TEARING WITH DOCETAXEL TREATMENT 

Tearing occurs in the majority of breast cancer patients who receive adjuvant docetaxel-based chemotherapy regimens, but it does not appear to be related to lacrimal duct obstruction (LDO), according to a new study.

The results, which do not support stenting of the lacrimal duct before beginning chemotherapy, were published online May 6 in the Journal of Clinical Oncology.

"Our take-home message is that docetaxel-containing adjuvant chemotherapy regimens are very commonly associated with tearing," said lead author Arlene Chan, MD, from the Curtin Health Innovation Research Institute, Curtin University, Perth, Australia. "Lacrimal obstruction is not common, and therefore surgical stenting is not indicated and patients can be reassured that in the vast majority of patients, it will resolve."

Symptomatic improvement can be achieved with conservative approaches. "It was outside the scope of study to identify effective interventions, but a warmed moistened cloth wiped across the closed eyes and lubricant drops are of symptomatic benefit in some patients," Dr. Chan told Medscape Medical News. "In the setting of severe or persistent symptoms, referral to an ophthalmologist should be considered."

Surveillance Needed for High-Risk Groups

In an accompanying editorial, Bita Esmaeli, MD, and Vicente Valero, MD, both from the University of Texas M.D. Anderson Cancer Center in Houston, agree that a prechemotherapy ophthalmologic evaluation is not necessary for all patients.

"However, we recommend regular surveillance and early evaluation, probing, and irrigation by an ophthalmologist with lacrimal expertise, and appropriate selection of patients for lacrimal stenting in the high-risk groups," they write.

The editorialists note that "clinical interventions to manage canalicular stenosis associated with docetaxel are critical to prevent permanent complete closure of canaliculi, the need for complex surgical repair, and poorer clinical outcomes" in some groups of patients. These include symptomatic patients, those with partial stenosis, those receiving docetaxel once per week, and those receiving docetaxel once every 3 weeks for a prolonged period.

No Relation Between Tearing and LDO

Ocular symptoms are commonly reported by women receiving adjuvant chemotherapy for breast cancer. These include eye irritation and discomfort, blurred vision, accommodation disturbance, photophobia, conjunctivitis, hyperemia, and excessive tearing, Dr. Chan and colleagues note. Previous research suggests that tearing can occur in up to 64% of women receiving docetaxel-based chemotherapy.

It has been thought that lacrimal obstruction is the primary cause of tearing, so duct stenting has been considered a treatment for select patients. In this study, the researchers evaluated LDO as causative factor of excessive tearing.

The study involved 100 women with early breast cancer and no previous ocular symptoms who had been recommended for docetaxel-based chemotherapy. Before and after the completion of chemotherapy, all patients underwent lacrimal drainage evaluation. Eye symptoms were evaluated before (baseline), during, and after the completion of chemotherapy.

The majority of patients (72%) had stage II breast cancer, 15% had stage I disease, and 13% had stage III disease. Mean was 52 years; 51% of the patients were pre- or perimenopausal and 49% were postmenopausal.

Overall, 86% of patients developed tearing at some point during adjuvant chemotherapy.

In 39% of patients, onset of tearing occurred on day 1 of cycle 2; in 30%, it occurred in cycle 3; in 12%, it occurred in cycle 4; in 5%, it occurred in cycle 5; and in 9%, it occurred in cycle 6.

In the 6 patients (6%) who experienced grade 3 tearing, complete symptom resolution was seen in 4 patients at the postchemotherapy follow-up visit, and improvement to grade 1 tearing was seen in 1 patient. The sixth patient had patent lacrimal ducts on postchemotherapy examination, the researchers note.

There was no significant difference in the development of tearing between the patients with punctal stenosis at baseline (27%) and those without (89% vs 85%).

There was also no difference in the development of tearing between patients with lacrimal duct obstruction at baseline (17%) and those without (94% vs 84%; P = .45).

There was more blepharitis at the end of chemotherapy than at baseline (42% vs 37%), and more minor corneal epitheliopathy (22% vs 18%). The presence of these ocular abnormalities did not correlate with the development or severity of tearing, the researchers write.

The study was supported by a grant from sanofi-aventis Australia. Dr. Chan and co-author Richard H. De Boer report a relationship with sanofi-aventis

J Clin Oncol. Published online May 6, 2013. Abstract, Editorial