SEF Chemo Patient Instructions

Updated: Apr 30, 2017

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DRUGS USED WITH SEF CHEMO

Carboplatin i.v. (chemotherapy drug)
Mesna i.v. (chemo side-effect preventing drug)
Ondasetron i.v. and oral (anti-nausea drug – used routinely)
Haloperidol oral (backup anti-nausea drug – rarely required)
Heparin i.v. flush (only enough to prevent clotting of your i.v. catheter or PICC line or implanted venous access port)

Carboplatin dosing can vary from weekly AUC1.6 (Area Under the Curve), to biweekly AUC3 or AUC4.

TREATMENT SCHEDULE – STANDARD 2 WEEK CYCLE (carboplatin dose AUC3 or AUC4)

Day #1 – Tuesday
An intravenous line is inserted. For patients who have an implanted i.v. port or a PICC line, that will be used instead.
You will receive i.v. mesna in the afternoon (between 1pm and 3pm), which will be a quick infusion (less than 5 minutes). The i.v. line will be flushed with heparin to prevent clotting.

Day #2 – Wednesday
You will receive a dose of mesna in the morning between 8am and 9am. Three hours later (around 11am – 12pm), you will receive an infusion of carboplatin chemo along with ondansetron to prevent nausea. Between the mesna and chemo infusions, you may leave the office if desired, or stay in your private infusion room or our lounge. The timing for your infusions can be found by looking at the following table:

DAY 1
MESNA
DAY 2
MESNA
DAY 2
CHEMO
DAY 3
MESNA
DAY 4
MESNA
1:00pm 8:00am 11:00am 9:00 – 10:00am 9:00 – 10:00am
1:30pm 8:00am 11:00am 9:00 – 10:00am 9:00 – 10:00am
2:00pm 8:00am 11:00am 9:00 – 10:00am 9:00 – 10:00am
2:30pm 8:30am 11:30am 9:30 – 10:30am 9:30 – 10:30am
3:00pm 9:00am 12:00pm 10:00 – 11:00am 10:00 – 11:00am

Since our office building opens at 8am (front door and elevators turn on at 8am), please do not come before 8am.

The chemo infusion generally takes less than 1 hour. If you are receiving a chemo-sensitizing medication such as i.v. metformin, i.v. phenylbutyrate or i.v. DCA, that medication will be given immediately after the carboplatin infusion. DCA is a fast infusion, approximately 15 minutes. Metformin infusion takes about 30-60 minutes, Phenylbutyrate infusion takes about 30-60 minutes. After the completion of your infusions, the i.v. line will be flushed with heparin to prevent clotting.

We request that you rest for the remainder of chemo day. Eat a light dinner, preferably bland, low fat, non-spicy soft food. Most patients do not get nausea, but many will say they felt less hungry that evening. You will also be prescribed pills (ondansetron or granisetron) to prevent nausea over the next 2 – 3 days. These should be used routinely. Ondansetron is to be started on the evening of the chemo dose, and is taken twice a day for a total of 6 doses. A second anti-nausea drug (haloperidol) may be prescribed as a backup in case the first one does not totally prevent nausea. That should be used only if needed.

Day #3 – Thursday

You will receive i.v. mesna in the morning (timing according to the table above). This will be a quick infusion (less than 5 minutes).
If you are receiving a chemo-sensitizing medication, it will be given after the mesna infusion.
The i.v. line will be flushed with heparin to prevent clotting.

Day #4 – Friday

You will receive i.v. mesna in the morning (timing according to the table above). This will be a quick infusion (less than 5 minutes). If you are receiving a chemo-sensitizing medication, it will be given after the mesna infusion. The i.v. line will be removed. If you have a PICC line or implanted port, it remains in place and will be flushed with heparin to prevent clotting.

Day #5 – Saturday
We request that you drink 8 glasses of water in the morning (for example, from 8am – 12pm). This is to help flush out any remaining chemo from your body.
In a small number of patients, we believe the chemo may stay in the body beyond the last mesna dose. This water flush should help remove it to prevent side effects.

TREATMENT SCHEDULE – GENTLE WEEKLY CYCLE (carboplatin dose AUC1.6)

Day #1 – Tuesday
Same timing as standard 2 week cycle. The dose of mesna is lower, to match the lower chemo dose.

Day #2 – Wednesday
Same timing as standard 2 week cycle. The dose of mesna is lower, to match the lower chemo dose.

Day #3 – Thursday
Same timing as standard 2 week cycle. The dose of mesna is lower, to match the lower chemo dose.

Day #4 – Friday
No mesna or chemo-sensitizer infusions on Friday.
We request that you drink 8 glasses of water in the morning (for example, from 8am – 12pm). This is to help flush out any remaining chemo from your body.
In a small number of patients, we believe the chemo may stay in the body beyond the last mesna dose. This water flush should help remove it to prevent side effects.

HOLIDAY SCHEDULE CHANGES

For statutory holidays falling on Monday:
SEF chemo will proceed as usual (Tues start date).
Since the blood lab will be closed on Monday, please get your routine blood test done on the Friday before.

For statutory holidays falling on Friday:
SEF chemo will be moved up by 1 day during that week. Instead of a Tuesday start date, it will be moved to Monday.
There will not be enough time to get your routine blood test done Monday morning (results may not come back in time for Tues chemo). Therefore, please get your routine blood test done on the Friday before. Depending on the patient, we may send an additional “stat” blood sample on Tues to confirm the blood counts are acceptable.

SIDE EFFECTS

Although the usual side effects of chemo are much less likely to show up with SEF chemo, you may experience symptoms of your cancer cells being destroyed rapidly. Some will report some pains in the region of large tumours. They are brief in duration, a few days at most. Your doctor can prescribe medication to control the pain. Reduced appetite, low energy and mild nausea are often noted.

Please report any new or worsening symptoms to the Berkeley Institute Service Center: medical@cancer-institute.com,  or to your doctor.

New headaches, changes in vision, loss of coordination, head spinning, difficulty walking and vomiting have been rarely noted. These are not direct SEF chemo side effects, but can be an indication of brain swelling. This can occur in patients with brain metastases that have not been discovered previously. If you experience symptoms like these, please report to your doctor immediately.

DIET

Please drink fluids regularly, but not a large volume at any given time. Water is fine. We would advise avoiding citrus or acidic juices. Something like unsweetened apple juice would be fine. Decaf coffee and low caffeine tea (like green tea) would be fine. If you are the type of person who forgets to drink, then please monitor the colour of the urine. Dark yellow indicates dehydration, and should be a reminder to drink more fluids.

During the first few days after the chemo, eating small amounts of soft foods frequently would be preferable to eating a large volume at a time. These are general guidelines. For detailed personal diet advice, please consult with your medical or naturopathic doctor.

GENERAL BLOOD TESTS

Routine blood test requisitions will be provided. We require weekly blood testing.
Patients in the Toronto or Southern Ontario areas, for treatment every 2 weeks: blood test done on Monday the week of SEF chemo, and on Tuesday or Wednesday during the week off.
Patients flying to Toronto every 2 weeks for treatment: blood test done on Friday or Saturday the week before SEF chemo, and on Monday during the week off.
Patients receiving low dose weekly treatment: blood test done every Monday
Special blood tests like tumour markers will be tested every 1-2 months (these do not apply to all patients).

CIRCULATING TUMOUR CELL (CTC) BLOOD TEST

We use the Maintrac circulating tumour cell count to help monitor response to therapy. The Maintrac CTC count is performed at a lab in Germany. It provides a measurement of the number of cancer cells in the blood circulation. Cost is about $600. This test is very useful to help measure response to therapy when no tumours are visible on routine scans. Even when tumours are measurable, it provides additional information about therapy effectiveness. Scans often show initial tumour size increase (applies to immunotherapy like “safe” chemo), but a falling CTC count confirms successful therapy. Maintrac CTC can also help determine when the cancer has been reduced sufficiently that therapy can be stopped. This test may be done every 1 – 2 months. Maintrac CTC is designed to measure carcinomas, but can be used for sarcoma, glioblastoma and other cancer types (not for myeloma, lymphoma or leukemia).

IMAGING TESTS

The exact type of imaging required will depend on the individual patient. We generally require ultrasound with Doppler and chest x-ray just before the start of treatment, and every 2 – 3 cycles after that (or every 4 – 6 cycles for the low dose SEF chemo protocol). Requisitions will be provided. In conventional oncology, Doppler is not routinely used for assessing tumours, so please check with your ultrasound lab in advance. If you are not certain, we recommend HiTek Medical Imaging at Leslie and Sheppard . This lab is near the Medicor office and they will do the type of testing that we require.

CT scans or MRIs will be ordered every 2 – 3 months, if applicable. These will be booked at your local hospital whenever possible. Note that CT or MRI scans can often falsely suggest early tumour growth with SEF chemo. This problem is unique to cancer immunotherapy, where immune attack on tumours causes swelling, making them appear larger initially. This issue is now well documented, and recognized by the American Society of Clinical Oncology. Even the appearance of “new” tumours after starting immunotherapy is not necessarily an indication of therapy failure. Most Canadian oncologist are not aware of this issue, because they generally do not use immunotherapies. We are aware of the issue, and will order the scans with the most suitable timing, and will help interpret the results for you.

SEF CHEMO AND NATURAL MEDICINES

Many of our patients receive natural medicines as part of their cancer therapy. While we have data about interaction of natural medicines and standard chemo (like carboplatin alone), we do not have data for SEF chemo (carboplatin with mesna). Also, a review of several of our initial patients has revealed that there is potential for interactions of natural medicines with the mesna, rendering it less effective. Therefore, we now strongly recommend stopping all natural medicines including vitamins (except vitamin D) prior to starting SEF chemo. They should not be re-started until the entire SEF chemo treatment is complete, or unless your doctor advises. Vitamin D should be continued. Natural medicines that are not absorbed (e.g. probiotics or certain topical medicines) are acceptable to use during SEF chemo treatment. If you feel there is a natural medicine that you absolutely must take, please check with Dr. Khan or Dr. Matsumura in advance.

CHEMO EXPOSURE ADVICE FOR FAMILY MEMBERS

Source: American Cancer Society – modified from the original

There are many things you can do during and after chemo to keep yourself and your loved ones from being affected by the drugs while your body is getting rid of them. It takes about 2 – 3 days for your body to break down and/or get rid of most chemo drugs.

Most of the waste comes out in your body fluids – urine, stool, tears, and vomit. The drugs are also found in your blood. When these drugs get outside your body, they can sometimes irritate skin – yours or even other people’s. Repeated exposure to small amounts of chemo drugs can cause cancer several years later (single or limited exposures are not likely to cause cancer). Exposing a pregnant woman to chemo drugs can harm the fetus. Since chemo appears in body fluids, toilets can create a mild risk for children and pets. During chemo and for 48 hours after chemo:

  • Flush the toilet twice after you use it. Put the lid down before flushing to avoid splashing. If possible, you may want to use a separate toilet during this time. If this is not possible, wear gloves to clean the toilet seat after each use.
  • Both men and women should sit on the toilet to use it. This cuts down on splashing.
  • Always wash your hands with soap and water after using the toilet. Dry your hands with paper towels and throw them away.
  • If you vomit into the toilet, clean off all splashes and flush twice. If you vomit into a bucket or basin, carefully empty it into the toilet without splashing the contents and flush twice. Wash out the bucket with hot, soapy water and rinse it, emptying the wash and rinse water into the toilet, then flushing it. Dry the bucket with paper towels and throw them away.
  • Caregivers should wear 2 pairs of throw-away gloves if they need to touch any of your body fluids. (These can be bought in most drug stores.) They should always wash their hands with warm water and soap afterward – even if they had gloves on.
  • If a caregiver does come in contact with any of your body fluids, they should wash the area very well with warm water and soap. It’s not likely to cause any harm, but try to take extra care to avoid this. At your next visit, let your doctor know this happened. Being exposed often may lead to problems, and extra care should be taken to avoid this.
  • Any clothes or sheets that have body fluids on them should be washed in your washing machine – not by hand. Wash them in warm water with regular laundry detergent. Do not wash them with other clothes. If they cannot be washed right away, seal them in a plastic bag.
  • If using throw-away adult diapers, underwear, or sanitary pads, seal them in 2 plastic bags and throw them away with your regular trash.

CARRBOPLATIN

(modified from the original document created by Cancer Care Ontario)

This document provides general information about your medication. It does not replace the advice of your doctors. Always discuss your therapy with your doctors.

Other name: Generic brand(s) available, Paraplatin AQ®
Appearance: Clear, colourless solution

What it is used for

  • Approved for treating ovarian cancer, lung cancer. Can be used for treating many other cancers (“off-label”).

Before using it

  • Tell your doctor if you have/had significant medical condition(s), especially if you have / had kidney disease, hearing problems, or any allergies, especially to other similar drugs such as oxaliplatin or cisplatin.
  • CARBOplatin may harm the unborn baby.
  • Let your doctor know if you are breastfeeding, pregnant or plan to become pregnant.
  • People who have cancer are at a higher risk of developing other cancers or blood clots. Also, some cancer medications, such as CARBOplatin, may increase these risks. You should discuss these with your doctor.

Pregnancy and breastfeeding

  • Do not use this drug if you are pregnant. If there is ANY chance that you or your partner may become pregnant, you and your partner together must:► Use 2 effective forms of birth control at the same time while taking this drug: Keep using birth control until 6 months after the last dose (general recommendation). Discuss with your healthcare team.
  • Tell your doctor right away if you or your partner becomes pregnant.
  • Do not breastfeed while taking this drug.
  • Effects on Fertility: Unknown

How it is given

  • This drug is given by injection into a vein.

While taking it

  • This drug can interact with other drugs; this can result in the drugs not working as well or cause severe side effects.
  • Make sure that your doctor and pharmacist have a complete list and any new changes of all your medicines and supplements, including prescription or non­prescription drugs, vitamins and herbals. Check with your doctor or pharmacist before starting or stopping any medicines/supplements.

Side effects and what to do

The following is a list of serious side effects that can occur with carboplatin alone without the SEF chemo protective regimen. It is expected that fewer side effects will occur with SEF chemo. Many of these side effects are uncommon with standard chemo, and are rare with SEF chemo. This is not a complete list – if you have any unusual symptoms, discuss with your doctor.

Side effects and what to do Contact doctor right away, or get emergency medical help Contact doctor as soon as possible (office hours) Contact doctor if it does not improve, or is severe
Nausea and vomiting

· May occur in hours to days after the chemo dose Drink clear fluids and avoid large meals. Get fresh air and rest.
· Limit spicy, fried foods or foods with a strong smell.
· Take anti­nausea drug(s) exactly as directed by your doctor. It is easier to prevent nausea than to treat it.
· Contact your doctor if nausea lasts more than 1 day or if any vomiting occurs.

X
Salt imbalance

(muscle twitching, weakness or cramping, confusion, irregular heartbeat)

High calcium levels in the blood

(confusion, severe muscle weakness, seizures, irregular heartbeat, thirst, frequent urination)

X
Kidney problems (lower back pain, body swelling)

· Also look for passing little or no urine, darkening or blood in urine, or recent unusual weight gain
· Your doctor may monitor for proteins in the urine regularly.
· Trouble with urination (less common). Drink regularly to prevent this problem.

X
· Unusual bleeding or bruising (black stools, coughing up blood, purple or red dots on skin, bleeding that will not stop)

· May occur in days to weeks after your dose is given / after treatment starts
· May be due to low platelets, but may occur even with normal platelets
· Use a soft toothbrush. Be careful not to cut or bruise yourself.
· Check with your doctor before any surgery or dental work.
· Use acetaminophen (Tylenol®) for fever, mild headache, aches or pains.
· Talk to your doctor first before using other drugs such as ibuprofen (Advil®) or naproxen (Aleve®) or aspirin, since they may increase bleeding risk. If taking aspirin regularly, talk to your doctor before you stop taking it.

X
Liver problems  (yellow skin or eyes, dark urine) X
Fever, chills, infection

· May occur in days to weeks after the dose is given after treatment starts
· Low white blood cells may make the body more prone to infection.
· Phone your doctor right away or go to the nearest emergency department, if your oral temperature is over 38°C or 100.4°F (unless stated otherwise by your healthcare team). Tell the healthcare team that you are on chemotherapy.
· Check your temperature, especially if you are feeling unwell with sweats, fever or chills. Take your temperature before using acetaminophen (Tylenol®), since it may mask fever.
· Wash your hands often. Avoid sick people and crowds.
· Check with your doctor before getting any vaccines.

X
Constipation (including abdominal pain)

· Eat a balanced diet with fibre such whole grains, fruit and raw vegetables.
· Drink plenty of fluids. Try light exercise regularly.
· Speak to your doctor if no bowel movement for 3 or more days.

X
Diarrhea

· May occur days to weeks after the drug is given / after treatment starts
· Drink plenty of clear fluids. Limit hot, spicy, fried foods, foods/drinks with caffeine, orange or prune juice.
· Try a low fibre diet (bananas, white rice, apple sauce).
· Take anti­diarrheal drug(s) if given to you by your doctor.

X
Seizures X
Allergic reaction

(fever, severe rash, itchiness, swollen face, lip or tongue, chest or throat tightness)
· Watch for symptoms during and shortly after the infusion

X
Blood clot

(limb pain or swelling, hardened vein in limb), may occur in lungs (cough, breathing problems, chest pain, coughing blood)

X
Stroke

(sudden loss of vision, speech, of the use of one arm or leg)

X
Heart attack (new chest pain, shortness of breath) X
High blood pressure

· Check your blood pressure regularly; medication to treat high blood pressure may be needed

  X
Poor appetite; do not feel like eating; weight loss

· Eat foods that you like and try to eat regular small meals.

  X

 

Go to SEF Chemo Main Web Page

For general questions: call Medicor at 416-227-0037
Email Dr. Khan: akhan@medicorcancer.com
Email Dr. Aguirre / Dr. Matsumura: medical@cancer-institute.com
Berkeley Institute International Website:  https://cancer-institute.com/

 SEF (“safe”) Chemo is a servicemark of Dr. Ken Matsumura and the Berkeley Institute, CA