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Chemotalk Newsletter

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Hello, May!

Allergic to chemo? Is that possible? A friend sent me a piece on chemotherapy that appeared on a Massachusetts General Hospital site, an article that I think is worth copying here in its entirety, because it contains information about allergic reactions to chemo that anyone who has had, or may have chemo in the future, should know:

CHEMOTHERAPY DESENSITIZATION

18/Mar/2009

In 2007, breast cancer survivor Judith Wolov was devastated to hear that her ongoing fatigue and weight loss were a result of different cancer weakening her body, a form of stage IV non-Hodgkins lymphoma. The good news, doctors assured her, was that this was a highly treatable cancer.

Her oncologists recommended routine infusion therapy with the drug Rituximab, a very effective first-line treatment for lymphoma. They were very optimistic that it would control Wolov’s cancer, alleviate her symptoms and leave her feeling like her usual, energetic self. Relieved at knowing there were excellent options for treatment, she signed the consent forms and scheduled her new drug-therapy appointment shortly thereafter.

What happened next was hardly routine. Wolov and her husband arrived to the outpatient clinic for what they thought would be a quick and uneventful visit. Nurses placed an IV line into her arm and started Wolov’s chemotherapy. Within seconds Wolov had alarming symptoms of an allergic reaction, and within only eight minutes she had gone into anaphylactic shock.

“As soon as they started the drip I felt uncomfortable and faint. At first I thought it was just anxiety, but within a few minutes I knew something was very wrong. I had trouble communicating and was blacking out. I was extremely scared that I might not wake up at all,” says Wolov. Nurses called a code, took immediate action to stop her infusion and resuscitated Wolov from what she describes as a horrific, near death experience.

Second option

Realizing that the Rituximab chemotherapy treatment was a risky option for her, Wolov was prescribed a different, second option of an oral chemotherapy. Although she responded well initially, a few months later her white blood cell count rose again, and it was clear that her lymphoma was back with a vengeance.

Her oncologist, John Erban, MD, suggested that she try another round of Rituximab, as it was the best medicine available to keep her particular type of cancer at bay. Judith refused, “I had such a violent response to this therapy before. I honestly thought I would just live out my days until the cancer took me, but I was not going to go through another life threatening, allergic reaction again.”

Dr. Erban, who had just accepted a new position with the Massachusetts General Hospital Cancer Center, persisted. “I knew that colleagues here in the Cancer Center were working cooperatively with Mass General allergy specialists and with Dr. Mariana Castells at Brigham and Women’s Hospital to help pioneer what’s known as desensitization chemotherapy,” says Erban. “By determining the severity of drug allergies using skin tests, they work in synergy with the oncology team to develop a protocol that enables patients like Wolov to undergo what previously had been risky treatments.”

Combating the allergy

Dr. Erban enlisted the help of Aleena Banerji, MD, and her colleagues from the Division of Rheumatology, Allergy and Immunology at Mass General. Dr. Banerji is specializing in desensitization drug therapy. Says Banerji, “There is an important need for this type of therapy today. Reactions occur in approximately 25 to 30 percent of patients receiving more than six cycles of a platinum-based chemotherapeutic agent. Reactions usually occur during the second or third line of therapy. Five or ten years ago, these patients with allergies would not have been able to receive the ideal, first-line treatment they may need. Many of these allergies are to drugs in the platinum family such as carboplatin, cisplatin and oxaliplatin.”

All of these are widely used to successfully treat some of the most common but difficult cancers. Adds Banerji, “Patients needing chemotherapy desensitization may need to stay overnight as an inpatient. It is critical that they be monitored on a floor with nursing staff that are specifically trained on how to administer the chemotherapy at particular intervals to prevent adverse reactions.” Due to this high level of staff education and by following individual patient protocols, Banerji notes that they have a 99 percent success rate in getting the right medication into patients despite previous allergic reactions.

For Judith Wolov, it meant following a pretreatment protocol along with admittance to an ICU level floor. Nurses had been prepared to be on the look out for the worst case scenario. The Rituximab chemotherapy was diluted and administered so slowly, over 27 hours, that her body was able to tolerate the treatment. As with other desensitization patients, her cancer responded just as well as a more typical chemotherapy patient.

Complete remission

After four of these desensitization treatments during the summer of 2008, Judith achieved a complete clinical remission from her once debilitating lymphoma. She is spending the winter with her husband at their Palm Beach, Fla., home enjoying golf, bridge parties and walks on the beach. “I am very grateful to the entire Mass General team that helped me fight this cancer,” exclaims Wolov. “I really believe that I am still alive today due to their tireless dedication in finding a solution using desensitization chemotherapy that made my successful treatment possible.”

* * *

That said, another article follows, this one appearing in a Canadian newspaper and having to do with clinical trials. It is based on Canadian procedures, but these are very similar in all the important ways, to those observed in the States.

Whether or not to participate in a trial is often a difficult decision, and can have many variables that have a direct affect on participants' health. This perspective on the process may be helpful:

CLINICAL TRIALS...IT'S NOT JUST A PHASE...

It may be a chance to save lives. (Published Sunday, October 5, 2008 in the Ottawa Citizen, written by Julie Mason.)

If you are a patient with a serious illness, choosing to participate in a clinical trial can be the most important -- and most difficult -- decision you'll ever make.

Like many people, I react to the words "clinical trial" by checking out urns at my local funeral parlour. I'm not alone in thinking that signing up means you are (a) dying or (be) a saint willing to sacrifice yourself for the good of others.

That perception may explain why ONLY THREE PER CENT of cancer patients in North America are involved in a trial. (Because of Canada's universal health care, the rate in Ontario is 12 per cent.)

The mantra of today's medical care is "evidence-based." In simplest terms, this means doing what's been proven to work. Whether it's which drug works best for strep throat, or the benefits of vaccinating young girls against future cancer, we want good scientific evidence behind our medical choices.
The clinical trial is a cornerstone of evidence-based medicine. Out of thousands of ideas, hunches and hopes that science offers every year, very few make it off the laboratory bench. We often hear about exciting "breakthroughs" in the lab or with animal studies. "It's a great time to be a mouse with cancer," says Dr. Judah Folkman, a pioneer of new cancer treatments.

The problem is translating such breakthroughs so they benefit actual human beings. That's where clinical trials come in.

Clinical trials fall into four phases. Phase I trials are very small, about 15 to 30 patients, and look at safety of a treatment, the best dose and method of administration and potential side effects. Phase II trials -- with more people but still fewer than 100 -- studies if the treatment is effective.

Treatments that make it to Phase III are tested on hundreds or thousands of participants. These are often multi-centre studies that link international trials to compare the new treatment with the best treatment available.
If the Phase III trial reveals the treatment to be safe and effective, it is submitted to Health Canada for approval. It then becomes a treatment option for all physicians. Phase IV trials may follow to consider long-term risks and benefits, as well as late-emerging side-effects.

Health Canada has a national system to ensure clinical trials are ethical and responsible and that patient safety is a primary concern. Potential participants receive extensive information on a trial. Nevertheless, the decision to participate is not made easily. Phase I and II trials are inherently risky, so are usually reserved for patients who can't, for a variety of reasons, use or benefit from standard treatments. If you have exhausted other possibilities, your hope is that these trials may offer a chance to be the first to try a "breakthrough" drug.

Phase III trials may benefit people who are getting along on standard treatment but hope for another drug that might be more effective or have fewer side-effects. The trial could prove the new medication is less useful than the original treatment. Many trials are randomized, assigning you to one or another arm of a study, so instead of getting a hoped-for new drug, you may end up in a control group with standard treatment.

* * *

Finally, I'm on a roll here, so I'm going to reproduce an article that appeared in the April 21 issue of "Science Times", from The New York Times. The article is by Tara Parker-Pope:

WHAT ARE FRIENDS FOR? A LONGER LIFE

In the quest for better health, may people turn to doctors, self-help books or herbal supplements. But they overlook a powerful weapon that could help them fight illness and depression, speed recovery, sow aging and prolong life: their friends.

Researchers are only now starting to pay attention to the importance of friendship and social networks in overall health. A 10-year-Australian study found that older people with a large circle of friends were 22 percent less likely to die during the study period than those with fewer friends. A large 2007 study showed an increase of nearly 60 percent in the risk for obesity among people whose friends gained weight. And last year, Harvard researchers reported that strong social ties could promote brain health as we age.

"In general, the role of friendship in our lives isn't terribly well appreciated," said Rebecca G. Adams, a professor of sociology at the University of North Carolina, Greensboro "There is just scads of stuff on families and marriage, but very little on friendship. It baffles me. Friendship has a bigger impact on our psychological well-being than family relationships."

In a new book, "The Girls From Ames: A Story of Women and a 40-Year Friendship" (Gotham), Jeffrey Zaslow tells the story of 11 childhood friends who scattered from Iowa to eight different states. Despite the distance, their friendships endured through college and marriage, divorce and other crises, including the death of one of the women in her 20s.

Using scrapbooks, photo albums and the women's own memories, Mr. Zaslow chronicles how their close friendships have shaped their lives and continue to sustain them. The role of friendship in their health and well-being is evident in almost every chapter.

Two of the friends have recently learned they have breast cancer. Kelly Zwagerman, now a high school teacher who lives in Northfield, Minn., said that when she got her diagnosis in September 2007, her doctor told her to surround herself with loved ones. Instead, she reached out to her childhood friends, even though they lived far away.

"The first people I told were the women from Ames," she said in an interview. "I e-mailed them. I immediately had e-mails and phone calls and messages of support. It was instant that the love poured in from all of them."

When she complained that her treatment led to painful sores in her throat, an Ames girl sent a smoothie maker and recipes. Another, who had lost a daughter to leukemia, sent Ms. Zwagerman a hand-knitted hat, knowing her head would be cold without hair; still another sent pajamas made of special fabric to help cope with night sweats.

Ms. Zwagerman said she was often more comfortable discussing her illness with her girlfriends than with her doctor. "We go so far back that these women will talk about anything," she said.

Ms. Zwagerman says her friends from Ames have been an essential factor in her treatment and recovery, and research bears her out. In 2006, a study of nearly 3,000 nurses with breast cancer found that women without close friends were four times as likely to die fro the disease as women with 10 or more friends. And notably, proximity and the amount of contact with a friend wasn't associated with survival. Just having friends was protective.

Bella DePaulo, a visiting psychology professor at the University of California, Santa Barbara, whose work focuses on single people and friendships, notes that in many studies, friendship has an even greater effect on health than a spouse or family member. In the study of nurses with breast cancer, having a spouse wasn't associated with survival.

While many friendship studies focus on the intense relationships of women, some research shows that men can benefit, too. In a six-year study of 736 middle-age Swedish men, attachment to a single person didn't appear to affect the risk of heart attack and fatal coronary heart disease, but having friendships did. Only smoking was as important a risk factor as lack of social support.

Exactly why friendship has such a big effect isn't entirely clear. While friends can run errands and pick up medicine for a sick person, the benefits go well beyond physical assistance; indeed, proximity does not seem to be a factor.

It may be that people with strong social ties also have better access to health services and care. Beyond that, however, friendship clearly has a profound psychological effect. People with strong friendships are less likely than others to get colds, perhaps because they have lower stress levels.

Last year, researchers studies 34 students at the University of Virginia, taking them to the base of a steep hill and fitting them with a weighted backpack. They were then asked to estimate the steepness of the hill. Some participants stood next to friends during the exercise, while others were alone.

The students who stood with friends gave lower estimates of the steepness of the hill. And the longer the friends had known each other, the less steep the hill appeared.

"People with stronger friendship networks feel like there is someone they can turn to," said Karen A. Roberto, director of the center for gerontology at Virginia Tech. "Friendship is an undervalued resource. The consistent message of these studies is that friends make your life better."

Amen!

See you next month.

And if you have any thoughts of how this newsletter could be improved, please email me directly, at jesmer_e@pacbell.net

Elaine Jesmer

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