It is often said that medicine is an art, and not a science. Although treatment decisions are made on the basis of scientific information, there is so much information that different "scientists" looking at the same information, come up with different interpretations, and different recommendations. Determining these recommendations is the "art" of medicine. Cancer is treated by a combination of four basic types of therapy: surgery, radiation therapy, chemotherapy, and hormone therapy. The recommended therapy in any given situation is based on many factors, so not every physician will view a situation in exactly the same way. A patient may receive several different opinions as to how to proceed. It may even seem that one physician is right and another is wrong, but that is not necessarily the case. Each physician is using his experience and knowledge to come up with the best recommendations he can using the available information. It is important that a patient is comfortable with the recommendations ultimately selected and that the patient truly believes that he or she is getting the best advice available. If this is not the case, a patient should seek another opinion.
The Treatment Team
Cancer is treated by a team of individuals. The physicians involved are often a surgeon, a radiation oncologist, a medical oncologist, and a primary care physician. There are also other non-physician individuals involved with care and recovery.
The surgeon is often the physician who makes the diagnosis by performing a biopsy. He will discuss surgical treatment options if the diagnosis of cancer has been made, and he will perform whatever operation is needed. He will see the patient after the operation to make sure that everything is healing properly, and he will remove sutures and drains when the time comes. Whether he will continue to see the patient after recovery from the operation will depend on the patient's wishes and how the other physicians involved are participating in the patient's care .
The medical oncologist is an internist specially trained in the treatment of cancer. He is the physician who will decide if any chemotherapy is indicated. If chemotherapy is to be given, he will decide what kind of chemotherapy, he will supervise its administration, and he will help treat any side effects.
The radiation therapist (also called a radiation oncologist) is the physician that administers radiation treatments. He will become involved with the care if radiation therapy is appropriate.
The primary care physician (family doctor, internist, or gynecologist) can be involved with the care as much as a patient desires. A patient can solicit his or her opinion regarding treatment options. After the initial treatment has been completed, a patient will have to see someone on a regular basis for routine examinations and lab work. The primary care physician is a good person to do this because he or she can attend to other health care needs at the same time.
The main treatment that we use for any type of cancer is called the primary treatment. However, with most cancers we ask, "Is there anything else we can do in addition to the primary treatment to prevent this cancer from coming back?". If we decide to give any extra treatment, this is called adjuvant therapy. For most cancers there are three types of adjuvant therapy: radiation therapy, chemotherapy, and hormone therapy.
Radiation works by passing a high energy beam through the part of the body to be treated. There are several different machines used to give radiation treatments. The treatments can be given by the Cobalt-60 machine or the linear accelerator. The difference between these machines is the amount of energy each machine delivers, which is a reflection of its effectiveness and how good it is at preventing side effects. Currently, the linear accelerator is the most common way to give radiation. The high energy beam that passes through the body causes toxic chemical changes in the cells that it passes through. Normal cells have the ability to correct the changes caused by the energy, but cancer cells do not. Therefore, the cancer cells are killed, while the normal cells survive. When radiation is given, a certain dose is calculated by a treatment planning computer. This dose is a balance between how much energy is needed to kill the cancer cells and how much energy the normal tissues can tolerate. There is a limit to how much radiation can be given to normal tissues, and the radiotherapist has to modify how much he gives depending on which normal tissues are in the treatment area. The dose of radiation that is given to an area of the body causes permanent changes in the normal tissues. Therefore, once that area of the body is treated it cannot be treated again. This is a one time treatment for this area of the body. (If one needed radiation treatments for something elsewhere in the body, that would be safe.)
The side effects of radiation therapy depend upon which area of the body receives the radiation. For example if the arm is radiated, a patient would not lose the hair on her head or would not get an upset stomach. These side effects occur if the head or stomach are radiated. As time passes after the treatments, long term effects that can develop include dry skin, darkening of the skin, wrinkling and mild loss of sensitivity.
In the past, we found that radiation treatments given for other diseases increased the chance that a person could develop cancer many years in the future. This often took 20-30 years to happen. However, most physicians believe that this is a safe treatment when used appropriately. They do not feel that there is enough risk of developing a cancer in the future as a direct result of the radiation to warrant withholding this type of treatment at the present time.
Chemotherapy is used frequently as adjuvant therapy for cancer because of our belief that treatment of the entire body is just as important as treatment of the involved organ. We call chemotherapy a systemic treatment because it treats the entire body. The general concept is that there may be cells that have escaped from the main tumor mass and are residing elsewhere in the body. By treating the entire body, we hope to eliminate these cells wherever they are. The chemotherapeutic agents take advantage of the differences between normal cells and cancer cells in such a way as to destroy the cancer cells and preserve the normal cells. We believe that a single dose of chemotherapy will eliminate half of the cancer cells remaining in the body. After a dose of chemotherapy the body is given a certain number of days or weeks to recover. Then, another dose is given. This is continued for a prescribed period of time, often six or twelve months.
The recommendations regarding chemotherapy change frequently - so you may know someone who was diagnosed with cancer just a few years ago who did not have chemotherapy recommended, but it may be recommended for someone else. The recommendation to give chemotherapy is made by an oncologist. He will take all the information that we have about a cancer and will determine the prognosis without chemotherapy and how it will be improved with chemotherapy. He will use statistics from studies of other patients to come up with these predictions.
For example, if looking at a situation, he feels that there is an 80% chance of being alive and well five years after surgery without chemotherapy and an 85% chance with chemotherapy -the possible benefit is small. This means that if a hundred patients are given chemotherapy only five will benefit from it. In this situation, chemotherapy may be offered but not strongly recommended.
However, an example of when chemotherapy is recommended would be a situation where there is a 40% chance of being fine in five years without chemotherapy, which can be increased to a 70% chance with chemotherapy. This means that out of a hundred patients thirty will have benefited from the treatment. This kind of improvement in the five year cure rate justifies taking the chemotherapy.
There are many different medications that are considered "chemotherapy". These medications are given alone, or in combinations of one, two, three, or even more at a time. This allows many different combinations of medications that can be called "chemotherapy". For this reason, it is very hard to compare the experience that one might have with chemotherapy to the experience that someone else had with chemotherapy. They might have had different medications, in different doses, and for different reasons. The chemotherapy that we are discussing here is adjuvant chemotherapy. Someone else that you may know that had chemotherapy might have had it to treat metastatic disease. This is an entirely different situation. In treatment of metastatic disease, a person has cancer that has already spread. They may have serious symptoms from the cancer. Patients in this situation are given chemotherapy to try to shrink the tumor. This is quite a different situation than giving chemotherapy to a healthy person with no symptoms to treat microscopic cancer cells that may exist somewhere in the body.
The side effects of chemotherapy depend on the exact medication and dose given, so it is important to ask the oncologist about this when he discusses treatment. The temporary side effects of chemotherapy given for cancer might include nausea, fatigue, vomiting, mouth sores or hair loss.
For certain cancers, such as cancer of the breast or prostate the presence of certain hormones in the body promotes the growth of the cancer. If that is the case, the oncologist may prescribe an antihormone medication or an opposite hormone to the one the tumor needs. This medication is usually in tablet form and is taken for several years. These types of medications are not believed to actually kill the cancer cells but to stop their growth. These medications have minimal side effects.
In some places, experimental treatment is being tried. By this I do not mean unusual, strange types of therapy but slight variations in the already accepted treatment. This might consist of different chemotherapy agents, different combinations of drugs, or different uses of radiation therapy. We call these experiments treatment protocols or clinical trials. The experimenters are trying to see if these different treatments might be better than the current treatments. If you are interested in learning about experimental therapy, mention it to the oncologist. He may be participating in treatment protocols here in town. If not, he may be able to refer you to a university oncology program for this information. One thing to keep in mind about experimental treatments is the treatment may be less effective than the currently accepted treatment. We just don't know yet - that is why it is considered experimental.