Cancer Treatments

Similar to a previous answer (http://talkabouthealth.com/for-what-types-of-non-hodgkin-lymphoma-is-rituxan-a-typical-treatment-option), the B cell non-Hodgkin’s lymphomas are usually treated with Rituxan. This is because all but a few of these lymphomas express CD20, the target antigen that Rituxan binds to. Rituxan has been shown the be beneficial a single agent therapy in indolent lymphomas, when combined with chemotherapy (R-CHOP or R-CVP are two examples) and for maintenance after initial treatment in the case of indolent lymphomas.

Xalkori is very successful in causing tumor shrinkage in most patients whose tumors have an ALK fusion. Efficacy is usually measured by tumor shrinkage, time to progression or survival.

For most patients, it will be safe to take a multivitamin during chemotherapy and radiation that does not contain more than 100% of the US RDA. This is certainly reasonable since it is often difficult to “eat well” during treatment. An exception might be patients who are receiving 5-FU based chemotherapy. There is an interaction between 5-FU and folic acid that can make dosing and managing side effects problematic. Check with your oncologist on that one.

Let me start by saying there are some components of citrus fruits that have anti-tumor activity in pre-clinical studies (those done in test tubes and mice). In particular d-limonene which is a monoterpene found in orange and lemon peels may be active against some tumors and is being investigated in phase I/II trials. Keep in mind this is a concentrated chemical extracted from citrus fruit and given in intravenous form—sound familiar? Yep, this is how chemotherapy got its start. In one trial I read, nausea and vomiting were “dose-limiting toxicities” (one goal of phase I trials is to see how much drug can be tolerated). Side effects like nausea and vomiting occur because of the effect of the drug on normal cells. Now with that said, there is no evidence that lemon juice is effective in the least for treating cancer. As for impact on “normal” cells—have you ever tried drinking much lemon juice? I think you’ll find there is an effect on normal cells.

Like all questions of work-life balance, this one is hard to answer because it is so personal.

My top priorities in life are spending time with my kids and husband, spending time with family and friends, and excelling in my job (I am a PhD-level microbiologist). I also had to learn how to excel at being a patient while still having time and energy for these other focal areas. In the heart of illness, my health trumped everything else. However, everything else could take on a new form. Instead of walking my kids to the playground, I laid on the floor and did puzzles. Instead of going out with friends, friends watched movies on the couch with me. Instead of going to work and performing an experiment, I worked on writing projects on my laptop at home. In short, I tried to keep my other priorities, but I adjusted my expectations for myself in them. And if I had a down day where I felt awful for whatever reason, I didn't force myself to tackle any of these other priorities.

My first piece of advice is to let your health take priority. You can't perform your other priorities if you are dead.

My second piece of advice is to continue to function at some level in your other priorities. This will help you maintain your sense of self-worth, keep you in close contact with your support network, and speed your recovery.

I was fairly active before my diagnosis -- running, tap dancing, swing dancing, etc -- and found that keeping up with my exercise/activities as much as possible was crucial to both my mental health and my recovery during treatment. I had four chemo infusions of taxotere/cytoxan (one infusion every 3 weeks) and was able to run through two of them (although not during the first week when the bone pain was too intense). After the third infusion, I had to dial it down to walking (I also had to let the dancing go). But once chemo was over and I was able to get rid of the excess water weight from the steroids, I was able to get back to running and even attain my old mileage within a couple of months. I also ran, danced, walked, etc. during 6.5 weeks of radiation which I believe is the number one reason why I didn't have too many issues with fatigue.

As far as motivation goes, running and dancing and doing all the things that made me feel normal and healthy and whole was my way of telling cancer it could suck it. It was also a way to stay in touch with my body and to appreciate what it could do, even under duress, even with a couple of essential parts missing.

The way I made it through chemo was just by dragging myself in, and doing it. No special strategies or skills. But I will say that what I learned to be helpful along the way was the other patients. We shared snacks, boob jokes, a little about ourselves. I called them my chemo clic.

Of course part of getting through chemo is dealing with side effects. I had very few. But let me tell you about the couple I had and what I did:

I had a few mouth sores and my oncologist prescribed a mouth wash that worked beautifully. I’m sorry I don’t remember the brand name, but know that your onc can prescribe something more effective than the over-the-counters if you have this problem.

I became severely neutropenic (very low white blood cells). I had to stop chemo for a few rounds and then push and push my doctor to give me booster shots to raise my white cells. (I was in a clinical trial that would not allow the boosters). So the point I want to make here is that in my case, I wanted to get around the road block that was preventing me from resuming treatment, and the way I dealt with it was to be my own advocate.

I was dawg tired! Who isn’t when they go through treatments? The neutropenia definitely heightened the fatigue. I was not good at taking naps, but I would suggest that you do this. Sleep or at least rest in bed or out in the sun on a nice day. Let your house work go some. If you have anyone around to help with the jobs you’re used to taking on, have them help you. I graciously accepted the few meals friends made and I made enough food to have leftovers to save me cooking the next night.

What else helped was having someone to talk to who would just listen, not tell me what to do, not make judgment calls. I found very few friends who were this supportive. But I’d suggest gravitating toward the ones who are, and maybe getting in a support group of other survivors or patients on similar paths.

Melanoma surgery usually involves a wide excision around the melanoma itself (typically 1 cm in radial diameter for every 1 mm in melanoma depth) and a sentinel lymph node biopsy. The margins (edges) of the wide excision are examined under the microscope to make sure all the melanoma is gone. Sometimes, usually just for non-invasive or very thin facial melanomas, a procedure called Moh's surgery is performed to minimize the amount of uninvolved skin removed. Moh's surgery involves removing a small amount of skin around the skin cancer and examining it immediately under the microscope. If melanoma cells are seen, then a couple of more millimeters of skin is removed and examined. This process is continued until the entire extent of the melanoma is removed. The process takes many hours of laborious work and that is why is is only used in areas of cosmetic or functional concern (typically the face) where wider excisions would be more problematic..

If the sentinel node has a deposit of melanoma in it, the other lymph nodes in the same area are at risk of having melanoma in them. Standard therapy would be to remove the rest of the lymph nodes in that basin (axilla, groin, neck). The lymph nodes are not connected in a 'chain-like' fashion but more of a 'spider's web' so the surgeon cannot just remove the 'next' lymph node in the chain and if it's negative, stop there. There is a large multi-national trial ongoing that randomizes sentinel node positive patients to either the standard of care (complete lymph node basin removal) or to observation of the basin with ultrasound every 3 months.

Balloon radiotherapy for breast cancer, also known as intracavitary brachytherapy, can deliver a focused dose of radiation to part of the breast. The standard since the 1980s has been whole breast radiation therapy given over a period of a few weeks. With the balloon placed by the surgeon, radiation can be delivered twice a day for ten treatments to make treatment more focused and convenient.

This is one form of accelerated partial breast irradiation, or APBI. This technique is investigational but promising enough that it's reasonable to consider as an alternative to whole breast radiation therapy. Depending upon how conservative you are regarding medical evidence, it may be best done only on a clinical trial or there are guidelines for treatment off protocol in selected circumstances, which I have answered on TalkAboutHealth before: http://bit.ly/mZ2Fdg

I offer this treatment to selected women but tend to favor standard whole breast radiation. There's a fair amount of hype about APBI but it's still not proven to be equally effective. I'm not sure if this is the NY Times article you meant, but I'll discuss this: http://nyti.ms/wVW62K

Recent data presented at the San Antonio Breast Cancer Symposium showed that women receiving APBI were "about twice as likely to have a mastectomy in the following five years" after treatment compared to women receiving whole breast radiation. Sounds terrible, right? I call foul on the NY Times:

1. The failure rate almost doubled; 4% vs. 2.2%. Had the NY Times presented it based upon success rate, 96% vs 97.8%, it's not news.

2. It's a retrospective, broad stroke study. There can be all sorts of bias and no ability to account for quality control in how the treatment was done for APBI.

3. Presentations at academic meetings are interesting, but it's not finalized, peer-reviewed research until it's published.

I'm conservative regarding use of APBI. Don't believe the positive hype, but I don't put too much stock in the NY Times article. I hope that answers your question!

In the United States there are two FDA approved forms of interferon. The first is standard, high-dose interferon, which is given over 12 months. The first month is given intravenously at 20 million units/m2, five consecutive days per week for 4 weeks. The remaining 11 months are given as subcutaneous injections at 10 million units/m2 three times per week. The second form is called pegylated interferon (Sylatron) and is given weekly at 6 mcg/kg/week subcutaneously for eight doses, followed by 3 mcg/kg/week subcutaneously for up to five years. There are several factors involved in choosing between the options, including convenience and length of therapy. If you are considering interferon, it’s also important to talk with your oncologist about clinical trials of medications designed to prevent melanoma from coming back after surgery.

Yervoy is FDA approved for stage IV melanoma and can be used in patients whose disease cannot be removed by surgery. The biggest benefit of Yervoy is that it improves the average survival of patients compared to other treatments, like chemotherapy. It’s important for patients to talk to their oncologists about the risks and benefits of Yervoy, which, because of the way it interacts with the immune system, can cause some serious side effects.

Patients with stage IV NSCLC are first treated with platinum chemotherapy which is a platinum drug (either carboplatin or cisplatin) plus another drug (Gemcitabine, Paclitaxel, Docetaxel or Alimta). At some point, unfortunately, patients will progress and their tumor will grow after the first type of chemotherapy is given. Generally at that point, a second line drug is used and the platinum doublet is abandoned.

There are three approved second line drugs (Tarceva, Alimta, Docetaxel) for NSCLC but their use is dependent on what a patient got in the first line. For instance, if a patient received Carboplatin and Alimta as a first line regimen, then the second line possibilities would be Tarceva or Docetaxel. Sometimes the drug Gemcitabine is also offerred. Unlike first line therapy, second line therapy is generally just one drug, not two. Response rates (the percentage of patients whose tumors shrink) is lower in the second line (only 10 to 15% of patients' tumors will shrink) depending on the patient the drug used. While those numbers are small, there is ample data that patients who go on to receive a second line drug live longer than those that don't receive any second line drug.

I think asking what were the most difficult side effects is like asking someone to describe the level of pain they are feeling. Two people can be experiencing the same exact thing yet their perception of it is very different. For me I think I had built up this idea that going through chemo would be the most horrid thing anyone could EVER experience and that was the bar I had set for myself. I was lucky and experienced minimal nausea thanks to anti-nausea medications. I also expereincved some slight neuropathy in my right foot which did cause some long term residual effects. I also had no appetite for 2-3 days after each chemo cycle. I had the tinny taste in my mouth when I ate. I was very tired all the time and just when I felt some energy returning it was time for the next treatment. I think the most difficult side effect was the bone pain. The overall body pain & exhaustion which, the closest thing I can compare it too is how your body aches when you have the flu then multiply it by 10. Emotionally painful was loosing my hair at first but ironically once it was gone I didn't feel as bad as I thought I would. Maybe it was because I was feeling so crummy overall, otherwise I just didnt care. I don't quite know for sure. For me though they were far from easy but I personally felt the side effects were manageable and I knew I had to deal with them because at least for me I had no choice but to have the chemo.

My PubMed search on "coffee enema" returned 4 citations. Two were about rectal burns caused by a hot coffee enema and a third was about acute colitis caused by a coffee enema. The fourth was either an editorial or a review but the abstract was not available so I don't know whether or not that paper contained a rational and evidence-based use for coffee enemas or not. Patients often ask me about using coffee enemas for a "detoxification" regimen. I can't find any evidence to support that, it doesn't make sense to my conventionally trained (yet open) mind, and it is potentially dangerous (though I am amazed that anyone actually uses HOT coffee). The danger I would worry about is potential electrolyte imbalances. So no, I don't recommend them.

We study many potential treatments. If the evidence rises to the level needed to confirm utility, we incorporate the results. I take great pains to point out that we do not have different standards of evidence for so-called “alternative” therapies. Furthermore, just because we study something does not mean that it is useful. In fact, and unfortunately, most drugs and substances that are studied under any circumstances do not turn out to be useful.

I was on the NASBP Protocol B-40. I was ramdomly put into the Groupe 3B where I first received Docetaxel combined with Gemcetabine for a period of 12 weeks witht he addition of Avastin. Then for another 12 weeks, I received AC with more Avastin. It was followed by a double mastectomy, including reconstruction with implants. Once done, I received 24 radio tx and 10 more injection of Avastin. What was so amazing, I had 4 tumors in my left breast who made a lump of about 2,5 inch diameter and several my lymph nodes were infected. Two tx into the b40 protocol, and my lump had diminished to the point where I didn't have any discernible lump during a manual eval. At mastectomy time, there was only an less than half-inch of cancer left in the breast.

It was incredible to see how fast I responded to chemo and how the combination with Avastin allowed to pratically melt my tumors away in so few tx.

Luckily my village showed up. My entire family stepped it up for me in a big way. My mom came to deliver food, pick-up and drop-off prescriptions, my cousins came to clean, my son's dad came by each day to bathe and get my son ready for bed and his bag packed for school the next day, my brother would baby sit so I could rest. Initially I thought wow this is going to be rough, but my family and friends truly provided a strong support system.

"Total" care is only as much as a person can handle. The following list is just an offering of choices. Each person going through a cancer journey should only feel obligated to do as much or as little as they can, to a level that makes them feel empowered and not overwhelmed. Also, it is our firm belief that every person has unique and different changes that they need to make in order to bring their body back into balance; therefore, the right combination of things will vary with each person. Knowing all of that, we encourage our patients to choose whatever sounds most fitting to them among the following complementary approaches:
1) PHYSICAL: dietary changes (e.g., vegetables and fruits, whole grains, beans and nuts, and a reduction in meat, refined grains, sugars, sweeteners, and dairy); exercise changes (e.g., daily walks or gentle yoga, preferably outside for Vitamin D if possible), herbal and vitamin supplementation (tailored to your needs for detoxification and immune boosting purposes), and weekly massage.
2) ENERGETIC: practices to unblock and balance your energy (acupuncture, tai chi, reiki, sat nam rasayan, Therapeutic Touch, pranayama, yoga, etc.)
3) MENTAL/EMOTIONAL/SPIRITUAL: calming your racing thoughts, releasing suppressed emotions or emotions from the past, deepening whatever gives you a sense of spirituality, etc. Examples include: psychotherapy, meditation, deep breathing, laughter, prayer, etc.

Hope that helps,
Kelly Turner, PhD and Aaron Teich, LAc
www.ShuniyaHealing.com
Twitter @ShuniyaHealing