M.Aired McInerney will never know if changing her treatment regimen has lowered her chances of surviving stage 3 triple-negative breast cancer. Her acute shortage of anticancer drugs forced her to change course not once, but twice.
McInerney, who was diagnosed in December 2022, said her doctor rearranged her medication regimen when Taxol (paclitaxel), one of the two drugs she was supposed to take, was not available at first. Instead, McInerney started two other chemotherapy drugs (adriamycin and cytoxan) in a regimen first, which she said was different from the standard treatment approach.
For the second time, after McInerney completed an infusion of adriamycin and cytoxan, she was to begin 12 weeks of taxol in combination with another chemotherapy called carboplatin. Taxol is back in stock at Penn Medicine’s Abramson Cancer Center in Philadelphia, where McInerney is being treated. However, carboplatin was only available for the first 10 weeks of the 12-week protocol.
For McInerney, who has a more aggressive form of breast cancer, the change felt like one blow after another.
“People have to go through so much, endure IVs and treatments, and do mental exercises to get through it,” said McInerney, a 38-year-old medical executive who lives in suburban Philadelphia. “And when I hear something is not available, it’s again really gut-wrenching, because it’s still out of control.”
In recent weeks, cancer physicians’ associations have been vocal about nationwide shortages of key drugs, including long-used generics such as carboplatin and cisplatin. According to the National Comprehensive Cancer Network, a nonprofit coalition of academic cancer centers, these drugs are the backbone of potentially curative treatments for breast, lung, prostate, and gynecologic cancers, as well as many types of leukemia and lymphoma.
Nearly all cancer centers (93%) report carboplatin shortages, A report in late May said 70% had supply problems similar to cisplatin. investigation It is administered by the National Comprehensive Cancer Network. Medical groups have issued guidance on how to distribute existing supplies. For example, the Society of Gynecologic Oncology released a series of statements, including a May 24 statement. Recommended Platinum agents are “preferred for therapeutic purposes or in situations where long-term clinical benefit is expected.”
For the patients and doctors involved, shortages mean difficult decisions to make in the already ubiquitous stress of a cancer diagnosis. McInerney recalled asking his doctor if he could replace the two doses of carboplatin he was missing. She was told she wasn’t. In other situations, patients may get an alternative drug, but it may not be the standard recommended go-to drug or may have more side effects, cancer doctors say. Alternatively, patients may have to travel farther to obtain the drugs they need.
“We’re all at a loss,” says Brian Orr, a gynecologic oncologist at the Hollings Cancer Center at the Medical University of South Carolina in Charleston.
C.Arboplatin and cisplatin, known as platinum drugs, offer the best chances of curing patients with cervical, ovarian, uterine and other gynecologic cancers, Orr said. “Except for a select few” [treatment] Advances have made platinum the most effective addition to cancer treatments that impact survival,” Orr said. “So it’s essential.”
Physicians treating gynecologic cancers at Hollings Cancer Center began distributing platinum shortly before the Society of Gynecologic Oncology issued guidelines, Orr said. As of late June, the dose of each carboplatin infusion had been slightly reduced and patients were still receiving the recommended total number of treatments, he said.
Regarding carboplatin availability, Mr. Orr said, “I think there are probably only a few weeks left to order before we run out of stock.” Meanwhile, clinics in the area are running out of carboplatin or cisplatin, and new patients are rushing to Hollings Cancer Center, an hour and a half from Beaufort, South Carolina, to get chemotherapy, he said.
In recent weeks, California oncologist Ravi Rao has estimated that only a third of patients can receive cisplatin or carboplatin on the day they arrive for their scheduled chemotherapy. “If we run out of medicine today, and someone comes to treat us tomorrow, and if they don’t have medicine, we just don’t give them,” said Rao, a member of Fresno’s large clinic and director of the Community Oncology Alliance, a nonprofit organization representing oncologists in the area.
In some cases, such as the protocol used for breast cancer patients, in hopes that the platinum would be available by then, Professor Rao reordered the injections and started the platinum-containing portion later in the sequence. For other patients, such as lung cancer patients, there are good alternatives, even if platinum isn’t in stock, he said.
But in some cases, no suitable alternative approach exists, Rao said of a recent decision regarding a 79-year-old man with stage 2 bladder cancer. The man was undergoing radiotherapy and was to receive carboplatin along with taxol. However, carboplatin, which is believed to be the more effective of the two agents, was not available during the first three cycles of the recommended six cycles of chemotherapy.
For the fourth cycle, Dr. Rao prescribed mitomycin. Mitomycin, a drug given to treat bladder cancer, is usually avoided in older patients because it is a “tough drug” that is likely to have serious side effects such as vomiting and diarrhea. If drug treatment doesn’t work, the next step is likely to remove the man’s bladder, he said.
“I told him, ‘I’m 79 and I haven’t given it to anyone, but I’m going to give it to you,'” Rao said. “We’re really careful with the dose reduction. I don’t want him to go all the way through treatment and never get effective chemotherapy.”
Oncologists may have to make these drug changes at short notice, with little advance information about when the drug will be unavailable or when it will be restocked, said Andrew Schumann, a cancer surgeon and medical ethicist at the University of Michigan.
“Most cancer treatments are based on high-quality evidence from clinical trials,” said Professor Schumann. testified about drug shortages at a parliamentary committee in March. “And drug shortages put us in a position where we have to make unevidence-based decisions because we’re just doing our best. It’s a very uncomfortable position for oncologists.”
M.Meanwhile, patients like Molly Young read headlines, count pills, and try not to worry. In late June, Young had only six doses of a targeted therapy called Tuxa (tucatinib) twice a day left as part of a multidrug regimen for stage 4 breast cancer. In her last two visits at the Walter Reed National Military Medical Center in Bethesda, Maryland, the drug was not available to her.
In the end, Young got more medicine before it ran out. Still, the 36-year-old singer and voice and piano teacher said the uncertainty can be unbearable at times.
“Even if I have all my meds, I still worry,” she said. “Will they do well? Am I suffering for a purpose? Will this really save my life? So there’s the extra worry of, ‘Do I have a toxic drug that’s hard to take and hard to handle?'”
Living with cancer can already be psychologically challenging, with a range of emotions ranging from anger and fear to feelings of overwhelm, as well as anxiety and depression.sometime in 2018 study 3,724 adult patients were enrolled, half of whom reported high levels of distress. The distress was related to physical problems such as fatigue and sleep disturbances.
Rao is particularly concerned about ovarian cancer patients because studies have shown that platinum enhances the chances of a cure. Nearly 20,000 women have been diagnosed I get ovarian cancer every year. About half of them will live at least another five years. For patients with advanced cancer, missing a single dose of platinum “affects the cure rate, no question about it,” Rao said. I just can’t say how much. ”
Cisplatin and carboplatin work similarly for ovarian cancer, but Dr. Rao prefers to prescribe carboplatin, which is less likely to cause nausea, fatigue, and other side effects. Christina Castro Garcia said when she first met Rao earlier this year after being diagnosed with stage 3 ovarian cancer, she assured me that the carboplatin and taxol regimen she was prescribed would have relatively mild side effects.
She was put on both drugs during her first chemotherapy cycle and felt tired and a little nauseous most of the time. However, only taxol was available in the second cycle. In her next two cycles, carboplatin became unavailable, so Castro-Her Garcia took cisplatin with taxol instead. She felt the effects of her increased side effects immediately.
“I probably vomited all day last time,” the 44-year-old said of her slow recovery from her last cycle last month. “Basically, I was throwing up for three days.
Castro Garcia credits her husband’s support and her religious beliefs with helping her cope with the lack of medicine in addition to cancer. But she added: “I literally feel like I’m walking in the dark not knowing what’s going to happen or what I’m getting for the day.”
McInerney, who has clinical training as a social worker, said she has witnessed the emotional strain of understaffed cancer care teams working hard for patients. If large institutions like the University of Pennsylvania are struggling to get enough of these drugs, what’s happening to cancer patients in more rural parts of the country, McInerney asked.
When Dr. McInerney asked about the effects of two underdosed doses of carboplatin, her cancer team said she believed she had received enough chemotherapy.
“But I’m still angry,” she said. “If I ever have a relapse in the future, it’s going to stay in the back of my mind. Is it because I started this way because Taxol wasn’t available? Was it because I didn’t get the final, complete protocol for these two of her treatments?”
