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Dr. Andrew Rynne
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Dr. Andrew Rynne

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What are the side effects of Paclitaxel?

Answered by
Dr.
Dr. Indranil Ghosh

Oncologist

Practicing since :2004

Answered : 1500 Questions

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Posted on Tue, 28 Apr 2015 in General Health
Question: Hi,

I am following up after the following thread
http://www.healthcaremagic.com/AskDoctorInboxServlet?page=viewQuery&queryId=180925

My mother had her third round of AC. She will be due for weekly Paclitaxel soon. I had some questions regarding that
1. How may patients of yours you see develop peripheral neuropathy?
2. What are the signs to watch out for to know if you are developing neuropathy or not
3. In US, there are multiple phase 2 trials going on to figure out if wearing cold mittens and cold socks can help with the symptoms. Link below
https://clinicaltrials.gov/ct2/show/NCT0000
https://clinicaltrials.gov/show/NCT0000
Experimental: Cryotherapy
Each patient will receive cryotherapy administered during weekly paclitaxel treatments by Elasto gelâ„¢ Hypothermia mitts and slippers. Patients will wear the mitts and slippers for 15 minutes prior to treatment start, for 60 minutes during treatment, and for 15 minutes following treatment completion, for a total of 90 minutes.

Cold cap has been proven to prevent hair loss during chemotherapy. This seems like a natural thing to do. What is your opinion? The idea is that cold temperature will lower the blood flow to hands and feet and will cause less side effects.
doctor
Answered by Dr. Indranil Ghosh 2 hours later
Brief Answer:
Yes neuropathy can be a problem

Detailed Answer:
Hi

Neuropathy is seen in around 15-20% of patients on paclitaxel. But around 5% only are grade 3 or higher (which means causing deterioration in quality of life). Any tingling/numbness or loss of sensation in glove and stocking distribution (fingers and toes) to be promptly reported to the treating physician. We should stop paclitaxel if it reaches grade 2 at least.

Crytotherapy/cold mittens etc to prevent neuropathy can be considered experimental at current time. That's why trials are going on.

Effect on scalp cooling on hairfall is modest at best and hence not popular among many oncology centers worldwide. But certainly it is something which should be tried more and more as it is relatively harmless.


Hope this helps.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh 6 hours later
Even for the weekly dosage, occurrence of neuropathy is 15-20%. Is it permanent?
doctor
Answered by Dr. Indranil Ghosh 1 hour later
Brief Answer:
yes

Detailed Answer:
In weekly paclitaxel the neuropathy is more because the total dose delivered is higher.

For example, 4 cycles of 3 weekly paclitaxel @175 mg/m2 = 700 mg/m2 total.
12 weeks of paclitaxel @80 mg/m2 = 960 mg/m2 total, almost 40% higher.

this article highlights this http://www.nejm.org/doi/full/10.1056/NEJMoa0000
"Grade 2, 3, or 4 neuropathy was more frequent with weekly paclitaxel than with paclitaxel every 3 weeks (27% vs. 20%)." And this is only grade 2-4, excluding grade 1.

Some of the neuropathy is permanent but some slow recovery is expected. Upto 2 years many of the symptoms have been shown to be persisting.
http://www.ncbi.nlm.nih.gov/pubmed?term=0000

Hope this helps
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh 21 minutes later
Our doctor told us that side effects of weekly taxol are much lower. This seems totally contrary. Are there any benefits doing weekly taxol. The survival benefits seems the same.
Also, we got the blood work done after 5th day of chemo and I am attaching the report. The lymphocytes seem to be lagging. The lymphocytes did not even recover fully before the last chemo and lymphocytes are so much required to prevent metastases. Does CSF not boost lymphocytes. Can we do something to help recover?
doctor
Answered by Dr. Indranil Ghosh 14 minutes later
Brief Answer:
yes, lymphocytes are bit low

Detailed Answer:
GCSF does not boost lympho, only neutrophils. But I think she can pull through with this much lympho. I don't think we have anything specific to increase the lymphos.

Make no mistake, weekly pacli is better than 3 weekly in terms of efficacy and less overall adverse effects. The study I quoted also highlights this. It is only the neuropathy which is more because it is related to the total dose delivered. If we give same amount of dose 3 weekly (say 240 mg/m2 X4 cycles) then also the neuropathy will increase, but the other side effects will be too much to bear. Hence weekly is preferred.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh 43 minutes later
Okay Thanks. But what about 175mg/m2. Will that also have worse side effects?
Also, regarding lymphocytes, should we expect them to stay low throughout the treatment?
doctor
Answered by Dr. Indranil Ghosh 53 minutes later
Brief Answer:
see below

Detailed Answer:
No, it has similar side effects as 80 mg/m2 every week except for increased body pains after chemo which is more in 3 weekly. But survival is worse in 3 weekly (refer to the article I mentioned).

Lymphos will likely remain low, especially during AC
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh 24 hours later
Thanks. Do the lymphos become better during paclitaxel
Is it okay for her to drink freshly prepared fruit and vegetable juices after carefully washing the fruits/vegetables with hot water and then juicing them.?
doctor
Answered by Dr. Indranil Ghosh 28 minutes later
Brief Answer:
yes during pacli they may improve

Detailed Answer:
Yes, sure you can give her carefully washed fruits or their juices. This does not increase the risks of infection.

There is one study in leukemia patients which illustrates this. Breast cancer has far lower risks than leukemia.
http://www.ncbi.nlm.nih.gov/pubmed/0000
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh 34 hours later
Thanks for pointing out that research. That really helped

I have been doing some research regarding Neuropathy and found that Glutamine seems to be helping in neuropathy. Glutamine seems to tumor promoter(in vitro) however the clinical data seems to suggest that it does not promote tumor and helps in reducing symptoms of neuropathy.
I found this good article
http://www.integrativeoncology-essentials.com/2013/02/use-glutamine-to-reduce-the-severity-of-mucositis-and-neuropathy-during-chemotherapy-or-radiation-therapy/

Study which suggests that glutamine promotes tumor
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/

Study which says that clinical evidence supports glutamine is helpful for cancer patients
http://www.ncbi.nlm.nih.gov/pubmed/0000/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000

Study suggesting benefit of glutamine
http://clincancerres.aacrjournals.org/content/7/5/1192.full
http://www.ncbi.nlm.nih.gov/pubmed/0000
http://depts XXXXXXX edu/integonc/clinicians/spc/l-glutamine.shtml

Currently placebo controlled clinical trials are in progress to evaluate the benefit of glutamine. I am not sure what the outcome was for this trial
http://www.cancer.gov/clinicaltrials/search/view?cdrid=452127&version=HealthProfessional

Please let me know what are your thoughts. I researched some forums and it seems the patients in US seem to be taking it
https://community.breastcancer.org/forum/6/topic/823615

Glutamine also seems to be helping in radiation induced mucositis. Also, what are the chances of getting severe mucositis in radiation treatment for breast cancer. The last thing we would want is to have her not able to eat properly.
doctor
Answered by Dr. Indranil Ghosh 1 hour later
Brief Answer:
Role of glutamine still not proven beyond doubt

Detailed Answer:
Gluitamine sure has some promising data, especially in preventing neuropathy but some studies have not shown benefit and some have. All are small studies. The randomized trial has not yet been published. Hence it is not a routine practice and not endorsed by any guideline.

Your mom need not worry about radiation induced mucositis as she will receive RT to the chest wall and not the oral mucosa. Hence no question of mucositis!
There is a remote possibility of esophagitis but it is really uncommon to see patients of breast cancer suffering from it.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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