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Treatment Name: Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®)

Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®) is a Chemotherapy Regimen for Cervical Cancer

How does cisplatin + paclitaxel + bevacizumab work?
Cisplatin and paclitaxel are designed to kill cancer cells. Bevacizumab is designed to slow the growth of cancer cells by decreasing the spread of blood vessels carrying nutrients to cancer cells.

Goals of therapy:
Cisplatin + paclitaxel + bevacizumab are given to shrink tumors and decrease symptoms of cervical cancer. This treatment is commonly given with the goal of improving both the quality and quantity of life.

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Schedule

  • Cisplatin intravenous infusion (I.V.) over one hour on Day 1
  • Paclitaxel I.V. over three hours on Day 1
  • Bevacizumab I.V. over 90 minutes on Day 1 of Cycle 1
    • then over 60 minutes for Cycle 2, if no infusion reactions occur
    • then over 30 minutes for Cycles 3 and on, if no infusion reactions occur

Estimated total infusion time for this treatment:

  • Up to 6 - 8 hours for Day 1 of Cycle 1.  Later cycles can be infused in about 5 hours if no reactions occur
  • 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, particularly with cisplatin

Cisplatin + paclitaxel + bevacizumab is usually given in an outpatient infusion center, allowing the person to go home afterwards. This is repeated every 21 days and is known as one Cycle. Duration of therapy may be indefinite (continuous), depending upon response, tolerability, and number of cycles prescribed.

Click here for common starting doses.

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Side Effects

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 with cisplatin + paclitaxel + bevacizumab are shown here:

  • Gastrointestinal events, including nausea and vomiting (52%)
  • Low white blood cell count [increased infection risk] (35%)
  • Pain (32%)
  • High blood pressure (25%)
  • Blood clots (8%)
  • Neutropenic fever (5%)
  • Fistula (3%)
  • Bleeding (3%)
  • Increased protein in urine (2%)
  • Hair loss (exact percent not reported in the clinical trial)
  • Anemia (exact percent not reported in the clinical trial)

Side effect videos Side Effect Videos
Nausea and VomitingNausea and VomitingPainPainBlood ClotsBlood ClotsNeutropenic FeverNeutropenic FeverBleedingBleedingHair LossHair LossAnemiaAnemia

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Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment begins, during each cycle, and before the next cycle. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and urine protein level, plus any others your doctor may order. CA-125 (Cancer Antigen 125) may be checked every cycle or less frequently to monitor response to therapy. Standard vital signs such as blood pressure are often checked frequently.

How often is imaging needed?
Imaging may be performed before treatment, every couple of cycles during treatment, and may be checked after treatment is completed. Imaging may include: chest radiography (chest X-ray), and computerized tomography (CT) scan or magnetic resonance imaging (MRI) of the abdomen and pelvis.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue cisplatin + paclitaxel + bevacizumab as planned, or delay or switch therapy.

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ChemoExperts Tips

  • Intravenous (I.V.) fluids may be given while receiving cisplatin to maintain good hydration and protect against kidney damage. These fluids may contain electrolytes such as potassium and magnesium
  • Cisplatin can cause severe nausea, but is usually well managed with appropriate anti-nausea medicines. Make sure your doctor prescribes anti-nausea medicines for you to have at home if necessary
  • This chemotherapy regimen can cause tingling and nerve pain in the hands and feet called, neuropathy. Tell your doctor if you are having any pain, especially if it is affecting your ability to complete your daily activities
  • There is a risk for serious infusion reactions from paclitaxel such as: trouble breathing, low blood pressure, severe swelling, or hives. These reactions are due to a component in the paclitaxel solution called Cremophor. You will receive several medications before receiving paclitaxel to decrease the risk of experiencing an infusion related reaction
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for cervical cancer. 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 Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®), 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 Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®). Depending upon your income, they may be able to help cover the cost of:

  • Cisplatin
  • Paclitaxel
  • Bevacizumab

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 Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®) 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 Cisplatin + Paclitaxel (Taxol®) + Bevacizumab (Avastin®)

Individual Drug Label Information

Cisplatin (Platinol®)

  • Cisplatin is an intravenous (I.V.) infusion that is typically given over one to two hours
  • Cumulative toxicity to kidneys from cisplatin can be severe 
  • Other toxicities from multiple doses are:  low blood counts, nausea, vomiting, and hearing loss
  • Dosage adjustments may be required for poor kidney function or bone marrow toxicity (low blood counts) 
  • Cisplatin is hazardous to a human fetus; women should avoid pregnancy while on this drug 
  • Women should not breast-feed while on cisplatin; it has been reported to be in human milk 
  • Patients on anticonvulsant drugs may have decreased levels while on cisplatin 
General Cisplatin (Platinol) Side Effects 
  • Kidney problems (nephrotoxicity), especially in elderly patients. 
  • Nausea and vomiting, both acute (within first 24 hours) and delayed (two to five days after infusion) 
  • Diarrhea 
  • Low blood cell counts (myelotoxicity, acute leukemia)
  • Hearing problems- ringing ears.  All patients should have a baseline hearing test done.  All children should have hearing test done before each dose and for several years after therapy is complete 
  • Low blood electrolytes:  magnesium, potassium, calcium, sodium, and phosphate
  • Nerve pain 
  • Vision problems; improvement and/or complete recovery usually occurs after stopping therapy 
  • Liver toxicity; recovery usually occurs after stopping therapy 
  • Click on the cisplatin (Platinol) package insert below for reported side effects and possible drug interactions

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

See DailyMed package insert.

Paclitaxel (Taxol®)

  • Paclitaxel is an intravenous infusion
  • There is a risk for serious infusion reactions such as trouble breathing, low blood pressure, severe swelling, or hives. These reactions are due to a component in the solution called Cremophor. You will receive several medications before receiving paclitaxel to decrease the risk of experiencing an infusion related reaction that include: a corticosteroid, diphenhydramine (Benadryl), and histamine-2 antagonists (Zantac or Pepcid).Patients who experience these type of severe reactions should not be rechallenged with paclitaxel.
  • This drug can cause low white blood cell counts. Complete blood counts (CBC) will be checked before each treatment to make sure your white blood cells are at a safe enough to use this drug
  • Dosage adjustments may be required for liver dysfunction, nerve pain or toxicity, low white blood cells, or low blood platelets
  • Nerve pain usually starts as tingling or a "pins and needles" feeling in the fingers or toes, but can worsen over time and lead to numbness. It is important to notify the doctor if there are any signs of nerve damage. If caught early, this is typically reversible but can become permanent if not addressed
  • Interacts with certain antifungal, blood pressure, cholesterol, erectile dysfunction, sedative, antibiotic, and anti-seizure medications.  Ask your doctor or pharmacist to review your medications for any possible interactions
  • Known interaction with grapefruit or grapefruit juice. Avoid eating grapefruit and drinking grapefruit juice as they may increase your risk of experiencing side effects
  • Avoid the natural supplement St. John’s Wort as this can possibly decrease the effectiveness of paclitaxel
  • Injection site skin reactions can occur:  itching, skin infection, skin falling off, skin death, and redness. Report any of these to your physician, even if this occurs several days after an infusion
  • Can cause fetal harm; this drug should not be used during pregnancy.  Women should avoid becoming pregnant while on this drug
General Paclitaxel (Taxol) Side Effects
  • Low blood neutrophil count (neutropenia)
  • Low white blood cells
  • Nerve pain and general pain
  • Low red blood cells and related fatigue
  • Infusion reactions - hypersensitivity
  • Hair loss
  • Nausea
  • Diarrhea
  • Mouth sores
  • Low blood pressure
  • Liver problems
  • Constipation
  • Fever and infection
  • Bleeding
  • Injection site reactions
  • Nail discoloration; usually reversible once paclitaxel is stopped
  • Click on the paclitaxel (Taxol) package insert below for all manufacturer reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaHair LossHair LossFatigue Fatigue BleedingBleedingConstipationConstipationPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Bevacizumab (Avastin®)

  • Bevacizumab is an intravenous (I.V.) drug
  • Use extreme caution in patients with a history of stomach and intestine perforations or disorders
  • Do not use 28 days before or after any surgery
  • Bleeding is more likely in patients taking this drug
  • Bevacizumab treatment may be delayed or stopped for: surgery, high blood pressure, protein in urine, severe infusion reactions
General Bevacizumab Side Effects
  • Infusion reactions: usually does not happen after first successful dose
  • Bleeding
  • Blood clots
  • Stomach and intestinal problems
  • Poor wound healing
  • High blood pressure
  • Protein leaking from kidneys into urine
  • Avoid during pregnancy, Bevacizumab is known to cause fetal harm
  • Ovarian failure
  • Click on the bevacizumab (Avastin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
BleedingBleedingBlood ClotsBlood Clots

See DailyMed package insert.

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References

Tewari KS, Sill MW, Long HG 3rd, et al. Improved survival with bevacizumab in advanced cervical cancer. N Engl J Med. 2014;370:734-743.

Created: March 7, 2016 Updated: August 30, 2016

What is Cervical Cancer?

A disease of the cells that line the inside of the uterine cervix. Cervical cancer is decreasing in the United States, but is still common worldwide. Known causes of cervical cancer include persistent infection with the Human Papilloma Virus (HPV), history of smoking, history of sexually transmitted diseases, certain autoimmune diseases, and chronic immunosuppression.

The stage of cervical cancer can vary at diagnosis. Stages of cervical cancer include I, II, III, IV. The effectiveness of the treatment and the goal of cure may depend upon the stage at diagnosis.

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 which therapy is appropriate for you.

Common starting doses

  • Cisplatin 50 mg/m2 intravenous infusion (I.V.) over 1 hour on Day 1
  • Paclitaxel 135 mg/m2 or 175 mg/m2 I.V. over 3 hours on Day 1
  • Bevacizumab 15 mg/kg I.V. over 90 minutes on Day 1 of Cycle 1
    • then over 60 minutes for Cycle 2 if no infusion reactions occur
    • then over 30 minutes for Cycles 3 and on, if no infusion reactions occur

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

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