A cancer treatment that uses drugs to stop the growth of cancer cells
Chemotherapy explained
 
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.
 
When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
 
When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).
 
Chemoembolisation of the hepatic artery may be used to treat cancer that has spread to the liver.  This involves blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anticancer drugs between the blockage and the liver.  
 
The liver's arteries then deliver the drugs throughout the liver.  Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the hepatic portal vein, which carries blood from the stomach and intestine.
 
The way the chemotherapy is given depends on the type and stage of the cancer being treated.
 
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If your oncologist believes you will benefit from chemotherapy, they will discuss the best treatment plan options with you.  
 
You may be prescribed one drug or a combination of drugs.
 
Depending on the stage of your bowel cancer, you may also be recommended treatment with targeted therapies.
 
The chemotherapy drugs approved by the Therapeutic Drugs Administration (TGA) in Australia for the treatment of bowel cancer are:
 
  • 5-FU (5-fluorouracil)
  • Capecitabine (Xeloda)
  • Oxaliplatin (Eloxatin)
  • Irinotecan (Camptosar)
 A combination of two or more drugs is common, for example:
 
  • FOLFOX (5-FU + Oxaliplatin)
  • FOLFIRI (5-FU + Irinotecan)
  • FOLFOXIRI (5-FU + Oxaliplatin + Irinotecan)
  • XELOX (Capecitabine + Oxaliplatin)
Each drug dose is calculated initially according to your body surface area.
 
Each drug has certain characteristic side-effects to be aware of.  These side-effects can be 'risk assessed' for likelihood by your oncologist, and dosages can be altered to suit your own circumstances.
 
These standard drugs are considered to have a moderate risk for developing common side-effects associated with bowel cancer chemotherapy, including nausea and vomiting, diarrhoea and febrile neutropaenia.
5-FU (5-Fluorouracil) 
 
At what stage is this treatment used?

  • At any stage of bowel cancer.  It is usually combined with folinic acid (Leucovorin Calcium).

Is this drug available via the Pharmaceutical Benefits Scheme (PBS) as a subsidised treatment?

  • Yes.

Download the Consumer Medicine Information (CMI) for Fluorouracil injection

Download the Consumer Medicine Information (CMI) for Leucovorin Calcium injection and tablets

Camptosar (lrinotecan)

At what stage is this treatment used?

  • First-line combination and second-line monotherapy treatment of metastatic bowel cancer.

Is this drug available via the Pharmaceutical Benefits Scheme (PBS) as a subsidised treatment?

  • Irinotecan is PBS-subsidised as a treatment option for advanced metastatic bowel cancer in patients with a WHO performance status of 2 or less. Note: In first-line usage, effectiveness and tolerance may be improved when Irinotecan is combined with an infusional 5-fluorouracil regimen (e.g. FOLFIRI).

Download the Consumer Medicine Information (CMI) for Camptosar.

Eloxatin (Oxaliplatin)

At what stage is this treatment used?

  • Adjuvant treatment of stage III (Dukes C) colon cancer after complete resection of primary tumour.
  • Treatment of metastatic bowel cancer.

Is this drug available via the Pharmaceutical Benefits Scheme (PBS) as a subsidised treatment?

  • Oxaliplatin in combination with 5-FU and folinic acid (FOLFOX) is PBS-subsidised as a treatment option for the adjuvant treatment of patients with stage III (Dukes C) colon cancer following complete resection of the primary tumour.
  • Oxaliplatin in combination with 5-FU and folinic acid (FOLFOX) or capecitabine (XELOX) is PBS-subsidised as a treatment option for metastatic bowel cancer in patients with a WHO performance status of 2 or less.
  • Oxaliplatin is not PBS-subsidised for the treatment of patients with stage II (Dukes B) colon cancer. Oxaliplatin is not PBS-subsidised for the adjuvant treatment of patients with rectal cancer.
  • Capecitabine in combination with oxaliplatin (XELOX) is listed as a PBS-subsidised treatment option for the adjuvant treatment of stage III (Dukes C) colon cancer, which allows Xeloda to be reimbursed as both monotherapy and as part of the XELOX combination.

Download the Consumer Medicine Information (CMI) for Eloxatin.

 Xeloda (Capecitabine)

At what stage is this treatment used?

  • Adjuvant treatment of stage III (Dukes C) colon cancer.
  • Treatment of advanced or metastatic bowel cancer alone or in combination.

Is this drug available via the Pharmaceutical Benefits Scheme (PBS) as a subsidised treatment?

  • Capecitabine is PBS-subsidised as a treatment option for metastatic bowel cancer.
  • Capecitabine is PBS-subsidised as a treatment option for adjuvant treatment of stage III (Dukes C) colon cancer, following complete resection of the primary tumour.
  • Capecitabine is not PBS-subsidised for the treatment of patients with Stage II (Dukes B) colon cancer.
  • Capecitabine is not PBS-subsidised for the adjuvant treatment of patients with rectal cancer.
  • Capecitabine in combination with oxaliplatin (XELOX) is listed as a PBS-subsidised treatment option for the adjuvant treatment of stage III (Dukes C) colon cancer, which allows Xeloda to be reimbursed as both monotherapy and as part of the XELOX combination.

Download the Consumer Medicine Information (CMI) for Xeloda.

Managing Side Effects

Chemo Induced Nausea and Vomiting (CINV)

Nausea and vomiting are two side-effects of cancer treatment that people often worry about the most.

Around 50 percent of people who undergo chemotherapy for bowel cancer experience nausea and vomiting, which might also cause dehydration, fatigue, loss of appetite and difficulty concentrating.

Some patients are more vulnerable to CINV than others. These include women (even more so if they experienced these symptoms during pregnancy), young people under age 50, and patients who have received previous chemotherapy treatments.

Other risks include a personal history of motion sickness, or problems with anxiety.

Many new medications are available to control CINV and it can now be prevented in the majority of people by carefully assessing your risk of developing these side-effects before you start treatment.

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How can I help manage chemotherapy induced nausea and vomiting?

  • Avoid eating solid foods immediately before and after treatment
  • Avoid caffeine and alcoholic drinks
  • Drink clear liquids such as sports drinks, ginger ale, lemon-lime sodas, or dilute, unsweetened fruit juices
  • Start with bland foods such as dry toast or crackers, then gradually increase to small, frequent meals throughout the day
  • Avoid spicy or greasy foods
  • Avoid favourite foods on days you are sick so they don't become nausea triggers
  • Avoid strong smells that may upset your stomach such as cooking odours, smoke, or perfume
  • Avoid lying flat for at least 2 hours following meals
  • Contact your specialist team if vomiting is severe or if you cannot keep anything down
  • Try doing some relaxing activities such as reading, puzzles, yoga, watching TV, or listening to music
  • Alternative therapies such as selfhypnosis, guided imagery, progressive muscle relaxation or acupuncture

Guidance on the use of medicinal cannabis

The prescribing and dispensing of medicinal cannabis products under specific circumstances is now legal in Australia.

The cultivation and manufacture of medicinal cannabis products have also been legalised by the Commonwealth, and in some cases, State and Territory governments.

Until more scientific evidence is available however, medicinal cannabis should be used only when approved treatments have been tried and failed to manage conditions and symptoms.

There is no evidence that medicinal cannabis has any anti-cancer activity in human studies or that it can slow the progression of these conditions.

The products will be available for use by bowel cancer patients for the prevention and management of chemotherapy-induced nausea and vomiting (CINV), and in palliative care, but only after standard treatments have failed.

While medicinal cannabis products can be used to treat nausea and vomiting due to chemotherapy, there is little evidence of any benefit to advanced cancer patients with chronic pain.

As there are few studies on medicinal cannabis treatment in palliative care, it is possible that it will interact with chemotherapy and other medications used in palliative care.

It should be used only after standard treatments have failed.

 

Side effects

Like all prescription medicines, medicinal cannabis products can have side effects.

Side effects vary and depend on the medicinal cannabis product type used and the patient being treated.

The known side-effects from medicinal cannabis treatment (both CBD and THC) include fatigue and sedation, vertigo, nausea and vomiting, fever, decreased or increased appetite, dry mouth, and diarrhoea.

THC (and products high in THC) have been associated with convulsions, feeling high or feeling dissatisfied, depression, confusion, hallucinations, paranoid delusions, psychosis, and cognitive distortion (having thoughts that are not true).

 

Access

Medicinal cannabis products can only be prescribed by a registered medical practitioner.

With the exception of nabiximols, medicinal cannabis products are not registered medicines in Australia, so they must be accessed through special pathways available for unapproved medicines.

 

Further information

Please visit Bowel Cancer Australia's guidance for the use of medicinal cannabis in Australia webpage for further information.

Increased risk of infection and neutropaenic sepsis

Infection at any time during your bowel cancer treatment can have a significant effect on how well you tolerate your treatment and can slow down your recovery times.

Neutropaenic sepsis – or febrile neutropaenia – means that you have a fever caused by infection linked to low levels of neutrophils (white blood cells) in the blood. This is a serious condition, and one of the potential side-effects of chemotherapy for cancer. Chemotherapy for bowel cancer carries a moderate risk of neutropaenia.

Infection as a result of side-effects of chemotherapy – when the body is already compromised – is considered to be a medical emergency which often results in hospital admission for treatment with antibiotic intravenous (IV) infusions.

It is possible to assess your personal risk of developing this side effect before starting a new treatment.

You can manage your personal risk actively by careful attention to personal hygiene and limiting contact with other potential sources of infection: other people, pets, food and washing hands after touching hard surfaces (especially in busy, communal areas).

 

Who is most at risk?

People most at risk of developing this serious problem are often older patients (over 65 years) who also have poor general health and other underlying health issues with heart, kidney or other problems with major organs.

Other factors known to increase risk of infection include a low baseline blood cell count as a result of previous chemotherapy treatments, along with current chemotherapy regimes that are being given in high doses.

That is why you will have your blood levels checked before each new cycle of treatment. Your pretreatment assessment should also include checking your temperature and blood pressure as these can also help to identify potential problems ahead, as will picking up undiagnosed, underlying respiratory infections, and other local infections at the site of IV ports, for example.

Your chemotherapy team should give you a special card with the signs and symptoms to look out for, and an emergency contact number to call if you notice any problems or have any concerns.

Where the personal risk is considered to be high, specialised medications can be prescribed to increase the production of these white cells where necessary, supporting the body and helping it to recover more quickly from the chemotherapy treatments.

Availability of Drugs in Australia
 
In Australia there are a number of government bodies responsible for the regulation and availability of bowel cancer treatments.
 
The Therapeutic Goods Act1989, Regulations and Orders provide a national framework for the regulation of therapeutic goods in Australia to ensure quality, safety and effectiveness of medicines. They also set out the requirements for inclusion of therapeutic goods in the Australian Register of Therapeutic Goods (ARTG), including advertising, labelling and product appearance, for example.
 
The Therapeutic Goods Administration (TGA) is a unit of the Australia Government Department of Health.  It carries out a range of assessment and monitoring activities to ensure therapeutic goods available in Australia are of an acceptable standard.  At the same time the TGA aims to ensure that the Australian community has access, within a reasonable time, to therapeutic advances.
 
All treatments used to prevent, cure or alleviate bowel cancer must be entered on the ARTG before they can be supplied in Australia.  Once approved and entered on the ARTG, they are available for human use and can be accessed privately.
 
Some treatments can then be recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) to be listed on the Pharmaceutical Benefits Scheme (PBS) as a subsidised treatment.  The Scheme is available to all Australian residents who hold a current Medicare card.
 
The PBAC is an independent statutory body established to make recommendations and give advice to the Minister for Health about which treatments should be made available as pharmaceutical benefits.
 
No new treatment may be made available as a pharmaceutical benefit unless the Committee has so recommended.
 
The Committee is required by the National Health Act1953 to consider the effectiveness and cost of a proposed benefit compared to alternative therapies.  In making its recommendations the Committee, on the basis of community usage, recommends maximum quantities and repeats and may also recommend restrictions as to the indications where PBS subsidy is available.
 
When recommending listings, the Committee provides advice to the Pharmaceutical Benefits Pricing Authority (PBPA) regarding comparison with alternatives or their cost effectiveness.
 
Some treatments may not be recommended by the PBAC if they are deemed not cost-effective, even if they are clinically proven.
 
The issue of drug availability has received a lot of media attention and can be confusing and complicated.  You should discuss all the options with your oncologist, and if a drug would be of benefit but it is not available via the PBS, you may consider accessing this privately or applying to a manufacturer to see if you are eligible to enter an access program or the drug made available on compassionate grounds.  Also, ask about clinical trials.
 
A list of the applications for consideration at each PBAC meeting is published six weeks prior to each meeting.  The sponsor of the submission will have already provided the PBAC with detailed clinical and economic data in support of the submission.  However, you are welcome to provide comments from a personal (i.e. patient, carer, member of the public, health professional) or group perspective for consideration by the PBAC when the submission is considered.
 
Bowel Cancer Australia advocates for improved access to affordable treatment options and makes relevant submissions to the PBAC on behalf of bowel cancer patients. For more information on Bowel Cancer Australia's advocacy efforts and listing of new bowel cancer treatments, visit our Access and Wait Times webpage.
 
Further details, including closing dates for submissions, can be found at the Pharmaceutical Benefits Advisory Committee webpage. The PBAC meets three times a year, usually in March, July and November.