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Treatment Name: Topotecan + Paclitaxel + Bevacizumab (Avastin®)

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

How does topotecan + paclitaxel + bevacizumab work?
Topotecan and paclitaxel are designed to target rapidly dividing cells-- this kills or slows the growth of cervical 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:
Topotecan + paclitaxel + bevacizumab is given to shrink tumors or alleviate symptoms of cervical cancer. It is not commonly given with the goal of cure, but may help patients live longer.

Schedule

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

Estimated total infusion time for this treatment:

  • Up to six hours for Cycle 1, Day 1; up to five hours for Day 1 of subsequent cycles if bevacizumab is well tolerated
  • Up to one hour on Days 2 and 3 of each cycle
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time 

Topotecan + paclitaxel + bevacizumab is usually given in an outpatient infusion center, allowing the person to go home afterwards. On occasion, it may be given in the hospital if someone is too sick for outpatient treatment.

Topotecan + paclitaxel + bevacizumab is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated until the treatment no longer works or until unacceptable side effects occur. Duration of therapy depends upon response, tolerability, and number of cycles prescribed.

Click here for common starting doses.

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 topotecan + paclitaxel + bevacizumab side effects are shown here:

Up to 25% of patients discontinue treatment due to unacceptable side effects.

Monitoring

How often is monitoring needed?  
Labs (blood tests) may be checked before each treatment and in-between treatments at the discretion of your doctor. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), urine protein level, plus any others your doctor may order. Cancer Antigen-125 (CA-125) blood test may be checked every cycle or less frequently to monitor response to therapy. 
 
How often is imaging needed?  
Imaging may be checked before treatment and periodically during treatment, which may be as often as before every other treatment cycle. Imaging may include: X-rays, magnetic resonance imaging (MRI), or computerized tomography (CT) scans. 
 
How might blood test results/imaging affect treatment?  
Depending upon the results, your doctor may advise to continue topotecan + paclitaxel + bevacizumab as planned, change doses, or delay or switch therapy.

ChemoExperts Tips

  • Paclitaxel may cause infusion reactions when used as an I.V. formulation. Patients may receive several medications prior to receiving paclitaxel (this is known as "pre-medication") to decrease the risk of infusion reactions. Common pre-medications given are a histamine-2 blockers such as famotidine (Pepcid®) or ranitidine (Zantac®), a histamine-1 blocker such as diphenhydramine (Benadryl®), and a corticosteroid such as dexamethasone
  • 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
  • Bevacizumab can impair your body’s ability to heal wounds. Talk to your oncologist about any planned surgeries and let your surgeon know you are taking this drug. Your schedule for surgery or chemotherapy may need to be altered
  • Bevacizumab can commonly cause high blood pressure. Consider keeping a blood pressure monitor at home. Your doctor may prescribe a medication to help lower your blood pressure if needed 
  • Seek help immediately if you experience severe abdominal pain with fever, nausea, or vomiting or if you are experiencing trouble breathing, severe chest pain, or redness, pain, and swelling in your arms or legs as these can be signs of life threatening condition
  • 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 Topotecan + Paclitaxel + 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 Topotecan + Paclitaxel + Bevacizumab (Avastin®). Depending upon your income, they may be able to help cover the cost of:

  • Topotecan IV
  • 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 Topotecan + Paclitaxel + 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 Topotecan + Paclitaxel + Bevacizumab (Avastin®)

Individual Drug Label Information

Topotecan IV (Hycamtin®)

  • ​Is intravenous (I.V.) infusion that is clear in color 
  • 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 neutropenia (low white blood cells), anemia (low red blood cells) and thrombocytopenia (low blood platelets) 
  • Can cause fetal harm; this drug should not be used during pregnancy.  Women should avoid becoming pregnant while on this drug.  Nursing mothers should discontinue breastfeeding during treatment
General topotecan (Hycamtin) side effects: 
  • Low white blood cells (neutropenia) 
  • Low red blood cells (anemia) 
  • Low platelets (thrombocytopenia) 
  • Pain 
  • Vomiting 
  • Infection 
  • Shortness of breath 
  • Fatigue 
  • Diarrhea 
  • Constipation 
  • Abdominal pain and blockage 
  • Click on the topotecan (Hycamtin) package insert below for all manufacturer reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaBleedingBleedingConstipationConstipationPainPainAnemiaAnemiaNeutropenic 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

1. Tewari KS, Sill MW, Long HJ III, et al. Improved survival with bevacizumab in advanced cervical cancer. N Engl J Med 2014;370(8):734-43.

2. Supplement to: Tewari KS, Sill MW, Long HJ III, et al. Improved survival with bevacizumab in advanced cervical
cancer. N Engl J Med 2014;370:734-43.

Created: May 11, 2017 Updated: October 24, 2018

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.

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.

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 is Dexamethasone (Decadron)?

Dexamethasone is an anti-inflammation drug that helps calm your body's reactions to many chemotherapy treatments.

Common Starting Doses

  • Bevacizumab 15 mg/kg intravenous (I.V.) infusion 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
  • Paclitaxel 175 mg/m2 I.V. infusion over 3 hours on Day 1
  • Topotecan 0.75 mg/m2 I.V. infusion over 30 minutes on Days 1, 2, and 3

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