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Oral VP-16 (Etoposide): How I Use It

The Sarah Cannon-Minnie Pearl Cancer Center, 250 25th Avenue North, Suite 412, Nashville, TN 37203

1. Background
   1. Variable absorption, but bioavailability is better; (70%-80%) with low daily doses.
      
   2. Data highly suggest that low plasma levels are as effective as higher levels, and with less myelotoxicity.
      
   3. Duration of therapy is key element not studied enough. Twenty-one days of oral etoposide appear too long; increases myelosuppression and no increase in activity. Optimal duration appears to be 7-15 days.
      
   4. Efficacy seems similar when using low doses daily for many days, i.e., 10 p.o. Very low doses can be given i.v. infusion for weeks without major toxicity in most patients.
      
   5. We use Etoposide incorrectly in nearly all settings; doses too high, duration not quite long enough. Solution: use low doses, 50-100 p.o. qd for 10 days only.
      
   
   
2. Use of Oral Etoposide in Combination
   I think low dose oral etoposide, 50/100 mg daily for 10 days can be substituted in any standard regimen using higher doses of etoposide except germ cell tumors. (I do not have the nerve to do this, but intellectually think it would be as effective and less toxic than 100 mg/m² daily i.v. x 5 days). We have used oral etoposide as part of a combination for elderly patients with aggressive lymphomas and results are good. Published in JNCI. Until and if further study refutes this, I think the best dose is 50 mg alternating with 100 mg orally for 10 days (the "optimal" dose and schedule).
   
3. Use as Single Agent for Palliation—a Long List
   1. Recurrent small cell lung cancer
      
   2. Recurrent lymphomas
      
   3. Recurrent germ cell tumors
      
   4. Recurrent advanced ovarian cancer
      
   5. Recurrent advanced breast cancer
      
   6. Recurrent medulloblastoma
      
   7. Untreated mesothelioma
      
   8. Untreated advanced gastric cancer
      
   9. Untreated advanced NSCLC
      
   10. Kaposi’s sarcoma with AIDS
       
   
   

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