A Guide for Patients Receiving PCV Chemotherapy  

 by Barbara Rattner, R.N., M.S., Karen Murtagh, R.N., John W. Henson, M.D., and Fred H. Hochberg, M.D.MGH Brain Tumor Center

Introduction

This booklet is designed to help you and your family have a better understanding of the PCV chemotherapy you will be receiving. Topics which are covered include:

    -the drugs which will be used

    -when each drug will be given    

    -the possible side effects of each drug

    -how to minimize possible side effects

    -schedule of follow up tests and visits

It is hoped that by providing you with this information, you will experience a greater sense of control over your disease and treatment, and feel more comfortable participating in your own care.

Overview of PCV Chemotherapy Regimen

The letters "PCV" refer to the three chemotherapy drugs which will be used in your treatment. The "P" stands for procarbazine, the "C" stands for CCNU, and the "V" stands for vincristine. These drugs also have other names, but these are the names used most often.

Chemotherapy is usually described as being given in cycles. A cycle is the time period during which the scheduled chemotherapy will be given. It also includes rest periods. For example, the PCV regimen is made up of a six week cycle (42 days). You will receive chemotherapy on day 1, days 8-21, and day 29 of the cycle. On the other days you will not receive chemotherapy. Your treatment will most likely consist of six cycles of PCV.

The entire treatment is performed as an outpatient. You will need to visit your doctor three times during each cycle (day 1, 8, and 29). Your doctor will examine you and look at your blood count results. You will be checked for any side effects and the size of the tumor will be checked on follow-up scans.

Schedule of Drugs During a Cycle

You will be receiving chemotherapy on certain days of each cycle. The actual schedule of what drug(s) you will receive on which days is:

CCNU pills - day 1

vincristine injection - day 8 and day 29

procarbazine pills - days 8 through 21 (every day for 2 weeks)

General Information About Chemotherapy

Often, when a person receives chemotherapy, more than one drug is used. This is because each drug acts in its own way to keep cells from dividing. By using multiple attacks on the tumor cells, there is a better chance of reducing the size of your tumor. This is why three drugs are being used in this regimen.

In addition to the cells in your tumor, there are normal cells in your body which are dividing. These normal cells can also be temporarily affected by chemotherapy and may lead to side effects. Specifically, the cells which can be affected are the cells in your bone marrow and the cells which line your gastrointestinal tract. The cells in the bone marrow form the blood cells that are circulating in your body. These cells include white blood cells which fight infection, red blood cells which carry oxygen and platelets which prevent bleeding. PCV chemotherapy rarely causes injury to the cells lining the gastrointestinal tract. Two other types of cells which may be affected temporarily or permanently are the female egg cells and those cells which produce sperm in the man. In men, chemotherapy can cause sterility, and therefore may make men unable to father a child. Men should discuss this with the doctor BEFORE starting PCV.

The possible side effects of chemotherapy will be discussed with you before you begin treatment. After your questions are answered, you will be asked to sign a consent form for your treatment. A copy of the consent form can be given to you if you wish.

If you are a woman of child-bearing years you need to use a reliable birth control method for the entire time, including the rest periods, you are receiving chemotherapy. If you are a man you should use a condom when you have sexual relations within 3 days of getting chemotherapy to protect your partner from exposure to the drug. The effects of many chemotherapy drugs can be harmful to the growth and development of a fetus, therefore you should not try to become pregnant or father a child while receiving chemotherapy.

When you are receiving chemotherapy, and for 3 days after, it is important that careful attention be paid to hand washing after urination. Since many chemotherapy drugs are removed from the body by the urine, careful handwashing will prevent family members from being exposed to the chemotherapy. If family members help you with personal care, they should wear rubber gloves when handling urine or vomitus. Clothing soiled with urine, vomit, or feces should be washed separately in hot soapy water.

Specific Information About Each Drug

CCNU

CCNU comes in capsule form and is taken by mouth on day 1 of your chemotherapy cycle. Your dose is decided upon by a calculation using your height and weight. Usually more than one capsule will be needed to make up your dose.

The most common side effect of CCNU is nausea and vomiting. In order to prevent or minimize this an anti-nausea drug will be prescribed for you. Some people find that taking the CCNU before they go to sleep and taking the anti-nausea medicine one hour before that, helps greatly in preventing nausea and vomiting. For example, if you normally go to bed at 11 PM, you would take the anti-nausea medicine at 10 PM and the CCNU at 11 PM. The nurse will review with you the time schedule for taking the CCNU and the anti-nausea medicine at the chemotherapy appointment.

Another side effect of CCNU which is common is a decrease in the number of white blood cells and platelets. This does not happen immediately, but occurs in a few weeks to a month. You probably will not notice any change in your day to day activities if this occurs, or you may feel a bit tired. A blood sample will be taken within 24 hours before your expected chemotherapy appointment; the results will help the doctor and nurse decide if you can receive chemotherapy. If the white blood cell count is low you may need to watch for and report any signs of an infection. If the platelet count is low you may need to be careful to avoid cutting yourself.

Signs and symptoms of infection include: fever, chills, sore throat, painful urination, chest congestion, headache, stiff neck or abdominal pain. You should call the doctor immediately if you have any of these symptoms. Good oral hygiene and handwashing can help prevent infections.

You may also need to be alert to signs of bleeding. Any unusual bruising, the appearance of tiny red dots on your skin, nosebleeds or blood in your urine or bowels or an unusual severe headache should be reported as soon as possible.

Women who have menstrual cycles and have not gone through menopause will probably notice a change in their cycle. The bleeding may lessen, become spotty or stop completely. The time between cycles may also change. The menstrual cycle usually changes after one or two complete cycles (42 - 84 days) of chemotherapy. Some women whose menstrual cycles stop undergo menopause, with or without symptoms. Women who are closer to the age of menopause may not go back to menstruating once chemotherapy stops.

The chemotherapy agents in the PCV regimen rarely cause hair loss. Sometimes CCNU can affect how the lungs work, but this effect is rare at the dose of CCNU used in this regimen. Other possible side effects of CCNU which are not common, include sensitive gums, sores in the mouth, and fatigue.

Vincristine

Vincristine is given by vein through a small needle placed in your arm which is connected to a small bag of salt water and tubing. The vincristine is in a small syringe which is then connected to the tubing and injected by the nurse. The injection only takes a few minutes.

Nausea and vomiting are rare so no anti-nausea medicine needs to be taken. Vincristine does not affect the blood counts.

The major side effect of vincristine is damage to nerves in the hands and feet or in other parts of the body. Some symptoms include tingling or numbness of the fingertips and/or toes, an achy jaw and constipation. These side effects are related to the total dose given over time, so if they occur, it may not be until after several treatments with this drug. Tingling or numbness can make it difficult to button or zip; it is usually a reversible condition, resolving after about six weeks. You should report this symptom at your next visit.

Eating a diet high in fiber, with plenty of fresh fruits or fruit juices and vegetables will help prevent constipation. Maintaining an active physical program, if possible, will also help prevent constipation. Your doctor should be called if you become unable to move your bowels, have swelling of your legs, or unusual stomach pain or bloating, or pain in your bones.

Procarbazine

Procarbazine is a capsule and is taken for 14 days: from day 8 through day 21. The major side effects of procarbazine are nausea and vomiting and a decrease in blood counts. A prescription for anti-nausea medicine will be given to you along with the prescription for the procarbazine. The procarbazine can be taken at bedtime, like the CCNU was, with the anti-nausea pill an hour before.

Procarbazine has less of a tendency to cause nausea and vomiting than CCNU. In addition, the nausea usually appears with the first three doses, and then disappears for the following 11 days. However, if you do experience nausea and vomiting which is severe, you should call your doctor. A change in the anti-nausea medicine may make you more comfortable.

There are certain foods which should not be eaten on the days you are taking procarbazine. Eating these foods may cause you to have headaches, nausea and a rapid pulse. If you eat a restricted food by mistake, the risk of side effects is very low, and you only need to notify your doctor if you develop symptoms.

The foods to avoid are:

Aged Meats (smoked, cured, prime), alcohol, avocado, bananas, broad bean pods, canned figs, aged cheeses, chocolate, cream, fava beans, game, kippered herring, licorice, liver, meat extracts, meat tenderizers, pickled herring, raisins, sour cream, soy sauce, yeast extracts, yogurt

You should also avoid over-the-counter cold medicines, nose drops, cough medicines, or diet pills, and reduce the amount of coffee you drink daily. In fact, it is a good idea to ask your doctor before starting any new medication while on procarbazine.

Procarbazine also may cause fatigue and loss of appetite and a rash. If you get a rash while taking procarbazine, call your doctor before you take the next dose.

In men, procarbazine can cause sterility. And therefore may make you unable to father a child. You should talk about the possibility of sperm banking with your doctor BEFORE you start taking the medicine.

Follow Up Visits

You will be seen by your doctor on days 1, 8 and 29. When you arrive at the clinic, you will have your blood drawn so that the blood count is known before your treatment. If you are taking anti-seizure medicine, a level may be checked.

During the visit with the doctor you will have the chance to talk about how the chemotherapy went at home and any side effects you had. The doctor will also do a neurological examination.

Once the doctor knows the blood count and has examined you and says you can get the chemotherapy, you will go to the Infusion Unit on Blake 2 for treatment by the nurse.

There is a section at the back of this booklet for recording any symptoms or questions you might have. You should bring the booklet with you when you come to the doctor so that all your questions can be answered. Feel free to ask or call the nurses to discuss questions or concerns as well.

Follow Up Tests

In order to see how the tumor is responding to chemotherapy, your doctor will schedule an MRI or CT scan periodically. This is often done before the start of cycles 3 and 5and after cycle 6. It is sometimes necessary to have a scan earlier or later, depending on how you are feeling.

When to Call the Doctor

You should call the doctor in the following situations:

-you have signs of infection—fever, chills, pain on urinating, unusual headache, stiff neck, sore throat, or abdominal pain

-you have signs of possible bleeding—unusual bruising, tiny red spots on your body, severe headache, unusual abdominal pain, bright red blood from the nose or rectum

-you have severe nausea and vomiting which is not relieved by the anti-nausea medicine, you vomit the anti-nausea medicine

-you develop a skin rash

-you develop constipation which is not relieved by your usual methods

-your urine output decreases even though you are drinking your usual amount.

These are some of the situations your doctor needs to know about. Sometimes it is hard to know whether to call your doctor about a certain problem. If you are unsure, you should make the call. This will help you avoid possible problems, and put your mind more at ease. Before beginning treatment you will be provided with phone numbers of the doctor and a number at which the doctor on call can be reached after hours or on weekends.

Self Help at Home

There are some important things for you to do at home during your treatment. These include:

-eat a healthy diet—while following the diet restrictions during procarbazine, including plenty of fresh fruits, fruit juices and vegetables to prevent constipation

-drink adequate fluids-- at least 2 quarts a day unless your doctor has restricted your fluid intake

-try to get some form of exercise-- even a little is better than none

-use good handwashing after toileting

-be alert to signs of infection or bleeding

-perform good mouth care and personal care

-write down your questions for your next visit. It is a good idea to keep all of your questions and notes in one notebook which can be purchased at any pharmacy

-ask your nurse for other pamphlets or reading material which may be helpful

-use your anti-nausea medicines as directed. It is easier to prevent nausea and vomiting than to stop it once it starts.

Notes to the Physicians of Patients on PCV

The doses of PCV agents are as follows:

-CCNU 110 mg/m2 orally on day 1

-vincristine 1.4 mg/m2 (maximum dose of 2 mg) i.v. on days 8 and 29

-procarbazine 60 mg/m2/day (maximum dose of 100 mg/day) orally days 8-21

Ondansetron 8 mg orally is excellent for control of CCNU-induced nausea. Compazine 10 mg orally for the first three nights of procarbazine is usually sufficient to control nausea, although some patients do better with ondansetron.

CBC values should be: ANC of 1,500 or greater and platelet count of 100,000 or greater before proceeding with each step of every cycle. Twenty-five percent dose reduction of CCNU is commonly required to avoid prolonged delays between cycles.

Chemotherapy should be administered by physicians who are trained in medical oncology. The doses of drugs in this booklet are intended as a general guide.