What are best practices for oncologists during the national platinum shortage?

In breast cancer, we are prioritizing patients with curable disease in which platinum agents are a critical part of the regimen or have actually shown a clear advantage (the only example of this is shown below in bold).

Use an alternative to a carboplatin-based regimen whenever possible. If no alternative exists, prioritize patients based on the criteria below:

1. Curative patients
2. Recurrent/metastatic patients on a clinical trial
3. Recurrent/metastatic patients not on trial

Specifically, our prioriti...

For thoracic malignancies, there are a number of ways one could address the platinum shortage:

1. In extensive-stage - small cell lung cancer (SCLC), the NCCN recommends 4-6 cycles of therapy. However we recognize that there is no evidence that 6 cycles are required, therefore, the use of only 4 cycles will reduce the use of carboplatin. Unfortunately, all randomized trials that have shown equivalency to carboplatin and etoposide also contain either cisplatin or carboplatin (cisplatin and irinotec...

During the chemotherapy drug shortage, I recommend utilizing the resources from the Society of Gynecologic Oncology on platinum and methotrexate drug preservation strategies (applicable for any oncology field) and gynecologic cancer-specific chemotherapy recommendations. These recommendations were developed using the best available evidence and made by a diverse task force of oncology experts, including pharmacists, gynecologic, medical and radiation oncologists, and DIHE experts:

https://www.s...

We all hope that shortages in platinum agents, BCG, etc. will be resolved soon. In the interim, regarding GU cancers, we prioritize cisplatin in:

1. Curative intent settings, e.g. germ cell neoplasms, neoadjuvant (or adjuvant) setting before (or after) radical cystectomy in MIBC.
2. Patients who already started chemotherapy, derive benefits and tolerate it well with a favorable benefit:risk ratio.
3. Patients on standard-of-care therapy (esp. if a clinical trial is not the only option).

There are addi...

In genito-urinary cancers, there are clinical situations where cisplatin has clearly shown to have higher efficacy with the potential for cure.

I would prioritize the use of cisplatin in eligible patients with

1. Germ cell tumor
2. Urothelial cancer in neoadjuvant and adjuvant setting.
3. Localized small cell carcinoma of the bladder or prostate.

In advanced metastatic urothelial carcinoma patients who are cisplatin eligible can be considered to receive cisplatin-based combination up to 4 cycles an...

In the setting of urothelial carcinoma, would make the following observations regarding platinum-based chemotherapy:

1. Prioritize cisplatin for neoadjuvant/adjuvant therapy in cisplatin-eligible patients.
2. Prioritize cisplatin for metastatic cisplatin-eligible patients with curable disease (nodal/soft tissue metastasis only).
3. Regarding the number of cycles, we have shown that targeting 4 cycles of platinum-based chemotherapy may be reasonable for metastatic disease. No clear benefit was shown in a ...

Thanks to Dr. @Dr. First Last for providing excellent guidance for thoracic cancers. Currently, we are in shortage and have to begin rationing cis and carbo to those who are most in need, those who are receiving curative-intent therapy. If the shortage gets worse, we will have to come up with alternative strategies for all patients. Let me build on Dr. @Dr. First Last's foundation:

1. ES-SCLC - Agree that 4 cycles are plenty for first-line therapy. CAV [cyclophosphamide, doxorubicin (or epirubicin...

Cisplatin is on the WHO Model List of Essential Medicines for Children and is a core part of treatment for many pediatric malignancies, such as Osteosarcoma, Germ Cell Tumors, Hepatoblastoma, and CNS tumors. In 2013, a Working Group on Chemotherapy Drug Shortages in Pediatric Oncology was formed, in response to a charge from the leadership of the Children's Oncology Group. This working group has published 2 papers, including a Consensus Statement on chemotherapy shortages in pediatric oncology (...

In GU oncology, there are several situations where carboplatin is commonly used:

1. Metastatic urothelial cancer, cisplatin-ineligible patients. A suitable alternative is the enfortumab-pembrolizumab regimen, now FDA approved, which can provide durable disease control in patients without the need for chemotherapy. This is quite reasonable for cisplatin ineligible patients regardless of the availability of carboplatin.
2. mCRPC, aggressive variant phenotype or NEPC/small cell. The cabazitaxel carboplat...

Best practice in the setting of any chemotherapy shortage:

1. Identify those patients for whom the drug is being used in curative intent and prioritize that use.
2. For other lines of therapy or for palliative intent, identify if there are other regimens that may be substituted in that setting.

In lymphoma, the use of carboplatin is focused in the second line. Our institution looked at patients with HL who were planned to receive ICE chemotherapy. Given the excellent data for the use of BV with nivo...

Regarding osteosarcoma management, the questions have circled around the methotrexate shortage. Now with both cisplatin and carboplatin shortages, it is difficult to effectively treat these patients until one of these drugs becomes available.

You could do ifos/dox cycles so that you’re using something active while waiting for the shortages to cool down. If you have carboplatin, you could do a carboplatin/ifos window until things become available per St Jude OS-91, or just use OS-99 with carbo, if...

Fortunately, cisplatin/carboplatin continues to be available so far, but in case there is a shortage or complete unavailability of platinum agents, options for NSCLC patients in the first line setting can be.

1. Ipi/Nivo alone (Hellmann et al., PMID 31562796).
2. Ipi/Nivo with 2 cycles of platinum doublet (Paz-Ares et al., PMID 33476593).
3. Gemcitabine/Vinorelbine (Gridelli et al., PMID 12837810).
   This can be combined with ICI.
4. Pembrolizumab alone for PDL-1>50% (Reck et al., PMID 33872070).