Les renseignements du Formulaire de médicaments s’adressent aux professionnels de la santé. Il ne s’agit pas d’un avis médical. Certains des renseignements, y compris ceux sur le financement des médicaments anticancéreux, ne s’appliquent pas à tous les patients. Les plans de traitement du cancer sont propres à chaque patient. Si vous êtes un patient, veuillez parler avec votre équipe soignante pour comprendre comment ces renseignements s’appliquent à vous.
CRBPGEMC
Adjuvant
Palliative
Regimen is considered appropriate as part of the standard care of patients; meaningfully improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR). Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.
gemcitabine | 1000 mg /m² | IV | Days 1 and 8 |
CARBOplatin | AUC 5 to 6 | IV | Day 1 |
Adjust carboplatin dose to AUC target (using Calvert formula) as outlined in "Other Notes" section. |
REPEAT EVERY 21 DAYS
Neoadjuvant / Adjuvant: For a 3 to 4 cycles unless disease progression or unacceptable toxicity occurs
Palliative: For up to 8 cycles unless disease progression or unacceptable toxicity occurs
Moderate + NK1 antagonist (Carboplatin AUC ≥ 5) (D1 )
Low (D8)
Moderate
Other Supportive Care:
Also refer to CCO Antiemetic Recommendations.
Doses should be modified according to the protocol by which the patient is being treated. The following recommendations have been adapted from clinical trials or product monographs and could be considered.
Dosage with toxicity
Dose on Day 1 of Cycle:
Worst Toxicity in Previous Cycle
|
Gemcitabine
|
Carboplatin
|
||
Non-Hematologic
(related organ)
|
|
Hematologic
|
% Full Dose*
|
% Full Dose*
|
Grade 3
|
or
|
Febrile neutropenia, thrombocytopenic bleeding |
75%
|
75%#
|
Grade 4
|
|
|
Consider discontinuing, or ↓ to 75% |
Consider discontinuing, or ↓ to 75% |
Day 8 holds in > 1 cycle |
75%
|
100%
|
||
Pneumonitis, Hemolytic Uremic Syndrome (HUS), Capillary Leak Syndrome (CLS), Posterior reversible encephalopathy syndrome (PRES) |
Discontinue | Discontinue | ||
Stevens-Johnson syndrome (SJS), Toxic epidermal necrolysis (TEN) | Discontinue | Discontinue | ||
* Do not retreat until AGC ≥ 1.5 x 109/L, platelets ≥ 100 x 109/L and toxicity ≤ grade 2. # use Egorin formula if isolated thrombocytopenia |
Toxicity on Day 8 of cycle
|
|
||||
Non-hematologic
(related organ)
|
|
Hematologic
|
Gemcitabine
(% Full Dose)
|
||
AGC
(x 106/L)
|
|
Platelets
(x 106/L)
|
|||
≤ grade 2
|
and
|
> 1000
|
and
|
> 100,000 |
100%
|
≤ grade 2
|
and
|
500-1000
|
or |
50,000-100,000
|
Consider Omit, or ↓ to 75%
|
Grade 3 or 4 |
or
|
< 500
|
or
|
< 50,000
|
Omit, ↓ to 75% at restart (if applicable) for non-hematologic toxicity
|
|
|
-
|
|
-
|
Discontinue
|
Hepatic Impairment
Bilirubin
|
|
AST/ALT
|
Gemcitabine
(% previous dose)
|
Carboplatin
(% previous dose)
|
1-2 x ULN
|
And/or
|
<2 x ULN
|
100%
|
100%
|
2-4 x ULN
|
2-5 x ULN
|
Caution
|
100%
|
|
> 4 x ULN |
> 5 x ULN
|
Caution, consider ↓
|
Caution, consider ↓
|
Renal Impairment
CrCl (mL/min)
|
Gemcitabine
(% previous dose)
|
Carboplatin
(% previous dose)
|
> 60
|
100%
|
Use Calvert formula
|
40-60
|
100%
|
|
20-40
|
Caution
|
|
< 20
|
Consider discontinuing or ↓
|
Discontinue
|
Refer to gemcitabine, CARBOplatin drug monograph(s) for additional details of adverse effects
Most Common Side Effects |
Less Common Side Effects, but may be |
|
|
Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph.
Recommended Clinical Monitoring
- Clinical toxicity assessment (including flu-like symptoms, fatigue, rash, edema, GI, pulmonary, neurotoxicity, infection, bleeding, ototoxicity).
- CBC before each cycle and on day 8.
- Baseline and regular liver function tests
- Baseline and regular renal function tests and electrolytes (including magnesium)
-
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
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Carboplatin, gemcitabine drug monographs, Cancer Care Ontario.
Neoadjuvant / adjuvant:
Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol 2005;48(2):202-5.
Booth CM, Siemens DR, Li G, et al. Perioperative chemotherapy for muscle-invasive bladder cancer: A population-based outcomes study. Cancer 2014;120(11):1630-8.
Cognetti F, Ruggeri EM, Felici A, et al. Adjuvant chemotherapy with cisplatin and gemcitabine versus chemotherapy at relapse in patients with muscle-invasive bladder cancer submitted to radical cystectomy: an Italian, multicenter, randomized phase III trial. Ann Oncol 2012;23(3):695-700.
Dash A, Pettus JA 4th, Herr HW, et al. A role for neoadjuvant gemcitabine plus cisplatin in muscle-invasive urothelial carcinoma of the bladder: a retrospective experience. Cancer 2008;113(9):2471-7.
Yeshchina O, Badalato GM, Wosnitzer MS, et al. Relative efficacy of perioperative gemcitabine and cisplatin versus methotrexate, vinblastine, adriamycin, and cisplatin in the management of locally advanced urothelial carcinoma of the bladder. Urology 2012 Feb;79(2):384-90.
Palliative:
De Santis M, Bellmunt J, Mead G, et al. Randomized phase II/III trial assessing gemcitabine/carboplatin and methotrexate/carboplatin/vinblastine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: EORTC study 30986. J Clin Oncol 2012;30(2):191-9.
Dogliotti L, Cartenì G, Siena S, et al. Gemcitabine plus cisplatin versus gemcitabine plus carboplatin as first-line chemotherapy in advanced transitional cell carcinoma of the urothelium: results of a randomized phase 2 trial. Eur Urol. 2007;52(1):134-41.
von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: Results of a large, randomized, multinational, multicenter, Phase III Study. J Clin Oncol 2000;18(17):3068-77.
September 2022 added PEBC guideline
Calvert Formula
DOSE (mg) = target AUC X (GFR + 25)
- AUC = product of serum concentration (mg/mL) and time (min)
- GFR (glomerular filtration rate) expressed as measured Creatinine Clearance or estimated from Serum Creatinine (by Cockcroft and Gault method or Jelliffe method)
(Calvert AH, Newell DR, Gumbrell LA, et al, Carboplatin dosage: Prospective evaluation of a simple formula based on renal function. J Clin Oncol, 1989; 7: 1748-1756)
Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
CCO and the Formulary’s content providers shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the Formulary or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the Formulary does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person’s use of the information in the Formulary.