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Treatment Protocols

 
Treatment Protocol Notes
  • A.C. doxorubicin + cyclophosphamide
  • Day 1: doxorubicin 60mg/m2.
  • Day 1: cyclophosphamide 600mg/m2. Repeat one time every 3 weeks for 4 cycles.
This treatment, commonly referred to as A.C. (Adriamyacin and Cytoxan), is given intravenously one time every three weeks for 4 treatments. It was a very common treatment used for many years until a slightly better regimen was approved. The regimen A.C. is still used but normally in combination with another drug (a taxane) administered after the four treatments. With all of the regimens you will see something called “M2” which is basically the way to calculate the drug dosage. It is based on the person’s weight and height.
  • T.C. docetaxel and cyclophosphamide
  • Day 1: docetaxel 75mg/m2 IV
  • Day 1: cyclophosphamide 600mg/m2 IV.  Repeat one time every 3 weeks for 4 cycles.
This is given intravenously one time every three weeks for four cycles. This is the most common regimen used by itself now instead of A.C. It is generally used for stage1 or 2 breast cancers. Some physicians will give 6 cycles instead of four which I feel is okay especially with stage 2 breast cancers. I use this regimen frequently.
  • A.C. (doxorubicin + cyclophosphamide) followed by weekly paclitaxel
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat one time every 3 weeks for 4  cycles
  • After completion of A.C. above
  • Day 1: paclitaxel 80mg/m2 IV one time each week for 12 weeks.
The A.C. is given in the traditional way one time every three weeks for four cycles and then paclitaxel is given intravenously one time every week for 12 weeks. This is also a common treatment especially in patients who have lymph node involvement or large cancers. I use this frequently.
  • A.C. (doxorubicin + cyclophosphamide) followed by paclitaxel
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat one time every 3 weeks for 4 cycles.
  • After completion of AC above
  • Day 1: paclitaxel 175mg/m2 IV. Repeat one time every 3 weeks for 4 cycles.
This is very similar to the prior treatment but if you notice on the diagram the paclitaxel is given as a much larger dose every three weeks instead of the lower dose weekly. This is the original way paclitaxel was given. It is still a very acceptable way to administer the drug. However a study (and I want to avoid studies in this book but I think this is important to understand this one) called ECOG1199 revealed it is better to deliver paclitaxel weekly as opposed to the larger dose every three weeks. There was an improvement in survival and also in my opinion it is easy to tolerate. I always use the weekly paclitaxel now following the A.C. when using these drugs together.
  • Dose-dense A.C. (doxorubicin + cyclophosphamide) followed by weekly paclitaxel
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV.Repeat one time every 2 weeks for 4 cycles.
  • After completion of A.C.above
  • Day 1: paclitaxel 80mg/m2 IV one time each week for 12 weeks.
Notice in the prior treatments we have discussed, A.C. is given one time every three weeks for four cycles. In the dose dense protocol, A.C is given one time every two weeks for four cycles. This is again referred to as dose dense chemotherapy. This is a very confusing concept to understand. Cancers which are estrogen and progesterone negative are more aggressive and grow faster. The thought is by giving the treatments – A.C. closer together meaning every two weeks as opposed to every three weeks there is less time for recovery of some of the surviving cancer cells. It is still just 4 treatments. Cancers which are estrogen/progesterone receptor positive have no benefit in giving the chemotherapy every 2 versus 3 weeks. It makes no difference. It is tougher as patients on the every two week treatment plan do not have the extra week to recover from side effects. There is also a slight increased risk of blood transfusions in those receiving the treatment every two weeks.
  • T.A.C.  (docetaxel + doxorubicin + cyclophosphamide)
  • Day 1: doxorubicin 50mg/m2 IV, followed by cyclophosphamide 500mg/m2 IV, followed by docetaxel 75mg/m2 IV. Repeat one time every 3 weeks for 6 cycles.
This is commonly used for stage 2 and 3 breast cancers especially those with lymph node involvement. Some physicians prefer this regimen to A.C. followed by weekly paclitaxel and there is essentially no difference. Personally I find T.A.C. chemotherapy tough to tolerate and have also experienced more infectious complications. Nevertheless, it is still a very powerful treatment.
  • F.A.C. (5-FU + doxorubicin + cyclophosphamide)
  • Days 1 and 8 OR Days 1 and 4: 5-FU 500mg/m2 IV.
  • Day 1: doxorubicin 50mg/m2 IV + cyclophosphamide 500mg/m2 IV. Repeat one time every 3 weeks for 6 sessions.
This is an older M.D. Anderson, Houston treatment but still used today. It is not used as frequently in the community but remains very acceptable for stage 1, 2, and 3 cancers. Sometimes it may also be followed by weekly paclitaxel for four weeks especially in cancers with extensive lymph node involvement.
  • E.C. (epirubicin + cyclophosphamide)
  • Day 1: epirubicin 75mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat one time every 3 weeks for 4 treatments/cycles.
This is not used very often.  It’s very similar to A.C.  Adriamyacin and epirubicin are very similar drugs but epirubicin may be less toxic on the heart but is much more expensive.
  • C.M.F (cyclophosphamide + methotrexate + 5-FU)
  • Days 1–14: cyclophosphamide 100mg/m2 orally.
  • Days 1 and 8: methotrexate 40mg/m2 IV + 5-FU 600mg/m2 IV. Repeat one time every 4 weeks times 6 cycles.

OR;

  • Day 1: cyclophosphamide 600mg/m2 IV, methotrexate 40mg/m2 IV, and 5-FU 600mg/m2 IV. Repeat one time every 3 weeks for 6 sessions.
The C.M.F treatment has been a long standing treatment and is still used today. It can be administered as partially oral meaning using pills or IV. The oral administration of the drug cyclophosphamide is thought to be a little bit better but the IV formulation is easier and still acceptable. I have used this treatment in patients who are elderly or have other health issues but are still in need of treatment for their breast cancer. It is well tolerated for the most part and probably one of the few treatments that do not guarantee hair loss.
  • A.C. (doxorubicin + cyclophosphamide) followed by docetaxel
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat one time every 3 weeks for 4 cycles.
  • Subsequent cycles after completion of AC above.
  • Day 1: docetaxel 75-100mg/m2 IV once every 3 weeks for 4 cycles.
This was used commonly for many years and still is reasonable for lymph node involved cancer and higher stages. However, over the past few years many oncologists have started using the AC followed by weekly paclitaxel more. It is still a very acceptable treatment.
  • T.C.H (docetaxel [Taxotere] + carboplatin [Paraplatin] + concurrent trastuzumab)
  • Day 1: docetaxel 75mg/m2 IV, followed by carboplatin AUC 6. Repeat one time every 3 weeks for 6 cycles.
  • Subsequent cycles
  • trastuzumab 4mg/kg week 1, followed by trastuzumab 2mg/kg for 17 weeks, followed by trastuzumab 6mg/kg every 3 weeks to complete 1 year total of trastuzumab therapy. The first dose of trastuzumab start with the first day of docetaxel and carboplatinum. Another acceptable, more convenient approach is to deliver the trastuzumab every 3 weeks during chemotherapy as opposed to weekly.
The above treatments are only used for patients who are HER2 negative. Now let’s look at some options for patients who are HER2 positive. The first treatment is T.C.H or docetaxel (Taxotere), carboplatin (Paraplatin) and trastuzumab (Herceptin). This treatment is given one time every three weeks for six cycles. Following completion of the 6 cycles the trastuzumab (Herceptin) must continue by itself to equal one full year of treatment. I do not want people to panic when they hear one full year of treatment because Herceptin itself does not give the typical side effects of chemotherapy. Herceptin is administered intravenously targeting the HER2 protein on the cancer cell so it spares some of the regular cells unlike chemotherapy which to be very honest is an atomic bomb that goes through and kills anything in its way and hopefully the cancer cells too. Patients who are receiving Herceptin alone frequently do not realize they are receiving the drug. Let’s discuss some of the side effects later.  Patients who are receiving this treatment will continue to overcome the side effects of the chemotherapy while still receiving the Herceptin. Radiation can start after the chemotherapy portion is finished as can hormonal therapy. You must think of Herceptin as targeted therapy not chemotherapy. T.C.H is my preferred treatment for HER2 positive patients.
  • A.C. (doxorubicin [Adriamycin] + cyclophosphamide [Cytoxan]) followed by paclitaxel (Taxol) + concurrent trastuzumab (Herceptin).
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat cycle every 3 weeks for 4 cycles.
  • Subsequent cycles
  • Day 1: paclitaxel 80mg/m2 IV once time each week for 12 weeks, plus
  • Day 1: trastuzumab 4mg/kg IV loading dose, followed by trastuzumab 2mg/kg IV once each week (or trastuzumab 6mg/kg IV once every 3 weeks) to complete 1 year of treatment.

OR

  • Cycles 1–4
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat cycle every 3 weeks for 4 cycles.
  • Subsequent cycles
  • Day 1: paclitaxel 175mg/m2 IV. Repeat one time every 3 weeks for 4 cycles, plus
  • Day 1: trastuzumab 4mg/kg IV loading dose, followed by trastuzumab 2mg/kg IV once each week (or trastuzumab 6mg/kg IV once every 3 weeks) to complete 1 year of treatment.
Another treatment option is adriamyacin and cytoxan every 3 weeks for 4 treatments followed by the weekly paclitaxel and trastuzumab (Herceptin). This is another popular way to deliver chemotherapy for HER2 positive cancers. However trastuzumab does not start until the adriamyacin and cytoxan portion is complete. This is because combining trastuzumab and adriamyacin together can cause an increase in heart complications. Frankly the particular type of HER2 based chemotherapy does really not matter. Some will say oncologists east of Mississippi tend to use more adriamyacin and cytoxan followed by paclitaxel and trastuzumab as this was tested by the NSABP Group in the Northeast of the U.S. Those west of the Mississippi tend to use more TCH as it was discovered by Dr. Slayman’s team at UCLA. Whether this is true or not, who knows?
  • Dose-dense A.C. (doxorubicin + cyclophosphamide) followed by dose dense paclitaxel + concurrent trastuzumab.
  • Day 1: doxorubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV. Repeat one time every 2 weeks for 4 cycles.
  • Subsequent cycles
  • Day 1: paclitaxel 175mg/m2 IV one time every 2 weeks times 4 cycles. 


OR

  • Day 1: paclitaxel 80 mg/m2 IV one time each week for 12 weeks.

plus

  • Day 1: trastuzumab 4mg/kg IV loading dose, followed by trastuzumab 2mg/kg IV once weekly until completion of paclitaxel. (or trastuzumab 6mg/kg IV once every 3 weeks)
  • Then administer trastuzumab 6mg/kg IV once every 3 weeks to complete 1 year of treatment.
This treatment is A.C. given in a dose dense fashion meaning one treatment every two weeks as opposed to every three weeks for four cycles followed by paclitaxel and trastuzumab. This is the dose dense way of giving chemotherapy with trastuzumab which again can be used in patients who are estrogen and progesterone receptor negative and HER2 positive. I do use this at times and patients seem to tolerate it well.
  • docetaxel + concurrent trastuzumab followed by F.E.C. (5-fluorouracil [5-FU] + epirubicin [Ellence] + cyclophosphamide) Weeks 1–8
  • Day 1: docetaxel 100mg/m2 IV. Repeat one time every 3 weeks for 3 cycles, plus
  • Day 1: trastuzumab 4mg/kg IV loading dose, followed by trastuzumab 2mg/kg IV once weekly for 8 weeks.
  • Subsequent cycles
  • Day 1: 5-FU 600mg/m2 IV + epirubicin 60mg/m2 IV + cyclophosphamide 600mg/m2 IV.Repeat cycle one time every 3 weeks for 3 cycles.
This treatment combines the drug docetaxel and trastuzumab followed by F.E.C.

I must admit I do not use the docetaxel at a 100mg/m2 as it is too toxic. However, it is a reasonable chemotherapy treatment based on European data.