Chemotherapy Dosing: Less Might Be More

It is not uncommon, during a months-long course of treatment, for the chemotherapy dose to be reduced. This can happen if your blood counts have been low or you experienced significant side effects or sometimes for other medical or psychosocial reasons. Non-medical reasons occasionally include planned events or travel and a wish to minimize possible side effects; note, of course, that this is not so relevant during the pandemic.

There is a small...group of oncologists and scientists who are considering the possibility that lower doses of some chemo drugs may be equally effective. 

There is a small, but growing, group of oncologists and scientists who are considering the possibility that lower doses of some chemo drugs may be equally effective and both easier on the patient and less expensive. Dr. Mark Ratain at the University of Chicago is usually given credit for this line of thinking. He tells a story about often asking people a question: If your doctor gave you a prescription for a new drug and told you to take it on an empty stomach, what do you think would happen if you took if after a meal? No one reportedly ever guessed the right answer: I could die from an overdose. But, with the drug nilotinib which was approved by the FDA in 2007 to treat chronic myelogenous leukemia (CML), that is exactly what could happen. We can only hope that prescribing oncologists were very clear with their patients about the possible danger!

As many of us have learned, cancer drugs can be very expensive and very difficult to take. In 2018, the worldwide cost of cancer drugs was around $150 billion and had gone up by at least 10% each year. In the United States, pharmaceutical companies can pretty much set their own prices, and Medicare is legally prohibited from negotiating those costs. This is not the case in other countries, and there is a growing hue and cry about trying to rein in drug costs. Hopefully this is an issue that can be quickly addressed.

Back to dosing. Much of the current conversation is focused on oral cancer drugs. Dr. Ratain published a study in 2010 that stated that, during the previous decade, eight of every nine FDA approved oral non-cancer drugs could be taken with food, but that all cancer drugs required an empty stomach. In 2018, he published a small study indicating that abiraterone, an oral drug used to treat prostate cancer, was prescribed to be taken fasting. However, he learned that a quarter dose could be taken with a low-fat breakfast and was just as effective as the larger fasting dose. Part of the good news is that patients don’t have to delay breakfast, but at least as good is the financial impact of taking less. The full dose of the brand name costs more than $9000/month; the generic is about $3000/month. Each of those price tags would be cut by three quarters.

Researchers are beginning to look at other oral cancer drugs and the possibility of changing recommended dosing. This is a challenging goal, and it can be tough to find funding for the necessary studies. Obviously, oncologists are reluctant to lower doses without hard science to support the change. If more were known, it is also obvious that there could be a reduction in toxic side effects as well as a big cost savings for individual patients and for our society as a whole.

There is not a big announcement hidden somewhere in this discussion. My thoughts are broad and related to the potentially very helpful study of the best use of cancer drugs. All of us want the maximum possible benefit and the minimum possible cost of both toxicity and finances. This is one intriguing way to move closer to that goal.