Summary of ASCO Clinical Guidance for Drug Shortages

ASCO: America Society of Clinical Oncology; SCLC: small cell lung cancer; CRT: chemoradiation; FU: fluorouracil; FOLFOX: oxaliplatin, leucovorin, and fluorouracil; RT: radiation therapy; CAPOX: capecitabine and oxaliplatin; FLOT: docetaxel, oxaliplatin, leucovorin, and fluorouracil; TCHP: docetaxel, carboplatin, trastuzumab, and pertuzumab; HER2: human epidermal growth factor 2; AUC: area under the curve; AC: doxorubicin and cyclophosphamide.

* As an example of when to prioritize use of an agent in limited supply, patients with limited-stage SCLC treated should be referred to a center where a platinum agent is available.^[2]

^¶ Most locally advanced, resectable esophageal and/or gastroesophageal junction carcinomas are managed with neoadjuvant CRT, followed by surgical resection. Radiosensitizing regimens for CRT include carboplatin plus paclitaxel, FU plus cisplatin, or FOLFOX. As examples of using an alternative treatment strategy:

• If cisplatin and carboplatin are in limited supply, neoadjuvant CRT with FOLFOX plus RT is an appropriate option.^[3] If FU is also limited, CAPOX may be used concurrently with RT.
• For gastroesophageal junction cancers, appropriate alternatives to neoadjuvant CRT may include perioperative chemotherapy. If FU is available, perioperative regimens include FOLFOX or FLOT.
• For further details and supporting evidence, refer to UpToDate topics on treatment of resectable esophageal, gastroesophageal, and gastric cancers.

Δ For the TCHP regimen used in early HER2-positive breast cancer,^[4] consider decreasing carboplatin to an AUC of 5 instead of 6 or omitting carboplatin.^[5] Similarly, for the KEYNOTE-522 regimen used as neoadjuvant treatment in triple-negative breast cancer,^[6] the standard dose of weekly carboplatin is an AUC of 1.5, but modifying to an AUC of 1 is acceptable given shortages of carboplatin. One could also start with AC plus pembrolizumab to be followed by paclitaxel and pembrolizumab, with or without carboplatin. ASCO recommends that providers consider prioritizing carboplatin for those whose tumors did not have a good response to AC plus pembrolizumab, but also notes that the incremental benefit of carboplatin in the KEYNOTE-522 regimen is unknown. For further details on the indications and efficacy of these regimens, refer to UpToDate topics on selecting neoadjuvant chemotherapy for HER2-negative and HER2-positive breast cancer.