Topic: Chemo Question

I am currently on Gemzar/Cisplatin.  On my MD Anderson orders it says chemo should be 6 hours.  Sometimes it is and sometimes it isn't.  I have talked to my local oncologist about it before after it only taking 4 hours and he said he would talk to infusion and he did and it went back to being 6.  Then last time it was bak to only 4.   Expressed my concern to the Dr. This time and he said t s fine that it doesn't matter.  For anyone else on this same regimen, what's your thought on this?  It concerns me.  If MDA says  hours I think I should be a chemo for 6 hours not 4.

Re: Chemo Question

Donna....hoping for others to chime in, but will also mail your posting to Karen, our oncologist nurse, for comments.
Hugs,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Chemo Question

Thank you Marion smile

Re: Chemo Question

Hi Danna,

My wife has had 18 gem/cis treatments so far, and I completely understand your concern.  Some treatments follow a similar process, but often, the treatment nurses have quirks in their approach...maddening.

Anyway, here is what I can say about your questions.

For Andrea, the Gem is supposed to be administered over 30 minutes, and the Cisplaten is administered over one hour.  Total would be 1.5 hours, no?  Well no.  The treatment also includes 2 bags (liters) of fluids and a small steroid bag as well.  How long this takes depends mostly on the total flow they allow. 

The chemo has a very proscribed flow rate (to hit the 30 min and 1 hour tagets).  However, the extra fluid flow rate is not specified, and in our experience is nurse dependent.  Some set the aggregate flow at 500-600 mL per hour, and others at 700-800 mL per hour.  The faster the flow rate, the faster the process goes.

I don't think there is an exact right answer.  If you have a port, you can probably handle a faster flow rate.  Without a port, I know they slow things down a bit. 

The main thing that they are looking for, I believe, is that you are well hydrated before/during/after the cisplatin.  If you are dehydrated to start, it could take a while to get your hydration enough to allow the cisplatin (for Andrea they monitor urine outflow to assess hydration).  You might even have to take an extra bag of fluids if your hydration is low (adding 90 minutes or so to the process).

Anyway, I think it could reasonably take 4-6+ hours based on the nurse's approach and the patient's hydration and ability to take the chemo (port vs. standard IV).  Perhaps MD Anderson lists the required time as an estimate if the patient requires hydration and does not have a port?

As a patient, it seems that the absolute best things you can do to protect yourself is to drink lots of liquids (all through the process), watch the nurses, and ask lots of questions!  You seem to be doing great so far.

good luck with your treatments,

Jason

Re: Chemo Question

Thanks Jason.  It's frustrating, seems like it should be done the same way every time.  My Gemzar is done over an hour and I was told that is the only crucial thing.  But to me, I think the fluids are crucial as well.  I do drink a ton of water all the time!!

Re: Chemo Question

Danna -
I agree with Jason. A lot of it has to do with who is doing the infusion. My husband does Gem/Oxaliplatin and it can be 4 hours to 6 hours and it just depends on who does the infusion. The first two infusions were done through a port and were fairly fast but now that they have pulled the port and we do it through a peripheral IV, they slowed it down. I know that they Gem they try to do over 90 minutes and then the Oxaliplatin is over 2 hours. The math says 3.5 hours but it can be a lot longer.
We have some nurses who are just slow in getting to the pump with when it alarms and others that are fast.
I would say it shouldn't matter as long as there are no symptoms but always follow your gut instinct, if you think it's too fast, say something.

KrisV

Any advice given is based on my experiences and should not be substituted for any medical recommendations. Please speak with your provider before making any changes.

Re: Chemo Question

Thanks for the response Kris.  Mine is done through a port.  I would just feel better if it was done the way MDA says it should e done and to me the slower the better.  They're just rushing it now because they have been getting so busy but that is not my problem.  You know what I mean?

8 (edited by KarenD Thu, 17 Oct 2013 09:18:52)

Re: Chemo Question

Hi Danna,

This is Karen!  Marion contacted me about your question.....and Jason's response it pretty spot-on. 

Here is what I emailed Marion:

As far as that question goes, there are many factors that go into chemo dosing.
Gemzar is generally over 30 minutes, Cisplatin anywhere from 2-3 hours rapid bolus infusion, or 6-8 hours.  (Plus pre-hydration with 1-2 Liters of normal saline pre-chemo and sometimes more afterwards.) BUT, with chemotherapy the patient's age, weight, their body surface area (BSA), their labs (hemoglobin/hematocrit, WBCs, absolute neutrophils, etc.  are all part of the calculation.  Also, with Cisplatin, the serum creatinine, liver and kidney functions, and urine output, come into consideration.  So it is a slightly difficult question to answer without all of the information.  Also, I don't know if she is on some sort of clinical trial being that they have orders from MD Anderson. That hospital or trial may have a different protocol than another.  (or the patient may have dose modifications based on the above listed criteria, or toxicity issues).

I'm curious if the chemo orders are for 6 hours total including pre-hydration, Gemzar, then Cisplatin?   Maybe it's 30 minutes of Gemzar, 2 hours Cisplatin, 1 hour hydration, I'm not sure.

What I would suggest, is to just ask the nurses that are giving the infusion.  Sometimes doctors will say "you will be in the infusion room for "this" many hours", when in reality, they are there for less time, or more.  Ask the nurses how long it takes for the Gemzar and why, how long do you run the pre or post hydration and why, and how long do you infuse the Cisplatin, and why? The nurses are following the doctors orders, but we are also required to have gone through training from ONS and become Chemo/Biotherapy certified, and be tested to hang chemo per the hospital and the Oncology Nursing Society protocols.
Chemotherapy orders are also checked by two chemotherapy pharmacists prior to mixing and again when done mixing, checked by the pharmacist/chemo nurse on receipt of the drug, then checked again with two chemo nurses before hanging the drug.   Many checks along the way, and if there were a mistake it will be caught.
The nurses will be able to explain their reasoning....and I'm sure there is a good explanation.  I'm sorry if I am not able to give a simple answer! Hopefully this response helps a little though.

In addition, Danna,  if you feel any sense of worry or concern over your infusion just let those nurses know.  YOU are the one getting the chemotherapy, and YOU should feel comfortable.  Ask them a million questions and they should take the time to explain everything.   It is their responsibility to do so.


I wish you the best,

Karen

(All information is my educated opinion only and not to be used as medical advice. Please consult your prescribing physician).

Re: Chemo Question

Karen,
Thanks for the response.  I am 30 weigh 142 lbs and labs are always fairly good.  Hemoglobin is always low and WBC was low for the first time ever.  I get two anti nausea bags, then fluids for 2 hrs which she has started combining with my Gemzar that runs about 70 minutes and my Cisplatin runs for about an hour.  I also usually get potassium which I did not notice this time.  It would all be fine if not for the fact that the first time I spoke to the Dr. About it he wasn't very happy and made them start doing it 6 hours again, then when it happens again and I ask he tells me they have plenty of experience and know what they're doing.  Then why did he get on them about t the first time?  All I did was ask I never said they didn't know what they were doing.  I will just wait till next MDA trip and talk to Dr. Javle and get a clear answer.  And no, I'm not on any clinical s.  The chemo has always been 6 hours long and now it's not and thats all I know.  Felt good to get that little rant out and thanks for all the helpful info Karen.  Maybe if I show that to my local Dr. He will better understand my concern and look for a better answer on his part to give me!

Re: Chemo Question

Hi Danna!

You're right, why would the doctor be upset the first time and not the second?   If I were getting chemo and there were any changes, I would want to know what in the world was going on too! smile 
Is the doctor you are speaking of your local oncologist, and he is following Dr. Javle's/MD Anderson chemo protocol?

Your pre-medication (before chemo) probably runs between 15 minutes and 30 minutes per bag.
Then you said 2 hours of hydration. Is the Gemzar running at the same time as your i.v. fluids or are they doing it after? (you said they "combined" this).
Then 1 hour of Cisplatin.
So maybe 4.5-5 hours?

Was it the entire process from start to finish that was 6 hours before? Pre-medication, hydration, Gemzar, Cisplatin?

What do you think the nurses are running in faster this time? The hydration maybe? I think the most important point is how fast the CHEMO is being infused.  The hydration can go faster or slower, the pre-meds can go faster or slower....but the chemo should be infused per the specific orders and required time frame, (the drug information from the drug company, etc. sets the standard).  unless there are issues.

As far as potassium in your bags of fluid, that was most likely because your potassium level was off a little when your labs results were reviewed and your oncologist ordered for it to be added. Or maybe you just got little mini bags of potassium. Those are usually a dose of 10 MEQ (milliequivalents)  and infuse over 1 hour per bag.


I hope you are feeling "ok" while getting your infusions.  Are your pre-meds keeping nausea at bay?  Are you able to get enough rest and adequate hydration? 

I will keep you in my thoughts, let me know what you hear back!

-Karen

(All information is my educated opinion only and not to be used as medical advice. Please consult your prescribing physician).

Re: Chemo Question

Danna I just thought of another thing,
when the pharmacists are mixing your chemo drugs up into the solutions, sometimes there is some "over-fill ".  The bags are not always the same. You will get the right amount of drug, but might be more or less diluent. (more fluids that the drugs were mixed with).

Just a thought.

-Karen

Re: Chemo Question

I see that a lot...the overfill of bags with my husband's chemo and I guess we are pretty lucky that we aren't there any longer than we are. They draw labs, doc comes in after labs are back and writes the orders then the nurse comes back with oral meds (Zofran and Dexamethasone and Lorazepam if needed) and about a half an hour later then start chemo. They do a dextrose flush just before the chemo, in between doses and then flush when they are done. I guess we could be there a lot longer if they were doing more bags of stuff.

So far he's always been well hydrated and numbers have been good....the white count is always a little high which makes the doc scratch his head and the doc was amazed that he hadn't lost any hair yet (of course there's not that much to lose).

Just ask lots of questions. The only thing I can think of is that the doc thought there might be issues if infused too fast the nurses found there weren't any issues with it so it didn't matter if it was infused faster.

KrisV

Any advice given is based on my experiences and should not be substituted for any medical recommendations. Please speak with your provider before making any changes.

Re: Chemo Question

Yes, this is a local oncologist following what Dr. Javle says.  Or supposed to be anyway.  When it takes 6 hours they are doing everything separate, when t is faster they are doing my fluids at the same time as the Gemzar and Cisplatin.  So it is still all being ran the same length of time I think, just several things at once instead of separate.  I am tolerating it well and have never been sick from chemo.  I'm just anxious to get ack to MDA and see Dr. Javle smile.  Kris, my WBC was always high too until this last time it was low.  But I have a uti infection is probably the reason.  My hair hasn't really fallen out either but it did start getting so thin that I had to cut it off short.  How long as your husband been on chemo?  Glad he's doing well with it.  Thanks everyone!!

Re: Chemo Question

He's been on it every other week since Aug 9th. We had to push one dose back since he was in the hospital the week before for a blood infection. And they told us 6 month total of chemo so we are looking at stopping sometime in February. Next Friday after the blood draws we get our mid-way point CT scan finally....although I don't think there is anything to see....I hope not. The surgeon was pretty sure they got it all with surgery.

I wish we still had the port in but they pulled the port after the last blood infection because they thought that might be the cause....still not sure but no more infections. He's got so many scars on his belly and chest now....looks a road map to nowhere.

KrisV

Any advice given is based on my experiences and should not be substituted for any medical recommendations. Please speak with your provider before making any changes.

Re: Chemo Question

When I was receiving chemo, different sites had different "push rates". Sloan Kettering had Gemzar at 30 min, and oxaliplatin at 4 hours, and Princeton had Gemzar at 1 hour and oxaliplatin at 5 hours. So I had to coordinate the different times, and get Princeton to push at the same rate. It might be as simple as that.

KrisJ
"Don't just have minutes in the day; have moments in time."
Any opinions I give are based on personal experiences, and are not based on medical knowledge. I strongly suggest receiving medical care and opinions.