Adelaide, Australia—The 2016 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) Annual Meeting on Supportive Care in Cancer marked the 25th anniversary of MASCC, and the 30th anniversary of ISOO. This year, 1075 delegates from >50 countries attended this international symposium.
The e-posters at the 3-day meeting addressed techniques for minimizing the adverse events associated with cancer treatments, as well as the psychological and social dimensions of a cancer diagnosis and treatment. Some of the many noteworthy topics pertinent to oncology pharmacists and other oncology professionals are summarized below.
- Dexamethasone Mouthwash Relieves Stomatitis in Patients with Breast Cancer
- Methadone Effectively Relieves Pain in Palliative Care Patients
- Omega-6 More Effective Than Omega-3 in Combating Cancer-Related Fatigue
- Subcutaneous Lignocaine Infusions Decrease Pain, Opioid Doses
Dexamethasone Mouthwash Relieves Stomatitis in Patients with Breast Cancer
Prophylactic use of dexamethasone mouthwash significantly minimized the incidence of all grades of stomatitis in postmenopausal women receiving everolimus and exemestane for the treatment of hormone receptor (HR)-positive metastatic breast cancer, according to the results of a multicenter study by Mark Chambers, DMD, MS, Professor, Department of Head and Neck Surgery, University of Texas M.D. Anderson Cancer Center, Houston, and colleagues.
“I believe this mouthwash to be a new standard of care for postmenopausal women receiving everolimus and exemestane for treatment of HR-positive and HER2-negative advanced or metastatic breast cancer,” noted co-investigator Hope S. Rugo, MD, Director of Breast Oncology and Clinical Trials Education, University of California San Francisco Helen Diller Family Comprehensive Cancer Center.
Stomatitis is a dose-limiting toxicity often associated with mammalian target of rapamycin inhibition. The SWISH study evaluated use of an alcohol-free steroid mouthwash to prevent stomatitis (grade ≥2) in patients with HR-positive and HER2-negative advanced breast cancer receiving everolimus and exemestane, compared with historical controls from BOLERO-2, which led to the approval of everolimus (plus hormone therapy) in patients with HER2-negative and HR-positive disease. A large number of patients in the trial had a rapid onset of stomatitis.
SWISH was a US-based, multicenter, single-arm, phase 2 prevention trial in which 86 postmenopausal patients with metastatic HR-positive and HER2-negative breast cancer received everolimus 10 mg and exemestane 25 mg, plus 10 mL of alcohol-free dexamethasone 0.5-mg/5-mL oral solution. Patients started the 8-week, 4-times-daily mouthwash regimen on day 1 of treatment; in the regimen, patients were told to swish for 2 minutes and spit, and to not eat for 1 hour after using the mouthwash.
The incidence of grade ≥2 stomatitis at 8 weeks was 2.4% compared with 33% in BOLERO-2 (P <.001). “This is highly significant, and an even more marked difference than we had expected,” Dr Rugo reported. The incidence of all-grade stomatitis at 8 weeks was 21.2%, a markedly reduced incidence rate compared with all-grade stomatitis reported in BOLERO-2 (67%).
“The majority of patients had minimal discomfort due to what we believe was the dexamethasone rinse,” said Dr Chambers.
Normal diet was reported in 94% of patients at 8 weeks, and ≥90% had no or few diet restrictions throughout the study. Most patients (95%) used the mouthwash 3 to 4 times a day. In addition, >70% remained on the mouthwash, as well as the 2 treatment drugs, for >8 weeks.
According to Dr Rugo, the mouthwash may also be warranted in patients receiving everolimus for other malignancies.
Methadone Effectively Relieves Pain in Palliative Care Patients
Methadone is an effective choice of opioid rotation in patients with advanced cancer, according to a new study led by Amy T.Y. Chang, MBBS, Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
Methadone targets multiple receptors and is considered an effective second-line opioid in managing cancer pain. However, despite its high oral bioavailability and low cost, its variable half-life and its complex pharmacodynamics and pharmacokinetic properties can be potential drawbacks.
The investigators analyzed 24 patients with advanced cancer who were prescribed methadone between January 2012 and December 2013. Adherence to methadone use followed the research department’s “Pain and Symptom Management” protocol, outlined below:
- Adherence to any 1 of the 4 indications for switching from oral morphine to methadone: morphine intolerance, morphine-refractory, renal impairment, neuropathic pain
- Titration methods with correct start of regular and as-needed doses
- Treatment review on day 6.
Pain scores were assessed at baseline, 2 weeks after methadone initiation, and at 3 months to document the effectiveness of methadone for pain control; toxicities were also reviewed.
The most common reasons for opioid rotation in the study population were morphine refractoriness (n = 19, 76%), followed by neuropathic pain (n = 9; 36%).
Methadone was well-tolerated in 75% of patients; among them, the main symptoms were drowsiness (38%), constipation (17%), and hallucinations (4%), “but some of the patients with poor tolerance were at a terminal stage of life,” Ms Chang noted. More than half (54%) of patients had rapid pain relief shortly after initiation of methadone, and more effective pain control was demonstrated at 1 and 3 months after initiation (58% and 75%, respectively).
“Only 46% compliance rate was noted in adherence to department protocol,” Ms Chang added. “But higher compliance of protocol on methadone use over time was seen, implying a structured guideline is effective for correct usage.”
The investigators found methadone to be well-tolerated with manageable adverse effects, but they encourage careful patient selection and earlier use to avoid methadone initiation near the end of life.
Omega-6 More Effective Than Omega-3 in Combating Cancer-Related Fatigue
High-dose omega-6 supplementation from soybean oil significantly reduced cancer-related fatigue (CRF) in breast cancer survivors, more so than high-dose omega-3 supplementation from fish oil, according to the results of a new study led by Luke J. Peppone, PhD, MPH, Assistant Professor, University of Rochester Medical Center, Rochester, NY.
Among breast cancer survivors, 30% to 80% have persistent and often debilitating CRF, and many patients describe it as their most distressing symptom. To compound the effect of this problem, CRF currently has no adequate treatment. Pharmaceutical interventions have limited efficacy and potential adverse effects, whereas behavioral interventions show promise but lack standardization and require a significant time commitment from the patient.
The aim of the study was to determine the preliminary efficacy of omega-3 supplementation (fish oil) with eicosapentaenoic acid and docosahexaenoic acid on CRF in breast cancer survivors compared with omega-6 supplementation with soybean oil.
Female breast cancer survivors between 4 and 36 months postadjuvant therapy reporting a CRF level of ≥4 (0-10 scale) were recruited for the multisite, longitudinal, phase 2, randomized controlled trial. Patients were stratified by baseline CRF (4-6 = moderate and 7-10 = high) and randomized into 3 arms: (1) high-dose omega-3 (fish oil 6 g/day), (2) low-dose omega-3/low-dose omega-6 (fish oil 3 g/day plus soybean oil 3 g/day), or (3) high-dose omega-6 (soybean oil 6 g/day), for 6 weeks.
A total of 108 survivors were evaluated (93% white; mean age, 60 years). Stratified analyses showed survivors with high baseline CRF significantly improved with omega-6 supplementation compared with omega-3 (Brief Fatigue Inventory change score: omega-6 = −3.0 vs omega-3 = −1.7; P = .04). Patients with moderate baseline CRF improved equally, with no differences observed between groups (Brief Fatigue Inventory change score: omega-6 = –1.3 vs omega-3 = –1.3; P = .98).
Although participants from all study groups had a decrease in CRF across all fatigue measures, the omega-6 supplementation significantly reduced CRF compared with omega-3, particularly among patients with high baseline CRF scores.
“Because this is a novel finding, replication is essential in moving this research forward,” Dr Peppone noted. “Future investigations need to attempt to elucidate the mechanism behind the effect of omega-6 and CRF.”
Subcutaneous Lignocaine Infusions Decrease Pain, Opioid Doses
According to a retrospective review of patients with cancer, subcutaneous lignocaine infusions were associated with decreased neuropathic pain scores and decreased opioid doses. The approach was deemed to be effective in almost half of patients, according to research led by Davinia Seah, MD, MPH, palliative care staff specialist, Sacred Heart Supportive and Palliative Care Service, St. Vincent’s Hospital, Sydney, Australia.
Intravenous lignocaine has been shown to effectively treat neuropathic pain, but limited studies have assessed the safety and efficacy of subcutaneous lignocaine infusions, particularly among palliative care populations. Dr Seah and her co-investigators conducted a retrospective review of patients with various malignancies who received subcutaneous lignocaine infusions for pain at Peter MacCallum Cancer Centre, Melbourne, Australia, between December 2010 and December 2014.
A total of 23 patients received subcutaneous lignocaine infusions (2 patients had 2 episodes). The median number of analgesic adjuvant medications was 4, and the median lignocaine dose used was 0.65 mg/kg per hour.
The median worst pain score decreased from 8 prelignocaine to 5.5 on the last day of subcutaneous lignocaine infusion. The difference in mean pain scores was 3.2, and in 15 of 25 episodes patients had a >2‑point decrease in their pain scores.
The median morphine oral equivalent dose decreased from 450 mg before lignocaine infusion to 238 mg after infusion. The mean morphine oral equivalent dose decreased by 213 mg when compared with preinfusion measurements.
“Lignocaine was deemed effective in 12 out of 25 episodes, subjectively,” Dr Seah noted. The results suggest that this approach is safe and well-tolerated for cancer pain, but further research is needed to evaluate its use in neuropathic pain.