Switch from BCG to gemcitabine and docetaxel

5 months 2 weeks ago #59840 by MaryF
It was intravesical, just like the BCG--pumped into the bladder, first one drug, then the other. The gemcitabine was first, for an hour and a half; then the gem was drained and the docetaxel was pumped in (same catheter, for those who are concerned about having to be cathed twice) and retained for two hours. It was a time-consuming process, but really no more difficult or painful than the immunotherapy treatments, according to my brother.

The nurse-practitioner who supervised the procedure said that some patients have problems with gemcitabine in particular, that it can cause the bladder to "spasm"--my brother didn't experience that, at least not this time. She said that most people find the docetaxel easy to tolerate--"like water," was what she said. She didn't expect there to be any follow-up effects in the days after the treatment, and so far there haven't been.

The drugs don't appear to have been heated before the procedure; I'll try to ask about that next month, but I don't think the hospital (Northwestern Memorial in Chicago) offers that therapy. Yet, at least.

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5 months 2 weeks ago - 5 months 2 weeks ago #59839 by joea73
We are so glad to hear that the first intravesical gemcitabine and docetaxel session well. Also, we appreciate very much for your sharing your brother's situation in detail. I am sure it will be helpful for those who may face a similar situation due to BCG shortage. Now it makes sense that your brother's doctor took a proactive approach to preserve your brother's bladder. Indeed, the treatment may be considered as a new cohort. Hopefully, it will turn out to be better than continuing BCG maintenance alone. It will be nice to know how gemcitabine and docetaxel were
administered in your brother's case, i.e. was gemcitabine instilled first followed by docetaxel? Were the drugs heated?

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5 months 2 weeks ago #59838 by MaryF
Ah--and for the record, I did try to rename this thread "Switch from BCG to gemcitabine and DOCETAXEL," rather than doxorubicin; I just got the drug names mixed up in my initial post.

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5 months 2 weeks ago #59837 by MaryF
Thanks, Joe--I really appreciate the links.

I should make it clear: my brother did have BCG induction and a a year of follow-up maintenance (gradually shifting to1/3 dose BCG as the shortage hit home). It worked--no recurrence--but he can't continue on BCG due to the shortage, so he's switching to gemcitabine/docetaxel once a month for continued maintenance. I gather that some doctors might well advise someone in my brother's position to go for observation instead of starting the chemo maintenance; my brother's doctor recommended he be pro-active, for several reasons, including the fact that he isn't a good candidate for bladder removal surgery. Most of the evidence on the gem/doce combo is based on people who couldn't tolerate BCG or, increasingly, can't get BCG, so my brother is apparently in kind of a new cohort.

For the record, he has his first chemo treatment yesterday, and it went well. I'll try to keep the forum posted, for at least anecdotal evidence on the efficacy of this regimen--since I suspect that more and more people are going to be facing my brother's choice during this [expletive deleted] BCG shortage!

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5 months 3 weeks ago #59818 by joea73
Below is the summary of my Googling and reading some books to understand about gemcitabine and doxorubicin.

The take-home is as follows

1. Gemcitabine and doxorubicin kill cancer cells (also normal cells) in two different ways.
2. Gemcitabine and doxorubicin are tolerable.
3. When Gemcitabine is given first and followed by doxorubicin the efficacy is higher.
4. When heated Gemcitabine and heated doxorubicin, the efficacy is more higher.
5. A reduced dose of BCG (i.e. 1/3) gives similar efficacy to a full dose.

1. Gemcitabine prevents DNA replication of cells and leads the cells to die.
Doxorubicin prevents cells from dividing into two daughter cells and leas the cells to die.

2. The University of Iowa studied the efficacy of gemcitabine and doxorubicin when they were given sequentially.
Of 45 patients who were treated with gemcitabine and doxorubicin, treatment success (no recurrence and no
cystectomy) were 66% at first surveillance,54% at 1 year and 34% at 2 years.


3. The University of Arizona studied the efficacy of heated gemcitabine and doxorubicin when they were given
sequentially. The treatment was given to 60 patients who did not respond well to BCG treatment. Of 60 patients, treatment success was 83% at first surveillance, 69% at 1 year and 55 at 2 years.

4. Treatment tolerance of the study at the University of Arizona
Thirty-one patients (52%) reported experiencing adverse symptoms during their GEM/DOCE treatment course,
but only 10 of these patients had symptoms (i.e. UTI) that impacted the treatment schedule with short 1-week
delays. All the patients were still able to finish their treatment course. The most common side effects noted were
mild fatigue (20%), hematuria (20%), mild urinary frequency/urgency (13%), dysuria (10%), and nocturia (7%).

5. BCG shortage

The supply chain of BCG by MERCK is very opaque. Some institutions have it and some don't. Looking for
BCG at other institutions is a possibility, especially when Dr. Kamat of MD Anderson recommended 1/3 dose for
even initial 6 weeks BCG induction course backed by the study in Europe during BCG shortage.


References

The study by the University of Iowa

"Sequential Intravesical Gemcitabine and Docetaxel for the Salvage Treatment of Non-Muscle Invasive Bladder Cancer"

content.iospress.com/articles/bladder-cancer/blc0008

The study by the University of Arizona

"Salvage Hyperthermic Gemcitabine and Docetaxel Combination Chemotherapy After BCG Failure in Non-Muscle Invasive Bladder Cancer Patients " 2019

content.iospress.com/articles/bladder-cancer/blc190245?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Bladder_Cancer_TrendMD_0

A panel discussion during American Urological Association virtual meetings July, 2020

"Filling the BCG Shortage Hole for Patients With NMIBC"

www.targetedonc.com/view/filling-the-bcg-shortage-hole-for-patients-with-nmibc

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5 months 4 weeks ago #59782 by MaryF
Thanks, Sara Anne--I appreciate the response, and it's very good to know that you've heard of this option. If anyone has any experience with any possible side effects, I'd really be interested.

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