Management of adverse events and other practical considerations in patients receiving capecitabine (Xeloda®)

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Evaluation of bioequivalence and safety analysis of capecitabine tablets and Xeloda® under postprandial dosing conditions in Chinese patients with solid tumor

OBJECTIVES

To compare the pharmacokinetic and safety of the test group capecitabine tablets (0.5 g) and the reference group capecitabine tablets (0.5 g).

METHODS

This study was registered at www.chinadrugtrials.org.cn under the registration number CTR20220138. 48 subjects with solid tumor were recruited and randomized to receive either the test group or the reference group at a dose of 2 g per cycle for three cycles of the entire trial.

RESULTS

The point estimate of the geometric mean ratio of Cmax for the subject and reference groups was 1.0670, which was in the range of 80.00%-125.00%. And the upper limit of 95% confidence interval was -0.0450 < 0. The statistics of geometric mean ratio of AUC0-t and AUC0-∞ (test group/reference group) and their 90% confidence intervals were in the range of 80.00%-125.00%, thus the test group was bioequivalent to the reference group under the conditions of this postprandial test. There were no major or serious adverse events. Conclusion: The pharmacokinetic profiles of capecitabine under postprandial conditions were consistent between the two groups. The two groups were bioequivalent and had a similar favorable safety profile in Chinese patients with solid tumor.

Assessment of patients' knowledge of their treatment with capecitabine at the National Institute of Oncology in Rabat

INTRODUCTION

Capecitabine is a molecule of choice in the therapeutic arsenal of anticancer drugs used in Morocco for the treatment of breast cancer and colorectal cancer. Its frequent use imposes a follow-up and a post-prescription monitoring of the treatment modalities as well as the adverse events that may occur following its administration.

OBJECTIVE

The objective of this study is to evaluate the level of knowledge of patients in the day hospital of an oncology facility about their treatment with capecitabine.

MATERIALS AND METHODS

This is a prospective study conducted over a period of 2 months (January-February 2022) at the day hospital in the National Institute of Oncology in Rabat, and it was conducted using a questionnaire in order to evaluate patients' knowledge about their treatment with capecitabine.

RESULTS

This study involved 95 patients, 76% claimed to have ever received pharmaceutical advice on capecitabine treatment. The main indications were colorectal and breast cancer. Ninety seven percent knew the indication for capecitabine and the action of the molecule on the relevant tumor. Eighty three percent receiving capecitabine therapy reported the occurrence of side effects and hand-foot syndrome was the most reported in 31.2% of the total listed side effects.

DISCUSSION

Capecitabine is an oral treatment of choice for colorectal and breast cancer in Morocco. Therapeutic education happens to be an effective tool in order to guarantee the best effectiveness and manage the possible side effects that can occur during the treatment.

Effects of Continuous Nutrition Care on Nutritional Status and Dietary Habits of Patients With Colorectal Cancer Receiving Adjuvant Chemotherapy After Surgery

Patients with colorectal cancer may experience symptoms such as diarrhea, nausea, and anorexia, during surgery and chemotherapy, which can increase the risk of malnutrition. In addition, dietary habits play a key role in the onset of colorectal cancer; therefore, it is necessary to improve dietary habits to prevent recurrence during treatment after diagnosis. In this study, a clinical nutritionist conducted 4 interviews for patients diagnosed with colorectal cancer and scheduled for colectomy: before surgery, after surgery, 1st chemotherapy, and 2nd chemotherapy, and provided nutrition care for each treatment course to determine its effects on nutrition status and disease prognosis. Significant weight loss but no decrease in muscle mass was observed during treatment. Body fat mass, although not statistically significant, showed a decreasing tendency. The percentage of people who responded 'yes' to the below items increased after compared to before receiving nutrition education: 'I eat meat or eggs more than 5 times a week,' 'I eat seafood at least three times a week,' 'I eat vegetables at every meal,' 'I eat fruits every day,' and 'I eat milk or dairy products every day.' These results indicate that the patients changed their dietary habit from a monotonous eating pattern to a pattern of consuming various food groups after receiving nutrition education. These results suggest that continuous nutrition care by clinical dietitians, according to the patient's treatment process, can help improve the patient's nutritional status and establish healthy eating habits.

Clostridium difficile Infection During Palliative Capecitabine Chemotherapy: A Case Report

Capecitabine has been used for triple-negative metastatic breast cancers both as monotherapy and in combination with other agents. However, its gastrointestinal side effects are one of the biggest challenges for its patient compliance, and often result in permanent drug withdrawal. There have been reports of it causing enterocolitis (mainly terminal ileitis) and even ischaemic colitis, but it has not frequently been directly associated with Clostridium difficile infection. We describe a case of a 65-year-old woman with triple-negative breast cancer on palliative capecitabine who presented with blood-streaked watery diarrhea and abdominal pain and was diagnosed with chemotherapy-induced severe colitis with superimposed Clostridium difficile infection. 

Conditions for the Implementation of a Patient Education Program Dedicated to Cancer Patients Treated by Oral Anticancer Therapy

INTRODUCTION

A patient education program has been developed in the field of cancer for supporting cancer patients undergoing oral anticancer therapies. Its implementation was tested in 3 different settings. The objectives of this study were to 1) identify barriers and facilitators for implementing the patient education program, 2) identify practices encouraging or hindering implementation and 3) produce recommendations for its dissemination.

METHODS

Twenty semi-structured interviews were conducted with caregivers from all three establishments.

RESULTS

The main factors associated with successful implementation were as follows: prescribers' representations on patient education, considered of low value; on oral anticancer therapies, considered too dangerous to be handled by the patient him/herself, the indefinite legitimacy of certain professions in charge of patient education programs; patients' engagement in their care pathway and provision of caregivers.

CONCLUSION

Recommendations include developing patient education culture within the environment of the medical doctors' curriculum, to consider contextual, pre-existing cooperative units for implementing patient education, to systematically send patients to patient education programs without practicing triage. Successful implementation of patient education critically depends on the prescribing physicians' perceived value of patient education. Patient education should become mandatory, integrated as part of the cancer care pathway. Physicians lack the necessary time and/or means to assess patients' capacity for engagement, without adequate strategies for their support. Therefore, physicians should systematically refer all patients to patient education, where nurses can tailor their coaching of cancer patients.

TRIAL REGISTRATION

The study protocol was approved by the IRB SUD EST I (N° EudraCT: 2016-A00113-48). All participants were given written and verbal information about the study and gave informed consent to participate.

Virtual Screening, Docking, Synthesis and Bioactivity Evaluation of Thiazolidinediones as Potential PPARγ Partial Agonists for Preparation of Antidiabetic Agents

Background:

Peroxisome proliferator-activated receptor gamma (PPARγ) is one of the key targets of insulin resistance research, in addition to being ligand-activated transcription factors of the nuclear hormone receptor superfamily with a leading role in adiposeness activation and insulin sensitivity. They regulate cholesterol and carbohydrate metabolism through direct actions on gene expression. Despite their therapeutic importance, there are dose limiting side effects associated with PPARγ drug treatments, thus a new generation of safer PPARγ drugs are being actively sought after treatment.

Methods:

In this study, we used computer aided drug design to screen new series of PPARγ ligands, and synthesized a series of potential thiazolidinedione derivatives such as 5,7- dibenzyloxybenzyl-3-hydroxymethyl-4H-coumarin-4-ketone, using 4-steps to synthesize the target compounds and built streptozotocin (STZ) induced insulin resistance rat model to measure their antidiabetic activity.

Results:

We found that 10 mg/kg concentration of compound 0701C could significantly decrease blood glucose and serum PPARγ, serum insulin levels in insulin resistance model rat.

Conclusion:

We would conclude that compound 0701C might serve as a potential PPARγ partial agonist.

Side Effects, Self-Management Activities, and Adherence to Oral Anticancer Agents

PURPOSE

There are growing concerns about patients' adherence to oral anticancer agents (OAAs), and the need for patients to engage in self-management of OAA-related side effects. We assessed associations among adherence, severity of side effects, and effectiveness of self-management of side effects in patients taking capecitabine.

METHODS

Adherence to capecitabine at 6 weeks was measured by the Medication Event Monitoring System among 50 patients with gastrointestinal cancers. Severity of side effects related to capecitabine and effectiveness of self-management of side effects were captured using the Modified Self-Care Diary at the time of enrollment and weekly for 6 weeks. Spearman's correlation, Mann-Whitney U-tests, and multiple linear regression were conducted, p<0.05.

RESULTS

Overall mean adherence rate was 85.4±14.1%. Adherence rate was not significantly correlated to the mean severity of total side effects at any time point and was correlated with the mean effectiveness of self-management of total side effects only at week 2 (rho=0.29, p=0.04). However, adherence rate was associated with the mean severity of one specific side effect, diarrhea, at 6 weeks (rho=0.36, p=0.01) and marginally correlated to the mean effectiveness of self-management of diarrhea at 6 weeks (rho=0.28, p=0.05). Mean severity of diarrhea at 6 weeks was an independent predictor of adherence rate (b=4.97, p=0.01), with the control of age (b=0.52, p=0.002), number of outpatient medications (b=1.12, p=0.007), health literacy (b=2.53, p=0.04), diagnosis of colorectal cancer (b=11.6, p=0.03), and capecitabine in combination with other chemotherapies (b=16.8, p=0.001) in the model.

CONCLUSION

This pilot study suggests ongoing examination of both severity and effectiveness of self-management of side effects in future studies of adherence to OAAs is merited. There is a need for future studies with larger sample sizes that explore the complex relationships among adherence, severity of side effects, and effectiveness of self-management of side effects in OAA therapy.

Effects of a nurse-led medication self-management programme in cancer patients: protocol for a mixed-method randomised controlled trial

BACKGROUND

With the widespread use of orally administered anticancer agents, self-management by cancer patients is inevitable, and adherence to medication is becoming the centre of interest in oncology.

METHODS/DESIGN

This mixed-method study is a two-phased approach with a combined quantitative and qualitative design. In the first phase, we will conduct a prospective randomised controlled study to assess the effects of a nurse-led medication self-management programme for patients receiving oral anticancer treatment. Patients with metastatic breast cancer, who have been newly prescribed an oral chemotherapy or a targeted therapy agent will be enrolled in the study. The participants will be randomly assigned to either the medication self-management support programme group (intervention group) or the conventional care group (control group). This will be an open-label study; therefore, neither the patients nor the nurses will be blinded. Nurses will provide patients in the intervention group with information by using the teach-back method, help patients set a goal based on their preferences, and solve problems through follow-up counselling. The primary outcome measure is adherence to medication, to be measured on the basis of the medication possession ratio (MPR), which is the ratio of the number of days of medication supply to the total days at a specified time interval. We hypothesize that the intervention group will have an MPR of ≥90 % that is significantly higher than that of the control group. Secondary outcome measures include self-efficacy, quality of life, psychological distress, severity and interference of symptoms, patient satisfaction, emergency department visits, and hospital admissions. In the second phase, we will conduct focus-group interviews with intervention nurses, and perform a content analysis to understand their role and challenges these nurses will face in the programme while improving patients' medication adherence.

DISCUSSION

The present study will be the first Japanese study to evaluate the effects of medication self-management support provided by nurses to patients with metastatic breast cancer who are receiving oral anticancer treatment. The study is characterised by a unique patient-centred approach aiming to help patients manage their medication based on their needs and preferences, with both quantitative and qualitative evaluations. The findings will contribute to the facilitation of medication management in cancer patients.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN-CTR), Japan, UMIN000016597. (27 February 2015).

Celecoxib can prevent capecitabine-related hand-foot syndrome in stage II and III colorectal cancer patients: result of a single-center, prospective randomized phase III trial

BACKGROUND

Hand-foot syndrome (HFS) is the most common adverse event induced by capecitabine. Some clinicians think that HFS is a type of inflammation limited to the hands and feet and can be prevented with a COX-2 inhibitor (celecoxib).

METHODS

We designed a single-center, prospective randomized clinical trial to test the hypothesis. From August 2008 to December 2010, stage II and III colorectal cancer patients receiving capecitabine-based chemotherapy enrolled in the trial voluntarily. All patients were divided randomly into two groups treated with or without celecoxib. All adverse events were recorded.

RESULTS

Grade 1 and grade 2 HFS were more common in the capecitabine group than in the capecitabine/celecoxib group (74.6% versus 57.4%, P = 0.034, 29.6% versus 14.7% P = 0.035). The use of celecoxib (P < 0.001, P = 0.003) and the level of dihydropyrimidine dehydrogenase (P = 0.048, P = 0.014) affected the incidence of grade 1 and 2 HFS, as determined by log-rank analysis. Multivariate Cox proportional hazards regression analysis indicated that the use of celecoxib was the only factor that affected the incidence of ≥ grade 1 HFS [Hazard Ratio (HR): 0.556, P = 0.001] and ≥ grade 2 HFS (HR: 0.414, P = 0.005).

CONCLUSIONS

Celecoxib can be used effectively and safely to prevent capecitabine-related HFS.

[Severe toxicity following capecitabine administration because of dihydropyrimidine deshydrogenase (DPD) deficiency]

Capecitabine is an anticancer agent, prodrug of 5 fluorouracil (5-FU) administered orally and with a narrow therapeutic index. In gastrointestinal cancer, capecitabine is indicated for the treatment of colorectal cancer and metastatic unresectable gastric cancer. The 5-FU is active by incorporation in the biosynthesis of nucleic acids. Inhibition of endogenous synthesis of thymidine is the main way of toxicity of 5-FU. 5-FU is metabolised by the dihydopyrimydine dehydrogenase (DPD). Patients with a DPD deficiency can experience severe toxicity of 5-FU. We report the case of a patient who presented signs of major toxicity justifying hospitalization in intensive care unit 11 days after capecitabine initiation. Investigations showed that he had a DPD deficiency. This case leads to explain the different biological ways to identify patients at risk of developing severe toxicity following capecitabine administration because of DPD deficiency. Is it possible to make a systematic screening before initiation of treatment with 5-FU or prodrug of 5-FU?

Effectiveness of a Home Care Nursing Program in the Symptom Management of Patients With Colorectal and Breast Cancer Receiving Oral Chemotherapy: A Randomized, Controlled Trial

Purpose

To assess the effectiveness of a symptom-focused home care program in patients with cancer who were receiving oral chemotherapy in relation to toxicity levels, anxiety, depression, quality of life, and service utilization.

Patients and Methods

A randomized, controlled trial was carried out with 164 patients with a diagnosis of colorectal (n = 110) and breast (n = 54) cancers who were receiving oral capecitabine. Patients were randomly assigned to receive either a home care program by a nurse or standard care for 18 weeks (ie, six cycles of chemotherapy). Toxicity assessments were carried out weekly for the duration of the patients' participation in the trial, and validated self-report tools assessed anxiety, depression, and quality of life.

Results

Significant improvements were observed in the home care group in relation to the symptoms of oral mucositis, diarrhea, constipation, nausea, pain, fatigue (first four cycles), and insomnia (all P < .05). This improvement was most significant during the initial two cycles. Unplanned service utilization, particularly the number of inpatient days (57 v 167 days; P = .02), also was lower in the home care group.

Conclusion

A symptom-focused home care program was able to assist patients to manage their treatment adverse effects more effectively than standard care. It is imperative that patients receiving oral chemotherapy are supported with such programs, particularly during initial treatment cycles, to improve their treatment and symptom experiences.

Pharmacology and therapeutic efficacy of capecitabine: focus on breast and colorectal cancer

Capecitabine (N -pentyloxycarbonyl-5-deoxy-5-fluorocytidine), an oral prodrug of 5-fluorouracil, has provided compelling efficacy data for the treatment of metastatic breast cancer and stage III or IV colorectal cancer, both as monotherapy and in combination regimens. The preferential conversion of capecitabine to 5-fluorouracil in neoplastic tissues renders this fluoropyrimidine particularly appealing for clinical use. The enzyme thymidine phosphorylase, which mediates the final step of the capecitabine activation pathway, is expressed in higher concentration in neoplastic than in healthy tissues. This makes capecitabine more tumor specific than other chemotherapeutic agents. Accordingly, capecitabine is generally well tolerated. In particular, the incidence of myelosuppression and alopecia is low, and the most common side effects, hand-foot syndrome and diarrhea, are usually manageable. Given its good toxicity profile, capecitabine was assessed in combination with several chemotherapeutic or biologic agents. In addition, the observation that thymidine phosphorylase is upregulated after treatment with other anticancer drugs, namely taxanes, provided a rationale for the prominent antitumor activity recently observed for the combination of capecitabine with these agents. This review provides an evidence-based update of clinical trials investigating the role of capecitabine in the treatment of breast and colorectal cancer, with special emphasis on pharmacological and safety issues that form the basis of currently used schedules.

Managing treatment side effects in advanced breast cancer

OBJECTIVES

To compare and contrast the side-effect profiles of antineoplastic therapy options used in the treatment of metastatic breast cancer.

DATA SOURCES

Published research articles, abstracts, and clinical experience.

CONCLUSION

Novel and existing antineoplastic agents used in the treatment of metastatic breast cancer generally have mild side effects, but can have the potential for serious reactions. Nausea/vomiting, diarrhea, stomatitis/mucositis, and dermatologic and cardiovascular effects are common. Strategies such as dietary changes, over-the-counter remedies, and dose modification can be used to counteract these mild effects.

IMPLICATIONS FOR NURSING PRACTICE

The oncology nurse should be aware of common adverse events associated with antineoplastic agents, recognize early side-effect signs, and be ready with effective strategies to mitigate side effects when and if they occur.

Toxicity profile and efficacy of oral capecitabine as adjuvant chemotherapy for Chinese patients with Stage III colon cancer

PURPOSE

The Xeloda in Adjuvant Cancer Therapy trial, conducted in a white population of patients, established capecitabine (Xeloda) as adjuvant chemotherapy for Stage III colon cancer. Given the ethnical difference in toxicity of adjuvant chemotherapy in colon cancer, this study was designed to evaluate the safety and efficacy of adjuvant capecitabine in Chinese patients with colon cancer.

METHODS

Chinese patients with curatively resected Stage III colon adenocarcinoma, who received adjuvant capecitabine, were entered into a prospective database. Oral capecitabine was given at 1,250 mg/m(2) twice daily, Days 1 to 14, every 21 days, for 8 cycles. Toxicities, laboratory abnormalities, and survival outcomes were evaluated.

RESULTS

Fifty-eight patients were entered into the database between August 2004 and October 2005. The median age was 63.9 years with a male-to-female ratio of 1.15:1. With a median follow-up duration of 20.9 months, 14 patients relapsed and 3 patients died. Disease-free and overall survival at two years was 69 and 97 percent, respectively. Grade 3 toxicities occurred as follows: stomatitis (1.7 percent), diarrhea (0 percent), hand-foot syndrome (41.4 percent), leucopenia (1.7 percent), neutropenia (3.4 percent), and hyperbilirubinemia (1.7 percent). No Grade 4 or 5 toxicity was noted. Compared with the Xeloda in the Adjuvant Cancer Therapy trial, a much higher incidence of serious hand-foot syndrome and a lower rate of severe diarrhea were found in this study.

CONCLUSIONS

A different toxicity profile of adjuvant capecitabine was noted in this study on Chinese patients with colon cancer compared with that reported in the Xeloda in Adjuvant Cancer Therapy trial, whereas the efficacy outcomes were comparable.

Topical henna for capecitabine induced hand-foot syndrome

Capecitabine is a chemotherapeutic drug for use in cancers. Hand-foot syndrome (HFS) is side effect of capecitabine which can lead the cessation of the therapy or dose reduction. Henna (Lawsonia inermis) is a traditionally used plant of Middle-East that is applied on hands and feet. Some of cancer patients in capecitabine treatment who developed HFS, we recommended to apply henna. In these patients, six patients were grade 3 HFS and four were grade 2 HFS. Complete response (CR) were seen in four of grade 3 HFS and all of grade 2; two grade 3 HFS improved to grade 1. So far, in the chemotherapy, there was no need of dose reduction and also no side effect of henna seen. Clinical improvement in these patients may relate to anti-inflammatory, antipyretic and analgesic effects of henna. Prospective studies are needed to show this therapeutic effect of henna.

Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre

Palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome (HFS) is a relatively common side effect of cytotoxic chemotherapy. Many cytotoxic drugs have been reported to cause the condition but it is more frequently associated with 5 fluorouracil (5FU), liposomal doxorubicin and cytarabine. The oral 5FU precursor, capecitabine is frequently associated with PPE and with the recent extension of its use to adjuvant treatment, the incidence of PPE is likely to increase. The initial symptoms are dysesthesia and tingling in the palms, fingers and soles of feet and erythema, which may progress to burning pain with dryness, cracking, desquamation, ulceration and oedema. Palms of the hands are more frequently affected than soles of the feet. This condition is painful and distressing to patients and in some incidences it results in patients not being able to work or perform normal daily activities. It can also result in treatment interruptions which impact on the efficacy of the treatment regimen. Effective and appropriate patient education from a specialist nurse prior to treatment is an essential part of patient management which will facilitate early identification of the symptoms and therefore prevent treatment delays and PPE progression. This article reviews current knowledge of the condition, including classification, and discussion of the findings of a clinical audit in a cancer centre. It includes the incidence, grading, management and impact of PPE on normal daily activities.

Les enjeux de l’observance pour les nouvelles chimiothérapies par voie orale : intérêt du modèle pharmacocinétique-pharmacodynamique

Nowadays, more and more oral anticancer chemotherapies are developed either for cytotoxic or new targeted drugs. But this relatively new route of administration in oncology drives to new problems in treatment management and particularly to non-compliance, i.e. the deviance of the actual way patients take their treatment with the prescription. Population PK-PD models and Monte-Carlo simulations allow to study the impact of non-compliance on toxicities. After a brief review on recent developments about oral chemotherapies, this work presents a simulation where non-compliance, modelled with a two state Markov chain defining four compliance profiles from excellent to poor, is linked to two dose-toxicity (continuous or categorical) population models. Simulated patients with the lowest compliance level were less exposed to treatment and therefore experienced less toxicity with shorter events. Nevertheless treatment efficacy is also lower, and this loss of efficacy may compromise patient's outcome. These results foresee the necessity of global simulations, combining compliance, toxicity and efficacy modelling.

Management of hand-foot syndrome induced by capecitabine

INTRODUCTION

Capecitabine (Xeloda) is a systemic prodrug of 5-fluorouracil (5-FU), which is administered in an oral formulation. Hand-foot syndrome (HFS) has proven to be a chronic dose-limiting toxicity of capecitabine, leading to significant morbidity in patients receiving this agent. The purpose of this review is to define the pathophysiology, risk factors, incidence and management of capecitabine-induced HFS.

METHODS

Literature for this review article was collected from the following databases: PubMed, CINAHL, and the proceedings of the American Society of Clinical Oncology (ASCO) confined to the years 1995-2006. The following key terms were used in the search: hand-foot syndrome, palmar-plantar erythrodysesthesia, capecitabine, Xeloda, colorectal cancer, and metastatic breast cancer.

RESULTS

HFS associated with capecitabine is a serious dose-limiting toxicity. Incidence of grade 3/4 toxicity is of extreme significance, and introduces the need for dose reductions and/or interruptions in capecitabine therapy. Drug-related therapies studied include topical emollients and creams, systemic and topical corticosteroids, nicotine patch, vitamin E, pyridoxine, and COX-2 inhibitors. However, due to the lack of randomized, controlled trials with these therapies, the current mainstay of treatment for the management of this toxicity is interruption of therapy and, if necessary, dose reduction.

CONCLUSION

Treatment interruption or dose reduction remain the only methods shown to effectively manage HFS, but supportive measures to reduce pain and discomfort and prevent secondary infection are very important. Many other prophylactic and treatment strategies have been investigated, with pyridoxine and COX-2 inhibitors being the most promising in case reports and retrospective studies; therefore, prospective, randomized, controlled trials are needed to prove their efficacy.

Hand-Foot Syndrome Variant in a Dihydropyrimidine Dehydrogenase–Deficient Patient Treated with Capecitabine

We present a case with dihydropyrimidine dehydrogenase (DPD) deficiency that manifested a variant of hand-foot syndrome (HFS). A 52-year-old man received capecitabine for adjuvant treatment of rectal cancer. On the ninth day of the first cycle, he presented to the clinic with a rash on the dorsum of both hands accompanied by symptoms of pain, erythema, swelling, and desquamation consistent with grade 3 HFS. The palms of his hands and soles of his feet were only tender with no apparent rash or discoloration. Dihydropyrimidine dehydrogenase activity was evaluated by radio assay using peripheral blood mononuclear cells. Dihydropyrimidine dehydrogenase activity was below normal: 0.12 nmol/minute/mg protein. Capecitabine was not resumed, and the rash resolved in 3 weeks with the use of pyridoxine and Udderly Smooth balm. Interestingly, HFS is rarely seen with 5-fluorouracil regimens containing selective DPD-inhibitors. This patient with DPD deficiency manifested a variant of HFS. The pharmacologic basis for the development of HFS in DPD-deficient patients warrants further investigation. Dihydropyrimidine dehydrogenase deficiency, if undiagnosed, can lead to death. In addition to severe to life-threatening toxicities akin to 5-fluorouracil, capecitabine can lead to unusual variants of common toxicities, including HFS, in DPD-deficient patients.

Capecitabine: a new adjuvant option for colorectal cancer

Colorectal cancer continues to pose a major public health threat in the United States. Without postsurgical adjuvant therapy, approximately 50% of patients will have recurrent disease and die within five years. Since 1990, five new chemotherapy agents have been added to the therapeutic armamentarium for management of colorectal cancer, and agents traditionally used to treat metastatic and advanced disease increasingly are being applied in the adjuvant setting. One such treatment, capecitabine, offers patients the benefit of oral dosing and permits at-home self-management. A phase III randomized trial, Xeloda in Adjuvant Colorectal Cancer Treatment, demonstrated that treatment with single-agent capecitabine was equivalent to bolus 5-fluorouracil with leucovorin with respect to disease-free survival and overall survival, with significantly less diarrhea, stomatitis, neutropenia, nausea and vomiting, and alopecia. This article reviews the findings and discusses how oncology nurses can help provide effective education and monitoring for patients using oral treatment in the adjuvant setting.

The vital role of education and information in patients receiving capecitabine (Xeloda)

Use of oral capecitabine (Xeloda) as home-based therapy leads to savings in healthcare resources and costs and oral chemotherapy is preferred by many cancer patients over intravenous (i.v.) 5-FU. The demands of patient management for oral therapy differ significantly from those of i.v. chemotherapy. Consequently, cancer programmes have begun to implement strategies to meet these unique demands, offer educational programmes for clinicians who prescribe capecitabine, and consider potential changes in staff responsibilities. To encourage patients to take an active part in their care, which is vital with home-based oral therapy, they must be properly informed about their treatment. Patient information needs to be specific for the cancer type and relevant for the country. Various tools have been developed, including prescription guides, diary cards and support kits, which are useful in reinforcing verbal discussions about the use of capecitabine and in helping patients to manage their treatment. Nurses have a vital role to play in encouraging the optimal use of capecitabine and prompt management of adverse events, thereby enabling the patient to achieve a better clinical outcome and maintain an improved quality of life in the home environment.

Implications of capecitabine (Xeloda®) for cancer nursing practice

Home-based therapy with oral capecitabine (Xeloda) has a number of advantages over i.v. hospital-based chemotherapy regimens, including improvement in patients' quality of life, and medical resource/cost savings compared with 5-FU/LV in metastatic colorectal cancer. In addition, the ability of capecitabine to extend survival beyond docetaxel in patients with previously treated metastatic breast cancer means that capecitabine plus docetaxel is a very cost-effective combination. Oncology nurses should prepare for the increased use of oral capecitabine as a single agent or in combination regimens in the outpatient setting. The use of this drug requires enhanced patient education skills, communication (e.g. telephone contact) and patient management on the part of the nurse. Oncology nurses will also need to accept a more significant and pivotal role in the clinical oncology team, not only as a point of contact between the patient and clinician, but also in documenting the benefits of capecitabine to ensure the effective management of patients receiving the drug.