Drug Holiday

Cancer treatments can be physically and emotionally draining, and you may desire a break from them sometimes. The weariness often comes as a form of adverse effect of cancer drugs. It may also come from the never-ending fear and anxiety of your illness. To address these challenges, taking a drug holiday and engaging in activities that distract you from the negative thoughts may be beneficial.

A drug holiday is a conscious decision, carefully planned between the doctor and patient, to temporarily cease taking regular medication for a period of time. This approach aims to strike a balance between the benefits of the drug and the negative side effects it may induce.

It is NOT intended when you:

• Forget to take a medication
• Run out of prescribed medication
• Deliberately stop your medication without consulting your doctor

“I look forward to a steroid/Alimta/treatment-free summer… I really just want to be a regular person.”

-Evalynn Linnea Olson (1959-2021), lung cancer fighter for 17 years, a participant in six clinical trials, advocate and blogger for cancer community.

To reduce the toxicity of medication. Doctors often order drug holidays or intermittent treatment to limit drug toxicity and provide temporary relief from side effects. This is especially common for patients undergoing chemotherapies and immunotherapies, which target both cancer and healthy cells.

Patients often receive intermittent chemotherapy for early and locally advanced lung cancer (cycles of treatment days and rest days). Patients will not receive treatment every day, giving their bodies a chance to recover from the cytotoxic effects of chemotherapy.

The adverse reactions to chemotherapeutic agents can be prevented by premedication using other drugs. These reactions include:

• Acute hypersensitivity – non-infectious pneumonitis
• Dyspnea, dry cough, fever
• Hypoxia – can progress rapidly to respiratory failure
• The toxicity-induced challenges can also make patients vulnerable and susceptible to opportunistic infection and radiation toxicity (if they undergo radiation therapy)

The cycle length varies between individuals and your cancer care team will plan the treatment regimen for you based on:

• Additional drugs to pair with the chemotherapeutic agents
• Concurrent or sequential schedule
• Types or subtypes of lung cancer
• Safety and effectiveness of chemotherapy

On the other hand, immune checkpoint inhibitors (drugs used in immunotherapies) have their unique set of toxicities. The adverse effects are often the result of immune system hyperactivation, causing the immune cells to attack normal, healthy cells.

Mild side effects like skin rash, fatigue, diarrhea, dry eyes, and joint/muscle pain are manageable. Whereas immune checkpoint inhibitors-induced pneumonitis is a major concern, it can be fatal for some patients on immunotherapy.

Doctors may order a drug holiday for patients presenting mild toxicity to immunotherapy and check them for pneumonitis via a CT scan. If pneumonitis progresses, the toxicities will have to be managed using drugs. In severe cases where patients develop hypoxia, the patients often require hospitalization and the immunotherapy must be discontinued permanently.

To restore drug response or to reduce drug tolerance. Among patients with EGFR-positive NSCLC, resistance to EGFR tyrosine kinase inhibitors (TKIs; a class of targeted therapy for EGFR-positive patients) is inevitable. Resistance to TKIs and cancer progression can occur at a median duration of 12 months after the targeted therapy.

Switching to the next line of TKIs and sometimes combined with chemotherapy are the options for these patients. However, numerous studies and trials have shown that a drug holiday from the initial TKIs can restore the patients’ response to the medications.

Certain types or subtypes of lung cancer are highly aggressive and prone to metastasis (spread to other parts of the body). They are also likely to recur within months from the initial treatment.

In the case of small cell lung cancer (SCLC), most patients either

• do not respond to the initial chemotherapy (refractory SCLC) or
• they develop chemoresistance and relapse in less than three months after treatment

For relapse and chemo-sensitive SCLC patients, a long drug holiday may resensitize the tumor to the same therapy, often at the same dosage and regimen as the initial treatment.

Other reasons for a drug holiday include:

• Fertility and pregnancy - individuals taking medications for lung cancer may need to temporarily stop their medications to conceive a child. While most cancer drugs pose risks to fetal development, the doctor may plan alternative treatments that minimize negative impact on the fetus.
• Assessment of treatment efficacy - a drug holiday can be used to evaluate how well a medication is working. By discontinuing the medication temporarily, healthcare providers can assess whether the condition has improved or worsened without it.

There are also non-medical reasons for a temporary break from cancer therapy:

• To improve the quality-of-life (QOL) - patients may experience psychological distress associated with long-term medication use. A temporary break from the medication can reduce stress and anxiety, thus improving mental well-being.
• To reduce the economic burden of patients - Some medications can be expensive. For those who have achieved remission in cancer, taking a break from treatment can help relieve the patients’ financial burden.

Remember that discontinuing certain medications or drugs can be dangerous, and taking a break from treatment may come with potential risks, even if it improves a patient’s quality of life. Discuss openly with your cancer team about your reasons for a drug holiday, your concerns and fears. They will base their recommendations on their expertise and your specific situations.

Related: Drug Holiday: A Double-Edged Sword?