- Cancer Care Guide
- All Services
- Behavioral Health Services
- Bone & Joint Care
- Cancer Care
- Diabetes & Endocrinology
- Emergency Care
- Health & Wellness
- Heart Care
- Hospitalist Care
- Integrative Care
- Intensive Care Unit
- Maternity & Pregnancy Care
- Occupational Health
- Other Services
- Primary Care
- Respiratory Care
- Surgical Services
- Vascular Services
- Weight Loss Surgery
- Women's Services
- Wound Care Center & Hyperbaric Medicine
Cancer Care Guide
Cancer treatment has come a long way in the past 30 years.
An illness which was once fatal in nearly all who were unfortunate enough to have the disease, has now become curable in over 50% of patients and treatable in one form or another for the remaining group. Much of this progress is attributable to a combination of new discoveries and many thousands of patients who volunteered to participate in clinical trials.
Treatments are now more powerful -- as are the side effects. However, the side effects are predictable and manageable. Newer treatments are constantly being announced, but they need to be viewed with some cautious optimism until they are established in their full role.
This overview has been designed by the medical staff at the Hematology and Oncology Center at Portsmouth Regional Hospital to assist patients and their families in educating themselves about cancer and its treatments, and it addresses the following:
- What is cancer?
- How is it treated – different methods of treatment and why they are chosen?
- Treatment side effects
- Newer therapies and Clinical Trials
- Non-Traditional Approaches
- Educational resources for patients
What is Cancer?
"Cancer" is a general term -- much as the term "automobile" is a general term. There are over 100 different types of tumors or cancer. Each type has its own set of behaviors which is known as the natural history of the cancer. Some tumors grow at one rate and others may grow at significantly slower or faster rates; some tumors remain in one location and some spread to other organs. Some tumors will respond to one kind of treatment but not to others. Taken together, this is called the natural history of the tumor.
It is important to remember that not all cancers are fatal. In 1970, the across-the-board mortality rate from cancer was approximately 80%. That figure has now been reduced to approximately 45- 50%. Great progress has been made in several types of tumors, and some tumors once considered fatal are now curable; these include childhood leukemia, some forms of lymphoma, some kinds of brain tumors, and some forms of breast and colon cancer.
While some tumors are not curable, they are controllable. These tumors can be put into remission, and the quality of the patient’s life will be improved for an extended period of time. Thus, if a lung tumor can be made to shrink or be reduced, the patient may have less coughing and/or have more energy. If a stomach tumor can be placed into remission, the patient will be better able to eat and possibly even gain weight. When a cure is not possible, the goal of the medical team becomes remission or palliation in order to make the patient’s quality of life better.
Different Types of Treatment
Cancer is treated in various ways depending on the circumstances. There are three major approaches to the treatment of cancer- surgery, radiation, and chemotherapy.
Surgery is often used to remove a tumor and/or to assist in making a diagnosis or obtaining further information about the extent of a tumor. Surgery can also assist in identifying if a tumor has spread, which sometimes may not be apparent on x rays or in a physical examination. If the tumor has not spread, then surgery alone may be sufficient as a treatment -- unless there is a known natural history for spread of the particular type of tumor. In that case, additional types of treatment (called adjuvant and discussed below) may be used.
The main side effect of any surgery is the immediate post-operative pain and the possibility of infection. Pain is usually controlled with analgesics and infections can be controlled with antibiotics when necessary.
Sometimes, a tumor is not treatable by surgery, but the surgery will be utilized as a method to reduce the tumor size. Large tumors, for instance, if reduced in size by surgery, are sometimes more treatable with additional forms of cancer therapies such as chemotherapy and/or radiation (discussed below). Or, large tumors may be inhibiting the function of other near by organs, and reducing the size of the tumor may help those other organs improve their function.
Radiation is another form of cancer treatment. Radiation may be used in several different settings. It can be used to treat an area where a tumor was located but where the surgeon was not able to completely remove it. It may also be used to relieve pain to a localized tumor, such as a tumor on the bone or spine. Radiation treatments are usually given once a day for 3-5 days per week for several weeks. Radiation can only be given to a small part of the body.
Side effects of radiation vary, depending on the site where the radiation is directed. Many people experience the equivalent of a sunburn of the skin where the radiation is directed. Depending on the organ affected by the radiation, the additional side effects vary. If the chest is the site of radiation such as for a lung tumor, the patient may experience minor difficulty swallowing. This side effect can be reduced by a break in the treatment or oral medications to soothe the throat.
Chemotherapy is drug treatment for cancer. In contrast to radiation, chemotherapy may go anywhere in the body. Chemotherapy may be given by mouth (oral) or by vein (intravenous). As with the other treatments for cancer, there are 3 different kinds of treatment or goals in the use of chemotherapy:
In the ideal setting, chemotherapy is used to cure a tumor, making it disappear and not return. If that is not possible, chemotherapy is used to prevent further spread of the tumor and to keep it from growing, and thereby improving the patient’s quality of life. Reducing the frequency or intensity of the cough of a lung cancer patient is an excellent example of this type of treatment.
When neither a cure nor tumor shrinkage is possible, then the goal of chemotherapy becomes palliation where drugs are used to help alleviate symptoms. The symptoms are often controlled with chemotherapy together with other drugs that are specifically directed toward those symptoms. For example, if a patient has severe nausea from a tumor, chemotherapy may be used in an attempt to reduce the size of the tumor along with anti nausea drugs to alleviate the patient’s symptoms.
There is one other goal of chemotherapy known as adjuvant chemotherapy. As noted previously, there are over 100 different types of cancer with many different natural histories. Some cancers are curable with surgery alone. However, we know from many years of experience that some tumors may be entirely removed by surgery and appear to be cured, but they return months or years later. These particular types of tumors have a natural history which is different from other types of tumors, and surgery alone may not be enough to control them. Because these particular types of tumors are known to reoccur, they are sometimes treated with chemotherapy even when the tumor is no longer present on x-ray or physical examination. In other words, the treatment is adjuvant to, or in addition to, the surgery and/or the radiation. Its goal is to prevent the return of the tumor. This kind of adjuvant treatment, while not a guarantee, has been quite successful in some forms of cancer such as breast cancer, some forms of intestinal cancer (colon and rectal cancers), and some kinds of lung cancer.
Side Effects and How they are Treated
All drugs have the potential for side effects. Aspirin, which is a relatively benign drug, can cause ringing in the ears or stomach irritation if given in sufficient quantity.
Cancer chemotherapy is no different. The drugs used have predictable and manageable side effects which can often be anticipated and treated.
Chemotherapy is designed to kill abnormal cells. But it can also harm normal cells, and this leads to the side effects. It is important to note that the list below is not all-inclusive, and not all drugs or chemotherapies have these side effects. Each treatment should be discussed with a physician to determine which ones may apply to the patient receiving treatment.
- Bone marrow suppression: The bone marrow is essentially the "factory" where blood cells are made. These include the red blood cells, the white blood cells, and the platelets. Red blood cells carry oxygen, and if they are diminished, as sometimes occurs, the patient may experience anemia, shortness of breath, or fatigue. If the white blood cells are diminished, the patient's immunity may be compromised, and the patient may incur an infection manifested by fever, sore throat, shortness of breath, shaking chills or burning on urination. Platelets are the elements of the blood which assist in clotting. If the platelets are low, the patient may experience easy bruising, excessive bleeding from minor cuts, serious internal hemorrhage or bleeding from unexpected sites such as mouth or in the urine.
Bone marrow suppression is managed by careful monitoring of the blood counts with frequent blood tests. If it becomes severe, there are medicines that can be used by injection which are able to counter this set of side effects. Often, instead of additional medicines, the simplest approach may be to reduce the doses of the chemotherapy or prolong the interval in between their administration.
- Nausea: This is a common side effect of chemotherapy and is usually controlled with oral anti-nausea medications known as anti emetics. The nausea, if it occurs, is usually no more than a day or two in duration. If it leads to vomiting, attempts to control the nausea are very important in order to prevent dehydration. Recently, the FDA has released powerful drugs which prevent nausea, making this side effect less intense.
- Diarrhea: This can be a short or long term side effect. Once again, it is usually well controlled with oral medication and usually lasts no more than a few days. Some recent, more powerful drugs also cause diarrhea for up to a week; but this is usually controlled with anti diarrhea medications. Serious diarrhea, like serious or prolonged vomiting can lead to dehydration, and the physician should be told of this in order to take additional steps to prevent dehydration.
- Taste changes: Many patient s complain of changes in their perception of taste of food. This can also lead to a loss of appetite or desire for food. Usually this problem improves several weeks after chemotherapy is stopped.
- Stomatitis: is a form of irritation to the mouth and throat. This leads to the equivalent sensation as having multiple cold sores and the attendant pain which may come with it. This leads to an inability to eat or, in some case, to drink fluids. This usually improves within one of two days after stopping chemotherapy and can be prevented in the future by adjusting the doses of the drugs.
- Neuropathy: This is sometimes also known as tingling of the fingers or feet and only occurs with some forms of treatment. It is as if the hands or feet have fallen asleep. It can lead to difficulty buttoning a shirt or a lack of sensation in the feet when walking. This symptom also improves within several weeks of stopping the drugs and can often be treated by reducing the drug dosage, lengthening the interval between dosing or in severe cases, stopping the drugs.
- Damage to reproductive tissues: This side effect may be temporary or permanent and can lead to sterility or the inability to have children. In women who are still menstruating, there may be a temporary or permanent loss of menstrual periods. Men who wish to preserve their sperm may do so at various sperm banks around the country prior to their treatment.
- Alopecia: or hair loss is a well-known side effect. It does not occur with all drugs, and when it does occur, it may be partial or complete. The loss of hair resolves when the chemotherapy is stopped, and the hair returns within several weeks to months after stopping.
Newer Therapies and Clinical Trials
Newer treatments for cancer are constantly being announced in the media. It is important to note that if a treatment is announced which cures mice of a particular cancer, it is at least 10 years and millions of dollars away from being available to humans. If a treatment is designated as "investigational;" this means that a company or the National Cancer Institute is usually testing this treatment, and that it is not generally available to the public until approved by the FDA. Access to investigational agents can only be done through participation in a clinical trial.
Newer therapies are being tested and approved by the FDA. In the 1990's, no less than 20 new cancer drugs were approved by the FDA for the treatment of various forms of lung cancer, breast cancer, leukemia, lymphoma, melanoma (a skin cancer), brain tumors and colon cancer. To the credit of the FDA, new procedures were implemented in the last decade to help bring these newer therapies to the public at a much quicker rate than in the past.
Because the newer therapies are often tested in only the sickest people first, their role in the less critically ill patient may not be known until long after the drug receives its initial approval from the FDA. Once approved by the FDA, many of these newer therapies continue to be tested in other tumor types. Because the testing continues long after the drug is approved, it may be years before the exact role of any "new" drug is really established. This can lead to confusion by the public. A new drug is announced in the press for a particular tumor and patients may rush to their physician to obtain it. Because the drugs have been tested in only the sickest patients, it may not be appropriate to have the "newest" therapy when there are existing standards of care.
What is a clinical trial?
This is a means by which patients may participate in a study of a newer therapy or a new means of looking at an older therapy. All clinical trials are conducted according to very strict ethical standards established by the Food and Drug Administration (FDA). Much of the current knowledge about cancer and its side effects comes from the many thousands of patients who volunteered over the last 50 years to participate in such efforts. As such, many patients actively seek to participate in trials because they represent cutting edge efforts and because they will be able to help others in the future who are afflicted with this disease.
Non-traditional therapies are sometimes used in place of or in addition to cancer chemotherapy. These may include such things as acupuncture, aromatherapy, herbs and other non-traditional techniques. Patients are always free to pursue these alternatives. The problem with many of them is that they have not been tested in a controlled clinical trial. Individual testimonies may find their way into the press or other forms of media such as the Internet. However, individual testimonies do not necessarily make it a standard of care -- or even one which is helpful. None of these alternatives are regulated by the FDA, and that can sometimes lead to exaggerated claims by the manufacturer. For example, much attention was paid to Laetrile many years ago. When properly tested, it was found to be of no benefit at all and in some cases, contained harmful levels of poisons in it.
If a patient should choose to pursue alternative therapies simultaneous with traditional approach, he or she should make their physician aware of this so that the physician may monitor any adverse interactions between the traditional approaches and the non-traditional approaches.
For those interested in alternative medicines, there is literature available from a branch of the National Institutes of Health known as National Center for Alternative Medicines. For those who have access to the Internet, the website is: www.nccam.nih.gov
Educational Resources for Patients
There are several resources for patients who wish to learn more about their treatments and about cancer in general. The main issue with which patients and their families need to be concerned is how accurate the information is that they are accessing. Many resources do not have their material reviewed by a qualified professional, and inaccurate or misleading information may find its way to the radio, the newspapers, or the internet without proper scientific review.
Your local library often has resources, and the Guild at Portsmouth Regional Hospital has created a Cancer Library at the Hematology and Oncology Center at Portsmouth Regional Hospital. Many publications are available in the library, and there is a computer to allow free access to the Internet for patients of the Center.
In addition, the American Cancer Society (1-800-620-7101) has pamphlets and books that can often be obtained for free. The American Cancer Society has also published an easy to read book entitled "The Consumer's Guide of Cancer Drugs" which is an easy to read book about cancer in general and how the treatments against it have developed.
For those with access to the Internet, there are web sites that have been peer reviewed and can be considered reliable. The list below is not meant to be comprehensive. The first three in the list are patient friendly and written in plain English. Internet sites which review and check their material would include such organizations as:
- Cancer411 www.cancer411.com
- Cancer Care www.cancercareinc.org
- CBS Health Watch www.cbsnews.com/sections/health/main204.shtml
- The National Institutes of Health www.nih.gov
- The National Cancer Institute www.nci.nih.gov
- Cancer Resource www.oncology.com
- Women's Health www.4women.org
- CancerNet www.cancernet.nci.nih.gov
- Cancer Information Network www.cancernetwork.com
- American Cancer Society www.cancer.org
- The Univ. of Pennsylvania www.oncolink.com/cancer