Cancer Treatment

My chiropractor has been great with trying to get them back in alignment. They were so off after chemo.

I also took it easy on exercising after chemo, started small and built up.

A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive!

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

The nurse who prepares or educates the patient who will be receiving chemotherapy sets the tone for the patient and his experience regarding his initial chemotherapy experience and his chemotherapy course of treatment.

It is important to discuss the side effects of chemotherapy, the chemotherapy protocol, and how the body responds to chemotherapy, the importance of blood test, laboratory tests, diet, exercise and taking your temperature. The patient should be made aware that his team of healthcare professionals will be monitoring him to see how he is feeling and if he is showing any side effects from his chemotherapy treatment.

The patient should be encouraged and know if he has any questions or appears to have any side effects from the chemotherapy at home or on the outside the chemotherapy setting to call and to speak to someone regarding his care.

I always say never assume that a simple nosebleed, is a simple nosebleed. One must speak to a healthcare professional on his team regarding possible side effects.

Furthermore, the nurse should inquire if the patient lives alone, what support systems are in place? What type of work does he do and how will chemotherapy affect his quality of life.

Here are some frequent questions that patients have asked me before they started chemotherapy.
1. What is chemotherapy?
2. Will this chemotherapy work with my cancer? Will it cure me?
3. Am I going to die?
4. How did this happen to me? Why did this happen to me?

I have found the first few questions from patients are more emotional questions. Because the patients are concerned about survival and what will be the outcome.

After I address these emotional concerns about their disease process, then other questions come up:
How long is the course of my chemotherapy therapy?
What are the side effects of the medications?
What will you give me for me nausea?
What can I eat or cannot eat during my chemotherapy day or after?
Does my hair fall out? When will my hair start to fall out?
How long does the infusion chemotherapy take?
What oral chemotherapy do I take? How is that different from an infusion?
What are pre-treatments?
What do I have to do the day before chemotherapy or after my chemotherapy treatment?
Does anything happen while I am receiving chemotherapy?
What do I need to bring to my appointment?
Will my treatment be painful?
Where will I have my treatment?
What will happen when I arrive for my chemotherapy?

At this time the nurse should check to see how well the veins could be access for chemotherapy administration. Perhaps the patient does not have good access and may need to have a port put in place.

Other information that should be included regarding chemotherapy education is:

- Sexuality
- Methods of adherence regarding chemotherapy and medications that are part of the chemotherapy protocol.
- Check to see if the proper test are ordered before the patient under goes chemotherapy
- Know that the patient or their family most likely has been seeking information pertaining to the chemotherapy and the cancer disease process though social media.

Discussing with my colleagues, the answer was always the same. “Never assume”, there are certain protocols that you must always maintain regarding the administration of chemotherapy or radiation.

1. Ask the patient his first and last name, birthday and make sure that it is correct on all orders.
2. Know the patient’s allergies and medical history
3. Inform the patient the side effects of the medications that they will be receiving or radiation.
4. Check the order for time, date, clear meaning of what is written, is the order appropriate to that patient and who wrote the order.
5. Check the BSA and the calculations to the order that is written.
6. Know the correct name of the chemotherapy agent that you will be administering to the patient.
7. Know what proper route, dose and quantity that you will be administering to the patient.
8. Know the side effects of the medications.
9. Check the Intra venous site to see good access, blood returned and patency.
10. Instruct the patient to what they are supposed to feel while the patient is receiving chemotherapy or radiation.
11. If you have any questions regarding what you are administering always ask before you administer. Never assume.

The majority of cases of ovarian cancer (approximately 75%) are diagnosed at stage III or IV (spread of cancer outside the ovaries and into the abdominal cavity or beyond). The primary difference is in prognosis. The percent of women with stage I ovarian cancer who are alive 5 years after diagnosis is around 83-89%. For women with stage II ovarian cancer, that number drops to 65-70%. For women with stage III, it drops to 32-45%; and for stage IV cancers, the number of women alive 5 years after their diagnosis is less than 20%.

The primary treatment for all stages of ovarian cancer is surgery. After surgery, chemotherapy is recommended for most women, regardless of stage.

My personal course of treatment followed that for Ovarian Cancer since that was my primary cancer. Upon my surgery it was found that there was a tumor that filled my entire uterus. The wording on my pathology report is "the endometrial and left ovarian tumors appear to be independent primaries. The cul de sac and right ovary tumors likely represent metastasis from the left ovary" My gyn/oncologist refered to the Ovarian Cancer as primary and the Uterine Cancer as Secondary Primary. I had a TAH/BSO (Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy) This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen. I also had my omentum and appendix removed. This was followed by 6 cycles of Chemo; Carboplatin and Taxol.

Stereotactic radiosurgery is a type of external beam radiation therapy utilizes very precise and multiple beams in a small number of treatment fractions (one to five), and with a high dose delivered per treatment fraction. Often times radiosurgery is a terminology people refer to for a single fraction and stereotactic radiosurgery when it is more than one fraction- up to five, but the terms are relatively interchangeable. There is no surgery or cutting involved, as the treatment is non-invasive. Radiosurgery can be used to treat lesions in the brain, such as brain metastases, for spine metastases, and in the body for primary lung tumors, lung metastases, other organ metastases, and now to the prostate as primary treatment. Because of the ablative response of the tumor to this type of treatment it is now also known as stereotactic ablative radiotherapy, or SABR.

Radiation therapy is used in the palliative settings for nearly all types of cancers. For example, it can be used to treat pain related to bone metastases from different primary sites, improve respiratory symptoms from a tumor blocking airways, improve swallowing conditions related to esophageal tumors. Radiation therapy can also be used in the prophylactic palliative setting for brain metastases, lesions in vertebral bodies before they cause pain or neurological symptoms, or impending bone fractures. For the majority of times a tumor causes symptoms there is often a role for radiation to address and improve them palliatively.

The study presented by Dr. Grace Smith at the San Antonio Breast Cancer Symposium entitled Partial Breast Brachytherapy is Associated with Inferior Effectiveness and Increased Toxicity Compared with Whole Breast Irradiation in Older Patients has garnered a tremendous amount of print and internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in the breast surgery and radiation oncology fields, it has become necessary to try to clarify the data on APBI, discuss the 'information' in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, Acellerated Partial Breast Irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer. Numerous retrospective studies and 2 prospective randomized (the gold standard) studies have shown no difference in survival, local-regional recurrence rates or complications between APBI and Whole Breast Irradiation (WBI). The American Society of Breast Surgeons Mammosite Registry has published more than 16 papes showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The abstract and presentation is drawn from the Medicare claims-SEER database which is a large database with cancer patient data linked to Medicare claims data. The database is managed by the NCI and sold to institutions to do research. The linked database has information about cancer type and treatments but no specific data on margin status, prognostic factors such as ER/PR and Her2Neu, or even local, regional or distant recurrence. The study stated that 'subsequent mastectomy' is a 'validated surrogate for local failure' although I am unaware of any literature that states this. The 'two-fold increased risk for subsequent mastectomy' is misleading (and inaccurate - it's 4.0% for APBI vs. 2.2% for Whole Breast Irradiation in their study). Both of these rates are quite small and questionable whether there is any clinical significance between the two. Not emphasized but equally (?more) important is the overall survival rates which were equivalent. The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast) but there is no statement regarding severity (were the APBI patients just placed on prophylactic antiobiotics and that is how an infection was defined?). Fat necrosis and breast pain were also significantly higher in the APBI group although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity or the fat necrosis or breast pain. Lastly, they state there was a 9.6% hospitalization rate for APBI patients vs 5.7% for WBI patients. This is quizzical since no diagnosis was given for hospitalization nor the time period over which they were hospitalized (was it APBI related[doubtful] or related to first chemotherapy cycle [perhaps] or other unrelated health issues [APBI often used in older, sicker patients who may not be candidates for 6-7 weeks of WBI]). In summary, this retrospective study of an inherently inacurate (no data on tumor characteristics and margin status - both known to be significant determiners of local recurrence) database with questionable outcomes (admission rate) and non-validated 'surrogate endpoints' (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and 2 prospective randomized trial to the contrary.

Breast cancer treatment has two main components: 1) getting rid of the tumor and 2) keeping the tumor from coming back and/or spreading. A surgeon takes care of the first. A medical oncologist – through chemotherapy and or hormonal therapy — and a radiation oncologist take care of the second. Chemotherapy is a systemic treatment – it keeps the cancer from spreading to distant sites in the body. Radiation is a local treatment — it keeps the cancer from coming back where it started: in the breast and in local lymph node areas.