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Treatment Name: BEAM (Carmustine + Etoposide + Cytarabine + Melphalan)

BEAM (Carmustine + Etoposide + Cytarabine + Melphalan) is a Chemotherapy Regimen for Autologous Stem Cell Transplant (autoSCT)

How does BEAM work?

Each of the medications in BEAM are designed to slow the growth of and kill cancer cells. BEAM is commonly given as the conditioning regimen for patients with non-Hodgkin lymphoma or Hodgkin lymphoma.

BBiCNU® (Carmustine)
EEtoposide
AAra-C (Cytarabine)
MMelphalan

Goals of therapy:

BEAM is given to kill residual lymphoma cells and to prevent relapse. BEAM is commonly given with the goal of cure.

Schedule

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How is BEAM therapy for autologous stem cell transplant given?

  • Carmustine intravenous (I.V.) infusion over two hours 6 days prior to stem cell infusion
  • Etoposide I.V. infusion over 1 to 2 hours once or twice daily on Days 5, 4, 3, and 2 prior to stem cell infusion
  • Cytarabine I.V. infusion over one hour twice daily on Days 5, 4, 3, and 2 prior to stem cell infusion
  • Melphalan I.V. infusion over 15 to 30 minutes one day prior to stem cell infusion

Estimated total infusion time for this treatment:

  • Over two hours on Day -6, up to six hours for Days -5 to -2; as short as 15 minutes for Day -1
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

BEAM usually requires an 18 to 28-day hospital stay (or sometimes longer), depending on bone marrow function recovery and how well the side effects of treatment are tolerated.

Click here for the common BEAM starting doses.

Side Effects

What are the most common side effects from BEAM for autologous stem cell transplant?

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects of BEAM are shown here. Side effects sometimes have percentage ranges [example: 74 – 100%, neutropenic fever] because they differed between clinical studies:

Watch videos on common BEAM therapy side effects below

Side effect videos Side Effect Videos
Hair LossHair LossNeutropenic FeverNeutropenic FeverNausea and VomitingNausea and VomitingDiarrheaDiarrhea

Monitoring

How often is monitoring needed?

Labs (blood tests) may be checked before treatment, then daily or every other day for the first few weeks while in the hospital, and then periodically after hospital discharge. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), blood magnesium, blood phosphorpus, plus any others your doctor may order.

How often is imaging needed?

Imaging may be checked before treatment to assess the status of lymphoma prior to transplant, during the 1st month during hospitalization if there is a concern for an infection or blood clot, then typically every 3 months after transplant for the first 2 years, every 6 months for the next 3 years, or whenever clinically indicated. Imaging may include: positron emission tomography (PET scan) or computerized tomography (CT scan) of the chest, abdomen, or pelvis. A chest x-ray may be needed if an infection such as pneumonia is suspected during hospitalization. An ultrasound may be performed to evaluate for formation of a clot during treatment.

How might blood test results/imaging affect treatment?

Daily or every other day labs will indicate bone marrow recovery after transplant. White blood cell recovery known as white blood cell engraftment typically occurs day 11 to day 21 after stem cell infusion depending whether growth factors support agents were used. During this time mouth sores tend to heal, nausea and vomiting decrease, antimicrobial prevention agents are discontinued and patient is prepared for discharge in the following days.

ChemoExperts Tips

What are the 7 most important things to know about BEAM while receiving therapy?

  • BEAM chemotherapy and stem cell transplant require a long stay in the hospital. Try to be as active as possible by taking walks in the hallway, or using an exercise bicycle in the room, if available. This will hopefully speed time to recovery
  • Antibiotics, antifungal agents, and antiviral medications are commonly used to prevent infection. The particular medications and schedules used may vary between institutions. Be sure to tell your doctor if you experience discomfort anywhere as this may be a clue to an infection
  • Recombinant hematopoietic (blood) growth factors such as filgrastim (Neupogen®) are frequently administered to patients following stem cell transplant in order to speed up white blood cell recovery and shorten duration of hospitalization
  • Nausea and vomiting are major side effects associated with BEAM chemotherapy and may last for a couple of weeks after chemotherapy is given. Tell your doctors how you are feeling. Your healthcare team may be able to administer several anti-nausea medications around-the-clock to reduce nausea
  • BEAM chemotherapy may result in the development of painful mouth sores and difficulty eating. Your team may increase the pain medication regimen and if needed, administer nutrition intravenously (by vein, I.V.) also known as Total Parenteral Nutrition (TPN)
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for lymphoma. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications.

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for BEAM (Carmustine + Etoposide + Cytarabine + Melphalan), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for BEAM (Carmustine + Etoposide + Cytarabine + Melphalan). Depending upon your income, they may be able to help cover the cost of:

  • Carmustine
  • Etoposide
  • Cytarabine
  • Melphalan

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as BEAM (Carmustine + Etoposide + Cytarabine + Melphalan) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with BEAM (Carmustine + Etoposide + Cytarabine + Melphalan)

Individual Drug Label Information

Carmustine (BiCNU®)

  • Carmustine is an intravenous (I.V.) infusion that is typically given over at least 2 hours
  • FDA Black-Box Warning for low white blood cells, low platelets, low red blood cells, and lung toxicity
  • Dosage adjustments may be required for decreased kidney function
  • Carmustine may interact with cimetidine to cause more severe bone marrow suppression (lower white blood cell, red blood cell, and platelet counts)
General side effects from Carmustine (BiCNU)
  • Low red blood cells, white blood cells, or platelets
  • Nausea or vomiting
  • Diarrhea
  • Lung toxicity
  • Injection site reactions may occur during administration of carmustine which often present as flushing of the skin and burning at the site of injection. 
  • Although rare, it has the potential to cause secondary cancers
  • Click on the carmustine (BiCNU) package insert below for reported side effects, possible drug interactions, and other prescribing information

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossBleedingBleedingAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Etoposide (VP-16)

  • Etoposide is an intravenous (I.V.) infusion that is typically given over 30-60 minutes or in some instances, as a continuous infusion
  • Etoposide interacts with grapefruit juice and can cause increased exposure to etoposide if taken together
  • Dosage adjustments may be required for decreased kidney or liver function
General Etoposide (VP-16) Side Effects
  • Often causes temporary hair loss, which is usually reversible after stopping etoposide therapy
  • Gastrointestinal side effects such as diarrhea, mouth sores, nausea and upset stomach can be common
  • Although rare, it has been linked to the development of acute leukemia (2-12%) and typically occurs 2-3 years after therapy
  • May cause low blood counts (white blood cells, red blood cells, and platelets)
  • Click on the etoposide (VP-16) package insert below for reported side effects and potential drug Interactions

Side Effect Videos
DiarrheaDiarrheaHair LossHair LossFatigue Fatigue BleedingBleedingAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Cytarabine (Ara-C)

  • Cytarabine is most commonly given as an intravenous infusion but may be given subcutaneously
  • FDA Black-Box Warnings for low white blood cells, low platelets, low red blood cells, nausea, vomiting, diarrhea, mouth sores, liver damage, and abdominal pain
  • Dosage adjustments may be required renal or liver function
  • May cause a series of symptoms known as Cytarabine (Ara-C) Syndrome within 6 to 12 hours after administration. Symptoms may include fever, rash, chest pain, muscle aches, bone pain, tiredness, and inflammation and redness of the eye
General Cytarabine (Ara-C) Side Effects
  • Low red blood cells, white blood cells, or platelets
  • Nausea or vomiting
  • Liver dysfunction
  • Click on the cytarabine (Ara-C) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue BleedingBleedingPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Melphalan (Evomela®, Alkeran®)

  • Melphalan is an intravenous (I.V.) infusion that is typically given over 15 - 30 minutes
  • Patients who experience a hypersensitivity reaction to melphalan should have the infusion stopped immediately and not receive further doses. A hypersensitivity reaction may result in itching, swelling, rash, fast heart beat, low blood pressure, or difficulty breathing
  • Dosage adjustments may be required for decreased renal function
  • Special care should be taken if melphalan is administered into a peripheral I.V. line due to the risk of the drug leaking out into the tissue (skin or muscle) and causing damage. This is known as extravasation. Unless peripheral veins are adequate, melphalan should be given into an injection port, or central venous line, such as a P.I.C.C line (Peripherally Inserted Central Catheter)
  • May cause suppression of ovary function resulting in menopause and end of periods in premenopausal women
  • May cause reversible or irreversible function of testicular function in men
  • Women of child-bearing potential should be advised to avoid becoming pregnant while receiving melphalan. If a woman becomes pregnant while receiving melphalan, she should be informed of potential hazards to the unborn baby
  • It is not known if melphalan is excreted in human milk, therefore women who plan to nurse a baby after receiving melphalan should be advised of the risks of breast-feeding
General side effects from Melphalan (Evomela®, Alkeran®)
  • Low red blood cells, white blood cells, or platelets
  • Gastrointestinal side effects such as diarrhea, mouth sores, nausea and upset stomach are common
  • May cause lung problems
  • Although rare, it has been linked to the development of acute leukemia or other cancers 
  • Acute hypersensitivity reactions, including anaphylaxis, were reported in 2.4% of patients
  • Click on the melphalan (Evomela®, Alkeran®) package insert below for reported side effects, possible drug interactions, and other prescribing information

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossFatigue Fatigue ConstipationConstipationPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

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References

1) Chopra R, McMillan A, Linch D, et al. The place of high-dose BEAM therapy and autologous bone marrow transplantation in poor-risk Hodgkin's disease. A single-center eight-year study of 155 patients. Blood 1993;81:1137-1145

2) Mills W, Chopra R, McMillan A, et al. BEAM chemotherapy and autologous bone marrow transplantation for patients with relapsed or refractory non-Hodgkin's lymphoma. J Clin Oncol 1995;13:588-595

3) Caballero MD, Rubio V, Heras I, et al. BEAM chemotherapy followed by autologous stem cell support in lymphoma patients: analysis of efficacy, toxicity and prognostic factors. Bone Marrow Transplant 1997;20:451-458

4) Jo J, Kang B, Jang G, et al. BEAC or BEAM high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: comparative analysis of efficacy and toxicity. Ann Hematol 2008;87:43-48

5) Wang E, Chen Y, Corringham S, et al. High-dose CEB vs BEAM with autologous stem cell transplant in lymphoma. Bone Marrow Transplant 2004;34:581-587

Created: March 19, 2020 Updated: March 19, 2020

What is Autologous Stem Cell Transplant (autoSCT)?

Autologous stem cell transplant or "bone marrow transplant" is a type of stem cell transplant in which a patient’s own stem cells are collected prior to administration of high-dose chemotherapy, or a combination of high-dose chemotherapy agents, with or without radiation.

High-dose chemotherapy is designed to kill more cancer cells, but it also destroys normal blood-producing cells in the bone marrow. Because of this, previously collected stem cells are infused after high-dose chemotherapy to allow the bone marrow to recover blood cell production faster and can prevent a potentially life-threatening infection from occuring.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose your therapy.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

Common BEAM starting doses

  • Carmustine 300 mg/m2 intravenous infusion over 2 hours on Day -6 prior to stem cell infusion
  • Etoposide 100-200 mg/m2 intravenous infusion over 1 to 2 hours once or twice daily on Days -5 to -2 prior to stem cell infusion
  • Cytarabine 100-200 mg/m2 intravenous infusion over 1 hour twice daily on Days -5 to -2 prior to stem cell infusion
  • Melphalan 140 mg/m2 intravenous infusion over 15 to 30 minutes on Day -1 prior to stem cell infusion

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability.

BEAM clinical trials

1) Chopra R, McMillan A, Linch D, et al. The place of high-dose BEAM therapy and autologous bone marrow transplantation in poor-risk Hodgkin's disease. A single-center eight-year study of 155 patients. Blood 1993;81:1137-1145

2) Mills W, Chopra R, McMillan A, et al. BEAM chemotherapy and autologous bone marrow transplantation for patients with relapsed or refractory non-Hodgkin's lymphoma. J Clin Oncol 1995;13:588-595

3) Caballero MD, Rubio V, Heras I, et al. BEAM chemotherapy followed by autologous stem cell support in lymphoma patients: analysis of efficacy, toxicity and prognostic factors. Bone Marrow Transplant 1997;20:451-458

4) Jo J, Kang B, Jang G, et al. BEAC or BEAM high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: comparative analysis of efficacy and toxicity. Ann Hematol 2008;87:43-48

5) Wang E, Chen Y, Corringham S, et al. High-dose CEB vs BEAM with autologous stem cell transplant in lymphoma. Bone Marrow Transplant 2004;34:581-587

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What does engraftment mean?

Engraftment is when the new blood-producing cells start to multiply in the bone marrow and appear the blood. White blood cell engraftment usually occurs first, prior to platelet or red blood cell engraftment, and is associated with the healing of mouth sores, resolution or abatement of nausea and neutropenic fever.

What is TPN?

Total Parenteral Nutrition (TPN) is the process of administering required nutrition intravenously, bypassing the normal process of food digestion in the gastrointestinal tract. It frequently consists of glucose, lipids, amino acids, electrolytes, vitamins, and minerals.

What is a conditioning regimen?

A conditioning regimen is a form of treatment used to prepare a patient for stem cell transplant. Conditioning regimens are used to make room in the bone marrow for new white blood cells, red blood cells and platelets to grow. They also help eliminate or kill any residual cancer cells and ensures that the body does not reject the newly infused stem cells. It often includes chemotherapy, monoclonal antibody, total body irradiation, or their combination.