Wednesday, March 18, 2009

Chemotherapy desensitization

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.”

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