Cancer Treatment Approaches

In modern medicine there are two different schools of treatment of medicine. They are radiation therapy and systemic therapy. While Systemic therapy includes drugs that spread throughout the body to treat cancer cells, radiation therapy involves directing radition beams on specific cancer cell.

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Systemic therapy includes chemotherapy, hormonal therapy, targetted drugs and immunotherapy.

Now , let us understand each of the treatment approaches better


Radiation Therapy

Radiation therapy or Radiotherapy is a treatment technique based on high energy ionizing radiations (such as gamma rays from a radioactive source like Cobalt-60, Iodine-32, high energy x-rays from a medical linear accelerator or proton/carbon ion based particle accelerators).
The goal of the treatment depends on the stage of the disease and radiation is used to control/kill malignant cells. Radiation therapy is often given before, during and after a systemic therapy like chemotherapy. Sometimes, Radiation therapy can be given as a part of adjuvant therapy to prevent tumor recurrence after surgery.
The exact intent of the treatment (curative, adjuvant, neoadjuvant therapeutic, or palliative) depends on the cancer tumor type, location of the tumor, and stage of the disease, as well as the general health of the patient.

Why Radiotherapy is usually delivered in fractions?

Radiation is delivered in fractions and not at one setting. When delivering an intended radiation dose, normal cells surrounding the cancer cells also get affected to an extent. Hence radiotherapy is given in fractions to allow for the cancer cells to recover in between two fractions. Radiation Oncologist is responsible for the overall care of the patient including deciding the fraction dosage.

What are treatment techniques available in Radiotherapy?


The following techniques are available for Radiotherapy:

  • Conventional Radiotherapy,
  • 3D-CRT
  • IMRT (Intensity-modulated radiation therapy)
  • IGRT (Image-guided radiation therapy)
  • VMAT (Volumetric Arc Therapy)
  • SRS (Stereotactic Radiosurgery) / SRT (stereotactic radiation therapy)/ SBRT (Stereotactic Body Radiation Therapy

Radiation Therapy Side Effects (often immediate)


Immediate

  • Nausea and vomiting
  • Damage to the epithelial surfaces / Burns on the skin
  • Mouth, throat and stomach sores
  • Intestinal discomfort
  • Swelling
  • Infertility

Late side effects

  • Hair Loss
  • Lymphedema (localized fluid retention and tissue swelling)
  • Cognitive decline
  • Effects on pituitary system (functioning of the thyroid gland)

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Chemotherapy

Chemotherapy has been used traditionally for cancer treatment and chemo-therapeutic agents are one of the most commonly used drugs in oncology

chemotherapy agents do not differentiate between normal human cells and cancer cells and thus normal cells equally that makes these drugs toxic.

To avoide these toxic effects, targeted drugs have been developed which are defined as drugs or other substances that block the growth and spread of cancer by interfering with specific molecules involved in tumor growth and progression


The treatment of cancer with cytotoxic chemicals formulated to kill rapidly dividing cells and stop them from growing. Chemotherapy kills cancer cells, which are rapidly dividing; however, chemotherapy also kills healthy cells

When is Chemotherapy given/ Types of Chemotherapy

Chemotherapy can be given to a patient at various stages of the disease. Based on the stage of the disease the goal of the chemotherapy provided varies.

Chemotherapy Use Goal of treatment
Chemotherapy alone Use of chemotherapy alone usually recommended for non-resectable, metastatic tumors or hematalogical cancer types
Neo-adjuvant use Prior to a surgery chemotherapy is administered to reduce the tumor burden (i.e. shrink the tumor size) to help improve surgical outcomes.
Adjuvant use Use of chemotherapy following surgery with curative intent; For example, post surgery in Stage I/II cancers the patient is given chemotherapy around tumor area to destroy remaining cancer cells for curing the disease.

Common Treatment goals with chemotherapy

The below list tries to capture the common goals of chemotherapy
  • Shrink tumor to improve surgical outcomes
  • Prevent recurrence of tumor
  • Delay the spread of tumor
  • Provide palliative care
  • Induce remission

How many times can Chemotherapy be given

Chemotherapy is given in cycles. A cycle is defined as a period of treatment and is followed a pre-determined period of rest. For example, if you have breast cancer and are receiving chemotherapy daily for a period of 1 week and then do not receive any chemotherapy for the next 3 weeks. These 4 cumulative weeks make up one cycle. This period of rest gives the body a chance to recover and build new healthy "normal" cells.

The frequency of chemotherapy is decided based on the type of disease, organ affected, agresiveness of the disease and health of the disease. Some chemotherapy drugs are given at a gap of a few weeks and sometimes on a daily basis.

Also, the amount of chemotherapy provided to the patient is determined by the body weight of the patient It is important to note that chemo administered in incorrect dosage/frequency can prove fatal for the patient and result in death.

How is Chemotherapy given

Chemotherapy drugs can be prescribed as tablets as well as are given as an infusion into the vein (intravenously). The IV route is the most common route of administration of the drug. In certain cases, the drugs can be given by inserting a tube with a needle into a vein in your arm or into a device in a vein in your chest.

Common Chemotherapy Agents

The below table list a few of the common chemotherapy agents in India

Chemotherapy Agents
Cisplatin
Gemcitabine
Capecitabine
Carboplatin
LEUCOVORIN (CALCIUM FOLINATE)
OXALIPLATIN
FLUROURACIL (5FU)
Irinotecan
Cyclophosphamide
Epirubicin

You can check out the prices of these common drugs HERE

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Targeted Therapy Agents

Targeted therapies are anti-cancer drugs that target specific genes or proteins that are found in cancer cells in the body. These therapies block cancer cells from living longer by killing them and/or instruct/block signals that tell cancer cells to grow and divide

US FDA Approved Targeted Therapy Agents

Cancer Therapy Name
adenocarcinoma of stomach / GI Cancer trastuzumab, ramicirumab
Bladder Cancer Atezolizumab (Tecentriq),Nivolumab (Opdyta/Opdivo) Pembrolizumab (Keytruda), Durvalumab(Imfinzi), Avelumab(Bavencio)
Brain Cancer Bevacizumab (Avastin), Everolimus (Afinitor)
Breast Cancer Everolimus (Afinitor), tamoxifen (Nolvadex), toremifene (Fareston), Trastuzumab (Herceptin), fulvestrant (Faslodex), anastrozole (Arimidex), exemestane (Aromasin), lapatinib (Tykerb), letrozole (Femara), pertuzumab (Perjeta), ado-trastuzumab emtansine (Kadcyla), palbociclib (Ibrance), ribociclib (Kisqali), neratinib maleate (Nerlynx, abemaciclib (Verzenio)
Cervical Cancer Bevacizumab (Avastin)
Colorectal cancer Cetuximab (Erbitux), panitumumab (Vectibix), bevacizumab (Avastin), zivaflibercept (Zaltrap), regorafenib (Stivarga), ramucirumab (Cyramza), nivolumab (Opdivo/Opdyta)
Endocrine/neuroendocrine tumors avelumab (Bavencio)
Head and neck cancer Cetuximab (Erbitux), pembrolizumab (Keytruda), nivolumab (Opdivo®)
Gastrointestinal stromal tumor Imatinib mesylate (Gleevec), sunitinib (Sutent), regorafenib (Stivarga)
Giant cell tumor of the bone Denosumab (Xgeva)
Kidney cancer Bevacizumab (Avastin), sorafenib (Nexavar), sunitinib (Sutent), pazopanib (Votrient), temsirolimus (Torisel), everolimus (Afinitor), axitinib (Inlyta), nivolumab (Opdivo), cabozantinib (Cabometyx), lenvatinib mesylate (Lenvima)
Leukemia Tretinoin (Vesanoid), imatinib mesylate (Gleevec), dasatinib (Sprycel), nilotinib (Tasigna), bosutinib (Bosulif®), rituximab (Rituxan®), alemtuzumab (Campath), ofatumumab (Arzerra), obinutuzumab (Gazyva), ibrutinib (Imbruvica®), idelalisib (Zydelig®), blinatumomab (Blincyto), venetoclax (Venclexta), ponatinib hydrochloride (Iclusig), midostaurin (Rydapt), enasidenib mesylate (Idhifa), inotuzumab ozogamicin (Besponsa), tisagenlecleucel (Kymriah), gemtuzumab ozogamicin (Mylotarg), rituximab and hyaluronidase human (Rituxan Hycela)
Liver cancer Sorafenib (Nexavar), regorafenib (Stivarga), nivolumab (Opdivo)
Lung Cancer Bevacizumab (Avastin), crizotinib (Xalkori), erlotinib (Tarceva), gefitinib (Iressa), afatinib dimaleate (Gilotrif), ceritinib (LDK378/Zykadia), ramucirumab (Cyramza), nivolumab (Opdivo), pembrolizumab (Keytruda), osimertinib (Tagrisso), necitumumab (Portrazza), alectinib (Alecensa), atezolizumab (Tecentriq), brigatinib (Alunbrig), trametinib (Mekinist), dabrafenib (Tafinlar)
Lymphoma Ibritumomab tiuxetan (Zevalin), denileukin diftitox (Ontak), brentuximab vedotin (Adcetris), rituximab (Rituxan), vorinostat (Zolinza), romidepsin (Istodax), bexarotene (Targretin), bortezomib (Velcade), pralatrexate (Folotyn), ibrutinib (Imbruvica), siltuximab (Sylvant), idelalisib (Zydelig), belinostat (Beleodaq), obinutuzumab (Gazyva), nivolumab (Opdivo), pembrolizumab (Keytruda), rituximab and hyaluronidase human (Rituxan Hycela), copanlisib hydrochloride (Aliqopa), axicabtagene ciloleucel (Yescarta), acalabrutinib (Calquence)
Multiple Myeloma Bortezomib (Velcade), carfilzomib (Kyprolis), panobinostat (Farydak), daratumumab (Darzalex), ixazomib citrate (Ninlaro), elotuzumab (Empliciti)
Ovarian epithelial/fallopian tube/primary peritoneal cancers Bevacizumab (Avastin), olaparib (Lynparza), rucaparib camsylate (Rubraca), niraparib tosylate monohydrate (Zejula)
Pancreatic Cancer Erlotinib (Tarceva), everolimus (Afinitor), sunitinib (Sutent)
Prostate Cancer Cabazitaxel (Jevtana), enzalutamide (Xtandi), abiraterone acetate (Zytiga), radium 223 dichloride (Xofigo)
Skin Cancer Vismodegib (Erivedge), sonidegib (Odomzo), ipilimumab (Yervoy), vemurafenib (Zelboraf), trametinib (Mekinist), dabrafenib (Tafinlar), pembrolizumab (Keytruda), nivolumab (Opdivo), cobimetinib (Cotellic), alitretinoin (Panretin), avelumab (Bavencio)
Tyroid Cancer Cabozantinib (Cometriq), vandetanib (Caprelsa), sorafenib (Nexavar), lenvatinib mesylate (Lenvima)

Each of the brand names are owned by the respective organizations.

FDA approval details as on Nov 2017

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Hormone Therapy

Certain cancers need hormones to grow in our body. Hormones are naturally produced chemicals produced within our body that help various organs of the body perform various functions.

In hormone therapy, doctors try to kill the tumor by manipulating the supply of the hormone to the tumor. This is done by taking medications that involve a hormone or a hormone-like chemical targeted at the specific tumor. This deprives the tumor cell from the hormones it needs to grow and slowly it starves to death.

Hormone therapy is typically common in breast and prostate cancer.

Side Effects of Hormone Therapy

Side effects largely depend on the drug type/the actual treatment prescribed by the physician

  • Nausea
  • Unexplained Weight loss/gain
  • Depresion / Mood Swings
  • Osteoporosis (bone loss) in women
  • Increased risk of stroke, blood clot in legs/lungs, cataracts

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