Patients shouldn’t burn out, and doctors shouldn’t burn out

Photo from personal archive

Photo from personal archive

Chemotherapy is an important step in the treatment of many types of cancer. Chemotherapy drugs can suppress the growth of tumor cells, but they are so aggressive that they also attack healthy tissue. The impact is often so strong that the patient must already be saved from the side effects of “chemistry”. Science has figured out how to protect the body from powerful, high-dose chemotherapy. However, in 2022, the number of treatment schemes where maintenance therapy is funded through the CHI system has halved. Leading Russian oncologists discussed the current situation a few days ago at a Round Table in Moscow. Why are these drugs not yet included in cancer treatment protocols? What decisions need to be made so that all cancer patients can receive this therapy? What are the most dangerous complications of chemotherapy? We talked about this with an oncologist, editor-in-chief of the section on practical recommendations in support of adjuvant therapy of the Russian Society of Clinical Oncologists (RUSSCO), head of the telemedicine technology department of the Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine, Doctor of Medical Sciences , Honored Doctor of the Russian Federation Oleg Gladkov.

– Is the problem with maintenance therapy really so acute and large-scale?

– The problem with history. Because it has been known since the moment patients with malignant tumors began to be treated with chemotherapy. Almost all variants of drug anticancer treatment are associated to some extent with the development of adverse reactions – the so-called side effects that occur during this treatment. Unfortunately, not all patients tolerate the treatment well and fully. The most common reactions occur during intensive chemotherapy regimens. For such treatment to be successful, supportive treatment is required.

What complications can occur during chemotherapy?

– Various, ranging from fever, stomatitis and loose stools and ending with inhibition of hematopoietic sprouts. It is this that hides the greatest danger for our patients – it reduces the production of neutrophils and platelets. These conditions – febrile neutropenia and thrombocytopenia – can be life-threatening for patients. Therefore, a number of chemotherapy regimens require the additional use of drugs without which we simply cannot complete them. This applies to diseases such as testicular cancer, breast cancer, non-Hodgkin’s and Hodgkin’s lymphomas, bladder cancer, colon cancer, pancreatic cancer, osteogenic and mesenchymal sarcomas, small cell cancer.

– Febrile neutropenia is a dangerous disease in itself. What happens to the body?

– Often after a course of chemotherapy, the number of neutrophils drops sharply: the white blood cells that are able to put a barrier to infection in the blood. As a result, the patient may develop toxic shock and sepsis. And the result can be death. Febrile neutropenia is a life-threatening condition that is fatal in 6-7, sometimes 10% of cases.

– How does the development of neutropenia affect the treatment of the main disease – cancer?

– The patient should prescribe anti-inflammatory treatment. The start of the next course of chemotherapy often has to be delayed. Accordingly, the effectiveness of the treatment decreases. And if you do not start using auxiliary drugs, then during the next course of “chemistry” you need to reduce the doses of drugs. This worsens the situation with reduced efficiency. In addition, in some cases it becomes the real reason for the incurability of the patient.

– What drugs can prevent the described complications?

– Erythropoietins are designed to stimulate the growth of erythrocytes – red blood cells. Granulocyte colony-stimulating factors can accelerate the maturation of white blood cells and contribute to an earlier and more significant appearance of leukocytes in the blood. This prevents the development of infections and allows you not to increase the intervals between chemotherapy courses.

– So it’s some kind of medical coverage?

– Much more than just a cover. This is an extremely important and necessary component of the treatment of patients with tumors. At the beginning of the conversation, I listed the types of cancer: in most cases, with these pathologies, without additional administration of drugs, it is necessary to reduce the dose of chemotherapy or increase the intervals between courses. This again directly affects patient survival.

– Even if we are talking about an early stage?

– We are talking about the early stages of the disease, when surgical treatment must be supplemented with intensive chemotherapy in order to destroy the tumor cells that have entered the blood, as well as the so-called micrometastases. This necessitates the use of high-dose and compact regimens, which must always be combined with granulocyte-colony-stimulating factors and erythropoietins.

– Are these drugs available to Russian patients?

– Medicines are available, but not in full, as their purchase is financed on a residual basis. They must be purchased at the expense of the remaining funds that the medical facilities receive from the Mandatory Medical Insurance Fund after traditional chemotherapy. This approach does not fully secure patients. For a long time, we have been negotiating with the Ministry of Health and the National Hospital for the purchase of the most necessary supportive drugs for all patients. For every cycle of chemotherapy, for every condition that requires their use.

– Why is it not yet possible to introduce these drugs into the CHI system?

– Additional costs… Our opponents point out that these drugs do not directly affect the tumor. This means that you can theoretically do without them. The fact that some of the patients will not receive full treatment and will live much less than they could, to an economist is clearly something in the category of statistical errors…

– But, judging by what you say, the use of concomitant therapy, on the contrary, benefits the state …

– Quite right: the use of these drugs prevents the development of complications, the treatment of which costs a lot of money. The therapy of the same febrile neutropenia is quite expensive.

– More expensive than the cost of buying these drugs?

– Apparently more expensive. The difference has never been calculated in our country, but such works have been published abroad.

– By the way, is accompanying therapy included in standard treatment protocols in developed countries?

– Yes, it is. If a scheme is used that requires the use of colony-stimulating factors as a concomitant treatment, then these drugs are prescribed immediately. There they are recognized as an integral part of chemotherapy.

– How long have you and your colleagues been trying to convince the regulator that we should do the same?

– Active – two years.

– Are these drugs available in Russia? Do we manufacture them or do we depend on foreign supplies?

– Fortunately, we produce ourselves. Today, there are companies in Russia that are able to provide colony-stimulating factors and erythropoietin to all cancer patients who need them.

– If the regulator again refuses to allocate funds for the purchase of drugs for concomitant therapy, what will this mean for patients?

– Many of them will not receive the necessary anti-cancer treatment in full. With all the consequences. In addition, accompanying therapy is also a matter of the patients’ quality of life. Tolerating chemotherapy is difficult. Adaptation suffers. When we carry out adequate auxiliary concomitant treatment, the patient begins to feel much more comfortable: he is not sick, no diarrhea, no high fever… Many patients even return to work.

– And what will the refusal of funding mean for doctors?

– Doctors, unfortunately, are used to working in such conditions. Because the situation with underfunding of concomitant therapy has been going on for a long time. But I will try to answer your question anyway. Doctors will feel constant dissatisfaction with the fact that treatment is not carried out fully, that patients do not tolerate chemotherapy well and die prematurely. Specialists will “burn out”.

– What types of cancer treatments will be most affected by underfunding?

– Hodgkin’s lymphoma, non-Hodgkin’s lymphomas, osteosarcoma, breast cancer, testicular cancer. The most vulnerable in this situation are patients who live far from oncology centers. It is more difficult for the doctor to manage the pathological process when the patient is at a considerable distance.


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