Small Lung Cancer Oncological Guidelines

CCC Chemotherapy Protocols
V9.0
General observations
Breast cancer
Gastrointestinal cancer
Gynaecological cancer
Haematological
Oesophagus
17
Gastric
19
Pancreas
22
Cholangiocarcinoma
24
Hepatocellular carcinoma
25
Neuroendocrine tumours
26
Colorectal
28
Anal
37
Ovarian
38
Endometrial
44
Cervix
46
Hodgkins disease
50
Non-Hodgkins Lymphoma
51
Head and Neck cancer
55
Thyroid
58
Lung cancer
Small cell
59
Non-small cell
62
Mesothelioma
67
Melanoma
68
Sarcomas
Soft tissue sarcomas
69
Osteosarcoma
71
Ewings sarcoma
73
Fibromatosis
78
Rhabdomyosarcoma
79
GIST
81
Urological cancer
Bladder
82
Renal
85
Prostate
87
Germ Cell
89
Primary CNS malignancy
93
Unknown Primary
98
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Author: Dr. D.B. Smith
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(continued)
Page
Emergency chemotherapy drugs
98
Bone metastases
99
Antiemetic protocols
101
GCSF policy
104
Prophylactic antibiotics
104
Erythopoietin policy
105
Intra-thecal chemotherapy policy
105
Wright formula
106
Cisplatin / carboplatin doses
106
Cisplatin hydration policy
107
Haematological parameters
108
Capecitabine renal function recommendations
108
Neutropenic sepsis policy
109
Platelet transfusion policy
110
Hypocalcaemia
110
Hypomagnesaemia
110
Ifosfamide renal toxicity and encephalopathy
111
Folinic acid rescue for high dose methotrexate
111
CCC dose banding policy
112
Surface Area Nomogram
119
North West Cancer Drugs Fund
120
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General observations
There is now an electronic version of the protocol book which is available on CCO Comms. This
will be updated monthly and represents the working version of the book. It also contains more
information and will have a hyperlink to the nurse work instructions for each protocol. The paper
version will continue but will only be updated annually.
Protocol Additions 2011-12

Maintenance pemetrexed in advanced NSCLC
Pazopanib in advanced renal cell carcinoma
Gefitinib in advanced NSCLC
In addition we have included all drugs currently funded by the Cancer Drugs Fund.
Cancer Drugs Fund
A number of treatments are now available via the Cancer Drugs Fund. The process for accessing
the fund is as follows:
Complete the relevant application form which can be found on the North West Cancer
Drugs Fund web site. The easiest way to find this is to type nw cancer drugs fund into
google and select the application forms button in the header on the home page.
E-mail the completed form to the pharmacy dept at CCC using:
ccftr.CytoPharmacy@nhs.net this address can be found by typing cco pharmacy into the
address book in outlook.
The form will be checked in pharmacy and sent to the network pharmacist who will
coordinate approval by the cdf. All request which fulfil the criteria are approved
automatically and the process usually takes about a week.
Off Protocol Treatment Policy

Inevitably situations will arise that are not covered by the standard CCC protocols. Consultants
who wish to use a non-protocol regimen should complete the non-protocol treatment form and
submit it to the Clinical Director for Chemotherapy for approval at least 5 days prior to the date
of cycle 1 of the proposed treatment. All reasonable requests will be granted.
Trials
Entry to clinical trials should be considered for all patients but individual studies have not been
listed due to frequent changes.
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Co-payments / top-ups / additional private care

The uptake of co-payments has been minimal and will be further reduced by by the introduction
of the Cancer drugs fund. However the process is still in place and is outlined below.
Co-payment refers to top-up funding by an NHS patient for an otherwise unavailable treatment.
NHS policy allows patients to fund elements of their care not currently available on the NHS
without losing their entitlement to continue with free NHS care.
The CCC co-payments policy considers access to systemic cancer treatments - chemotherapy or
targeted therapies - that are currently not funded for use in NHS patients. A copy of the policy
can be obtained from pharmacy or found on the CCC website and includes all the required
documentation:
Co-payment algorithm
Additional Private Treatment Form
Patient information leaflet.
Financial agreement forms.
The self-funded drug may be a single agent or given in combination with standard treatments, in
which case the costs incurred relate only to the self-funded drug. However it should always be
clear which components of treatment are privately funded and which are provided as NHS
treatments.
The patient commits to self-funding the treatment for the duration of the entire programme under
supervision by the responsible consultant i.e. a specific number of cycles or indefinite period
while there is evidence of a maintained benefit and response. This will include the costs of
treatment preparation and delivery, payment of any investigations needed, and any supportive
care drugs given as a direct consequence of receiving the self-funded treatment.
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Breast Cancer
Adjuvant
Epi-CMF
Epirubicin 100mg/m2 iv day 1 repeated at 21 day intervals x 4 cycles
followed by CMF x 4 cycles
Laboratory Investigations
Ensure normal renal and hepatic function prior to cycle 1 and repeat during subsequent cycles
if clinically indicated
Where renal / hepatic function are abnormal treatment is at physician discretion
LV ejection fraction prior to cycle 1 if history of cardiac problems
Fbc prior to each cycle.
Standard fbc limits for administration apply
CMF
Cyclophosphamide
Methotrexate
5-Fluorouracil
100mg/m2 po days 1-14 in divided doses

40mg/m2 iv days 1 and 8
For patients unable to tolerate oral cyclophosphamide substitute

iv cyclophosphamide 600mg/m2 days 1 and 8
Folinic acid rescue not normally required unless patients develop signs of Methotrexate toxicity,
then 15mg 6 hourly x 6 doses starting 24hrs post Methotrexate with subsequent cycles
Cycles are repeated at 28 days from day 1 to a total of 6 cycles.
Where renal / hepatic function are abnormal treatment is at physician discretion but
Methotrexate is hazardous in the presence of renal insufficiency
Fbc prior to each cycle, not required on day 8
AC
Doxorubicin 60mg/m2 + cyclophosphamide 600mg/m2 iv day 1 repeated at 21 day intervals for 4

cycles has been shown to be equivalent to 6 cycles of CMF.
Fbc prior to each cycle
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Epirubicin 90mg/m2 IV + cyclophosphamide 600mg/m2 IV day 1 repeated at 21 day intervals for

4 cycles. Alternative to AC in this situation
EC
FEC / Docetaxel
This protocol is available for node +ve patients according to NICE guidance
Patients may receive primary prophylaxis with pegfilgrastim after each cycle
FEC
5-Fluorouracil
Epirubicin
Cyclophosphamide
500mg/m2 IV day 1
100mg/m2 IV day 1
500mg/m2 IV day 1
Repeat at 21 day intervals for 3 cycles

Followed by
Docetaxel 100 mg/m2 iv x 3 cycles at 21 day intervals
Pre-medication: Dexamethasone 8mg oral bd x 3 days start 24hrs pre-docetaxel
NB: See section on advanced disease for dose modifications and precautions.
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Trastuzumab
For patients who fit HERA trial inclusion criteria
Non-metastatic potentially operable primary invasive breast cancer

HER2 positive (IHC 3+ and / or FISH positive)
Completed definitive surgery and radiotherapy
Completed at least 4 cycles of adjuvant or neoadjuvant chemotherapy
Within 9 weeks of chemotherapy / radiotherapy / surgery, whichever is last.
ECOG PS 0 or 1
Baseline LVEF > 55% after completing chemotherapy
No serious cardiac illness
Trastuzumab
8mg/kg iv loading dose over 90min then 6mg/kg over 60min and thereafter over
30 min every 3 weeks for 12 months (18 cycles) if no problems.
Stop at any time if CCF develops
LVEF at 3, 6, 9 and 12 months
Stop trastuzumab if LVEF falls by 10 points or to <50%
Repeat after 3-4 weeks and if LVEF:
50+ continue with trastuzumab
44-49 and within 10 points of baseline continue with trastuzumab
< 44 stop trastuzumab
Neo-adjuvant
Indication / Treatment plan

Patients with locally advanced disease or to allow less radical surgery in patients with operable
tumours.
Options include six cycles of EC/AC or four cycles EC/AC followed by four cycles docetaxel at
100mg/m2
HER-2 +ve patients may commence trastuzumab following completion of anthracycline based
treatment ie concurrently with docetaxel if this is being given provided LVEF normal after
completion of the anthracycline. Patients should then have the remaining 14 cycles of trastuzumab
as adjuvant treatment.
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AC/EC
Doxorubicin
Epirubicin
Cyclophosphamide
60mg/m2 iv day 1
or
90mg/m2 iv day 1
+
600mg/m2 iv day 1
Repeat at 21 day intervals for up to 6 cycles.

Docetaxel
100 mg/m2 iv q 21 days x 4 cycles

Pre-medication:
Dexamethasone 8mg oral bd x 3 days start 24hrs pre-docetaxel
NB: See section on advanced disease for dose modifications and precautions.
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Advanced disease
First line
Doxorubicin
75mg/m2 iv day 1
Repeat at 21 day intervals usually to a maximum of 6 cycles
AC
Doxorubicin
Cyclophosphamide
50mg/m2 iv day 1
500mg/m2 iv day 1
Repeat at 21 day intervals usually to a maximum of 6 cycles

Normal fbc limits for administration apply
Docetaxel
75-100 mg/m2 iv day 1 q 21 days, max 6 cycles

Pre-medication:
Dexamethasone 8mg oral bd x 3 days start 24hrs pre-docetaxel
Criteria
Previously received full dose anthracycline as adjuvant therapy

or
Less than six months since anthracycline based adjuvant therapy
or
Unsuitable for anthracycline therapy
NB: See section on 2nd/3rd line treatment for dose modifications and precautions.
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Docetaxel / Capecitabine
Docetaxel
Capecitabine
Pre-medication
75mg/m2 iv day 1
+
1000mg/m2 bd oral days 1-14
NB see capecitabine renal function recommendations p105
Dexamethasone 8mg bd x 3 days start 24hrs pre-docetaxel
Repeat at 21 day intervals, max 6 cycles

Criteria
PS 0-1 NB very fit patients only
Recurrent following adjuvant anthracycline therapy
Paclitaxel / Gemcitabine
Paclitaxel
175mg/m2 iv day 1
Gemcitabine
Pre-medication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg
16mg
50mg

Criteria
PS 0-1 NB very fit patients only
Recurrent following adjuvant anthracycline therapy
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Cyclophosphamide
Methotrexate
5-Fluorouracil
CMF
100mg/m2 po days 1-14 in divided doses

For patients unable to tolerate oral cyclophosphamide substitute
iv cyclophosphamide 600mg/m2 days 1 and 8
Where renal / hepatic function are abnormal treatment is at physician discretion but care if
renal function significantly deranged
Fbc prior to each cycle, not required day 8
Cycles are repeated at 28 days from day 1 to a total of 6
CMF (iv) Cyclophosphamide
Methotrexate
5-Fluorouracil
600mg/m2 iv day 1
40mg/m2 iv day 1
600mg/m2 iv day 1
Cycles repeated every 21 days to a maximum of 6
Where renal / hepatic function are abnormal treatment is at physician discretion but consider
omitting Methotrexate if renal function abnormal
*Bevacizumab
10mg/kg iv infusion
Repeat at 14 day intervals
Criteria Advanced disease
Triple negative
First line chemotherapy
In combination with paclitaxel
*NB available via the Cancer Drugs fund
*Eribulin
cycle
1.4mg/m2 eribulin mesylate (equivalent to 1.23mg/m2 eribulin) iv days 1 and 8 of a 21 day

Criteria At least 2 prior chemotherapy regimens for advanced disease
Evidence of response to prior chemotherapy
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Patients with compromised liver or marrow function
Doxorubicin
20mg/m2 iv weekly for patients with compromised liver or marrow function due to tumour
infiltration
Ensure normal renal function prior to cycle 1 and repeat during subsequent cycles if clinically
indicated
Patients with abnormal hepatic function should be treated cautiously
Normal limits for administration apply with the exception that for patients with marrow
infiltration treatment may be continued at lower platelet and neutrophil counts at treating
physician discretion.
Continue with weekly treatment usually for 6-8 weeks before changing to fortnightly or 21 day
cycles depending on response. Maximum total dose 450mg/m2
Paclitaxel 80mg/m2 iv weekly for patients with compromised liver or marrow function who have previously
received anthracyclines.
Pre-medication
Dexamethasone
Chlorpheniramine
Ranitidine
8mg iv before first cycle

4mg iv before second and subsequent cycles
10mg iv
50mg iv
Laboratory investigations
indicated
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Second or Third line
Vinorelbine
25 - 30mg/m2 iv day 1 and 8 of a 21 day cycle.

or
60- 80mg/m2 oral day 1 and 8 of a 21 day cycle
Repeat at 21 days from day 1
Reassess after every 2 cycles, maximum 6 cycles
Criteria:
WHO performance status 0-1

Endocrine resistant
Prior alkylating agent therapy
75-100mg/m2 iv q21 days maximum 6 cycles
or
60-75mg/m2 if moderately impaired liver function / heavily pre-treated / extensive
bone metastases
NB: severe toxicity may result in patients with major impairment of liver
function
Docetaxel
Reassessment after two cycles and continue to a maximum of 6 only if responding or

stable disease.
Pre-medication
Dexamethasone 8mg bd x 3 days commence 24 hours pretreatment
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Capecitabine
1000-1250mg/m2 oral twice daily for 14 days followed by 7 days off

or
850-1000mg/m2 twice daily for 14 days followed by 7 days off
if heavily pre-treated or elderly
Repeat at 21 days from day 1 for up to six cycles.
Criteria
Failed or unsuitable for anthracycline and/or taxane

PS 0-2
Bisphosphonate
Zoledronic acid
4mg iv in 100mls Sodium chloride 0.9% over 15-30 minutes repeated at 28 day
intervals.
Criteria:
Performance status 0-2

Symptomatic / extensive bone metastases
Calcium supplements:
Patients should have their serum calcium measured every four weeks and Adcal
D3 tablets prescribed as necessary.
Renal impairment
Cr clearance
Dose
>60
50 - 60
40 - 49
30 39
< 30
4.0mg
3.5mg
3.3mg
3.0mg
no treatment
Serum creatinine should be repeated every 4 weeks and if it rises significantly during
treatment zoledronic acid should be witheld until the creatinine has returned to within
10% of the baseline prior to starting.
For patients with creatinine clearance < 30ml/min ibandronic acid 50mg weekly oral
may be considered. *This is available via the off-protocol mechanism
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Management of patients with HER2 +ve cancers

Trastuzumab
4 mg/kg loading dose i.v. over 90 minutes followed by 2mg/kg/week i.v. over 30 minutes
for 8 doses then 6mg/kg every 3 weeks over 30minutes.
or
8mg/kg iv loading dose over 90min then 6mg/kg over 60min for one dose and then over
30 min thereafter if no problems every 3 weeks
Criteria:
Strongly HER2 positive (HER2 3+ by IHC or FISH positive)

Trastuzumab given together with a taxane or vinorelbine as first or second
line treatment or second / third line as a single agent.
NB not with anthracycline and with care within close proximity to anthracycline
therapy (< 6 months).
LVEF: baseline ECHO/MUGA + 3 monthly repeat advised for patients receiving
treatment with trastuzumab.
Lapatinib (Tyverb) + capecitabine

Lapatinib 1250mg po daily continuously
+
Capecitabine 1000mg/m2 oral twice daily for 14 days followed by 7 days off
or
850mg/m2 twice daily for 14 days followed by 7 days off
if heavily pre-treated or elderly
Repeat at 21 days until progression or toxicity. For some responding patients continuing
with lapatinib alone may be the right approach if capecitabine toxicity becomes
unacceptable.
Criteria
Prior anthracycline, taxane and trastuzumab

PS 0-2
IHC 3+ or FISH +ve cancer
*Available via the Cancer Drug Fund
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*Paclitaxel Albumin (Abraxane)

260mg/m2 iv repeat at 21 day intervals
Consider if no longer safe to continue with paclitaxel or docetaxel. Patients may be able to receive
Abraxane with premedication and appropriate precautions.
Criteria Metastatic breast cancer
Situations where taxanes are indicated
*Available via the Cancer Drugs Fund
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Gastrointestinal Cancer
Oesophageal Carcinoma
Adjuvant
Not currently recommended as standard therapy
Neoadjuvant
Cisplatin/5FU
Cisplatin
5-Fluorouracil
Capecitabine
80mg/m2 iv day 1
1g/m2 over 24hrs iv days 1-4
or
1000mg/m2 bd x 14 days
Repeat at 21 days for two cycles.

Criteria
PS 0-1
Cr Cl > 50ml/min
Operable oesophageal cancer
Ensure normal hepatic function prior to cycle 1 and repeat during subsequent cycles if
clinically indicated
Calculate creatinine clearance prior to each cycle and administer cisplatin according to
guidelines
Locally advanced
Chemo-radiation protocol
Cisplatin/5FU
Cisplatin
80mg/m2 iv day 1 and 29
5Fluorouracil 1g/m2 iv over 24hrs days 1-4 and 29-32
or
Capecitabine 825mg/m2 oral bd Mon-Fri during XRT
+ XRT
followed by two additional cycles after completion of XRT
guidelines
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Cisplat/Capecitabine + XRT (SCOPE trial protocol)

Cisplatin 60mg/m2 iv day 1 and 29
+
Capecitabine 625mg/m2 oral bd days 1-21
Repeat at 21 day intervals for 4 cycles with radiotherapy concurrent with cycles 3 and 4
guidelines
Metastastic
Cisplatin/5FU
Cisplatin
5-Fluorouracil
Capecitabine
80mg/m2 iv day 1
1g/m2 iv over 24hrs days 1-4
or
Repeat at 21 day intervals, max 4-6 cycles

guidelines
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Gastric / Adenocarcinomas of Gastro-oesophageal junction Carcinoma

Neoadjuvant / Adjuvant
For patients with operable cancers after initial staging
ECF/X x 3 cycles Surgery -- ECF/X x 3 cycles
ECF/X
Epirubicin
50mg/m2 iv day 1
Cisplatin
60mg/m2 iv day 1
5-Fluorouracil 200mg/m2 / day via continuous iv infusion for 21 days
or
Capecitabine 625mg/m2 bd days 1-21
guidelines
Locally advanced / metastatic
ECF/X
Epirubicin
50mg/m2 iv day 1
Cisplatin
60mg/m2 iv day 1
or
Repeat at 21 day intervals for a maximum of 4-6 cycles
guidelines
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Epirubicin
50mg/m2 iv day 1
Oxaliplatin
130mg/m2 iv day 1
or
EOF/X

guidelines
Cisplatin/fluoropyrimidine/Herceptin
80mg/m2 iv day 1
5-Fluorouracil
Cisplatin
Capecitabine

or

Herceptin
Criteria
8mg/kg iv day 1 loading dose

6mg/kg iv every 21 days until progression
PS 0-1
Cr Cl > 50ml/min
HER 2 status IHC 3+ or FISH +ve
guidelines
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Second line
Irinotecan
250mg/m2 iv day one of a 21 day cycle repeat x 4 cycles

Option to increase to 350mg/m2 if well tolerated
atropine 600ug s/c prior to irinotecan
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Pancreatic cancer
Adjuvant
5-Fluorouracil+Folinic acid
5-Fluorouracil 425mg/m2 iv daily days 1-5

Folinic acid 50mg iv daily days 1-5
Cycles are repeated at 28 days for 6 cycles.
NB: For patients over 70yrs and those with borderline performance status the dose of 5Fluorouracil should be reduced to 370mg/m2 per day.
Gemcitabine
1g/m2
Criteria
iv weekly for 3 weeks followed by one week break

Repeat 28 day cycles for up to 6 cycles.
.
PS 0-2
R0, R1 resection M0
NB: transaminases may rise during gemcitabine therapy
Advanced
First line
Gemcitabine + Capecitabine
Gemcitabine
1g/m2
Capecitabine
po bd for 21 days
825mg/m2
Repeat 28 day intervals for up to 6 cycles.
Criteria
iv days 1, 8, 15
PS 0-1
CA19-9 every 4 weeks
Day 8 or 15
Platelets 75 99 x109/l continue at full dose
Platelets < 75x109/l omit gemcitabine
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Gemcitabine
1g/m2

Repeat 28 day cycles for up to 6 cycles.
or
iv weekly for seven weeks followed by one week break for first cycle
then 3 weeks on, one off as above.
Criteria
PS 0-2
Day 8 or 15
Platelets 75 99 x109/l continue at full dose
Platelets < 75x109/l omit gemcitabine
Second line
Ox-Cap
Oxaliplatin
Capecitabine
85 mg/m2 iv day 1
900mg/m2 oral bd x 9 days
Repeat at 14 day intervals for 6 cycles then reassessment

Criteria
PS 0-2
Relapse < 6 months post adjuvant chemotherapy
Progression free interval > 3 months following first line therapy
Fbc and creatinine prior to each cycle
Normal fbc limits for administration apply with the exception that the lower limit for platelets
for administration of Ox-Cap is 75 x 109/l
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Cholangiocarcinoma / Gall Bladder Carcinoma

Advanced
Gemcitabine + Cisplatin
Gemcitabine
1000mg/m2 day 1 and 8
Cisplatin
25mg/m2 day 1 and 8
Repeat at 21 day intervals for a maximum of 6 cycles

Criteria PS 0-1
Gemcitabine
1g/m2

Repeat 28 day cycles for 4- 6 cycles.
Criteria
PS 0-2
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ECF/EOX
Epirubicin
50mg/m2 iv day 1
Cisplatin
60mg/m2 iv day 1
5-Fluorouracil 200mg/m2 / day via continuous iv infusion
or
Oxaliplatin
130mg/m2 iv day 1
Epirubicin
50mg/m2 iv day 1
guidelines
Hepatocellular carcinoma*
Sorafenib
Sorafenib Initial dose 200mg bd

increasing to 400mg bd over 4 weeks to 400mg bd oral continuously
Continue until disease progression
Criteria
PS
0-2
Normal bilirubin
Transaminases < 2xULN
Normal renal function
Fbc, U/Es, LFTs prior to each cycle

Discontinue if deteriorating renal or liver function
*NB Available via the Cancer Drug Fund
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Neuroendocrine tumours
High mitotic rate, anaplastic histology, clinically aggressive
Etoposide
Cisplatin
Etoposide / cisplatin
120mg/m2 iv days 1-3

70mg/m2 iv days 1
Repeat at 21 day intervals max 6 cycles

Criteria
PS 0-1
Cr cl > 50ml/min
Patients with rapidly progressive disease
guidelines
Low mitotic rate, well differentiated histology, clinically indolent

short acting analogue titrated to achieve maximum benefit then switch to long
acting preparation
Somatostatin
*Everolimus (Afinitor)
10mg oral daily
Ensure normal renal and hepatic function prior to each cycle 1

Criteria
*NB
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First or Second line therapy
Only available via the Cancer Drug Fund
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*Sunitinib (Sutent)
37.5mg oral daily


Criteria
*NB
No prior anti-VEGF therapy
Progression on first line therapy

Streptozotocin/Doxorubicin
Streptozotocin
Doxorubicin
500mg/m2 iv days 1-5 repeat every 6 weeks

50mg/m2 iv day 1 repeat every 3 weeks
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Colorectal
Adjuvant
5FU/FA
5-Fluorouracil 370mg/m2 iv + folinic acid 50 mg iv weekly x 24 weeks
Fbc prior to every fourth week
Capecitabine
1250mg/m2 oral twice daily for 14 days followed by 7 days off

Consider 1000mg/m2 for patients over 70yrs
Repeat at 21 days from day 1 for eight cycles.
Repeat creatinine if clinically indicated
OxMdG
Consider for younger high risk patients

Oxaliplatin
Folinic acid
5-Fluorouracil
5-Fluorouracil
85 mg/m2 iv day 1
350mg flat dose two hour infusion day 1
400mg/m2 15 minute bolus day 1
2400mg/m2 46hr infusion day 1

Not suitable for patients with pre-existing neuropathy or conditions predisposing to neuropathy
for administration of OxMdG is 75 x 109/l
OX-Cap may be used as an alternative (see below)
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Rectal cancer - Chemoradiation

5FU + XRT
5-Fluorouracil 1000mg/m2 iv days 1-4 and 22-26 (or final week)

Or
5-Fluorouracil 300mg/m2 + Folinic acid 50mg
iv weekly during the radiotherapy
Capecitabine + XRT
Capecitabine 825mg/m2 oral bd Mon-Fri during XRT

Fbc each week during chemotherapy
5FU/FA
5-Fluorouracil 300mg/m2 iv + folinic acid 50 mg iv weekly during XRT
Fbc prior to every fourth week
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Advanced Colorectal Cancer
First line
Single agent
MdG:
MdG
Folinic acid
5-Fluorouracil
5FU
350mg flat dose two hour iv infusion day 1

400mg/m2 15 minute iv bolus day 1
2800mg/m2 46hr iv infusion start day 1
repeat at 14 day intervals, re-evaluate after 6 cycles.

Capecitabine
1250mg/m2 oral twice daily for 14 days

Consider 1000mg/m2 if age >70yrs
Issue Date:
Ensure normal renal and hepatic function prior to cycle 1 if clinically indicated
30th April 2012
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9.0
Combination chemotherapy
Consider for good PS status patients with relatively bulky disease who need a more rapid response.
IrinMdG Irinotecan 180mg/m2 iv + atropine 600ug s/c prior to irinotecan
MdG:
Folinic acid
5-Fluorouracil
5-Fluorouracil

2400mg/m2 46hr infusion start day 1

Review after 12 weeks and consider continuing to 24 weeks if:
SD / response.
Acceptable toxicity
Criteria: PS 0-2
I-Cap
Irinotecan 180mg/m2 iv + atropine 600ug s/c prior to irinotecan

Capecitabine 900mg/m2 oral bd x 9 days
SD / response.
Acceptable toxicity
Criteria: PS 0-1
Issue Date:
30th April 2012
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OxMdG
Oxaliplatin
Folinic acid
5-Fluorouracil
5-Fluorouracil
85 mg/m2 iv day 1

Avoid in patients with pre-existing neuropathy
Ox-Cap
Oxaliplatin
85 mg/m2 iv day 1
Capecitabine
XELOX
Oxaliplatin
130 mg/m2 iv day 1
Capecitabine
Normal fbc limits for administration apply.
Issue Date:
30th April 2012
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OxMdG + Cetuximab
Oxaliplatin
Folinic acid
5-Fluorouracil
5-Fluorouracil
Cetuximab
85 mg/m2 iv day 1
Week 1 400mg/m2 iv day 1 over 2 hours using 0.2um in-line filter
Then 500mg/m2 iv over 1 hour every 2 weeks
Premedication
Dexamethasone 8mg
Chlorpheniramine 10mg
Ranitidine 150mg

Fbc and biochemistry prior to each cycle
Criteria
KRAS wild type cancer

PS 0-1
Metastatic disease confined to the liver and potentially resectable if downsized
Primary resected or resectable
IrinMdG + Cetuximab
Irinotecan
Folinic acid
5-Fluorouracil
5-Fluorouracil
Cetuximab
180mg/m2 iv + atropine 600ug s/c prior to irinotecan

2400mg/m2 46hr infusion start day 1
Week 1 400mg/m2 iv day 1 over 2 hours using 0.2um in-line filter
Then 500mg/m2 iv over 1 hour every 2 weeks
Premedication
Dexamethasone 8mg
Ranitidine 150mg

SD / response.
Acceptable toxicity
Criteria
Issue Date:
30th April 2012
KRAS wild type cancer

PS 0-1
Metastatic disease confined to the liver and potentially resectable if downsized
Primary resected or resectable
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*Bevacizumab 14 day schedules:

21 day schedules
Bevacizumab 5mg/kg iv infusion

Bevacizumab 7.5mg/kg iv infusion
Criteria
Advanced colorectal cancer

First line chemotherapy
With oxaliplatin or Irinotecan based combination chemotherapy
*NB
Available via the Cancer Drug Fund
Second / third line chemotherapy
Irinotecan + MdG (see above)
Oxaliplatin + MdG (see above)
I-Cap (see above)
Ox-Cap (see above)
Irinotecan
180mg/m2 iv day 1 of a 14 day cycle

or
350mg/m2 iv day one of a 21 day cycle
Issue Date:
30th April 2012
Ensure normal renal and hepatic function prior to cycle 1 and repeat during
subsequent cycles if clinically indicated
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*Irinotecan + Cetuximab
Criteria
- Must have KRAS wild type cancers
- Previously responded to chemotherapy
- Second or third line chemotherapy
- performance status (0-1)
400mg/m2 iv day 1 over 2 hours using 0.2um in-line filter
500mg/m2 iv over 1 hour every 2 weeks
Cetuximab
Week 1
Then
Irinotecan
180mg/m2 iv every 2 weeks + atropine 600ug s/c
Premedication
Dexamethasone 8mg
Ranitidine 150mg
Continue until progression / unacceptable toxicity

* Cetuximab single agent

Criteria
- Must have KRAS wild type cancers
- Previously responded to chemotherapy
- third line chemotherapy
- performance status (0,1)
Cetuximab
Week 1
Then
400mg/m2 iv day 1 over 2 hours using 0.2um in-line filter

500mg/m2 iv over 1 hour every 2 weeks
Premedication
Dexamethasone 8mg
Ranitidine 150mg
Continue until progression / unacceptable toxicity

Issue Date:
30th April 2012
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MMC + MdG
Mitomycin-C 7mg/m2 iv day 1 repeat every 6 weeks (max 4 doses)

+
Folinic acid
350mg flat dose two hour infusion
5-Fluorouracil
5-Fluorouracil
Repeated at 14 day intervals
MMC + Capecitabine
Mitomycin-C 7mg/m2 iv day 1 repeat every 6 weeks, max 4 doses

Capecitabine 1000mg/m2 oral bd for 14 days repeat at 21 day intervals
Issue Date:
30th April 2012
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Anal Carcinoma
Localised squamous carcinoma of the anus
Combined XRT + chemotherapy

Mitomycin C
5-Fluorouracil
5-Fluorouracil
Capecitabine
12mg/m2 iv day 1 only (max 20mg)

1000mg/m2 iv over 24hrs days 1-4
1000mg/m2 iv over 24hrs daily x 4 during final week of XRT
or
825mg/m2 bd oral on each XRT treatment day
Palliative / Metastatic
Cisplatin/5FU
Cisplatin
5-Fluorouracil
Capecitabine
60mg/m2 iv (max 120mg) day 1

or
Repeat at 21 day intervals max 4 courses

guidelines
Mitomycin C / Fluoropyrimidine
Mitomycin C
5-Fluorouracil
Capecitabine
7mg/m2 iv day 1 repeat every 6 weeks, max 4 cycles

1000mg/m2 iv over 24hrs days 1-4 repeat at 21 day intervals
or
1000mg/m2 bd po days 1-14 repeat at 21 day intervals
Issue Date:
30th April 2012
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9.0
Gynaecological Cancer
Epithelial Ovarian Cancer
First Line Chemotherapy
Paclitaxel/Carboplatin
175mg/m2 iv over 3 hours
AUC 5/6
iv over 1 hour
Paclitaxel
Carboplatin
Paclitaxel premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg
16mg
50mg
Repeat at 21 day intervals maximum 6 courses
Criteria
Stage Ib-IV
Minimal residual disease / bulk residual disease
PS 0-1
Cr Cl > 50ml/min
Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if
CA125 prior to each cycle
or
Carboplatin
Carboplatin AUC 5/6 x (GFR + 25) iv at 21-28 day intervals x max 6 cycles
Issue Date:
30th April 2012
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Second line chemotherapy

Relapse > 6 months post platinum
Single agent carboplatin
Carboplatin AUC 5-6 iv x q28 days x 4-6 cycles
Single agent cisplatin

Cisplatin 80mg/m2 iv q 21 days x 4-6 cycles
Paclitaxel + carboplatin
See 1st line section for doses + pre-medication schedule
Repeat at 21 day intervals, max 6 doses
Issue Date:
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Carboplatin + Gemcitabine
Carboplatin
Gemcitabine
AUC4 iv at 21 day intervals

1000mg/m2 iv days 1 and 8 of a 21 day cycle
Repeat at 21 day intervals to a maximum of 6 cycles

Carboplatin + Liposomal Doxorubicin (Caelyx)

Carboplatin
Liposomal Doxorubicin (Caelyx)
AUC5
30mg/m2 iv

Paclitaxel 70mg/m2 iv weekly

Pre-medication
Dexamethasone
Chlorpheniramine
Ranitidine
8mg iv before first cycle

4mg iv before second and subsequent cycles
10mg iv
50mg iv
indicated
Issue Date:
30th April 2012
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Second / Third line chemotherapy options

Paclitaxel 175mg/m2 iv over 3hrs
or
135mg/m2 iv over 3hrs (depending on PS / prior treatment)
Premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg iv
16mg iv
50mg iv

Criteria
PS 0-1
No prior taxane therapy
Previous platinum
Liposomal doxorubicin (Caelyx)

40-45mg/m2 by iv infusion initially at 1mg/min q 28 days
Maximum 6 cycles
Criteria
PS 0-2
Platinum resistant / refractory
No evidence of intestinal obstruction
1.25mg/m2 daily iv over 30 minutes for 5 days q 21 days
Topotecan
or
3mg/m2 iv weekly on days 1, 8, 15 of a 28 day cycle
Maximum 4 cycles
Criteria
PS 0-2
Cr Cl > 40ml/min
Fbc prior to each dose
Issue Date:
30th April 2012
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Gemcitabine
1000mg /m2 iv days 1,8,15 of a 28 day cycle.

Criteria
PS 0-2
Reassess after 3 cycles, maximum 6 cycles

Etoposide 50mg bd oral x 7days of 21 day cycle max 6 cycles
Chlorambucil
10mg daily oral x 14 days of 28 day cycle max 6 cycles
Doxorubicin
60mg/m2 iv q21 days, max 6 cycles
Consider LV ejection fraction if history of cardiac disease
Issue Date:
30th April 2012
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Epithelial Ovarian Cancer Mucinous Histology

First line
Carboplatin / Paclitaxel or single agent carboplatin
Platinum refractory
Capecitabine
1250mg/m2 oral twice daily for 14 days

Capecitabine should be the treatment of choice where a central line is contra-indicated eg
I-Cap
Failed central venous catheterisation

Receiving anticoagulants but NB interaction between warfarin and capecitabine
Irinotecan 180mg/m2 iv + atropine 600ug s/c prior to irinotecan

Capecitabine 900mg/m2 oral bd x 9 days
SD / response.
Acceptable toxicity
Criteria: PS 0-1
Issue Date:
30th April 2012
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Ox-Cap
Oxaliplatin
85 mg/m2 iv day 1
Capecitabine
Repeat at 14 day intervals for 6 cycles then re-assessment
Endometrial Carcinoma
Epithelial
Advanced
Doxorubicin/Cisplatin/Paclitaxel
Doxorubicin
Cisplatin
Paclitaxel
45mg/m2 iv day 1
50mg/m2 iv day 1
160mg/m2 iv day 2
Premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg
16mg
50mg
Maximum of 6 cycles at 21 day intervals

guidelines
Issue Date:
30th April 2012
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Mixed Mullerian Tumours
Doxorubicin
75mg/m2 iv at 21 day intervals x 6 cycles depending on response
or
Cisplatin Cisplatin 80mg/m2 iv at 21 day intervals x 6 cycles
guidelines
or
Doxorubicin/Cisplatin
Doxorubicin 50mg/m2 iv
Cisplatin
50mg/m2 iv
Maximum of 6 cycles at 21 day intervals

guidelines
Issue Date:
30th April 2012
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Cervical Cancer
Adjuvant
Not currently recommended as standard therapy
Pre-XRT
BMC
Bleomycin
Mitomycin-C
Cisplatin
30,000 iu iv day 1
10mg/m2 cycles 1,3
50mg/m2 iv day 1
Repeat every 14 days for 2-4 cycles

guidelines
Advanced Squamous Carcinoma
Cisplatin / Topotecan
Criteria
Cisplatin
Topotecan
1.
2.
3.
>6m from completion of chemo-radiation to relapse

no prior radiosensitising cisplatin
PS 0-1
50mg/m2 iv day 1
0.75mg/m2 iv days 1-3
Repeat at 21 day intervals for 4-6 cycles
guidelines
Issue Date:
30th April 2012
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Paclitaxel/Cisplatin
50mg/m2 iv
Paclitaxel
Cisplatin
Chlorpheniramine
Dexamethasone
Ranitidine
10mg
16mg
50mg

Criteria
1.
2.
3.

PS 0-1
guidelines
Topotecan
Criteria
1.
2.
3.
Topotecan
PS 0-2
<6 months post chemoradiation
prior radiosensitising cisplatin
1.2mg/m2 (max 2mg) iv days 1-5

Dose Modification
Episode of neutropenic sepsis reduce dose for ensuing cycles by 40%
Interval neutrophil count 0.5-1.0 x109/l or platelets 10 50 x109/l 20% reduction
Interval neutrophil count <0.5x109/l or platelets <10x109/l 40% reduction
Issue Date:
30th April 2012
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Advanced Non-squamous carcinoma

Paclitaxel/Cisplatin
Criteria
1.
2.
3.

PS 0-1
Paclitaxel
Cisplatin

50mg/m2 iv
Chlorpheniramine
Dexamethasone
Ranitidine
10mg iv
16mg iv
50mg iv
Paclitaxel
Criteria
1.
2.
3.
PS 0-2
<6 months post chemoradiation
prior radiosensitising cisplatin
Paclitaxel 135mg/m2 iv over 3hrs

Premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg
16mg
50mg
Issue Date:
30th April 2012
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Chemo-radiotherapy schedules
Criteria
bulky 1B or 2B
PS 0-1
Normal liver / renal / haematology
(1)
40mg/m2 iv (max 70mg) in 1 litre Sodium chloride 0.9% over 60min weekly x max 6 weeks
30mg/m2 if XRT fields large
Cisplatin
guidelines
or
(2)
Cisplatin
5-Fluorouracil
80mg/m2 iv day 1
1g/m2 iv days 1-4 and 29-32
guidelines
Erythropoietin may be used to maintain haemoglobin levels during combined modality therapy in these patients.
Carcinoma of the Vulva

Chemoradiation
Mitomycin C
5 Fluorouracil
12mg/m2 (max 20mg) iv day 1

1000mg/m2 iv days 1-4 and 29-32
Issue Date:
30th April 2012
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Haematological Malignancies
Hodgkins disease
Early HD
PET/CT as part of staging
Group I
Involved field XRT
Group II
ABVD x 3 + IF XRT
Group III
Three cycles full dose chemotherapy + IF XRT

or
6 cycles full dose chemotherapy + IF XRT if residual abnormality
Advanced HD
Stages III / IV or I / II with mediastinal bulk + / - B symptoms
ABVD
Doxorubicin
Bleomycin
Hydrocortisone
Vinblastine
Dacarbazine

10000iu/m2 iv day 1 and 15
100mg iv
day 1 and 15
day1 and 15 (max 10mg)
6mg/m2 iv
Repeat at 28 day intervals to CR + 2, min 6 max 8 cycles

ChlVPP
Vinblastine 6mg/m2 iv days 1 and 8 (max 10mg)

Chlorambucil 6mg/m2 po days 1-14
Prednisolone 40mg po days 1-14
Procarbazine 50mg oral tds days 1-14
Repeat 28 days from day 1 x 6 cycles)
Issue Date:
30th April 2012
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Non-Hodgkins Lymphoma
Low grade
First line
CVP-R
600mg/m2 iv day 1
1.4mg/m2 iv day 1 (maximum 2mg)
50mg orally days 1-5
iv day 1
375mg/m2
Cyclophosphamide
Vincristine
Prednisolone
Rituximab
Repeat at 21 day intervals to a maximum of 6-8 cycles.

*Bendamustine

*NB available via the Cancer Drug Fund
CHOP-R
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
750mg/m2
50mg/m2
1.4mg/m2
50mg po
iv day 1
iv day 1
iv day 1
days 1-5
Rituximab
375mg/m2
iv day 1

Criteria: fit patients with bulky disease
Issue Date:
30th April 2012
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*Maintenance Rituximab
Rituximab
375mg/m2
iv every 3 months for 2 years
Criteria CR or PR following first line therapy

Must commence within 2 months of completion of first line therapy
Mantle Cell Lymphoma

*Bendamustine 120mg/m2 iv days 1 and 2
Criteria Option for first line therapy
Second Line
*Bendamustine 120mg/m2 iv days 1 and 2
Criteria
Unable to receive R-CHOP

Unable to receive high dose therapy
Issue Date:
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Second / third line
Chlorambucil +/- Prednisolone

10mg daily orally for 14 days
Chlorambucil
+
Prednisolone
20mg oral daily for 14 days

Repeat at 28 day intervals for up to 6 cycles
Fludarabine
40mg/m2 orally days 1-5 (only 3 days if heavily pre-treated)
Fludarabine

Criteria
Progressed after alkylating agents and anthracyclines

Age < 75yrs
PS 0-1
Normal marrow function
NB: patients receiving fludarabine should have all blood products

Irradiated
Rituximab
Issue Date:
30th April 2012
375mg/m2
in 500ml Sodium chloride 0.9% iv weekly x 4
Criteria
Stage III / IV follicular / Mantle cell NHL

Chemoresistant (prior alkylating agent and anthracycline chemotherapy)
Normal renal / hepatic function
Anticipated survival > 3 months
Age < 65yrs
PS 0-2
Not eligible for a clinical trial
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Intermediate / High grade

Stage I
CHOP x 3 + involved field XRT
Stage II-IV
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Rituximab
CHOP-R
750mg/m2
50mg/m2
1.4mg/m2
50mg po
375mg/m2
iv day 1
iv day 1
iv day 1
days 1-5
iv day 1
(max. 1mg if aged >70)

Relapsed Intermediate / High grade

A proportion of patients with relapsed intermediate / high grade NHL may be salvaged with high dose
chemotherapy + marrow / PBSC rescue. Patients in this situation should be discussed with the NHL MDT at the
Royal Liverpool Hospital.
Issue Date:
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Head and Neck Cancer

Locally advanced disease
XRT +Cisplatin/5FU
80mg/m2 iv day 1
Cisplatin
5Fluorouracil
Repeat at 21 day intervals for 2-4 cycles prior to XRT

guidelines
or
XRT + CTX
Cisplatin 100mg/m2 iv days 1, 22, and 43 with concomitant XRT

guidelines
or
XRT + Cisplatin / 5FU / Docetaxel

Cisplatin
5Fluorouracil
Docetaxel
80mg/m2 iv day 1
1000mg/m2 over 24hrs iv days 1-4
75mg/m2 iv day 1
Repeat at 21 day intervals for 3 cycles prior to CTX/XRT

Criteria
Locally advanced SCC suitable for CTX/XRT

PS 0/1
Creatinine clearance > 50mls/min
guidelines
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XRT + Cetuximab*
400mg/m2 iv loading dose 1 week prior to XRT
250mg/m2 iv weekly during XRT
Cetuximab
Criteria
Locally advanced SCC suitable for CTX/XRT

Unsuitable for cisplatin eg creatinine clearance < 50mls/min
PS 0/1
*Available via the off protocol mechanism

Recurrent or Metastatic Disease
Cisplatin/5FU
80mg/m2 iv day 1
Cisplatin
5Fluorouracil
or
Cisplatin
Cisplatin
100mg/m2 iv
guidelines
Issue Date:
30th April 2012
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2nd Line Chemotherapy for advanced disease

Paclitaxel
135-175mg/m2 iv over 3hrs

Dose depends on PS and extent of prior therapy
Premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg iv
16mg iv
50mg iv

Criteria
PS 0-1
Nasopharyngeal Carcinoma
Chemoradiation + Adjuvant Chemotherapy
Criteria
Nasopharyngeal carcinoma Stage III/IV

Creatinine clearance > 50ml/min
Chemoradiation
Cisplatin 100mg/m2 days 1, 22, 43 to start prior to XRT
guidelines
followed by:
Adjuvant chemotherapy
Commencing 21 days after 3rd cycle of cisplatin
Cisplatin
5Fluorouracil
80mg/m2 iv day 1
1g.m2 iv over 24 hrs days 1-4

guidelines
Issue Date:
30th April 2012
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Thyroid Cancer
Medullary Thyroid Cancer
Sorafenib
400mg bd oral continuously

Criteria
PS
0-2
Locally advanced unresectable / metastatic
First line

*NB available via the Cancer Drug

Papillary or Follicular Thyroid Cancer
Sorafenib
400mg bd oral continuously

Criteria
PS 0-2
Refractory to radioiodine

*NB available via the Cancer Drug
Issue Date:
30th April 2012
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Lung Cancer
Small Cell
Good PS + Limited stage
Concurrent chemotherapy + XRT
Cisplatin/etoposide
Etoposide
Cisplatin
120mg/m2 iv days 1-3 (or oral 240mg/m2 day 3)

70mg/m2 iv days 1

XRT commences with cycle 2
guidelines
Good / Intermediate PS
Carboplatin / Etoposide
Carboplatin
Etoposide
Etoposide
AUC 5 iv day 1
100mg/m2 iv day 1
200mg/m2 po days 2 and 3
Repeat at 21 day intervals x 4 - 6 cycles

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Poor PS
Many poor PS patients will be too ill potentially to benefit from chemotherapy and symptomatic care will be
the most appropriate option. For those judged to be fit enough the following may be considered:
(1) Carboplatin
AUC 4 / 5 iv q 21 days x 4 cycles
(2) Etoposide
50mg oral bd x 7 - 10 days repeat at 21 days from day 1max 6 courses
Second Line Chemotherapy
(1) Etoposide
50mg oral bd x 7 - 10 days repeat at 21 days from day 1max 6 cycles / progression
(2) Carboplatin
AUC x 5-6 iv q 21 days for 4 cycles
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Cyclophosphamide
Doxorubicin
Vincristine
(3) CAV
750mg/m2 iv
50mg/m2 iv
1.4mg/m2 iv
Repeat at 21 days for 4 6 cycles

(4) Topotecan
2.3mg/m2 oral daily for 5 days

Repeat at 21 day intervals , maximum 4 cycles
Criteria
PS 0-2
Cr Cl > 40ml/min
Issue Date:
30th April 2012
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Non-Small Cell Lung Cancer

Adjuvant
Criteria
Stage 1-3 completely resected

PS 0-1
Cisplatin/Vinorelbine
Cisplatin
80mg/m2 iv day 1
Vinorelbine 25mg/m2 iv day 1 and 8 or oral 60mg/m2 day 1 and 8
Repeated at 21 day intervals x 3 cycles
guidelines
or
Carboplatin/Vinorelbine
Carboplatin AUC x 5 iv
Vinorelbine 25mg/m2 iv days 1 and 8 or 60mg/m2 oral day 1 and 8
21 28 day cycle x 3 cycles
Carboplatin/Vinorelbine (split dose) Carboplatin AUC x 2.5 iv days 1 and 8
Vinorelbine 25mg/m2 iv days 1 and 8 or 60mg/m2 oral day 1 and 8
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Locally advanced
Chemotherapy + XRT
Cisplatin 20mg/m2 iv days 1-4 and 16 - 19

+
Vinorelbine 15mg/m2 iv with XRT fractions 1, 6, 15 and 20
Followed at 4-6 weeks by:
Cisplatin 80mg/m2 day 1
Vinorelbine 25mg/m2 day 1 and 8
guidelines
Advanced
Cisplatin / Pemetrexed
Cisplatin 75mg/m2 iv
Pemetrexed 500mg/m2 iv
Repeat at 21 day intervals x 4 cycles
Vitamin B12 inj 1 week prior to start + every 9 weeks until completion
Folic acid 400ug daily oral during treatment
Dexamethasone 4mg tds for 3 days start day before pemetrexed
Stop all NSAIDS during chemotherapy
Criteria: Non-squamous carcinomas

PS 0-1
Issue Date:
30th April 2012
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Cisplatin/Vinorelbine
Cisplatin
80mg/m2 iv day 1
Vinorelbine 25mg/m2 iv day 1 and 8 (oral vinorelbine 60mg/m2 day 1and 8)
guidelines
Gemcitabine/Carboplatin
Carboplatin AUC x 5 iv
Gemcitabine 1250mg/m2 iv days 1 and 8
NB: transaminases may rise during treatment
Carboplatin/Vinorelbine
Carboplatin
Vinorelbine
Or
oral vinorelbine
AUC x 4/5 iv
60mg/m2 day 1 and 8

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Vinorelbine
25-30mg/m2 iv days 1 and 8 of a 21 day cycle

or
60-80mg/m2 oral days 1 and 8
Max 4 courses
Criteria:
No prior chemotherapy
PS 0-2
Gemcitabine
Gemcitabine 1000mg/m2 iv days 1, 8, 15 of a 28 day cycle
NB: transaminases may rise during treatment
Gefitinib
250mg oral daily

Criteria
Locally advanced / metastatic NSCLC

EGFR mutation +ve
First line
Maintenance Pemetrexed
Pemetrexed
500mg/m2 iv
Repeat at 21 day intervals until progression
Dexamethasone 4mg tds for 3 days start day before pemetrexed
Criteria: Non-squamous carcinomas

PS 0-1
CR/PR/SD following first line chemotherapy
First line CTX with Platinum + vinorelbine/paclitaxell/gemcitabine/docetaxel
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Second line Chemotherapy

75mg/m2 iv q 21 day cycle x max 4 cycles
Docetaxel

Criteria
PS 0-1
Previous response or stable disease to platinum based chemotherapy
Progression free interval following platinum based chemotherapy > 6m
Erlotinib (Tarceva)
150mg oral daily initially for 4 weeks and continued thereafter if
symptomatic or objective response
Erlotinib
Criteria
Progression following chemotherapy for advanced disease

Fit to receive docetaxel as second line therapy
No prior andi egfr therapy
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Mesothelioma
Cisplatin / Pemetrexed
Pemetrexed 500mg/m2 iv
Dexamethasone 4mg b5 for 5 days start day before pemetrexed
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Melanoma
Advanced
850mg/m2 iv q 21 days max 6 cycles
Dacarbazine
Gemcitabine + treosulphan
Gemcitabine 1000mg/m2 iv days 1 and 8
Treosulphan 3500mg/m2 iv days 1 and 8
Carboplatin
Carboplatin AUC 5/6 x (GFR + 25) iv at 21-28 day intervals x max 6 cycles
*Ipilimumab
3mg/kg iv over 90min

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Soft Tissue Sarcoma

Adjuvant
There is no proven role for adjuvant chemotherapy for soft tissue sarcomas. However treatment may be considered
when chemo-sensitive tumours such as rhabdomyosarcoma, synovial sarcoma are resected with close margins.
Neo-adjuvant
Suggested protocol for down sizing prior to surgery
Doxorubicin
Mesna prior to ifosfamide
Ifosfamide + Mesna
Mesna post ifos/mesna infusion
20mg/m2 day 1,2,3

3g/m2day 1,2,3
3g/m2 / 3g/m2 day 1,2,3
3g/m2 day 1,2,3
Advanced
There is no evidence that combinations are superior to single agents as palliative chemotherapy
First line
Doxorubicin
Doxorubicin
75mg/m2 iv q 21 days x 6 cycles
Ensure normal renal and hepatic function prior to cycle 1 and repeat during subsequent
cycles if clinically indicated
Second line
Pre Ifosfamide Mesna
Ifosfamide/Mesna
Post Ifosfamide Mesna
Ifosfamide
3g/m2 days 1,2,3

3g/m2 days 1,2,3
3g/m2 days 1,2,3

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Dacarbazine
800mg/m2 iv day 1
Trabectedin
1.5 mg/m2 as IV infusion over 24 hours every 21 days
Consider in advanced STS after anthracyclines and ifosfamide or intolerant/contraindications

to anthracyclines and ifosfamide.
PS 0-2
.
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Osteosarcoma / MFH of bone / Leiomyosarcoma of Bone

Neoadjuvant / Post operative schedule
PAM x 2 -> Surgery (week 10) -> PAM x 2 -> Doxorubicin - Methotrexate x 2
Cisplatin
60mg/m2 iv day 1,2
Doxorubicin 25mg/m2 iv days 1,2,
Methotrexate 12g/m2 iv days 22 and 29
PAM
Folinic acid rescue
Start 24 hrs post start of Methotrexate infusion with 30mg iv 6 hourly

Switch to oral after 6 doses if not vomiting
Methotrexate levels at 24, 48, 72 hrs etc.
Continue until Methotrexate undetectable ie <0.1M usually 4-5 days
Methotrexate level
Folinic acid dose 6hrly
< 0.1M
<0.5-5M
5-50M
>50M
Stop rescue
15-30mg 6hrly
200mg/m2 6hrly
1000mg/m2 6hrly
In addition patients urinary pH should be >7 prior to starting Methotrexate infusion

NB: do not give methotrexate if renal function is abnormal or in the presence of a
third space. Also avoid all non-steroidal anti-inflammatory agents prior to
treatment and until Methotrexate undetectable.
Doxorubicin /Methotrexate
Doxorubicin 37.5mg/m2 iv days 1,2
Methotrexate 12g/m2 iv days 15 and 22
Folinic acid rescue see above
Criteria
Cisplatin/Doxorubicin
Age < 40yrs

PS 0-2
Cisplatin
100mg/m2 iv day 1
Doxorubicin 25mg/m2 iv days 1,2,3 (20mg/m2 days 1-3 age > 60yrs)
Repeat at 21 days x 3 cycles then surgery then 3 further cycles.
Criteria
Not suitable for PAM schedule.

PS 0-2
guidelines
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Advanced Osteosarcoma
Cisplatin/Doxorubicin
Cisplatin
100mg/m2 iv day 1
Doxorubicin 25mg/m2 iv days 1,2,3
Repeat at 21 days x 6 cycles
guidelines
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Ewings Sarcoma
Non-metastatic Ewings Sarcoma/PNET/Askin tumour / Rhabdomyosarcoma
Fbc/Biochemistry/Ca/Mg/Cl/HCO3 each cycle

Early morning urine PO4, Creatinine, osmolarity at baseline and repeat every other cycle of VIDE
Echo/MUGA baseline/cycle 4 if indicated/cycle 6/ end Rx / pregnant
Bone scan/CT chest/MRI primary/Marrow biopsy at baseline
MRI primary after cycles 2, 4, 6(omit after 2 if good response)
Neoadjuvant
VIDE (cycles 1-6)
1.5mg/m2 (max 2mg) iv
20mg/m2 iv
1g/m2
150mg/m2 iv
1.5g/m2 / 1.5g/m2 iv
1.5g/m2 iv
Vincristine
Doxorubicin
Mesna
Etoposide
Ifosfamide/Mesna
Mesna
Pegfilgrastim
day 1
days 1-3
day 1
days 1-3
days 1-3
days 3
6mg subcutaneous injection day 4
Evaluation after cycle 4:

If surgical resection likely proceed to cycles 5 and 6
If radiotherapy to be definitive local therapy proceed to cycles 5 and 6
If disease progression discontinue and consider surgery or radiotherapy
If pre-surgery XRT planned proceed to cycles 5 and 6 omitting doxorubicin
Dose modifications
Haematological toxicity
Delayed recovery of wbc / platelets > 6 days reduce etoposide 20%
Neutropenic sepsis grade 3 or 4 reduce etoposide 20%
Further episodes repeat etoposide 20% reductions
GI / Mucositis
Graded 3 or 4 reduce etoposide by 20%
Cardiac function
LVEF < 40% omit doxorubicin and substitute Actinomycin-D 1.5mg/m2
Repeat echo after next cycle and consider reintroducing doxorubicin if LVEF has recovered.
Definitive local treatment
Surgery should occur 21 days after cycle 6 or as soon as recovery allows.
Radiotherapy should commence concurrent with cycle 7 omitting Actinomycin-D from concurrent cycles.
If radiation is required following surgery it should commence after cycle 8 omitting Actinomycin-D from
concurrent cycles.
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VIA (cycles 7-14)
Vincristine
Actinomycin D
Pre Ifosfamide Mesna
Ifosfamide/Mesna
Post Ifosfamide Mesna
1.5mg/m2 (max 2mg) iv

0.75mg/m2 (max 1.5mg)iv
1g/m2
1.5g/m2 / 1.5g/m2 iv
1.5g/m2
day 1
days 1-2
days 1-2
days 1-2
NB: omit Actinomycin-D during radiotherapy
Haematological toxicity
Delayed recovery of wbc / platelets > 6 days reduce Act-D and Ifosfamide by 20%
Neutropenic sepsis grade 3 or 4 reduce Act D and Ifosfamide by 20% + add GCSF
Further episodes should be managed with serial 20% reductions
GI / Mucositis
Grade 3 or 4 reduce Ifosfamide + Act D by 20%
Renal Toxicity
GFR > 60 no change
GFR 40-59 reduce Ifosfamide by 30%, reduce etoposide by 30%
GFR < 40 switch Ifosfamide to cyclophosphamide 1500mg/m2 on day 1 only reduce
etoposide by 30%
Cardiac function
LVEF < 40% or 10% decrease from previous level, delay chemotherapy and repeat in 7
days. If recovered proceed with chemotherapy. If still impaired consider omission or
dose reduction of Ifosfamide.
VAC
Vincristine
Actinomycin-D
Mesna
Cyclophosphamide/Mesna
Mesna
1.5mg/m2 iv (max 2mg)

0.75mg/m2 iv (max 1.5mg) day 1 and 2
500mg /m2 iv pre cyclophosphamide
1500mg/m2 / 1500mg/m2 iv day 1
1500mg/m2 iv post cyclophosphamide
Repeat at 21 days for 4 6 cycles

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VACA
(In patients unsuitable for VIDE previously NOT exposed to anthracyclines actinomycin D and
doxorubicin on alternate cycles)
Vincristine
1.5mg/m2 iv (max 2mg) D1
Mesna
Mesna
Actinomycin-D

1200mg/m2 / 1200mg/m2 iv day 1
1200mg/m2 iv post cyclophosphamide
0.5mg/m2 iv (max 1mg) day 1,2,3
Alternating with
20mg/m2 iv day 1,2,3
Doxorubicin
Etopside / Ifosfamide
Etoposide
Pre-Ifosfamide Mesna
Ifosfamide/Mesna
Post ifosfamide Mesna
120mg/m2 iv
500mg/m2
3g/m2 / 3g/m2 iv
1.5g/m2 iv
days 1-3
days 1-3
days 1-3
days 1-3
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Palliative Ewings
Etoposide / cisplatin
Etoposide 120mg/m2 iv days 1-3
Cisplatin 50mg/m2 iv days 1-2
or
Carboplatin AUC 5 iv day 1
Etoposide 120mg/m2 iv day1 240mg/m2 po days 2,3
Criteria
PS 0-1
Cr cl > 50ml/min for cisplatin
guidelines
Cyclophosphamide/ Topotecan
Relapsed Ewings sarcoma
Relapsed/ 2nd line rhabdomyosarcoma
D1-5
Topotecan 0.75 mg/m2
Cyclophosphamide 250 mg/m2 D1-5
Cycle repeated every 21 days
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Gemcitabine/Docetaxel
Relapsed metastatic osteosarcoma
Selected metastatic soft tissue sarcomas (3rd line)/ uterine leiomyosarcoma
Relapsed Ewings (if other 2nd line is not suitable)
D1
Gemcitabine 675 mg/m2 iv over 90 minutes
D8
Gemcitabine 675 mg/m2 iv over 90 minutes followed by

Docetaxel 75-100mg/m2 iv over 60 minutes
Dexamethasone 8 mg bd for 3 days to start 24 hours pre docetaxel (ie D7-9)

Cycle repeated every 21 days
Irinotecan/Temozolomide
Relapsed Ewings sarcoma
Relapsed/ 2nd line rhabdomyosarcoma
D1-5, D8-12
Irinotecan 20 mg/m2 iv
D1-5
Temozolomide 100mg/m2 po
Cycle repeated every 21-28 days
Paclitaxel
Angiosarcomas
(2nd line or 1st line if not suitable for doxorubicin)
80 mg/m2 weekly up to 12 weeks
175 mg/m2 every 21 days (4-6 cycles, review after cycle 3)
Oral Etoposide
Palliative metastatic Ewings or rhabdomyosarcoma
Etoposide 50-100mg bd 7-14 days (at clinicians discretion)
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Aggressive fibromatosis
1st Line
Tamoxifen +/- NSAIDs
2nd Line
Methotrexate 30 mg/m2 (usually 50mg total dose)
Vinblastine 6 mg/m2 (usually 10mg total dose)
Every 1-2 weeks
Duration of course at clinicians discretion
Vinorelbine can replace vinblastine if neuropathy a problem.
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Rhabdomyosarcoma
Baseline investigations:
- FBC, U+Es, LFTs Bone chemistry
- CT thorax / Abdo staging
- Bone marrow aspirate and trephine
- Bone Scan
- If paramningeal site- CSF
- Consider early morning urine for phosphate, creatinine, osmolarity for Ifosfamide containing regimes
For patients aged < 40 years:
IVADo regime for high risk rhabdomyosarcoma (see separate regime)
Maintenance therapy:
Vinorelbine 25 mg/m2 IV D 1, 8, 15
Cyclophosphamide 25 mg/m2 PO OD D 1-28
Every 28 days
Maintenance therapy following IVADo to be used in:
1.
2.
For Alveolar Rhabdomyosarcoma maintenance therapy following IVADo for 6 cycles ( i.e. 6 months)
For metastatic disease on intensive treatment, if no residual disease or limited residual disease, IVADo to
be followed by maintenance treatment for 12 cycles
For patients > 40 years:

IVAD
Vincristine 1.4 mg/m2 (max dose 2mg) D1

Doxorubicin 30 mg/m2 D1, D2
Mesna 1.2g/m2 pre ifosfamide D1,D2
Ifosfamide 3g/m2 D1,D2
Mesna 2.4g/m2 post ifosfamide in 2 divided doses D1,D2
VAC
Vincristine
Actinomycin-D
Mesna
Mesna
1.5mg/m2 iv (max 2mg)

0.75mg/m2 iv (max 1.5mg) day 1 and 2
1500mg/m2 / 1500mg/m2 iv day 1
1500mg/m2 iv post ifosfamide

IVA
Vincristine 1.5mg/m2 (max dose 2mg) D1

Actinomycin D 1.5 mg/m2 (max single dose 2mg) D1
Mesna 1.2g/m2 day D1,D2
Ifosfamide 3 g/m2 + Mesna 3 g/m2 D1,D2
Mesna 2.4g/m2 split into 2 doses
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IVADo Regime for High Risk Rhabdomyosarcoma

Cycle 1
Week
Cycle 2
IVADo
IVADo
IVADo
Cycle
5
Week
I=
Cycle 3
IVA
13
Cycle
6
14
IVA
16
15
Cycle 4
IVADo
Cycle
7
17
18
IVA
19
Surgery/
Radiotherapy
10
Cycle
8
20
IVA
22
21
Mesna 1.2g/m2 over 1 hour pre ifosfamide

Ifosfamide 3g/m2 + Mesna 3g/m2 over 3 hours
Mesna 2.4g/m2 over 8 hours (split into 2 doses)
Cycle
9
23
24
IVA
25
D1, D2
V=
Vincristine 1.5mg/m2 (max single dose 2mg) D1
A=
Actinomycin D 1.5 mg/m2 (max single dose 2mg) D1
Do=
Doxorubicin 30 mg/m2 D1,D2 for cycles 1-4
Each cycle:
WCC>2
Neutrophils> 1.0 ( or physicians discretion)
Platelets > 80
Weekly vincristine to be given irrespective of pancytopenia unless unwell
Reassess after cycle 3. If not CR or PR > 1/3rd consider 2nd line treatment + RT
PAM Chemotherapy for Resectable Osteosarcoma

AP
1
Week
Cycle 1
M
2 3 4
M
5
AP
6
Cycle 4
AP
17
Week
AP -
18
19
M
20
M
21
A
22
Cycle 2
M
7 8 9
SURGERY
M
10
11
Cycle 5
M M
23 24 25
Cycle 3
AP
12
A
26
Cycle 6
M
27 28
13
14
M
15
M
16
M
29
Doxorubicin 25 mg/m2 D1, D2, D3

Cisplatin 60mg/m2 D1, D2
M-
Methotrexate 12 g/m2 (With folinic acid rescue)
A-
Doxorubicin 37.5 mg/m2 D1,D2
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Gastro-intestinal Stromal Tumours

Adjuvant
Criteria
Tumour
> 5cm
Mitoses
> 5 mitoses/50 HPF
SI / colonic primary
Imatinib po 400mg daily for 12 months
Imatinib (Glivec)
Criteria
Imatinib 400mg daily orally until progression

PS 0-2
c-Kit positive
locally advanced / metastatic disease
Fbc / biochemistry prior to each visit
Dose reduce if significant toxicity / rising hepatic transaminases
Sunitinib (Sutent)*
Criteria
Sunitinib
50mg orally daily for 4 weeks followed by a two week break
PS 0-2
c-Kit positive
locally advanced / metastatic disease
previous response to imatinib
Fbc / biochemistry prior to each visit
*Available via the off protocol mechanism
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Urological Cancer
Bladder Cancer - Transitional cell
Neoadjuvant
Cisplatin/Gemcitabine
70mg/m2 iv day 1
1g /m2 iv days 1,8,15
Cisplatin
Gemcitabine
Repeat at 28 day intervals for 3 cycles prior to cystectomy

guidelines
Cisplatin / Gemcitabine split dose
Cisplatin
Gemcitabine
35mg/m2
1000mg/m2
iv days
iv days
1 and 8
1 and 8
Repeated on a 21 day schedule for up to 4 cycles

guidelines
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Concurrent Cisplatin / XRT

Cisplatin/XRT
Cisplatin
30-40mg/m2 iv weekly x 4-6 weeks as an outpatient

(max 60mg) iv over 1 hour
XRT 55Gy in 20# (4 x weekly cisplatin infusions)
or
XRT 64Gy in 32# (6 x weekly cisplatin infusions)
Criteria
PS 0-1
Poorly differentiated TCC bladder
pT2-4a, N0, M0
guidelines
Advanced
Cisplatin/Gemcitabine
70mg/m2 iv day 1
1g /m2 iv days 1,8
Cisplatin
Gemcitabine
Repeat at 21 day intervals for up to 6 cycles.

guidelines
Cisplatin / Gemcitabine split dose

Cisplatin
Gemcitabine
35mg/m2
1000mg/m2
iv days
iv days
1 and 8
1 and 8
Repeated on a 21 day schedule for up to 4 cycles

guidelines
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Carboplatin/Gemcitabine
Carboplatin
Gemcitabine
AUC4 / 5 iv
1g /m2 iv days 1,8 of a 21 day cycle
For patients with impaired renal function

Repeat at 21/28 day intervals for up to 6 cycles.
Laboratory Investigation
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Renal cancer
Advanced
First line
Alpha Ifn
Interferon
by s/c injection:
week 1
Mon 5mu
Wed 5mu
Weeks 2 + 10mu Mon / Wed / Fri
Criteria
Fri 10mu
PS 0-1
Relapse post nephrectomy > 12 months
Low volume disease
Patients should have 2 out of 3 criteria
50mg daily x 4 weeks followed by 2 week break
Sunitinib (Sutent)
6 week cycles repeated until progression

Criteria
PS 0-1
Pazopanib
800mg daily
Criteria
First line advanced disease

No prior cytokine therapy
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Sorafenib
Sorafenib 400mg bd orally continuously until progression

Criteria
PS 0-1
Progression on/following cytokine therapy
*Temsirolimus
25mg iv weekly
Premedication
Criteria
*NB
First line therapy

Poor risk patients
10mg oral daily
*Everolimus (Afinitor)

Criteria
*NB
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Second line therapy

Biopsy proven RCC
Must have had prior VEGF inhibitor
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Prostate Cancer
Mitoxantrone
12mg/m2 iv (max 20mg) q 21 days

Criteria
Maximum total dose 140mg/m2
Endocrine refractory disease

PS 0-1
Normal fbc, renal, liver function
No cardiac failure
Docetaxel 75mg/m2 iv q21 days

Prednisolone 10mg daily until completion of chemotherapy
Docetaxel

Reassessment after two cycles and continue to a maximum of 10 only if responding or stable
disease.
Criteria: WHO Performance Status 0-1
Hormone resistant
*Abiraterone
Issue Date:
Abiraterone 1000mg oral daily + prednisolone 10mg daily

Criteria
Castrate resistant
Prior docetaxel chemotherapy
*NB
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*Cabazitaxel
Cabazitaxel
25mg/m2 iv infusion.
premedication
Dexamethasone 16mg
Ranitidine
50mg

*NB
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Germ Cell Tumours

Adjuvant
Stage I Pure Seminoma
Carboplatin
AUC x 7 iv - one dose only
EDTA clearance required to calculate AUC

Ensure normal hepatic function prior to treatment
Stage I Non-seminomatous testicular GCT

Criteria:
BEP3
vascular or lymphatic invasion

Bleomycin
Etoposide
Cisplatin
30000iu iv day 1, 8, 15
50mg/m2 iv days 1-2

guidelines
Tumour markers: HCG,AFP,LDH where appropriate prior to each cycle
Low risk all GCT

BEP3
Bleomycin
Etoposide
Cisplatin
30000iu iv day 1, 8, 15
50mg/m2 iv days 1-2
Repeat at 21 day intervals for 3 cycles.

guidelines
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Intermediate / High risk all GCT

Bleomycin
Etoposide
Cisplatin
BEP5
30000iu iv days 1,5, 15 cycles 1-3

20mg/m2 iv days 1-5
Repeat at 21 day intervals x 3 cycles then EP5 for a further 3 cycles (i.e. omit
bleomycin)
guidelines
CNS disease
POMB / ACE + Intrathecal (IT) Methotrexate
POMB
Day 1
Day 2
Day 3
Day 4
Vincristine
Methotrexate
Folinic acid
Bleomycin
Bleomycin
Cisplatin
2mg iv
1g/m2 iv over 24hrs (Standard dose is 300mg/m2)
15mg 6hrly x 12 doses start 12 hrs after completion of Methotrexate
15mg iv over 24hr
15mgiv over 24 hr
120mg/m2 iv over 12hr
guidelines
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ACE
Act D
Etoposide
Cyclophosphamide
0.5mg iv days 1-3

500mg/m2 iv day 3
Intrathecal (IT) Methotrexate 12.5mg flat dose

folinic acid rescue 15mg 6hrly x 4 start at 24hrs
Ensure normal renal and hepatic function prior to cycle 1 and repeat during subsequent cycles if
Repeat cycles at 14 days from day 1, POMB, POMB, ACE, POMB, ACE etc 4-5 cycles of POMB.
Initial organ failure

Low dose cisplatin / etoposide
Etoposide 100mg/m2 iv
Repeat daily x 2-3days depending on clinical situation
guidelines
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Relapsed NSGCT
TIP
Paclitaxel
Ifosfamide
Cisplatin
175mg/m2 iv 3hr infusion day 1

1000mg/m2 (+mesna) iv days 1-5
20mg/m2 iv days 1-5
Premedication
Chlorpheniramine
Dexamethasone
Ranitidine
10mg iv
20mg iv
50mg iv
Repeat at 21 day intervals x 4 cycles

guidelines
High dose chemotherapy
Issue Date:
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May be curative in selected patients with drug sensitive relapsed disease.
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Primary CNS Malignancy

Glioblastoma Multiforme concomitant Temozolomide + XRT
75mg/m2 oral daily day 1 to completion of XRT
Temozolomide
Dose 1 hour pre-XRT and in am at weekends

Co-trimoxazole 960mg oral daily Mon / Wed / Fri until lymphocyte count normal after
completing XRT
Ensure normal renal and hepatic function prior to cycle 1 and repeat during subsequent cycles if clinically
indicated
Fbc weekly
if neutrophils < 1.5
or
Platelets < 100
Withhold Temozolomide until neuts > 1.5 and platelets > 100
If neutrophils < 0.5 or platelets < 10 stop Temozolomide
Criteria
Age 18 70
PS 0 1
Absence of HIV, chronic hepatitis B and hepatitis C
Adjuvant Temozolomide
Temozolomide 150mg/m2 oral days 1-5 cycle 1
200mg/m2 oral days 1-5 cycle 2-6 if nadir neutrophil count > 1.5 on cycle 1
Issue Date:
Ensure normal renal and hepatic function prior to cycle 1 and repeat during subsequent cycles if
If at any time neutrophil recovery is delayed by > 21 days treatment is discontinued
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Astrocytoma
First line
Lomustine (CCNU)
40mg oral daily days 1-4
Repeat at 4-6 week intervals until progression / unacceptable toxicity

Second line
(1)
Temozolomide
Temozolomide 150mg/m2 oral daily for 5 days

Escalate to 200mg/m2/day for 5 days depending on toxicity
Repeat at 28 day intervals maximum 6 cycles
Criteria: PS 0-3
Glioblastoma multiforme / anaplastic astrocytoma
Prior nitrosourea
Adequate marrow reserve (plts >100 neut > 1.5)
No prior Temozolomide
Third line options
(1)
Etoposide
50mg oral bd for 14 days q 21-28 days
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(2)
100-150mg/m2/day oral days 1-14 q 28 days
Procarbazine
Oligodendroglioma / mixed tumours

First line
PCV
Procarbazine
60mg/m2 oral days 8-21
Lomustine (CCNU) 110mg/m2 oral day 1
Vincristine
1.4mg/m2 (max 2mg) iv day 8 and 29
Repeat on a 6 week schedule
Second line
Consider radiotherapy
Third line
Temozolomide

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Primary CNS Lymphoma

De Angelis
(Modified)
Weeks 1, 5, 9
Day -1-7 allopurinol 300mg/day
Vincristine
1.4mg/m2 (max 2mg) iv bolus weeks 2,
Methotrexate

With adequate folinic acid rescue (see below) and urinary
alkalinisation
Procarbazine
100mg/m2 oral daily for 7 days
Weeks 3, 7
Vincristine
1.4mg/m2 (max 2mg) iv bolus weeks 2,
Methotrexate

With adequate folinic acid rescue (see below) and urinary
alkalinisation
Dexamethasone
16mg/day week 1
12mg / day week 2
8mg/day week 3
6mg/day week 4
4mg/day week 5
2mg/day week 6
Folinic acid rescue
Start 24 hrs post start of Methotrexate infusion with 30mg iv 6 hourly

Switch to oral after 6 doses if not vomiting
Methotrexate levels at 24, 48, 72 hrs etc.
Continue until Methotrexate undetectable ie <0.1M usually 4-5 days
Methotrexate level
Folinic acid dose 6hrly
< 0.1M
<0.5-5M
5-50M
>50M
Stop rescue
15-30mg 6hrly
200mg/m2 6hrly
1000mg/m2 6hrly
In addition patients urinary pH should be >7 prior to starting Methotrexate infusion

NB: do not give methotrexate if renal function is abnormal or in the presence of a
third space. Also avoid all non-steroidal anti-inflammatory agents prior to Rx and
until Methotrexate undetectable.
Calculate creatinine clearance prior to each cycle and administer methotrexate only if clearance
is > 50mls/min
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Medulloblastoma (adult)
Relapse following surgery / XRT
First line
PCV
Procarbazine
CCNU
Vincristine
60mg/m2 oral days 8-21

110mg/m2 oral day 1
1.4mg/m2 (max 2mg) iv day 8 and 29
Repeat on a 6 week schedule

Second line
Temozolomide

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Adenocarcinoma of Unknown Primary Origin

Possible GI primary
MdG / capecitabine / gemcitabine
Possible breast primary
Manage as for similar stage breast cancer
Possible ovarian primary
Carboplatin 5 x (GFR+25)
Possible lung primary
Carboplatin / Gemcitabine
Midline nodal disease
+/- lung metastases

BEP3 x max 4 cycles depending on response
Undifferentiated carcinoma Etoposide / platinum

Etoposide
Cisplatin
120mg/m2 days 1-3 (or oral 240mg/m2)

70mg/m2 days 1
guidelines
CCC Emergency Chemotherapy Drugs

Likely cancers requiring treatment:
Lymphoma
Germ Cell Tumours
Small Cell Lung Cancer
Drugs Available
Cisplatin
Etoposide
Doxorubicin
Cyclophosphamide
Vincristine
Pegfilgrastim
30mg in 250ml Sodium chloride 0.9% x 2 doses

100mg x 2 doses
50mg
800mg
2mg
6mg
These drugs will be stored in oncology pharmacy in the fridge in the dispensary area labelled Fridge 3. The fridge
will be labelled as containing Emergency Chemotherapy Drugs. Cisplatin will be stored at room temperature on top
of fridge 3.
Emergency chemotherapy should be prescribed by a consultant and entry to the pharmacy will be via the CCC bleep
holder only.
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Bone Metastases
There is increasing evidence from studies in a number of malignancies that intravenous bisphosphonate therapy can
ameliorate bone pain and reduce the risk of skeletal complications in patients with bone metastases. At present for
suitable patients the recommended treatment is zelodronate + Adcal D3 until progression.
Bisphosphonates
Zoledronic acid
4mg iv in 100mls Sodium chloride 0.9% over 15-30 minutes repeated at 28 day intervals.
Criteria: Performance status 0-2
Symptomatic / extensive bone metastases
Calcium supplements:
Renal impairment
Patients should have their serum calcium measured every four weeks and
Adcal D3 prescribed as necessary.
Cr clearance
(Cockcroft-Gault)
>60
50 - 60
40 - 49
30 39
< 30
Dose of zoledronic acid

4.0mg
3.5mg
3.3mg
3.0mg
no treatment
Serum creatinine should be repeated every 4 weeks and if it rises significantly during treatment
zoledronic acid should be witheld until the creatinine has returned to within 10% of the baseline
prior to starting.
Cockcroft-Gault Creatinine Clearance Formula
Men
((140 age) x wt x1.23) / creatinine
Women
((140 age) x wt x1.04) / creatinine
NB
Weight in kg, Creatinine in umol/l
Ibandronate (Bondranat)
Bondranat has yet to be shown to be as effective as zoledronic acid in reducing the incidence of
skeletal events and thus we cannot recommend it as routine treatment. However for patients who
have difficulties with venous access or renal impairment it may be requested via the off protocol
mechanism.
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*Denosumab
120mg sc repeat at 4 week intervals

Supplement with calcium 500mg and Vit D 400 iu if not hypercalcaemic.
Criteria
difficult venous access

Poor renal function
*Available via the cancer drugs fund
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CCC anti-emetic guidelines for cytotoxic chemotherapy
Oral And IV anti-emetic formulations have equivalent efficacy
CCC Classification of chemotherapy by emetic potential (updated February 2012)
LEVEL
High Emetic Risk
(>90 % frequency of
emesis)
AGENT
Cisplatin 50mg/m
Cyclophosphamide > 1500mg/m
Dacarbazine
Procarbazine (oral)
Streptozocin
AC Combination defined as either doxorubicin or epirubicin with
cyclophosphamide
Doxorubicin >60mg/m2
Epirubicin >90ml/m2
Ifosfamide > 10g/m2
Moderate Emetic Risk

(30-90 % frequency of
emesis)
Bendamustine
Carboplatin
Cisplatin < 50mg/m
Cyclophosphamide 1500mg/m
Cyclophosphamide (oral)
Dactinomycin
Doxorubicin <60mg/m2
Epirubicin <90mg/m2
Etoposide (oral)
Ifosfamide <10g/m2
Interferon alpha <10million international
units/m2
Irinotecan
Lomustine
Melphalan >50mg/m
Methotrexate 250 mg/m
Oxaliplatin
Temozolomide (oral)
Vinorelbine (oral)
Low Emetic Risk

(10-30 % frequency of
emesis)
Cabazetaxel
Capecitabine
Docetaxel
Doxorubicin (Liposomal)
Eribulin
Etoposide (IV)
Evorolimus
Fludarabine (oral)
Fluorouracil
Gemcitabine
Interferon alpha <5 <10million

international units/m2
Methotrexate >50mg/m < 250mg/m
Mitomycin
Mitoxantrone
Nilotinib
Paclitaxel
Paclitaxel-albumin (Abraxane)
Pemetrexed
Sunitinib
Topotecan
Vandetanib
Minimal Emetic Risk

(<10 % frequency of
emesis)
Alemtuzumab
Alpha Interferon
Bevacizumab
Bleomycin
Cetuximab
Chlorambucil (oral)
Erlotinib
Fludarabine
Gefitinib
Imatinib (oral)
Interferon alpha <5million
international units/m2
Ipilimumab
Lapatinib
Melphalan (oral low-dose)

Methotrexate 50mg/m
Pazopanib
Panitumumab
Rituximab
Sorafenib
Rituxumab
Temsirolimus
Trastuzumab
Vinblastine
Vincristine
Vinorelbine (IV)
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Emetic Risk
HIGH CISPLATIN REGIMENS
Aprepitant 125mg PO day 1, 80mg PO
daily days 2-3
+
Dexamethasone 12mg PO/IV day
1then 4mg BD PO days 2-4 (as TTH)
+
Ondansetron 24mg PO or 12mg IV
(maximum 32mg) day 1
+
Domperidone 10-20mg four times a
day as required
HIGH NOT CONTAINING
CISPLATIN
Dexamethasone 12mg IV/oral PO/IV
day 1 then 4mg BD PO days 2-4 (as
TTH)
+
Ondansetron 24mg PO or 12mg IVday
1, then 8mg twice a day PO days 2-4
(as TTH)
+
day as required
MODERATE
Dexamethasone 8mg PO/IV day 1 then
4mg twice a day PO days 2-4 (as TTH)
+
Ondansetron 16mg PO or 8mg IV
(maximum 32mg/day) day 1
+
day as required
Second Line
Antiemetic Failure
Ondansetron 8mg
+
dexamethasone 8mg
+
Lorazepam 1mg by
Ensure antiemetics have been

taken regularly.
Commence on first line
antiemetics for breakthrough
nausea and vomiting
Treat on subsequent courses of
chemotherapy with second line
agents
IV infusion over 24 hours
Aprepitant 125mg PO day 1,

80mg PO daily days 2-3
+
Dexamethasone 12mg PO/IV
day 1then 4mg twice a day PO
days 2-4 (as TTH)
+
Ondansetron 24mg PO or 12mg
IV (maximum 32mg) day 1

taken regularly.
nausea and vomiting
chemotherapy as for second
line
Aprepitant 125mg PO day 1,

80mg PO daily days 2-3
+
Dexamethasone 12mg PO or IV
days 1-4
+
Ondansetron 16-24mg PO or 812mg IV (maximum 32mg) day
1

taken regularly.
nausea and vomiting
chemotherapy as for high risk
LOW
Dexamethasone 8 mg PO or IV
day 1
+
day as required

taken regularly.
nausea and vomiting
chemotherapy as for moderate
risk
MINIMAL
Routine prophylaxis not always
required.
day as required
Recommend Domperidone post

chemotherapy to be taken
regularly.
nausea and vomiting
chemotherapy as for low risk
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ALTERNATIVES/BREAKTHROUGH
Cyclizine 50mg three times a day is often used for protracted nausea
Prochlorperazine 5-10mg oral three times a day
Prochlorperazine Suppositories 25mg three times a day
Metoclopramide 10-20mg four times a day
Levomepromazine 6mg at night (this can be increased to 12mg)
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GCSF
Primary Prophylaxis
Patients receiving FEC/Docetaxel adjuvant chemotherapy for breast cancer and VIDE for STS have a high risk of
neutropenic events and in line with ASCO guidelines we recommend primary prophylaxis with pegfilgrastim 6mg
24hrs post chemotherapy.
Secondary Prophylaxis
In other situations where the risk of neutropenic events is lower we do not routinely recommend primary
prophylaxis with GCSF and CCC policy is that secondary prophylaxis is reserved for the following situations:
(1) To maintain dose intensity in potentially curable malignancies where the dose limiting toxicity is neutropenia eg
-
Germ cell tumours

Intermediate / high grade lymphomas
Hodgkins disease
Sarcomas prior to potentially curative surgery
Adjuvant chemotherapy
Thus if chemotherapy is delayed due to a neutropenic episode defined as either:

Infection associated with neutropenia (neutrophil count < 1.0x109/l)
or
Total wbc < 3.0x109/l and neutrophil count < 1.0 x109/l on the day the chemotherapy cycle was due.
Then prophylaxis with pegfilgrastim 6mg s/c administered 24hrs post chemotherapy.
(2) Infection associated with protracted neutropenia > 7 days
There is no evidence that giving GCSF to patients with neutropenic sepsis improves outcomes in terms of
survival or reduced incidence of medical sequelae. However for febrile patients with neutropenia lasting more
than 7 days GCSF may be considered.
Palliative Chemotherapy
Patients who are receiving palliative chemotherapy should be managed with appropriate dose reductions if problems
with neutropenia arise.
Prophylactic antibiotics
The use of prophylactic antibiotics following cyctotoxic chemotherapy can result in a small reduction in febrile
episodes but at the expense of side effects and the potential risk of inducing antibiotic resistance and increasing the
risk of clostridium difficile infection. The use of prophylactic antibiotics is not therefore recommended routinely but
should be reserved for patients thought to be at particularly high risk of infection. The current CCC protocol is:
Ciprofloxacin 500mg oral daily days 9 20 post chemotherapy
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Erythropoietin
Erythropoietin may be used to maintain haemoglobin levels during chemotherapy in patients where transfusion is
contra-indicated eg.
Religious grounds
Cardiac failure
In addition erythrpoietin may be considered in patients who have required two or more transfusions and who are due
to receive further chemotherapy.
Erythropoietin may also be used to maintain haemoglobin levels during combined modality therapy for cervical
cancer
Protocol
Hb > 12 no treatment required
Hb < 12 darbepoetin 150ug / sc weekly
If Hb rises to > 14 stop until Hb < 12 then restart at 100ug / week
If Hb rises by > 2g/dl / month reduce dose to 100ug / week
If Hb does not rise after 4 weeks treatment increase to 300ug / week
If no response after a further weeks then stop treatment.
Intrathecal (IT) Chemotherapy

Department of Health regulations now dictate that intra-thecal chemotherapy may only be prepared and
administered by specific named individuals.
Prescriptions must be written on the intra-thecal prescription form

Patients must receive any IV chemotherapy prior to IT treatment
The doctor administering the IT drugs must collect them in person from pharmacy.
The drugs must be checked by the doctor and a qualified chemotherapy nurse prior to administration
All staff members involved (doctor, nurse, pharmacist) must be on the current IT chemotherapy register.
Methotrexate is the only drug we use as intrathecal therapy at a flat dose of 12.5mg.
Cytosine, thiotepa and hydrocortisone may also be given intrathecally.
All other chemotherapy drugs are potentially lethal when administered intrathecally
In addition any diluent used to prepare an intrathecal drug must be aqueous based and not alcohol based.
Intrathecal chemotherapy must always be given under the direction of a consultant and administered by one of the
doctors on the CCC approved list.
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Creatinine Clearance
Wright Creatinine Clearance Formula
Women
((6580 (38.8 x age)) x bsa x 0.832) /creatinine
Men
((6580 (38.8 x age)) x bsa ) /creatinine
Weight in kg
Creatinine in umol/l
NB
Calvert formula for Carboplatin dosage

Carboplatin dose in mg = AUC x (Creatinine clearance + 25)
Desired area under the curve (AUC) normally 4-6 depending on protocol and clinical situation
Cisplatin dose guidelines

Cisplatin is nephrotoxic and thus patients must have their renal function measured prior to each cycle.
Creatinine clearance
Cisplatin dose
> 50mls /min
100%
40 50 mls / min
75%
< 40mls / min
no further cisplatin
Patients should only commence cisplatin chemotherapy if they have an adequate performance status ie 0-2. The
only exception to this is patients with advanced germ cell tumours with poor PS who may commence treatment
with low dose etoposide / platinum.
Patients should only receive second and subsequent cycles of cisplatin if they are well and have suffered no
deterioration in performance status.
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Cisplatin Hydration Policy

Cisplatin doses 20 40mg/m2 (Outpatients)
Cisplatin in 1000mL Sodium Chloride 0.9%
IV over 1 hour
Cisplatin doses 20 40mg/m2 (Inpatients)

Prehydration
Post-hydration
Sodium Chloride 0.9% 500mL

Monitor urine Output
IV over 1 hour
IV over 1 hour
IV over 1 hour
Cisplatin doses 41 - 80mg/m2 (Inpatients/Daycase)
Prehydration
Post-hydration
Furosemide
Sodium Chloride 0.9% 1000mL (+ 20mmol Potassium
Chloride)
Monitor Urine Output
Chloride )
PO 20mg
IV over 90 minutes
IV over 90 minutes
IV over 90 minutes
Cisplatin doses >81mg/m2 (Inpatients)
Prehydration
Post-hydration
Furosemide
Chloride)
Monitor Urine Output
Chloride)
PO 20mg
IV over 2 hour
IV over 4 hours
IV over 4 hour
IV over 4 hour
n.b. Where Urine Output is of concern, please contact a clinician for advice.
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Haematological Indices Guidelines for the administration of chemotherapy

(1)
Platelets > 100x109/l
+
Total WBC > 3 x109/l
+
Neutrophils >1.0x109/l
administer
administer
administer
(2)
Platelets <100x109/l
or
Total WBC < 2.9 x109/l
or
Neutrophils < 1.0x109/l
physician discretion
These guidelines assume that patients are well with good performance status, that other acute toxicities have
resolved and the patient has not had a previous episode of neutropenic sepsis.
In some situations chemotherapy is given despite lower blood count values than those noted above. These
include patients receiving adjuvant chemotherapy, those with curable metastatic malignancies such as germ cell
tumours and lymphomas and also patients with bone marrow infiltration. These situations will be dealt with on
a case by case basis.
Capecitabine
Renal function recommendations
Prior to starting treatment:
Cr cl > 50
full dose
Cr cl 30 49
75% dose
Cr cl <30
omit
During treatment if there was a rise in serum creatinine the Cr cl should be re-calculated and
further treatment adjusted according to the above
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Neutropenic Sepsis Policy

Patients admitted with a fever associated with neutropenia (N < 1x109/l) are scored according to the presence or
absence of risk factors.
Age
> 60yrs
< 60
=0
=2
Dehydrated requiring iv fluids
No
Yes
=3
=0
Hypotensive
Systolic <90
>90
=0
=5
Presence of COPD
Yes
No
=0
=4
Symptoms related to infection
None
Mild
Moderate
Severe
=5
=5
=3
=0
Was the patient already in hospital
Yes
No
=0
=3
Score
17 + = low risk
<17 = high risk
Low risk:
Co-amoxiclav 625mg tds + ciprofloxaxin 750mg bd
or
Oral doxycycline 200mg bd + ciprofloxaxin 750mg bd
If penicillin allergy
or
Ceftazidime iv 1g bolus then 2g / 24 hours continuous infusion
If unable to take oral medication or already on antibiotics at home
or
Ceftazidime iv 1g bolus then 2g / 24 hours continuous infusion + vancomycin
If evidence of central line infection
High risk:
Gentamicin + piperacillin/tazobactam (Tazocin) 4.5g tds
Gentamicin + iv ciprofloxacin 400mg bd if penicillin allergy
Add vancomycin if central line infection suspected
Other pathogens
Anaerobic infection suspected: metronidazole 500mgtds
Atypical respiratory infection suspected: Clarithromycin 500mg bd
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Platelet Transfusion Policy

Platelets required if:
Platelets < 10x109/l
Platelets < 100x109/l and significant bleeding
Hypocalcaemia
Calcium gluconate 10% 10mls tds then orally if needed
Hypomagnesaemia
Patients who present with symptoms suggestive of hypomagnesaemia
Patients who have previously had hypomagnesaemia and who are due to have further platinum
chemotherapy.
Symptomatic patients with Mg <0.5 or <0.4 regardless of symptoms.
Consider urgent replacement if Mg <0.4 and cardiac history (IHD, AF, AVF).
If normal renal function: 40 mmol in 250 mls Sodium chloride 0.9% over 2 hours.
If suspected abnormal renal function (Cr >125umol/l) or already an inpatient: 40 mmol in 1L Sodium
chloride 0.9% over 8 hours.
Give 40 mmol and re-assess symptoms.
Re-check Mg if symptoms persist or if indicated for other reasons
Do not give more than 40 mmol in one day.
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Ifosfamide Encephalopathy and Methylene Blue

Most mild cases of ifosfamide encephalopathy will spontaneously resolve within 24-72 hours. However, consider
use of methylene blue if Grade 3/ Grade 4 neurotoxicity (i.e. somnolence >30% of time, disorientation/
hallucination/ echolalia/ perseveration/ coma, or seizures on which consciousness is altered, or which are prolonged,
repetitive or difficult to control).
Methylene Blue 50mg IV every 6 hours.
For future infusions, methylene blue 50 mg prior to infusion of ifosfamide and 50mg every 6 hours during infusion
Ifosfamide Renal Toxicity

Pre-treatment:
Serum
Na, K, Ca, PO4, Cl, total CO2/HCO3, AP
Early morning urine
PO4 Creatinine, Osmolarity
Tp/Creat = PO4 serum PO4 urine x Creat serum umol/l

Creat urine
GFR
> 60
40-59
< 40
Tp/Creat
>1.0
0.8-0.99
<0.8
HCO3
>17.0
14.0-16.9
>14.0
Action
Ifosfamide 100%
Ifosfamide 70%
Switch to cyclophosphamide 1500mg/m2
IV Day 1
Folinic acid rescue for High Dose Methotrexate

Time after starting
methotrexate
24 HRS
48 hrs
72 hrs
96 hrs
120 hrs
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Methotrexate Plasma concentration in micromol/L

If serum creatinine is greater that 50% of normal limit,
double the folinic Acid dose
Start folinic acid 15mg/m2 IV every 6 hours, then follow table below
< 0.1M
0.5 5M
5 50M
>50M
Stop rescue
15mg-30mg
200mg/m2
1000mg/m2
6 hourly
6 hourly
6 hourly
15mg-30mg
200mg/m2
1000mg/m2
6 hourly
6 hourly
6 hourly
15mg-30mg
200mg/m2
1000mg/m2
6 hourly
6 hourly
6 hourly
15mg-30mg
200mg/m2
1000mg/m2
6 hourly
6 hourly
6 hourly
Stop rescue
Stop rescue
Stop rescue
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CCC Dose Banding Policy

Rationale
It is widely recognised that using body surface areas (BSA) is not the most accurate method of calculating
chemotherapy doses. Dose banding does not result in a significant dose variation from the traditional
method as the maximum variation between the standard dose and the dose comprising each band is 5% or
less. A range of pre-filled syringes may be used to administer the dose. This system has worked
successfully in Cancer Centres in the UK 1, 2.
For all intravenous chemotherapy agents there is a threshold below which it is not possible for pharmacy
to guarantee the accuracy of a given dose. This usually corresponds to approximately 5% of a standard
dose e.g. 10mg of Docetaxel.
Given that the calculation of chemotherapy doses on the basis of surface area is at best an educated guess,
treatment is unlikely to be compromised by rounding the dose to the nearest 5% increment.
Oral agents have to be dose rounded often to a much larger tolerance e.g. Etoposide 10-16%.
Dose banding has been defined as a system whereby, through agreement between prescribers and
pharmacists, doses of intravenous cytotoxics calculated on an individual basis, which are within defined
ranges or bands are rounded up or down to predetermined standard doses. The initial step is to decide on
the bands and how best to arrive there from the calculated dose. Taking BSA to 2 decimal place and
rounding the dose to the nearest 1ml volume (taking concentration into account) appears to be the
simplest way forward. All cytotoxic doses are rounded up/down, which allows easier manipulation
within pharmacy.
For the following drugs the doses prescribed should be rounded or banded to the indicated pharmacy
tolerance level. For drugs not on this list clinicians should round the dose to the nearest figure that
approximates to 5% of the total dose.
Drugs dispensed at CCC

Actinomycin-D (Dactinomycin)
Doses rounded to nearest 0.5mg dose
Aldesleukin (Proleukin) 18 *106 IU /1ml
Doses rounded to nearest 1MU (*106) dose
Alemtuzumab (30mg/1ml Vial)
Used for TBI patients at CCC Usual dose 10mg
Bevacizumab (400mg /16ml and 100mg / 4ml)
Doses rounded to nearest 25mg dose
Bleomycin (15000 IU Vial)
Usual dose either 15,000IU or 30,000IU
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Liposomal Doxorubicin (Caelyx) 20mg /10ml

Liposomal Doxorubicin 45mg/m2 (Do not dose band trials)
BSA
1.3 -1.49
1.5- 1.69
1.7-1.89
>1.9
60mg
70mg
80mg
90mg
Calcium Folinate 300mg /30ml vial

Folinic acid syringes for 5FU/FA regime dispensed as 50mg flat dose
DeGramont type regimes dose dispensed at 350mg flat dose
Carboplatin 10mg/ 1ml (60ml Vial)
Cetuximab (100mg /50ml Vial)
CMF Regimes
BSA (m2)
< 1.39
1.40 - 1.59
1.60 -1.74
1.75 - 1.84
> 1.85
5FU Dose
800mg
900mg
1000mg
1100mg
1200mg
Methotrexate Dose
55mg
60mg
65mg
70mg
80mg
Cyclophosphamide Dose
50mg TDS14/7
50mg TDS 14/7
50mg TDS 14/7
50mg TDS 14/7
50mg TDS 14/7
If Cyclophosphamide 50mg BD 14/7 or 50mg QDS 14/7 required, Dr to specify on script.

Cisplatin (100mg /100ml)
Cyclophosphamide (1gram Vial)
Doses >1000mg should be rounded to the nearest 100mg dose.
Dacarbazine (1gram Vial)

Doses >1000mg should be rounded to the nearest 100mg dose.
Docetaxel (80mg Vial)
BSA (m2)
1.40 1.59
1.60 1.79
1.80 2.00
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Docetaxel Dose (100mg/m2)

150mg
170mg
190mg
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Doxorubicin (200mg / 100ml Vial)

Doses should be rounded to nearest 2mg dose
Doses > 80mg should be supplied in presentations corresponding to the nearest 10mg
Etoposide (500mg /25ml)

Etopophos (Etoposide Phosphate) 100mg Vial
Epirubicin (50mg /25ml Vial)

Doses > 80mg should be supplied in presentations corresponding to the nearest 10mg
Epirubicin 50mg/m2
DOSE (mg)
70
80
90
100
1.54 1.69
1.70 1.89
>1.90
Epirubicin 100mg/m2
DOSE (mg)
1.31 1.34
1.35 1.44
1.45 1.54
1.55 1.64
1.65 1.74
1.75 1.84
1.85 1.92
>1.93
130
140
150
160
170
180
190
200
Epirubicin and Doxorubicin doses > 80mg should be dose banded to the nearest 10mg dose
Epirubicin and Doxorubicin doses < 80mg should be rounded to nearest 2mg dose
5-Fluorouracil (500mg / 100ml Vial)
Doses < 1000mg should be rounded to nearest 50mg dose

5-Fluorouracil doses >1000mg should be rounded to the nearest 100mg dose.
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5 Fluorouracil LV5 Pumps

For DeGramont type regimes should be banded as below:
2400mg/m2
BSA
1.45 1.51
1.52 1.61
1.62 1.71
1.72 1.82
1.83 1.92
>1.93
Dose
3500mg
3750mg
4000mg
4250mg
4500mg
4750mg
2800mg/m2
BSA
1.45 1.47
1.48 1.56
1.57 1.65
1.66 1.72
1.73 1.86
1.87 2.00
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Dose
4000mg
4250mg
4500mg
4750mg
5000mg
5500mg
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5 Fluorouracil doses at 1000mg /m2

BSA
1.26 1.35
1.36 1.45
1.46 1.55
1.56 1.65
1.66 1.75
1.76 1.85
1.86 1.95
>1.96
Dose
1300mg
1400mg
1500mg
1600mg
1700mg
1800mg
1900mg
2000mg
Gemcitabine (1gram Vial)

Doses dispensed to nearest 38mg dose
BSA (m2)
1.40 1.49
1.50 1.69
1.70 1.89
1.90 2.00
Gemcitabine Dose (1000 mg/m2)
BSA (m2)
Gemcitabine Dose (1250 mg/m2)
1.40 1.49
1.50 1.69
1.70 1.89
1.90 2.00
1800mg
2000mg
2300mg
2500mg
1400mg
1600mg
1800mg
2000mg
Irinotecan (100mg / 5ml)

BSA (m2)
1.40 1.59
1.60 1.79
1.80 2.00
Irinotecan Dose (180mg/m2)

260mg
300mg
340mg
Ifosfamide (2gram Vial)

Methotrexate (500mg / 20ml)
Mesna (1000mg / 10ml)
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Mitomycin (10mg Vial)

Mitoxantrone (20mg /10 ml)
Oxaliplatin (100mg and 50mg Vial)
BSA (m2)
1.40 1.59
1.60 1.79
1.80 2.00
Oxaliplatin Dose (85mg/m2)

130mg
150mg
170mg
Paclitaxel (300mg / 50m, 100mg / 16.7ml, 30mg / 5ml)

Doses < 230mg rounded to nearest 6mg dose
Paclitaxel 175mg/m2 should be banded to the strengths below:
BSA
1.30 1.34
1.35 1.42
1.43 1.46
1.47 1.62
1.63 1.79
1.80 1.94
1.94 2.00
Dose
230mg
240mg
250mg
270mg
300mg
330mg
350mg
Pemetrexed (500mg / 20ml)

Rituximab (100mg and 500mg Vial)
Topotecan (4mg Vial)
Trastuzumab (150mg Vial)
Treosulfan (1gram and 5 gram Vial)
Vinblastine (10mg / 10ml Vial)

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Vincristine ( 2mg / 2ml)

Vindesine (5mg /5ml)
Vinorelbine (50mg / 5ml)
Doses rounded to nearest 5mg dose as below
BSA (m2 )
1.25 to 1.34
1.35 to 1.44
1.45 to 1.54
1.55 to 1.64
1.65 to 1.74
1.75 to 1.84
1.85 to 1.94
1.95
IV dose
25 mg/m2
Dose (mg)
30
30
35
40
40
45
45
50
Oral dose
60 mg/m2
Dose (mg)
80
80
90
100
100
110
110
120
IV dose
30 mg/m2
Dose (mg)
40
45
50
50
55
55
55
60
Oral dose
80 mg/m2
Dose (mg)
100
110
120
130
140
140
150
160
Oral Vinorelbine is available in 20mg and 30mg Capsules

25mg IV Vinorelbine = 60mg Oral Vinorelbine dose
30mg IV Vinorelbine = 80mg Oral Vinorelbine dose
The dose of oral Vinorelbine is approx 2.5 times that of IV Vinorelbine
References
1.
2.
Plumridge R, Sewell G. Dose banding of cytotoxic drugs: A new concept in cancer

chemotherapy. Am J Health Syst Pharm 2001; 58: 1760 4.
Baker J P, Jones S E. Rationalisation of chemotherapy services at the University
Hospital Birmingham NHS Trust. J Oncol Pharm Prac 1998; 4: 10 14.
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Surface area Nomogram
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The North West Cancer Drugs Fund

A number of treatments are now available via the Cancer Drugs Fund. The process for
accessing the fund is as follows:
Complete the relevant application form which can be found on the North West
Cancer Drugs Fund web site. The easiest way to find this is to type nw
cancer drugs fund into google and select the application forms button in the
header on the home page.
E-mail the completed form to the pharmacy dept at CCC using:

ccf-tr.CytoPharmacy@nhs.net this address can be found by typing cco
pharmacy into the address book in outlook
The form will be checked in pharmacy and sent to the network pharmacist
who will coordinate approval by the cdf. All request which fulfil the criteria
are approved automatically and the process usually takes about a week.
Please wait until the funding approval notification is received before arranging
the treatment appointment.
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Small Lung Cancer Oncological Guidelines

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CCC Chemotherapy Protocols

Head and Neck cancer

Soft tissue sarcomas

Primary CNS malignancy

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Emergency chemotherapy drugs

Intra-thecal chemotherapy policy

Cisplatin / carboplatin doses

Cisplatin hydration policy

Capecitabine renal function recommendations

Neutropenic sepsis policy

Platelet transfusion policy

Ifosfamide renal toxicity and encephalopathy

Folinic acid rescue for high dose methotrexate

CCC dose banding policy

Surface Area Nomogram

North West Cancer Drugs Fund

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Protocol Additions 2011-12

Off Protocol Treatment Policy

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Co-payments / top-ups / additional private care

Additional Private Treatment Form

Patient information leaflet.

Financial agreement forms.

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

100mg/m2 po days 1-14 in divided doses

For patients unable to tolerate oral cyclophosphamide substitute

Doxorubicin 60mg/m2 + cyclophosphamide 600mg/m2 iv day 1 repeated at 21 day intervals for 4

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Epirubicin 90mg/m2 IV + cyclophosphamide 600mg/m2 IV day 1 repeated at 21 day intervals for

Repeat at 21 day intervals for 3 cycles

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

For patients who fit HERA trial inclusion criteria

Non-metastatic potentially operable primary invasive breast cancer

Indication / Treatment plan

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Repeat at 21 day intervals for up to 6 cycles.

100 mg/m2 iv q 21 days x 4 cycles

Dexamethasone 8mg oral bd x 3 days start 24hrs pre-docetaxel

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith

Repeat at 21 day intervals usually to a maximum of 6 cycles

75-100 mg/m2 iv day 1 q 21 days, max 6 cycles

Dexamethasone 8mg oral bd x 3 days start 24hrs pre-docetaxel

Previously received full dose anthracycline as adjuvant therapy

30th April 2012

Author: Dr. D.B. Smith

Authorised by: Dr. D.B. Smith