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ambulatory chrono-chimiotherapy
- Joseph Watine (7 April 2001)
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Some important considerations regarding Chemotherapy at home
- Ahmed Nadeem Abbasi (11 April 2001)
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Joseph Watine, Eur Clin Chem Hôpital de Rodez, France
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As suggested by Borras et al. [1], home chemotherapy is quite likely to be more satisfactory than outpatient treatment for colorectal cancer patients. There is however an even more satisfactory way to administer chemotherapy in these patients: ambulatory chrono-therapy [3-9]. Home chemotherapy may well “increase patients’ compliance with treatment and satisfaction, particularly with regard to nursing care” [1]. Ambulatory chrono-chemotherapy not only can do the same, but also it decreases the toxicity of chemotherapy, and, to a lesser extent, increases its efficiency [4-9]. It is also better tolerated psychologically, and improves the patients’ quality of life [3]. References 1) Hrushesky WJ, Bjarnason GA. The application of circadian chronobiology to cancer chemotherapy. In: Cancer. Principles and Practice of Oncology. Fourth Edition. V.T. De Vita, S. Hellman, S.A. Rosenberg (eds). Fourth Edition. JB Lippincott Company, Philadelphia. 1993, pp. 2666 -2686. 2) Borras JM, Sanchez-Hernandez A, Navarro M, Martinez M, Mendez E, Ponton JLL, Espinas JA, Germa JR. Compliance, satisfaction, and quality of life of patients with colorectal cancer receiving home chemotherapy or outpatient treatment: a randomised controlled trial. BMJ 2001;322:826. 3) Bertolini R, Focan C, Bartholome F, Baro V. Comparative psychological aspects of two different types of chemotherapeutic administration (chronotherapy vs. traditional chemotherapy) on quality of life of cancer patients at advanced stage. In Vivo. 1995;9: 583-587. 4) Falcone A, Allegrini G, Antonuzzo A, Brunetti I, Pfanner E, Lencioni M, Masi G, Danesi R, Del Tacca M, Conte P. Infusions of fluorouracil and leucovorin: effects of the timing and semi-intermittency of drug delivery. Oncology. 1999;57: 195-201. 5) Focan C, Kreutz F, Focan-Henrard D, Moeneclaey N. Chronotherapy with 5-fluorouracil, folinic acid and carboplatin for metastatic colorectal cancer; an interesting therapeutic index in a phase II trial. Eur J Cancer. 2000;36: 341-347. 6) Focan C, Levi F, Kreutz F, et al. Continuous delivery of venous 5- fluorouracil and arterial 5-fluorodeoxyuridine for hepatic metastases from colorectal cancer: feasibility and tolerance in a randomized phase II trial comparing flat versus chronomodulated infusion. Anticancer Drugs. 1999;10: 385-392. 7) Giacchetti S, Perpoint B, Zidani R, et al. Phase III multicenter randomized trial of oxaliplatin added to chronomodulated fluorouracil- leucovorin as first-line treatment of metastatic colorectal cancer. J Clin Oncol. 2000;18: 136-147. 8) Lévi F, Zidani R, Misset JL. Randomised multicentre trial of chronotherapy with oxaliplatin, fluorouracil, and folinic acid in metastatic colorectal cancer. International Organization for Cancer Chronotherapy. Lancet. 1997;350: 681-686 (Comment in Lancet. 1997;350: 1325-1326). 9) Mormont MC, Waterhouse J, Bleuzen P, Giacchetti S, Jami A, Bogdan A, Lellouch J, Misset JL, Touitou Y, Levi F. Marked 24-h rest/activity rhythms are associated with better quality of life, better response, and longer survival in patients with metastatic colorectal cancer and good performance status. Clin Cancer Res. 2000;6: 3038-3045. |
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Ahmed Nadeem Abbasi, Locum Consultant Clinical Oncologist Singleton Hospital, Swansea
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First of all I would like to convey my appreciation to Borras et al for performing this trial which will definitely lead the way forward on this important issue of provision of oncological care to cancer patients at home. I would like to make some comments re; this trial. [ 1 ] Large teaching hospital setting This study is performed in a large teaching hospital. One cannot expect to achieve similar results in the common setting of peripheral clinics ,where chemotherapy day unit facilities are provided to a wider population of patients who attend the day units with a wide range of malignancies. The geographical considerations are quite important and one has to see the provision of specialised facilities in a district hospital setting. [ 2 ] Non – Compliance Rate The overall compliance with treatment in this study is quoted as 64 %,33out of 45in the chemo at home arm & 23 out of 42 in the chemotherapy at outpatients clinic arm.[ table – 2 ] .The non-compliance rate of 35.6% [ 45% ( 19 out of 42 patients )in the Outpatients arm and 27% ( 12 out of 45 patients ) in the Home arm ] is quite high and in my personal opinion one has to keep this figure in mind before drawing any conclusions from this study. It represents more than a third of the total participants of the study. [ 3 ] Safety It is quoted that home chemotherapy seems an acceptable and "safe" alternative to outpatient treatment that may improve compliance with treatment. [ Ref.; 1 ] As I mentioned earlier compliance with treatment has to be taken within the context of absolute numbers as we know that more than third of the patients were not able to complete their prescribed course of systemic chemotherapy. It would be appropriate to define and describe the term "safety" before drawing any firm inferences. [ 4 ] Availability of resources In the United Kingdom Systemic Chemotherapy can only be administered by certified nursing staff. Availability of trained staff is a major issue of concern and consideration in this scenario. This fact becomes more pronounced in the setting of peripheral oncology services where provision of care at home is an important component of overall management of cancer patients. [ 5 ] Personal Qualities of Nursing Further elaboration is required for the proper description of this item.[ table – 3 ]. I presume that the nurses involved in the administration of chemotherapy both at home and at the outpatient’s clinic have the same qualifications and have the same standard of specialised professional training . [ 6 ] Satisfaction with the health care A significant difference was found between groups in the perception of nursing availability,with the hospital outpatients considering that they had to wait longer to receive chemotherapy than the patients treated at home [ table – 3 ]. This factor cannot be compared effectively in the two arms of a study as it looks quite obvious that a patient visiting an outpatient clinic is expected to wait for some length of time before a health carer, specialist oncology nurse in this case, is available to attend him or her. REFERENCE 1 Borras A, Sanchez-Hernandez A, Navarro M, Martinez M, Mendez E, Ponton JLL, Espinas JA , Germa JR.Compliance , Satisfaction, and Quality of life of patients with colorectal cancer receiving home chemotherapy or outpatient treatment : a randomised controlled trial. BMJ 2001;7290: 826 – 828. With regards, Yours sincerely, Ahmed Nadeem Abbasi,
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