The changing paradigm for supportive care in cancer patients

Abstract

Dear Editor, With scientific advances in cancer supportive care and the incorporation of effective supportive care strategies into contemporary cancer treatment, there has been a substantial reduction in the occurrence of severe toxicities traditionally associated with cytotoxic chemotherapy over the past two decades. For example, appropriate prophylaxis with antiemetics (including a 5-HT 3 antagonist, corticosteroid, and NK-1 antagonist) has greatly reduced chemotherapy-induced nausea and vomiting, colony-stimulating factors have curbed febrile neutropenia, and the integrated use of mouth care and palifermin has decreased the severity of oral mucositis. In addition, the introduction of structured management and care pathways into clinical practice has widely promoted these supportive care strategies for patients. We may not currently have all the answers on the prevention of chemotherapyinduced toxicities, but most oncology clinicians today can capably handle toxicities which were previously considered difficult to manage.Innovations in cancer therapeutics have improved the oncologist's toolkit to cure and control many cancers previously difficult to manage. Targeted therapy agents are now commonly used in the management of cancers ranging from chronic myeloid leukemia to renal cell carcinoma, and new indications and increased lines of therapy continue to arise. Initially "targeted" drugs were thought to have unique mechanisms for targeting cancer cells and were considered to produce fewer side effects than traditional cytotoxic chemotherapy. Importantly, however, clinicians are now observing a number of emerging and highly prevalent side effects associated with the use of targeted therapies [1]. These agents, which carry with them significant financial cost, are also associated with an increase in chronic complications that can decrease a patient's quality of life [2]. We must, therefore, strive to understand and be responsive to the side effects of these novel therapeutics to enable optimal patient adherence to and participation in their treatment.In this commentary, we highlight toxicities that are commonly associated with targeted therapies, namely dermatological, gastrointestinal (diarrhea and stomatitis), hepatotoxicity, cardiotoxicity, neurotoxicity, and immunotoxicity. More importantly, we will emphasize the current impediments to understanding the mechanisms behind emerging side effects and the lack of effective strategies for managing these toxicities. Dermatological toxicitiesCommonly associated with targeted agents is a range of dermatological toxicities, which are different from the skin toxicities seen with traditional cytotoxic chemotherapy. The first of these class-related skin toxicities is observed with epidermal growth factor receptor inhibitors (EGFRI), including agents used for the treatment of lung (gefitinib, erlotinib, and afatinib), pancreatic (erlotinib), breast (lapatinib), head and neck (cetuximab), and colorectal cancers (cetuximab and panitumumab). They usually manifest as papulopu...

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