Cancer: Therapies - Medical Essentials
THE MEDICAL TREATMENT OPTIONS we’ll be looking at depend on the type of cancer you have and the stage (size and spread). It may be possible to have:
- SURGERY to remove the cancer, but this can’t necessarily guarantee that every cell is gone and it won’t come back. Surgery deals directly with cancer by removing the cancer cells as much as possible. This often means also taking out healthy tissue to be sure cancer cells have not spread or will not spread to it. Obviously surgery can cause other problems in attempting to remove the cancer.
- RADIOTHERAPY to kill cancer cells with radiation, but this also harms healthy tissue and functioning.
- CHEMOTHERAPY to kill cancer cells with drugs, but again the side effects again can be serious.
- HORMONE THERAPY – Some types of cancer need hormones to grow. Hormone therapy treats the cancer by cutting off the hormone supply. These different types of treatment can be given on their own or together. For some types of cancer, you may have all of them – breast cancer, for example (very much a disease of our age group).
- BIOLOGICAL THERAPIES – Research into cancer treatment is going on all the time, lead by innovators like the Cancer and Polio Research Fund, the other dedicated groups we list under Useful Organisations, and many others. One major result of this worldwide effort has been the emergence of Biological Therapies. These use natural body substances (or drugs developed to block them) to fight cancer.
In our discussion of medical therapies below we’ll also look at new areas of cancer treatment including GENE THERAPY and STEM CELL TRANSPLANTS.
Despite the most intensive treatment, it’s possible for some cancer cells to survive and begin to grow into a new tumour in the future. ADJUVANT TREATMENTS are treatments given alongside main cancer treatment. They try to reduce the risk of your cancer coming back by killing off any stray cells
that might be there.
MEDICAL TREATMENTS used for cancer are outlined below, using some of the excellent information from the CancerBackup and Cancer Research UK’s sites, edited and digested with reference to the Help the Aged website.
SURGERY
Surgery is one of the main treatments for cancer. If you have a cancer that is completely contained in one area and has not spread, surgery may cure it by removing it. Since all the cancer cells must be removed, surgery may also have to remove seemingly healthy tissues around or connecting to the site of the cancer in the hope of leaving none behind.
Because it is a local treatment focused on one area, surgery may not be the right choice, or not enough by itself, for people whose cancer has spread or is likely to spread to another part of their body. They may be offered a systemic treatment such as radio or chemotherapy, biological therapy, or hormone therapy as well or instead. Obviously a cancer like leukaemia can’t be cured by surgery because the cancer cells could be anywhere in your body.
If surgery is possible, it may well cure a cancer. This will depend on:
- Whether the cancer can be completely removed
- Whether a border or margin of healthy tissue, free of cancer cells, is removed with the cancer
- Whether the cancer has already spread before the surgery
Sometimes, although all the scans look clear, cancer cells have already broken away from the primary cancer and travelled to another part of the body. These secondary cancers may just be too small to see and are called micrometastases. Sometimes the surgeon may also find that the cancer may have spread further than first thought. This may mean the operation takes longer, be more extensive, or not be worthwhile.
Usually, the surgeon will remove the main lymphatic vessels and lymph nodes that are nearest to the cancer, or the organ where the cancer is. This is because the main draining lymph nodes and vessels are the most likely place for cancer cells to have spread. [NB. this removal can cause other problems which we discuss below. Don’t hesitate to get second opinions about the possibility of using other techniques for the same purpose].
Because there may be cancer cells that have broken away from the primary cancer, your doctor may recommend that you have radiotherapy or chemotherapy after your surgery. This is called ‘adjuvant’ treatment.
Sometimes radiotherapy or chemotherapy are given before surgery to help shrink the cancer and make it easier to remove. This is called ‘neo-adjuvant’ treatment.
There are always short term problems after any surgery, including pain, potential for infection, blood clots etc. You should expect good pain management. There is no need to be excessively strong about enduring pain.
The hospital will help you to be mobile as soon as possible and use standard procedures to deal with the standard down-sides to surgery.
Longer term problems after surgery don’t happen to everyone, but two notable ones are:
Chronic nerve pain – sometimes starting a couple of months after an operation. This is due to nerve endings that were damaged during the operation growing back. It can last for a few months or longer. Usually it goes away, but very occasionally, it can be permanent. Nerve pain can be dealt with or at least effectively managed in a number of ways. See the Alliance pages on Chronic Pain.
Lymphoedema is fluid build up. It usually occurs in an arm or leg, but can happen elsewhere in the body where lymph nodes have been removed. Most people will not get lymphoedema. But if you notice swelling in your hands or feet, after surgery to the armpit or groin, you should tell your doctor. Once lymphoedema has happened it cannot be cured, but if caught early it can be treated and controlled. Check CancerHelp UK about this, particularly if you are going to have an operation for breast cancer. If you are, talk to one of our suggested breast cancer organisations.
Learn about the advantages and problems associated with particular operations from any of our recommended short-list in Useful Organisations.
CHEMOTHERAPY
Chemotherapy is treatment with anti-cancer drugs. You may have chemotherapy:
- To shrink a cancer before surgery
- To reduce the risk of a cancer coming back after surgery
- Along with radiotherapy
- By itself to cure a cancer
- To control symptoms and improve quality of life when a cancer is too advanced to cure
There are over 50 different kinds of chemotherapy drugs used to destroy cancer cells. If several drugs are given at once the treatment is called combination chemotherapy.
Chemotherapy drugs specifically target and destroy cells that divide, such as cancer cells. The drugs travel through the bloodstream, affecting cancer cells all over the body. Unfortunately they also affect other cells, particularly those that divide regularly such as hair follicles and those in the lining of the mouth,
digestive system and bone marrow. This results in side effects such as nausea, diarrhoea, hair loss and an increased chance of developing infections.
Chemotherapy treatment is designed to destroy as many cancer cells as possible whilst doing as little damage as possible to healthy cells. The healthy cells that are affected will be able to repair themselves over time.
Different chemotherapy drugs cause different side effects, and some people may have very few. Cancer treatments cause different reactions in different people and any reaction can vary from treatment to treatment. It may be helpful to remember that almost all side effects are only short-term and will gradually disappear once the treatment has stopped.
You should of course tell your doctor or chemotherapy nurse if you find that the treatment or its side effects are making you unwell. They may want to change your treatment, and can help you deal with the side-effects. The benefits of treatment should hugely outweigh the problems over time.
RADIOTHERAPY
Radiotherapy is the use of X-rays or similar rays to destroy cancer cells and tumours. It may be given before or after surgery or chemotherapy, or possibly at the same time as chemotherapy, if so this is called chemoradiotherapy.
As well as for curative purposes, radiotherapy can be given to people with terminal cancer to reduce the size of a tumour and thus help to relieve any pain that they may be feeling. The aim is to give the maximum dose of radiation to the tumour and the minimum to the healthy tissue around it. You may have radiotherapy:
- To shrink a cancer before surgery
- To reduce the risk of a cancer coming back after surgery
- Along with chemotherapy
- By itself to cure a cancer
- To control symptoms and improve quality of life when a cancer is too advanced to cure
Radiotherapy can be external or internal. External radiotherapy is a bit like having an X ray, although you will usually have a course of treatments. In some situations, your doctor may suggest just one treatment, for example to
treat lung cancer, or cancer that has spread to the bones. The high energy rays are produced by a large machine and are directed at the part of the body being treated.
Internal radiotherapy is radiotherapy from inside the body. This can be targeted radiotherapy in the form of a drink or injection. Or it may be radioactive wires or pellets implanted into the area where there is a tumour.
While external radiotherapy can destroy cancer cells, it can also have an
effect on some of the surrounding normal cells. The side effects that may occur are described in this section. It is important to remember that no person will have more than a few of them, and for many people they may be very mild.
As radiotherapy affects people in different ways, it is difficult to predict exactly how you will react to your treatment. Before you start your treatment, the staff will discuss with you any likely side effects of the particular treatment you are having. They can also give tips on how to deal with them and how they can be treated. Being aware of side effects in advance can help you to cope with any problems that occur.
Most side effects of radiotherapy disappear gradually once the course of treatment is over. However, the side effects may continue for a few weeks.
STEM CELL and BONE MARROW TRANSPLANTS
Stem cell or bone marrow or transplants are used to treat a variety of different cancers. They are sometimes called stem cell or bone marrow rescue. This is because the bone marrow or stem cells are used to replace the cells in your bone marrow that have been killed off by high dose chemotherapy or total body radiotherapy.
Stem cells are of course much in the news these days, and this therapy involves very early and undeveloped forms of blood cells. Red cells, white cells and platelets can all develop from them. They are normally found in the bone marrow, but doctors have found ways of getting them into the bloodstream so they can be collected more easily.
These transplants can form part of a cure for some types of cancer. You can be given a very high doses of chemotherapy, sometimes with radiotherapy. The stem cells can then be used to replace those that the cancer treatment has killed off. Because you have the stem cells replacing the healthy ones the treatment has damaged, your body can tolerate higher doses of treatment to cure the cancer.
Side effects of bone marrow and stem cell transplants are mostly about the more intense chemo and radiation therapies they’re allowing. Basically you’re having higher doses of these therapies, so their side effects can be more severe.
The main side effects of the chemo and radio-chemo therapies – increased through these higher doses – are:
Risk of infection
Drop in red blood cells (anaemia)
Risk of bleeding
Sickness and diarrhoea
Sore mouth
Difficulty eating and drinking
Feeling tired and run down
All these side effects are at their worst when you have just had your transplant / treatment, and for a couple of weeks afterwards. When your blood counts start to rise you will start to feel better. There’s a huge list of Do’s and Don’ts associated with these transplants, and many effects to watch out for. Search or ring CancerBackup, Macmillan or one of our other suggested cancer organisations for everything you need to know.
CancerHelp UK suggests you may want to ask your doctor some of the following questions about having one of these transplant and high dose therapy combinations:
What are the long term side effects?
Will this transplant cure my cancer?
Will I be able to go back to work after this treatment?
BIOLOGICAL THERAPY
Biological therapies are treatments that use natural body substances or drugs made from natural body substances. They can help to
- Treat a cancer
- Control side effects caused by other cancer treatments such as chemotherapy
Biological therapies are also sometimes called Biological Response Modifiers (BRM’s), Biologic agents, or simply ‘biologics’. The names refer the fact that they stimulate the body to respond biologically (or naturally) to cancer. There are many different types of biological therapy including immunotherapy treatments.
Biological therapies are quite a different approach from chemotherapy and radiotherapy. They all help kill cancer cells, but doing so with natural body substances, or treatments developed from a natural body substances, has
some clear advantages in being less destructive or toxic to normal cells.
Many types of biological therapies for cancer are still in their experimental stages. They are currently not suitable for treating all types of cancers – but for some cancers they could be the best choice of treatment. Some biological therapies may be given as part of a clinical trial when other treatments, such as chemotherapy, are no longer working. Your cancer doctor is of course your reference about whether or not biological therapy is going to help your type of cancer or not.
People sometimes use the terms ‘biological therapy’ and ‘immunotherapy’ to mean the same thing, but not all biological therapies are immunotherapies.
Immunotherapy is treatment using natural substances that the body uses to fight infection and disease. In other words, substances that are part of the body’s immune system. Because it uses natural substances, immunotherapy is one form of biological therapy. In fact, the first biological therapies for cancer were all immunotherapies.
Other types of biological therapy have now been developed which are not immunotherapies. They use substances that are still natural, but are not part of the immune system. Among the classes of biological therapies are:
MONOCLONAL ANTIBODIES – There is a lot of research going on into the use of monoclonal antibodies (MABs) to treat cancer. MABs are proteins, made in the laboratory from a single copy of a human antibody. Monoclonal just means ‘all of one type’.
MAB’s act in the same way as immune system proteins that seek out and kill foreign matter in your body, such as bacteria and viruses. MABs are designed to recognise abnormal proteins on the outside of cancer cells. They can then seek out and kill these cancer cells.
Different antibodies have to be made for different types of cancer. Perhaps the best known is the extremely importent new breast cancer drug Herceptin (Trastuzumab), which recognises breast cancer cells that produce too much of the protein HER 2 (are ‘HER 2 positive’). Rituximab recognises CD20 protein on the outside of non Hodgkin’s lymphoma cells. ADEPT is a treatment using antibodies that recognise bowel (colon) cancer.
Most monoclonal antibodies are still experimental and are only being tested for a few types of cancer, but they are increasingly coming into use. This is exciting research because it may be possible to kill cancer cells without damaging other body cells. Thanks to pioneering work by the CANCER AND POLIO RESEARCH FUND and others, this remarkable approach to cancer has survived initial cancer establishment cynicism and now is well supported and developing.
Other forms of biological therapy in use or development include:
Cancer vaccines – the idea is to get the body to mount its own immune response, rather than make the antibodies in the laboratory and give them to the patient. Many vaccine approaches are being tried, and one preventing the major cause of cervical cancer is much in the news having been found effective and licensed. It is, however, early days for most vaccine development.
BCG vaccine for bladder cancer is a type of immunotherapy but not really a ‘cancer vaccine’. It’s a vaccine for tuberculosis. As it happens it’s just also very effective for helping to stop early bladder cancers growing back in the bladder
Growth factors – Growth factors are natural substances that stimulate the bone marrow to make blood cells. We can now make some of these substances artificially and use them to increase the number of white blood cells, red blood cells and stem cells in the blood. Erythropoietin or EPO is a famous one, having been abused by cycle racers and athletes. It encourages the body to make more red blood cells, so increases your haemoglobin levels and the levels of oxygen in your body tissues. Other growth factors are being developed which may boost platelets but these are not yet in routine use.
Cancer growth blockers - This type of biological therapy uses the substances cells use to signal to one another. Many of these signalling chemicals control the growth and multiplication of cells. Scientists have been able to make drugs that block these signals and so may be able to stop cancers from growing and dividing.
Anti angiogenesis treatment - ‘Angiogenesis’ means the growth of new blood vessels. Cancers need to grow their own blood vessels as they get bigger. Without its own blood supply, a cancer cannot continue to grow because, as it gets bigger, the cancer cells will be too far away from a supply of food and oxygen. Anti angiogenic drugs are a type of biological therapy that stops tumours from developing their own blood vessels. Two of the better known examples are:
- Thalidomide, mainly for treating myeloma but also in trials for other types of cancer.
- Avastin (Bevacizumab), a type of monoclonal antibody that has been investigated for bowel cancer.
Interferon alpha – Interferon alpha was one of the first immunotherapies used to treat cancer. It is a natural substance produced in the body, in very small amounts, as part of the immune response. Now that it is possible to make it in the laboratory, doctors can use it in much larger quantities as a treatment to boost the immune system and help fight cancer. Interferon alpha can help to stop cancer cells growing. It may also boost the immune system and so help
it attack the cancer, and it may affect the blood supply to the cancer cells. In cancer care, doctors use interferon most often to treat melanoma, kidney cancer and myeloma.
Interleukin 2 (IL-2)- Interleukin 2 (IL-2) is a protein made naturally by the body as part of the immune system. When made artificially in the laboratory, it is
called ‘aldesleukin’. It may also be called IL2, interleukin 2, aldesleukin or Proleukin. In cancer care, it’s most often used to treat kidney cancer.
Gene Therapy – Gene therapy may be used to treat cancer in the following ways:
- specially made genes could be put into the cancer cells to make them more sensitive than normal cells to treatments such as chemotherapy
- genes may be given into cancer cells and then activated to produce a poisonous substance (toxin) that kills the cell
- genes could be introduced into cancer cells which make those cells more obvious to the body’s own defences (the immune system), so that they are destroyed ‘naturally’ by the cells of our immune system
- damaged genes may be replaced by the correctly working version
- new genes could be put into normal cells to make them more resistant to the side effects of treatment such as radiotherapy and chemotherapy. This protects the normal cells from the treatments so that higher doses can be given. At present the risk of damage to normal cells often limits the doses that can be used.
This is new medicine, and mostly happening in research labs or clinical trials.
Hormone therapy – Hormone treatments are treatments using sex hormones, or drugs that work against these hormones to treat cancer. This type of treatment is only used for particular types of cancer that are called ‘hormone sensitive’ or ‘hormone dependent’. These cancers are
- Breast cancer
- Prostate cancer
- Uterine (womb) cancer
Hormone treatments are also sometimes used for kidney cancer, thyroid cancer and melanoma.
‘Blocking’ sex hormones: This type of treatment is used for breast and prostate cancer. These cancers are hormone dependent. The cancer cells
are stimulated to grow by oestrogen (breast cancer) or testosterone (prostate cancer).
The drug Tamoxifen is taken by women with breast cancer to stop oestrogen from getting to the breast cancer cells. Drugs called aromatase inhibitors block oestrogen in women who have been through the menopause. There are also quite a few different hormone treatments used for prostate cancer to stop testosterone from getting to the cancer cells.
Giving hormones as treatment – For some cancers, taking hormones can cause them to shrink. These treatments are often used for advanced cancers. But they can also be used to try to prevent recurrence in some cases. Progesterone is sometimes given to treat uterine cancer or kidney cancer.
PALLIATIVE CARE
People who have been diagnosed with cancer may also be offered palliative care, especially if the cancer is at an advanced stage and other treatment is not possible. Palliative care is provided by a team of professionals and aims to improve quality of life. The idea is to prevent and relieve suffering by identifying, assessing and treating pain and other problems. Palliative care:
- intends neither to hasten or postpone death;
- affirms life and regards dying as a normal process;
- offers a support system to help patients live as actively as possible until death;
- offers a support system to help the family cope during the patients illness and in their own bereavement;
- uses a team approach to address the needs of patients and their families, including bereavement counselling, if needed;
- integrates the psychological and spiritual aspects of patient care.
A member of the palliative care team might offer advice on managing physical symptoms such as breathlessness, nausea and loss of appetite. Or they could help patients and family members to understand their feelings. They can also help with practicalities like arranging care at home.
Palliative care services should be available to all patients, if and when they need them. Your doctor will supply help and information about this. Cancerbackup and Macmillan can tell more, and Marie Curie Cancer Care are the specialists for everything you need to know and the actual care you need.
END OF LIFE issues come up here. We are inevitably facing fear, helplessness and loss at this stage. As far as we can see, Marie Curie Cancer
Care is the go-to organisation at this time. Ask them about hospice care,
respite breaks for those caring for someone at home, and expert free home nursing care. We’ve been in the position ourselves of not know which way to turn until we discovered that nursing and hospice care at home can be arranged. Cancerbackup and Macmillan can also help in this regard.
Some of the Complementary Techniques we describe below can also help make end of life a powerful and even a wonder-full time. Hard to believe, but true. Complementary techniques and Self-Help are our next subjects. For living with and getting over both cancer and the side effects of treatment they are critically important. For terminal cancer we would suggest that some of them could also make a life-changing and death-changing difference.
With regard to all the treatment options we’ve discussed above, it may be helpful to note the following, adapted from Merck Geriatric’s advice on cancer treatment for older people:
Age per se is not usually the deciding factor as to whether aggressive treatment is warranted. Merck says all the forms of medical treatments for cancer can work for us. Advances in a number of areas have made the use of chemotherapy safer for older people, although other conditions of ageing may rule out – or make chemotherapy less well tolerated by – some elderly patients. Nausea and vomiting from chemotherapy, however, tend to be less intense in the elderly.
Radiation therapy has also become more tolerable and safer with newer technologies and improved techniques. Older people have some special problems to watch out for, but even some seemingly frail elderly patients can tolerate modern radiation therapy.
Pain control is especially important in the care of older cancer patients. Although pain control is often considered part of end-of-life care, persons with cancer may have chronic pain or intermittently painful complications of cancer during any stage of their disease and it may continue over the course of many years. The goal is to achieve an acceptable level of pain control with tolerable
adverse effects. Merck strongly advises that comfort must be emphasized and the patient reassured that pain will be aggressively managed. Opioids are used to treat severe pain… Addiction should not be an issue for prescribers, and patients should be reassured that fear of addiction should not affect their use of these drugs. [See the Alliance pages on Chronic Pain on this website for more on this subject.]
TRYING EXPERIMENTAL TREATMENTS – You may be given false hope by reading about all the splendid new approaches to cancer, including the disposable newspaper miracle cure stories. There are clinical trials of advanced and new treatments going on, and you can ask your cancer specialist if one might be appropriate for the condition you’re dealing with. Remember, however, that a trial could wind up giving you worse treatment as a control subject than if you had stayed out of it. The experiment itself could also be worse than the disease. This is not to say that a new treatment might not work wonders, but be very cautious.
CURE OR REMISSION?
These days, some cancers have very high cure rates. Testicular cancer, for example, is usually cured even if it has spread. Other cancers can return many years after they have first been treated. So you may find your doctor very unwilling to use the word ‘cure’ even though there is no sign that you have any cancer left. Your cancer will be said to be in remission. This means there is no sign of cancer in your body. If there are any cancer cells left:
There are too few to find
There are too few to cause any symptoms
They are in an inactive state and are not growing
You may be on some form of long term treatment to try to keep any remaining cancer cells in an inactive state, for example, tamoxifen for breast cancer. Being on this type of long term treatment doesn’t mean your cancer is definitely still there. You may have been cured, but the doctor cannot know this.
The point is that however successful the treatment, there can be no certainty about if or when your cancer may return. This uncertainty is one of the things that makes a diagnosis of cancer so difficult to live with. On the other hand, there are no guarantees about anything in life other than that we will all die. In a sense learning to live with cancer is about learning to live, and to find peace and security here and now in a life full of future hazards and the certainty of death which we all have in common. Cancer is quite a strong motivation to learn more about this (see Complementary Techniques below).
The medical treatment of cancer has changed and continues to change so much that we can now reasonably include cancer as a “chronic condition” on this website. Most of us are, as Penny Brohn Cancer Care says, living with, rather than dying from cancer. In fact learning to live well as a result of cancer can actually help to cure it.
