60 thousand rupees in our country and this drug is not available in any government medical college.

Even with the introduction of bio-similars like CANMab, the cost of treatment remained to the tune to 40-45 thousand rupees per dose. I know many families, who sold their houses & jewelry to fund for their loved one’s Herceptin treatment. One such patient was Mrs. Laxmi (name changed), who had Stage III HER-2-neu positive breast cancer. She hailed from an average middle class family and the news of diagnosis of breast cancer was a huge shock for her. To add to her woes, she got to know that she would require close to 6 lakh rupees to fund for her Herceptin treatment. After a lot of deliberation with the family, she decided to fund her treatment by selling her wedding jewelry. Fortunately, things worked out well for her and she is still alive & healthy, 5 years after her cancer diagnosis. Other patients are not so lucky, as they do not possess such reserve money to fund for their HER treatment.

The Indian government’s new AMRIT scheme (Affordable Medicine & Reliable Implants for Treatment), might turn out to be a huge boon for these breast cancer patients. This scheme aims to bring down the cost of essential cancer medicines by 50-60%. The first AMRIT center was inaugurated recently at AIIMS and soon other centers would be started all across the country. Although the list of drugs which will be made available at these centers has not been released, I am hoping that Herceptin would be one of them. This would really help us in treating HER 2 positive patients, thereby leading to increased survival rates.

If this scheme is properly implemented, it will truly turn out to be an “AMRIT” for Indian cancer patients.

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Palbociclib – A novel drug for metastatic breast cancer

The issue which has been lingering on in the Breast cancer community in the last few days has been the significant clinical benefit shown by Palbociclib in patients with advanced breast cancer in a phase 2 clinical trial. The results of the PALOMA-1 trial were discussed in a recently concluded meeting of the American Association for Cancer Research.

Palbociclib is an inhibitor of cyclin-dependent kinases (CDK) 4 and 6 and it inhibits cell proliferation and cellular DNA synthesis by preventing cell-cycle progression from G1 to S phase. In simple terms, it prevents cell division.

In the trial, patients were randomly assigned to the combination of daily palbociclib 125 mg for 3 weeks followed by 1 week off plus continuous daily letrozole 2.5 mg, or to daily letrozole. Treatment continued until disease progression, unacceptable toxicity, or withdrawal from the study, and tumors were assessed every 2 months.

Patients with hormone receptor positive metastatic breast cancer, demonstrated a significantly better progression-free survival as compared to patients receiving only hormonal treatment. The progression-free survival was significantly better with palbociclib plus letrozole than with letrozole alone (20.2 vs 10.2 months; hazard ratio [HR], 0.488; BP = .0004).

Although there was a positive trend seen in the overall survival analysis as well but the survival data was not mature enough to be shared currently.

The drug was well tolerated and the most common adverse effects were neutropenia, leukopenia, fatigue, and anemia.

Although some people are claiming that this drug will turn out to be the next standard of care in metastatic breast cancer, others share a more guarded opinion. There have been quite a few drugs which have shown promise in phase 2 trials but have not performed well in subsequent phase three trials.

The phase 3 trial (PALOMA-2) is currently underway and only time will tell whether Palbociclib is really beneficial or not.

The other issues which Indian patients & doctors need to consider are:

1. Cost & availability of the drug in India; cost/ benefit ratio

2. Overall survival benefit

 

Chemo curls – Some like them, some don’t

Curls

 

Hair loss is a common side effect of most of the chemotherapeutic drugs used in the management of Breast Cancer and this period is quite traumatic for patients. It takes them some time to adjust to their new appearance, but their problem does not stop there.

After chemotherapy, majority of the breast cancer survivors start curly hair and no one exactly knows the reason behind this. This trend is universal and not restricted only to India. There is a lot of information about this on the net but no one exactly knows the scientific explanation behind this phenomenon. After reading a lot of survivor stories, I could infer that the texture of the hair after chemo is certainly different from a patient’s original hair and although some patients experience slight improvement in the quality and texture of their hair over time, for majority, this problem is life long.

For some patients, hair growth after chemo is a morale booster and they welcome this hair growth, without being concerned about the texture and the quality of hair. But for some patients, managing these curls can be quite a problem. It takes them a long time to get used to their new appearance and new hairstyle.

The following websites provide more information about chemo curls and how to manage them

http://www.naturallycurly.com/curlreading/living/curls-after-chemo-hair-loss

http://www.naturallycurly.com/curlreading/living/chemo-curls-a-survivors-tale

http://www.nbcnews.com/health/chemo-curls-another-kink-cancer-recovery-1C9386921

Our Pink Crusader

Chemo curls

A Doctor’s Experience With Nausea – What the Patient Must be Experiencing?

I come across patients everyday complaining of terrible nausea & vomiting after chemotherapy and I try to console them by saying that it will get better with time. Sometimes, I feel that unless you have experienced something yourself, you cannot explain the feeling to some other person.

I have been fortunate enough not to encounter chemo myself, but my understanding of post chemotherapy nausea and the helplessness which one feels in that situation came during our recent whale watching trip in South Africa. Me, my wife and her sister were in a small boat along with 5 other people searching for whales off the coast of Knysna, South Africa. The three of us suffer from motion sickness but we never anticipated that this boat ride will give us a tough time. The initial 30-40 minutes of the boat ride were quite comfortable, as the water was calm. The problem started when the boat started getting rocked by huge waves in the middle of the ocean. My wife was the first one to get started, followed by her sister. I was sitting in the middle, passing the bucket around from one person to the other. They must have vomited at least 5-6 times during our two hours whale watching trip and there was very little we could do to help them out. In fact, towards the end of the boat ride, I also experienced a terrible pang of nausea, followed by a bout of vomiting. It is at that time I realised what cancer patients must be feeling every time they undergo chemotherapy. It is such a terrible feeling and no amount of medicines or consoling helps at that time.

The only saving grace for us was that we had an excellent whale sighting during our trip and every time someone on the boat vomited (5 out of the 8 members on the boat vomited), the whale used to come out to check on us 🙂 🙂 (attaching some pictures)

Concerned whale checking us out :)

Concerned whale checking us out 🙂

Whale 1