Conventional Treatment of Cancer

The number of treatment choices an individual has will depend on the type of cancer, the stage of the cancer, and other individual factors such as age, health status, and personal preferences. An individual should discuss all treatment options with their cancer team. It is important to ask questions and to understand all the cancer treatment options available.

The four major types of treatment for cancer are surgery, radiation, chemotherapy, and biologic therapies. The specific cancer treatment will be based on the individual's needs. Certain types of cancer respond very differently to different types of treatment, so determining the type of cancer is a vital step toward knowing which treatments will be most effective. The cancer's stage (how widespread it is) will also determine the best course of treatment, since early-stage cancers respond to different therapies than later-stage ones. The individual's overall health, lifestyle, and personal preferences will also play a part in deciding which treatment options will be best.

It is important for individuals to understand the goals of treatment. The treatment can either be palliative, which helps control symptoms (such as pain), or curative, which may help cure the cancer and decrease the chances of it returning. The goal of cancer treatments and therapies is to increase the quality of life for the individual suffering from this condition.

Chemotherapy:

While surgery and radiation therapy are used to treat localized cancers, chemotherapy is used to treat cancer cells that have metastasized (spread) to other parts of the body. Chemotherapy is also used in combination with surgery and/or radiation or to shrink tumors, which helps surgery be easier on the patient and safer. Depending on the type of cancer and its stage of development, chemotherapy can be used to cure cancer, to keep the cancer from spreading, to slow the cancer's growth, to kill cancer cells that may have spread to other parts of the body, or to relieve symptoms caused by cancer. Not all individuals will respond the same way to chemotherapy treatments and some individual's will have more success than others.

Prior to chemotherapy: The individual undergoing chemotherapy may be asked to take some medications prior to the procedure (called pre-medications), including: steroids, such as prednisone (Deltasone ®) or hydrocortisone (Solu Medrol ®); antihistamines (allergy medications), such as diphenhydramine (Benadryl ®); anti-nausea medications, such as ondansetron (Zofran ®); sedatives, such as alprazolam (Xanax ®); or antibiotics, such as levofloxacin (Levaquin ®).

During chemotherapy: Individuals will be given the chemotherapy medication(s) by whichever route the doctor thinks best. Chemotherapy drugs can be given by mouth, injected through a syringe into a vein, artery, or muscle; given intravenously though an IV drip device; placed into a catheter (tube) that goes into the bladder, chest cavity, brain, spinal cord, liver, or abdomen; or, they can be applied to the skin. The decision on what route to use depends on several factors, mainly the type of tumor and the drug being used.

At the same time, individuals may be given other medications to fight the side effects of chemotherapy, including steroids, allergy medications (anti-histamines), anti-nausea medications, sedatives, and antibiotics.

Chemotherapy drugs: Almost all chemotherapy agents currently available kill cancer cells by affecting DNA synthesis or function, a process that occurs through the cell cycle. Each drug varies in the way this occurs within the cell cycle.

The major categories of chemotherapy agents are alkylating agents, antimetabolites, plant alkaloids, antitumor antibiotics, and steroid hormones. Each drug is categorized according to their effect on the cell cycle and cell chemistry.

Alkylating agents kill cells by directly attacking DNA. Alkylating agents may be used in the treatment of chronic leukemias, Hodgkin's disease, lymphomas, and certain carcinomas of the lungs, breasts, prostate, and ovaries. Cyclophosphamide (Cytoxan ®) is an example of a commonly used alkylating agent.

Nitrosoureas act similarly to akylating agents and also inhibit changes necessary for DNA repair. These agents cross the blood-brain barrier and are therefore used to treat brain tumors, lymphomas, multiple myeloma, and malignant melanoma. Carmustine (BCNU or BiCNU ®) and lomustine (CCNU, or CeeNU ®) are the major drugs in this category.

Antimetabolites are drugs that block cell growth by interfering with certain activities, usually DNA synthesis. Once ingested into the cell, they halt normal development and reproduction. Antimetabolites may be used in the treatment of acute and chronic leukemias, choriocarcinoma, and some tumors of the gastrointestinal tract, breast, and ovary. Examples of commonly used antimetabolites are 6-mercaptopurine (Purinethol ®) and 5-fluorouracil (5FU, or Leucovorin ®).

Antitumor antibiotics are a diverse group of compounds. In general, they act by binding with DNA and preventing RNA synthesis. These agents are widely used in the treatment of a variety of cancers. The most commonly used drugs in this group are doxorubicin (Adriamycin ®), mitomycin-C (Mutamycin ®), and bleomycin (Blenoxane ®).

Plant (vinca) alkaloids are anti-tumor agents derived from the periwinkle plant (Vinca sp.). These drugs act specifically by blocking cell division during mitosis (a stage of division). They are commonly used in the treatment of acute lymphoblastic leukemia, Hodgkin's and non-Hodgkin's lymphomas, neuroblastomas, Wilms' tumor, and cancers of the lungs, breasts, and testes. Vincristine (Oncovin ®) and vinblastine (Velbe ®) are commonly used agents in this group.

Steroid hormones are useful in treating some types of tumors. This class includes adrenocorticosteroids, estrogens, antiestrogens, progesterones, and androgens. Although their specific mechanism of action is not clear, steroid hormones modify the growth of certain hormone-dependent cancers. Tamoxifen (Nolvadex ®) is an example, which is used for estrogen dependent breast cancer.

Platinum-based chemotherapy drugs contain the metal platinum. They are used to treat various types of cancers, including sarcomas, some carcinomas (e.g. small cell lung cancer and ovarian cancer), lymphomass and germ cell tumors. Examples include platinol (Cisplatin ®), carboplatin (Paraplatin ®), and oxaliplatin (Eloxatin ®).

Often, a combination of chemotherapy is used instead of a single drug. Chemotherapy is given in cycles, each followed by a recovery period. The total course of chemotherapy is often about six months, usually ranging from three to nine months. After a cancer is removed by surgery, chemotherapy can significantly reduce the risk of cancer returning. The chances of cancer returning and the potential benefit of chemotherapy depend on the type of cancer and other individual factors.

After chemotherapy: After chemotherapy, individuals may be given any of the following medications: anti-nausea drugs, injections of immune-system boosting drugs (to increase white blood cells that fight potential infections) several days after the chemotherapy has been given, or other drugs, including steroids, antihistamines, anti-nausea medications, sedatives, and/or antibiotics.

Side effects of chemotherapy: A major concern with chemotherapy is the possibility of long-term side effects and complications, such as heart damage, lung damage, liver damage, and secondary cancers (including leukemia). Although these severe effects occur in only a small number of people, great effort is being put into finding equally effective regimens with less toxicity. Drug regimens have been developed that substantially diminish the likelihood of long-range, life-threatening complications, including acute leukemia in people who have received multiple courses of chemotherapy and radiation therapy.

Side effects of chemotherapy depend on the type of drugs, the amounts taken, and the length of treatment. The most common are nausea and vomiting, temporary hair loss, increased chance of infections, and fatigue (extreme tiredness). Many of these side effects can be uncomfortable or emotionally upsetting. However, most side effects can be controlled with medicines, supportive care measures, or by changing the treatment schedule.

Fatigue is one of the most common side effects of radiation and chemotherapy. Like most other side effects, fatigue will usually disappear once the treatment is complete. Individuals need to get plenty of rest, eat a well-balanced diet (less meats, dairy, and fats, and more vegetables), and drink plenty of water.

Hair loss may occur with some types of chemotherapy. Some individuals experience hair loss during chemotherapy treatments (and sometimes with radiation treatment to the head) while others do not, even with the same drugs. If hair loss does occur, it usually begins within two weeks of the start of therapy and gets worse one to two months after the start of therapy. Hair growth often begins even before therapy is completed. Most people are able to find suitable ways of managing the hair loss until it grows back, with specially designed hats, scarves, and wigs.

Medications for side effects of chemotherapy: Some individuals who experience certain side effects of chemotherapy may be prescribed medications to counteract these effects. Several drugs are now available for use alone or in combination to help reduce a few of the most common side effects, such as nausea, vomiting, and fatigue.

Anzemet ® (dolasetron mesylate): Anzemet ® helps prevent and relieve nausea and vomiting from surgery or chemotherapy. Researchers believe that nausea and vomiting during chemotherapy is associated with the release of serotonin from special cells in the small intestine. Anzemet ® blocks these nerve endings in the intestine and prevents signals to the central nervous system. Anzemet ® is available in tablet form and by injection.

Compazine ® (prochlorperazine): Prochlorperazine helps control nausea and vomiting after surgery or chemotherapy. Prochlorperazine is available in capsule, tablet, and liquid form, and by suppository or injection. Prochlorperazine can cause drowsiness and may interact with other medications or alcohol.

Kytril ® (granisetron hydrochloride): Kytril ® is an anti-nausea medication FDA-approved for patients undergoing chemotherapy. Kytril ® is typically given 60 minutes before chemotherapy. In some cases, a second dose is given about 12 hours after the first dose. Kytril ® is available in tablet form and by injection.

Phenergan ® (promethazine): Promethazine has sedative, antihistamine, and mild anti-nausea properties. It may be used to help prevent or treat nausea due to chemotherapy. Promethazine may be available in tablet form or as an oral syrup, suppository, or injection.

Procrit ® (epoetin alfa): Procrit ® helps the body produce more red blood cells, which help relieve fatigue due to chemotherapy. Since chemotherapy affects both normal and cancerous cells, it can decrease the number of red blood cells, which leads to anemia (lack of red blood cells to carry oxygen) and a feeling of extreme tiredness.

Neupogen ® (filgrastim): Neupogen ® is the trade name for granulocyte colony stimulating factor (G-CSF, or filgrastim). Neupogen ® is a protein-based drug that stimulates the production of white blood cells. White blood cells are important for protecting the body from infection. Neupogen ® is used to increase white blood cells, and to decrease the risk of infection, in conditions such as cancer. Neupogen ® can be used subcutaneously (SC) or intravenously (IV). Side effects may include nausea, bone pain, and swelling or redness at the injection site. Contacting a doctor immediately is recommended by healthcare providers if the individual develops a fever, chills, sore throat, congestion, diarrhea, or redness, pain, or swelling around a wound or sore while using Neupogen ®.

Zofran ® (ondansetron): Zofran ® helps to relieve nausea and vomiting associated with chemotherapy. Zofran ® is available in pill form, as a liquid solution, and by injection. The first dose of Zofran ® (tablet form) is usually administered 30 minutes before chemotherapy and then at regular intervals for one to two days after chemotherapy.

Myelodysplastic syndrome: Myelodysplastic syndromes are diseases of the blood and bone marrow, often caused by chemotherapy. Blood cells, such as red blood cells that carry oxygen to tissues and white blood cells that help produce cells for immunity, are damaged by chemotherapy medicines. Symptoms of myelodysplastic syndrome include fatigue and chronic tiredness, shortness of breath, chilled sensation, chest pain (occasionally), an increased susceptibility to infection, and an increased susceptibility to bleeding. Patients who experience low blood cells counts during chemotherapy may also be given medications to help raise blood cell or platelet counts. For example, patients who suffer from neutropenia, a decrease in the number of neutrophils (a type of white blood cell), may be given certain growth factors, such as the granulocyte-macrophage colony stimulating factor (GM-CSF, sargramostim, or Leukine ®) or Neupogen ®.

Radiation therapy:

Radiation therapy uses high-energy rays to kill cancer cells. It is considered a local therapy, meaning that it should be used to target areas of the body invaded by tumor masses. A radiation oncologist will plan and supervise therapy. The area to be treated will be carefully mapped out and the treatment machine will be adjusted so that only the lymphoma cells are exposed to a full dose of radiotherapy. Because of the need to target the radiation at exactly the right area of the body, a mold is sometimes made that will help to hold that part of the body still and in position during the treatment sessions.

Normal cells surrounding the lymphoma are spared the full dose, and these cells are usually able to repair themselves more easily than lymphoma cells. Therefore, radiotherapy can often control or destroy lymphoma cells, while causing only temporary damage to normal cells.

Radiotherapy is usually given on an outpatient basis, with the patient visiting the hospital up to five times a week. Before each treatment, the patient is carefully positioned, usually lying on a treatment table. Parts of the body that are not being treated may be covered. It is important to remain completely still during the treatment. Each treatment usually lasts only a few minutes and causes no discomfort. Although the patient is left alone during the actual treatment, the radiotherapy technician watches from an observation room and it is possible to talk to the individual through a microphone. A course of radiotherapy typically lasts between two and six weeks, depending on the patient's individual circumstances. The length of radiation treatment varies depending on the stage of the disease. Radiation therapy may be used alone, but is commonly used in conjunction with chemotherapy.

Depending on how and where the radiation is administered, it may cause certain side effects such as fatigue (extreme tiredness), loss of appetite, nausea, diarrhea, and skin problems. Radiation of lymph node areas may result in suppression of the immune system to varying degrees. Irradiation of the underlying bone and the marrow within the bone may result in suppression of the blood counts.

Surgery:

Surgery is the treatment of choice for many types of cancer, such as colon or breast. Treatment depends on the stage of the disease and the overall health of the patient. Chemotherapy and radiation therapy may be used as adjuvant treatment or in addition to surgery.

Cryosurgery: During cryosurgery, a doctor uses very cold material, such as liquid nitrogen spray, or a cold robe to freeze and destroy cancer cells or cells that may become cancerous (such as irregular cells in the cervix that could become cervical cancer).

Electrosurgery: Electrosurgery is the application of high-frequency electrical currents by a doctor. These currents can kill cancer cells, such as in the mouth or on the skin.

Laser surgery: Laser surgery is used to treat many types of cancer. Laser therapy uses high-intensity light to treat cancer and other illnesses. Lasers can be used to shrink or destroy tumors. Lasers are most commonly used to treat superficial cancers (cancers on the surface of the body or the lining of internal organs) such as basal cell skin cancer and the very early stages of some cancers, such as cervical, penile, vaginal, vulvar, and non-small cell lung cancer.

Mohs' surgery: Mohs' surgery is useful for removing cancer from sensitive areas such as near the eye. Mohs' surgery is also useful for assessing how deep a cancer is growing. Mohs' surgery is performed by carefully removing cancer layer by layer with a scalpel or knife. After removing a layer, the doctor will evaluate the cells under a microscope until all the abnormal cells have been removed and the surrounding tissue shows no evidence of cancer.

Laparoscopic surgery: In laparoscopic surgery (or minimally invasive surgery), a surgeon uses a laparoscope to see inside the body without making large incisions. A laparoscope is a telescopic rod lens system that is usually connected to a video camera. Several small incisions are made and a tiny camera and surgical tools are inserted into the body. The surgeon watches a monitor that projects what the camera sees inside the body. The smaller incisions mean faster recovery and a reduced risk of complications. Laparoscopic surgery is used in cancer diagnosis, staging, treatment, and symptom relief.

Robotic surgery: In robotic surgery, the surgeon sits away from the operating table and watches a screen that projects a three-dimensional image of the area being operated on. The surgeon uses hand controls that tell a robot how to maneuver surgical tools to perform the operation. Robotic surgery helps the surgeon operate in hard-to-reach areas. But robotic surgical systems are expensive and require specialized training, so robotic surgery is only available in specialized medical centers.

Clinical trials:

Human studies of promising new or experimental treatments are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Clinical trials are not commonly used as treatments for cancer, but are an option. A doctor will help get information on various clinical trials available for certain types of cancer. There is no guarantee of success in clinical trials for the patients, and some individuals will actually not receive medication (the placebo).

Types of clinical trials: There are three phases of clinical trials in which a treatment is studied before it can be approved by the U.S. Food and Drug Administration (FDA).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and find out how much of it can be given safely. Doctors watch patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors running the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the best dose of the drug (based on the results of the phase I study) and closely observed for an effect on the cancer. The doctors will also look for side effects.

Phase III clinical trials: Phase III studies are done to see if the new treatment is better than what is already available. They involve large numbers of patients. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.

If an individual enrolls in a clinical trial, a team of experts will monitor their progress very carefully. The study is especially designed to pay close attention to the individual with cancer. However, there may be risks. Even with animal testing and laboratory studies, it is difficult to determine what side effects may occur in individuals undergoing clinical trials for cancer. It is important to discuss all potential risks and benefits carefully with a healthcare provider before making a decision to enroll in a clinical trial.

Other therapies:

Photodynamic therapy: Photodynamic therapy (PDT) is another type of cancer treatment that uses lasers. In PDT, a drug called a photosensitizer or photosensitizing agent is injected into a patient and absorbed by cells all over the individual's body. After a couple of days, the agent is found mostly in cancer cells. Laser light is then used to activate the agent and destroy cancer cells. Because the photosensitizer makes the skin and eyes sensitive to light for approximately six weeks, individuals undergoing PDT are advised to avoid direct sunlight and bright indoor light during that time.

Perillyl alcohol: Perillyl alcohol is a naturally occurring chemical with anticancer activity. Perillyl alcohol is found in lavender, cherries, and mint. The use of perillyl alcohol for cancer treatments is in phase I clinical trials.

Laetrile: Laetrile is a substance derived from a chemical called amygdalin, which is found in the seeds of apricots, plums, and bitter almonds. Laetrile is publicized as an antineoplastic (prevents the development of a tumor or neoplasm) drug, although there is no supporting evidence.

Pain control:

Pain may be acute or chronic. Acute pain is severe and lasts a relatively short time. It is usually a signal that body tissue is being injured in some way, and the pain generally disappears when the injury heals. Chronic or persistent pain may range from mild to severe, and it is present to some degree for long periods of time. Some individuals with chronic pain that is controlled by medicine can have breakthrough pain. This occurs when moderate to severe pain "breaks through" or is felt for a short time. Breakthrough pain may occur several times a day, even when the proper dose of medicine is given for chronic and persistent pain.

Pain may be caused by the cancer itself. Whether the individual has pain and the amount of pain they have may depend on the type of cancer, the stage (extent) of the disease, and the individual's pain threshold (tolerance for pain). Most of the pain comes when a tumor presses on bones, nerves, or body organs. Pain can also be caused by the treatment or procedures for diagnosing cancer.

Cancer pain is usually treated with analgesic (pain relieving) drugs, both prescription and non-prescription, and with non-drug treatments such as relaxation techniques, biofeedback, imagery, and others. Healthcare providers recommend asking a doctor or pharmacist for advice before taking any medicine for pain.

Pain will generally be graded on a Pain Intensity Scale. Using a pain scale is helpful in describing how much pain a patient is feeling. Using the Pain Intensity Scale, individuals answer questions and assign a number from zero to 10 according to their pain level. No pain gets a zero, while a 10 is the highest level of pain imaginable. Questions can include the severity of pain, how pain changes with medication, and how bad the pain is during the day and night. If one medicine or treatment does not work for the pain, there is almost always another one that can be tried. Changes may also be made in the frequency and dosages to help increase the pain relief.

Medications for pain: The type of medicine and the method by which the medicine is given depend on the type and cause of pain. Non-opiate (non-narcotic) pain medications are given for mild to moderate pain. These drugs can generally be purchased over-the-counter (OTC) and may include acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin ®). It is best to check with a healthcare professional before taking any OTC medication. NSAIDs can slow blood clotting, especially if the individual is on chemotherapy due to drug interactions.

For moderate to severe pain, opiate (narcotic) medications may be given. These drugs include morphine (MS Contin ®), fentanyl (Duragesic ®), hydromorphone (Dilaudid ®), and oxycodone (Percocet ®, Oxycontin ®). Individuals must have a prescription for these medications, and the medications are generally time released, meaning their effects last more than a few hours. Nonopiods may be used along with opioids for moderate to severe pain. Opiate medications may cause side effects such as drowsiness and constipation. Their use may also cause addiction, both physical and psychological, in a short length of time. For breakthrough pain, immediate-release opiates may be given, such as oral morphine (Oramorph ®) or oxycodone (Roxicodone ®). A prescription is required for these medicines. A short-acting opioid, which relieves breakthrough pain quickly, needs to be used with a long-acting opioid for persistent pain. It is important to tell a doctor or pharmacist if taking any OTC medication, as some OTC medicines may contain acetaminophen (Tylenol ®). Some prescription pain medications, such as oxycodone/acetaminophen combination (Percocet ®) or hydrocodone/acetaminophen (Lortab ®, Vicodin ®) may also contain acetaminophen, thereby increasing the potential for acetaminophen induced liver toxicity.

Individuals who take opiates for pain sometimes find that over time they need to take larger doses. This may be due to an increase in the pain or the development of drug tolerance. Drug tolerance occurs when the body gets used to the medicine and does not relieve the pain as well as it once did. Many individuals do not develop a tolerance to opiates. If tolerance does develop, usually small increases in the dose or a change in the kind of medicine will help relieve the pain. Increasing the doses of opiates to relieve increasing pain or to overcome drug tolerance does not always lead to addiction. Alcohol should be avoided when taking medications for pain due to a potential for interactions. Using alcohol in combination with pain medications can lead to overdose symptoms such as weakness, difficulty in breathing, confusion, anxiety, or more severe drowsiness or dizziness. It is recommended to use caution when driving automobiles or operating heavy machinery when taking opiate pain medications. Medications for pain may also cause nausea and vomiting in sensitive individuals.

For tingling and burning pain associated with some cancers, antidepressant medications (such as amitriptyline or Elavil ®) or anticonvulsant medications (such as gabapentin or Neurontin ®) may be used. Both these medications may cause drowsiness and sedation.

For pain caused by swelling, steroid medications, including prednisone (Deltasone ®), may be used. Side effects of steroid medications include edema (swelling) and a decline in immune system function.

Pain medications may be given by several different routes, including orally (by mouth), topically (on the skin), and rectally (into the anus as a suppository). Pain medications may also be given by injection, including: subcutaneous (SC) injection or injected just under the skin using a small needle), intravenous (IV) or injected directly into the vein through a needle, and intrathecal and epidural injections that are placed directly into the fluid around the spinal cord (intrathecal) or into the space around the spinal cord (epidural). Patient-controlled analgesia (PCA) pumps may also be used. PCA pumps help control the amount of pain medicine an individual takes. When pain relief is needed, the individual can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube placed in the body using a minor surgical technique.

Non-drug treatments for pain: Non-drug treatments are now widely used to help manage cancer pain. There are many techniques that are used alone or along with medicine. Some individuals find they can take a lower dose of medicine with such techniques. These methods include: acupuncture, art therapy, focusing, healing touch, prayer, psychotherapy, transcutaneous electrical nerve stimulation (TENS), and yoga. See the "Integrative Therapies" section of this monograph for more information on these techniques.

Support groups:

Resources exist that provide cancer patients and their loved ones with an opportunity to learn ways of coping with the uncertainty that cancer brings and links to support groups that give them a chance to meet others who face similar issues. Support groups offer patients and loved ones emotional support, an opportunity to learn ways of coping with the uncertainty and changes in their lives, a chance to meet others who face similar issues, and a time to explore issues faced by all cancer survivors. Support groups for cancer patients can be located by asking a healthcare provider, such as a doctor or social worker, for more information.

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