Chemotherapy is a kind of treatment that uses drugs to attack cancer cells. It is called a "systemic treatment" since the drug, entering through the blood stream, travels throughout the body and kills cancer cells at their sites. The drugs may rarely be intended to have a local effect, but in most cases, the intention is to destroy cancer cells wherever they may exist in the body.
Chemotherapeutic drugs are chemically designed to target cells that are dividing and growing rapidly. Once they reach the cancer cells, they act to retard their growth, eventually resulting in their destruction.
Chemotherapy may be given at home, in a clinic or in a hospital. The frequency of chemotherapy can be daily, weekly, monthly or an on-off schedule depending on the type of drug, the body's response and the type of cancer. The chemotherapy is decided on the basis of the type of cancer. The dosage is calculated on the basis of the patient's body weight and the drug's toxicity.
At present more than 50 anticancer drugs have been discovered. They are used in several ways:
The drugs are delivered to the affected cells in the following forms:
Since chemotherapy also affects normal actively dividing cells such as those in the bone marrow, the gastrointestinal tract, the reproductive system and in the hair follicles, most patients experience some degree of side effects, which may include any or all of the following:
It should be emphasized that side effects depend on the type and number of drugs used, that individuals react very differently, and that all side effects are temporary and disappear once treatment is completed.
Radiation therapy involves the use of carefully targeted doses of x-rays or other high-energy rays to kill cancer cells and shrink tumours. While given as a preventive measure for early cases of cancer, it is also administered as a palliative treatment for pain relief in advanced cases. Radiotherapy may be used alone or together with surgery or chemotherapy.
Radiotherapy can be given in two ways, either as external beam radiotherapy (external radiotherapy) or as a radioactive implant (internal radiotherapy).
External Radiotherapy: This treatment involves the high energy rays being directed to the cancer by various machines which include cobalt 60, linear accelerator and betatron. The dosage and duration of the treatment depend on the patient's weight and general health, the type, size and location of the tumour and whether surgery and chemotherapy have been used or are planned in the future. A typical course lasts 4 to 6 weeks with treatment for 5 days per week and a weekend break to allow time for normal cells to recover and rebuild. The attending physician checks the patient's progress to measure the total radiation delivered.
Radiotherapy is not at all painful. It is very similar to a x-ray but takes a little longer. It is important for the patient to remain still during the process, since radiotherapy must be directed accurately at the same place each time. For this reason the treatment sessions are preceded by a marking session during which the exact treatment spot or area is identified. Once the area for radiation has been determined, it is marked either with tattoo marks or indelible ink to guarantee that the identical area is treated every time. In some cases a shell or prosthesis may be needed to protect adjacent areas during radiation and the marks may be made on the shell. During the treatment, which takes only a few seconds, the patient is alone in the treatment room, but constantly monitored by the radiographer through a viewing window or on a TV monitor.
Internal Radiotherapy: This kind of Radiation Therapy is given by inserting radioactive needles or wires into the tumour while the patient is under general anesthesia. Over a few days, a high dose of radiotherapy is given directly to the tumour from the inside rather than a lower daily dose from the external source over a longer period of time.
The treatment must be administered as an in-patient procedure in a hospital during which time, the patient is kept in isolation. To avoid the risk of exposure to radiation, visitors, doctors and nurses may only visit for a short period of time. Pregnant women and children should not visit at all. Treatment takes a few days after which the needles are removed.
Risks and Side Effects: Common side effects include any or all of the following:
As with chemotherapy, it should be emphasised that side effects vary from patient to patient and range from none to very serious. Most effects are temporary and disappear once treatment is completed.
Bone marrow is a soft fatty tissue found inside the bones. It produces blood cells (red blood cells, platelets and white blood cells). When the patient develops disease of the blood cells (anemia, leukemia, or lymphoma) or when cancer treatment like chemotherapy and radiation therapy damages or destroys the bone marrow, a transplant with healthy bone marrow is needed to save the patient's life. Patients also need bone marrow transplants when they have dangerously low white blood cells (which are needed to fight infection) as a result of cancer treatment.
What the Procedure Involves:
First a donor is identified through a process called HLA tissue typing. The best match is a twin, a brother or sister and finally an unrelated person. The patient is given a high dose of chemotherapy to destroy all the bone marrow in the body. Bone marrow is taken from the donor in the operating room under general anesthesia. Some of patient's bone marrow is removed from the top of the hipbone (iliac crest). The bone marrow is filtered, treated, and transplanted immediately or frozen and stored for later use. The donor's bone marrow is transfused into the patient through a vein (IV line) and is naturally transported back into the bone cavities where it grows quickly to replace the old bone marrow. This is called allogeneic bone marrow transplant.
In a newer version of the therapy, called autologous bone marrow transplant, the bone marrow is taken from the patient himself, treated with drugs to kill any cancer cells and frozen. This is later thawed and transfused back into the patient after initial high dose chemotherapy.
The hospitalization period for bone marrow transplant is from 4 to 6 weeks, during which time the patient is isolated and strictly monitored because of the increased risk of infection. The legs in particular are moved often to reduce the risk of deep venous thrombosis. Besides the usual risks associated with any kind or surgery, such as reaction to medication and problems of breathing due to the effect of anesthesia, bleeding and infection during surgery itself, there are additional risks associated with bone marrow transplants. The major problem with allogeneic transplants is graft versus host disease. This is the opposite of graft rejection seen in other organ transplants where the body rejects the organ as a foreign body. In this case, the transplanted bone marrow attacks the host cells as though they were foreign organisms and drugs to suppress the immune system (immunosuppressive medications) must be taken indefinitely, weakening the body's ability to fight infections.
The patient will require attentive follow-up care for 2 to 3 months after discharge from the hospital. It may take 6 months to a year for the immune system to fully recover from this procedure. Relatively normal activities can be resumed as soon as the patient feels well enough and after consulting with the doctor. However, vigorous physical activities should be avoided.
Another promising development is called peripheral blood stem cell transplantation. In this, stem cells (the precursor blood cells from which all blood cells develop) are removed from the patient before treatment and returned after chemotherapy or may be received from a donor.
Bone marrow transplant patients are usually treated in highly specialized centers and the patient stays in a special nursing unit to limit exposure to infections. In India, bone marrow transplant is offered only at a few centres, Tata Memorial Hospital, Mumbai, All India Institute of Medical Sciences, New Delhi and Christian Medical College, Vellore.
Hormones are chemicals secreted by the body. These chemicals are responsible for controlling physical development from puberty to old age. Some types of tumours require the presence of hormones to grow. Doctors try to kill such tumours by manipulating the body's hormone supply. This involves administering a hormone or hormone-like chemical, which counters the required hormone's effects. This technique, called hormone therapy, deprives the body of the hormone needed for tumour growth. Malignancies of the breast and prostate are especially vulnerable to this kind of treatment.
In earlier forms of the therapy, organs responsible for hormone production, ovaries in the case of women and testes in the case of men, as well as the adrenal glands were removed. This resulted in severe physical and psychological side effects including hot flashes, increased risk of heart disease, men growing breasts and facial hair in women.
Thanks to some new drugs, treatment can stem hormone supply without these unacceptable side effects. Tumour cells have proteins that sit on the cell surface and combine chemically with hormones in the bloodstream, taking them inside and using them to grow. These proteins are called receptor sites. The new drugs compete with hormones for these sites. They are taken into the cell in preference to the hormone and kill the cancer cell from within. The most successful example of this is Tamoxifen, a drug used for breast cancer therapy, which competes with estrogen, a hormone needed by breast cancer cells for growth.
The tumour must first be tested for the presence of estrogen receptors to ascertain whether they will respond. A positive test means that the cell has estrogen receptors and that the cancer depends on hormones to grow and so is likely to shrink with hormone manipulation. The more the receptors, the better the chance of success. Tamoxifen may be used along with another hormone deprivation drug, called aminogluthethimide, which targets the adrenal glands, another hormone producing site. Steroids may be needed while therapy is going on, but once therapy is stopped, the adrenal glands will again start normal functioning.
In an analogous case, the drug Leuprolide has been used to treat prostate cancer by starving tumours of testosterone. However the effect may not last for very long. After a year or two, the body becomes immune to hormone suppression and the cancer could become resistant to the therapy. So doctors are beginning to use a drug like flutamide along with leuprolide to ensure a more complete deprivation of the male hormone. This therapy is especially useful for men who cannot have surgery.
The real value of hormone therapy is in combination with other therapies. They may be used before surgery to shrink a tumour to an operable size or after surgery to mop up or control cells that escaped the scalpel. In some cases this may be enough, but in others, chemotherapy may still be indicated to finish the job. However, less toxic doses of these drugs may then be required.
Although side effects to hormone therapy are far milder than those to chemotherapy, they should not be dismissed. Men may notice softened skin or larger breasts, while women may develop a lowered voice. Hot flashes can be relieved by daily doses of Vitamin E. Weight gain from steroids can be reversed by taking a low sodium diet and regular exercise. These side effects are all reversible.
Side effects must be closely monitored to determine how the treatment is working. If you experience bone pain, for example, it could be an indication that hormones are affecting distant sites. Reporting such side effects to the doctor is very important.
Breast self examination (BSE) is a simple, painless procedure that women can carry out by themselves at home, to detect any changes occurring in their breast. It has been proven to be an effective early detection technique for breast cancer.
Some facts about BSE:
The focus of a BSE is not on finding a lump, but on NOT finding it. The idea is to familiarize yourself with your breasts in their normal state so that you will notice a difference.
For further information on Breast Self Examination click here.
I found a lump in my breast ... does that mean ...
You have breast cancer? Not necessarily. Lumps can be due to a variety of causes (e.g., hormonal imbalances) apart from cancer. And as a matter of fact, the majority of breast lumps are not cancerous. However, a lump should never be ignored. You should visit a doctor and have it checked out without any delay. For that matter, you should get ANY change in the breast, like a lump or thickening, nipple discharge, skin dimpling or puckering, color change, pain or irritation to the breast or nipple area checked by a medical professional.
What kind of doctor do I go to? A gynecologist?
No. Gynecologists may not have adequate experience of tumors. Go to a surgeon, or better still, walk into one of CPAA's OPDs where you can avail of a free cancer screening.
What exactly will happen?
The doctor will take your personal and family medical history and palpitate (feel) the lump. After this, you might be asked to get some investigations done. These could be any of the following:
Based on the results of these tests, you might then be advised to get investigative surgery done.
An operation done under general anesthesia. The surgeon will remove the lump and send it for a histo-pathological examination. A technician will observe the lump under a microscope and determine whether it is malignant or not. This report will come in about 20 minutes, while you are still under anesthesia. If the report indicates the lump is benign, that's the end of it.
If the lump is malignant, the surgeon will proceed to remove some lymph nodes from your armpit, to try to establish if, and how much, the disease might have spread.
The final report comes in a few days later, after a detailed analysis of the tissue taken from the lump and lymph nodes.
So that means I don't necessarily have to lose my breast?
Absolutely not. Mastectomy, ie removal of the breast, was the default course of action 20 years ago, but breast cancer treatment has changed a lot since then. Today, doctors prefer to take a less drastic route of lumpectomy (removal of the lump), followed by adjuvant (ie additional) therapy in the form of radiation, chemotherapy or hormonal medication, as the case may be. Mastectomy is now recommended only in the following cases: the lump is large, the breast is small, the tumour is almost attached to the chest wall or the results of the surgery will be cosmetically unacceptable.
But won't a lumpectomy instead of mastectomy mean a higher risk of recurrence?
No. There are studies, which show that the majority of women with early stage disease - stage I and II, treated by breast conservation procedures and radiation have the same survival as women treated with mastectomy.
What's Stage I and II?
Stages are a way to classify the spread of the disease.
Would they do the mastectomy right away?
Not without taking your permission first. But with cancer, it is always advisable not to delay.
Will I need to be admitted to hospital for a lumpectomy?
Yes. The operation is performed under general anesthesia.
How long will I need to be in hospital?
That varies according to the patient and hospital. Typically the stay ranges from 3 to 5 days. You will have to go back afterwards for the lymph to be drained away.
If things are taken out of my armpit, will it affect my arm movements?
No. Provided you do the exercises, which will be shown to you by the physiotherapist before you leave hospital.
However, since the nerve is cut during surgery, a feeling of numbness in the upper arm is normal.
What is this T1N0M0 thing the doctor wrote on my report?
T-N-M is a system of classification of the tumor. T refers to the size of the tumor. N stands for the nodes that tested positive. M refers to metastasis, ie whether the tumor is spread.
And what's Grade II? Does it mean things are very bad?
No. Grade is a way of classifying the kind of tumor. It has nothing to do with the Stage of the illness.
OK, now that the final report has come, what next?
Based on the findings, as well as the doctor's qualitative reading, a course of treatment will be prescribed. This would typically be a combination of the following:
Radiation, the use of high energy x-rays to destroy cancer cells in the area being treated
Chemotherapy, the use of chemicals (drugs) to kill cancer cells or stop them from growing
Hormonal Therapy, the use of drugs that block the action of hormones like estrogen which promote the growth of some cancers
Will I have to stop working?
Not necessarily. In fact, doctors prefer that patients keep themselves busy as it prevents them from brooding over their illness. Just be careful not to overexert yourself. Avoid rush hours while traveling and ask your employer if you can do some work from home.
Chemotherapy ... that means my hair will fall out?
Once again, not necessarily. Individual constitutions react in very different ways, and different treatment protocols lead to varying amounts of hair loss. What actually happens is this: the chemicals are designed to attack and kill any fast growing cells that might be in the body. Besides the cancer cells they are targeted for, normal cells also get affected. Hair follicles are among the first to get affected, and so hair falls. Mind you, the loss is temporary. When you stop chemotherapy, your hair will grow back. In fact, many patients have reported their hair growing back thicker and glossier.
What about side effects of radiation?
Side effects from radiation depend on the dose and the area being treated. Common side effects include the following:
How long will the treatment take?
That depends on what you have been prescribed. Radiation therapy is generally given in 32 sessions, daily, Monday to Friday. Chemotherapy is administered in 3-8 sessions spaced out at intervals of 3 weeks. Hormonal treatment can be for anything from 2-10 years.
How could this have happened? No one in my family has breast cancer ...
Only 5 - 10% of women who develop breast cancer have a family history of the disease.
According to the American Cancer Society, the following factors have been shown to be related to increased risk of breast cancer:
Even so, seventy-five percent of breast cancers occur in women with no known risk factors.
All women are at risk for breast cancer. The two most significant risk factors are being female and getting older. As a woman ages, her risk increases.
What else should I know?
Until we know more about preventing breast cancer, early detection of the disease while the tumor is small, provides more treatment options and the best chance of survival. And that is why Breast Self Examination is so important.
Increasingly, breast cancer patients see work as therapeutic. For employers, the issue is telling employees it's OK to take time off
By Laura DiDio, Managing, July 27, 1998
Jeanne felt the lump in her left breast as she was dressing in the morning. She wasn't terribly worried. After all, statistics show that 80% of breast lumps are benign. At any rate, she didn't have time to worry. Jeanne, a vice president and MIS manager at a New York brokerage house in her late 30s, was rushing to catch a plane to speak at a business meeting. She filed the nagging doubts away along with her presentation. Unfortunately, the lump was malignant.
Ellen's story is similar, but it hits closer because she's a manager at Computerworld. Like Jeanne, Ellen, who's in her early 30s, detected her breast lump herself and didn't think it was cancer. Ellen got the bad news from her doctor at the worst possible time - at the height of Computerworld's production schedule.
Overnight, Jeanne, Ellen and the five other women I spoke with became statistics. They are among the one in eight women between the ages of 20 and 95 who the National Cancer Institute estimates will develop breast cancer. The American Cancer Society estimates that 178,700 women in the U.S. will be diagnosed with breast cancer this year. And 1,600 men will get the disease.
STAYING ON TRACK
But as breast cancer becomes an unfortunate-yet-more-commonplace fact of life, women managers in the high-pressure, high-tech world are starting a trend of their own. They frequently choose to continue working full time and arrange their various chemotherapy and radiation treatments so that their careers - and personal lives - will be impacted as little as possible.
It's a trend that Dr. Helena Chang says she's seeing more of as director of the Revlon UCLA Breast Cancer Center in Los Angeles. The center is at the forefront of developing methods of early breast cancer detection. It's also a pioneer in helping women deal with the psychological and social after effects of the cancer.
"Women whose jobs involve a lot of physical activity tend to take more time to recuperate from breast cancer treatment. Women at higher-level, higher-paid leadership positions tend to be more aggressive and handle both job and cancer at the same time," Chang says.
All of the women I spoke with emphasized that they had the full support of their superiors, and it would not have been a problem to take days or even weeks off while undergoing treatment.
Jeanne required two operations and did take a few weeks off to recuperate. But she didn't miss a day of work during her regimen of chemotherapy and radiation.
"Work was therapeutic for me," Jeanne says. "I didn't want time off. I wanted normalcy."
Ellen expressed similar sentiments. "I didn't want to feel like I was sick. I wanted my regular life. It was very important for me not to miss work," she says.
To accomplish that, the women scheduled their chemotherapy treatments for late Friday afternoons. "That let me work the whole week and sleep on the weekends," Jeanne says. She was also taking Nupogen shots to boost her white blood cell count. "This was great because it meant I could get the chemo in the doctor's office instead of going to the hospital, which took more time."
Ellen's Friday afternoon chemotherapy treatments were followed by six weeks of radiation, five days a week, first thing in the morning. "It wasn't until the fifth week that I got tired. But I was determined to make it through the day no matter how many cups of coffee it took," she says.
In response to life in the '90s that includes realities such as breast cancer, high-level executives are becoming increasingly sensitized to their employees' needs to take time off, telecommute or rearrange their schedules to accommodate treatment or family crisis situations.
"Many people don't want to take time off or ask their bosses for special treatment," observes Emilie McCabe, a vice president in IBM's Software Solutions division. "As a manager, I've sometimes stepped in and encouraged them to do so. I feel it's my responsibility to let people know that it's OK to take time for themselves."
Chang agrees. "Health takes priority. I understand that women with breast cancer feel more upbeat going back to work for even half a day," she says. "But I also tell them, 'You don't have to be a superwoman. If you feel exhausted, take more time at home. The work will still be there when you get back.' "
DiDio is Computerworld's senior editor, security and network operating systems.
Cervical cancer is the most common form of cancer among women in India. Almost one third of all cancers seen in women in India are cervical cancers. 2-3% of all women over the age of 40 will develop some form of cervical cancer. Although the average age at diagnosis is 45, cases at 20-30 years have been noted.
Who is at risk?
The cervix is the neck of the uterus, which protrudes into the vagina providing a canal between the two. Malignant cell changes in the cervix usually take many years to develop. Now, treatment for cervical cancer requires minimal surgery if caught early, leaving fertility intact. If the disease is advanced, a total hysterectomy, removal of the uterus and cervix is needed making it impossible to have children. Fortunately, cervical cancer is easily detected with a Pap smear test.
The test is named after the Greek American doctor, George Papanicolaou, who invented it. During a pelvic examination, the doctor first examines the vagina. Then with the blunt tip of a depression stick or a cotton swab, two or three sample scrapings are taken, one from the outer cuff of the cervix, one from the area just inside the cervical canal and a possible third from the vaginal wall. The cells are smeared onto a slide and sent to a laboratory for microscopic examination to reveal precancerous changes, called dysplasia. Slides are classified as follows:
As is evident from the above classification, an abnormal slide does not necessarily mean cancer. Quite a few women do have mild, moderate and even severe dysplasia but don't develop cancer because the condition is successfully treated. This may take the form of treatment of an infection with antibiotics. Further diagnosis may be indicated by looking for lesions and tissue biopsy, followed by removal of the lesion if necessary.
The whole procedure is quick and painless and provides the best protection against advanced cervical cancer. Studies show that the test reveals abnormal cell changes as much as eight years before a full fledged cancer develops. The test can detect 90% of potential cancers early enough to ensure a 100% cure.
In the West, death rate from cancer of the cervix and uterus has dropped more than 70% since the 1940s when the test was first introduced. The Pap test is the most widely used and effective tool available to doctors for cancer prevention, but it can only be effective if it is given a chance to be used. In India the full potential of the test is yet to be realized since women do not get themselves screened every year. Most women do not think it necessary to visit a gynecologist on a regular basis. For women over 40, the visit becomes even less frequent. In a survey done by CPAA, it was found that most women have last visited their gynecologist when they were last pregnant. This is one reason why more older women fall victim to cervical cancer.
Pap tests are recommended every year for all healthy women over the age of 20 and those under 20 who are sexually active.
Note: A Pap smear does not always detect cancer of the endometrium (wall of the uterus) and ovaries. Always consult a doctor about any abnormal bleeding or pain.