Cancer Care

 What is Chemotherapy?

 

Chemotherapy is a type of cancer treatment method which uses drugs to kill cancer cells. It is known as "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, ultimately 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.

Currently there are more than 50 anticancer drugs which have been discovered. They are used in several ways:

  •  Monotherapy or only one drug
  •  Combination chemotherapy or a group of drugs which work together
  •  Combined modality or chemotherapy along with other treatment such as surgery and radiotherapy
  • The drugs are delivered to the affected cells in the following forms:
  •  Oral (tablet form, by mouth)
  •  Intravenous or Intramuscular (injected by needle into a vein or muscle)
  •  Intrathecal chemotherapy (injected through a needle in the back)

Since chemotherapy also affects normal 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:

Nausea and vomiting : This is a common side effect of chemotherapy. It can be controlled with anti- sickness drugs (anti-emetics), which your doctor will prescribe.

Fatigue : Chemotherapy affects different people in different ways. Some find they can lead normal during treatment, but many find they become tired and have to take things more slowly. Just relax as much as you can and be careful not to over-strain. Taking short naps may help.

Hair loss : This is the least harmful side effect, yet can be the hardest to bear. Usage of a cold compress around the scalp helps reducing the hair loss to some extent while undergoing chemotherapy. Hair will grow back surprisingly quickly once treatment is over.

Susceptibility to infections : When the drugs act on cancer cells, they also destroy normal cells including white blood cells, which fight infections. When white blood cells are in short supply, the body's immune system is weakened making you susceptible to infections. Any fever should be reported so that your doctor can prescribe antibiotics.

Decrease in blood cell count : During chemotherapy, you may become anaemic. Regular blood tests are done to ensure this does not happen. If necessary, blood transfusions are given. Mouth sores and ulcers: Some chemotherapy drugs cause sores and ulcers in the mouth. Regular use of a mouthwash is very important.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.

What is Radiation Therapy?

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. 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 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 sessions 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 tumor while the patient is under general anesthesia. Over a few days, a high dose of radiotherapy is given directly to the tumor 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 treatment procedure in a hospital during 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:

Fatigue : The body uses a lot of energy during treatment due to stress, regular trips to hospital and the repair work to normal cells exposed to radiation. The best way to handle fatigue is to limit activities and increase sleep. Consumption of good nutritional food is also very important.

Skin Problems : The skin in the treatment area frequently becomes dry, itchy, darkened, red or tanned. Do not rub, scratch or scrub this skin. Ask the doctor for a lotion which will not interfere with treatment. Protect the skin from the sun.

Hair Loss : Hair loss usually occurs at the area of treatment. The hair will re-grow when therapy is complete.

Loss of Appetite : This may be caused by nausea, stomach pain, and change in taste and difficulties in swallowing. Maintain a balanced diet and eat whenever possible. A soft diet is best and plenty of nourishing liquids like milk, soup and coconut water. Smoking, drinking alcohol and eating hot, spicy food should be avoided.

Digestive Tract Problems: Upset stomach, nausea, diarrhoea and constipation have been observed when radiation is being delivered to the lower abdominal area. Most of these problems can be controlled with medication, which the doctor will prescribe.

Effect on Sexual and Reproductive Function: Radiation therapy, when applied to reproductive organs can cause a decrease in the number of sperm or viable ova, reducing the ability to fertilise. There may be a possible decrease in sexual desire and impotence in men.

Lymphodema : The swelling of the arm due to damaged axillary lymphatic vessels either by surgery or radiation causes the lymph to collect in the lower arm. Lack of vessels and the force of gravity make it difficult to pump the fluid back into circulation causing swelling and discomfort. Take special care to avoid infection and injury to the affected arm.

As with chemotherapy, it should be emphasized 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.

What is Bone Marrow Transplant?

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 (anaemia, 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 required 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 anaesthesia. Some of patient's bone marrow is taken out 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 defrozen 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 observed 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 anaesthesia, 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 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 healthcare centres 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.

What is Hormone Therapy?

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 required for tumour growth. Malignancies of the breast and prostate are especially vulnerable to this type 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 hes 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 pormonreference 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. 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 a similar 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.

Side Effects:

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 the working of the treatment. 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 Facts

Breast self examination (BSE) is a simple, painless procedure which 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 method 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.
  •  BSE should be performed every month from the age of 20.
  •  Women, who regularly do a BSE, learn to identify how their breasts should feel and are more likely to detect even small changes at an earlier stage.
  •  Women themselves discover nearly 95% of all cancerous lumps.
  •  80% of all breast lumps found through BSE do not turn out to be cancerous.
  •  Doctors are not necessarily as good at finding lumps in a patient's breast as the patient herself.
  •  Women who perform BSE are likely to find lumps as small as ¼ to ½ inch in diameter as opposed to 1 ½ inches in the case of women who do not. This makes a difference of six months to a year in the start of treatment, and consequently, in the chances of a favourable outcome.
  •  BSE should be performed at the same time each month. A good time is just as the menstrual period is ending when the breasts are least sensitive.

Frequently Asked Questions about Breast Cancer

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Healthy Attitude

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 and the Pap Test

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 to 3 percent 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?

  •  Women who were married at an early age.
  •  Women who have had multiple pregnancies.
  •  Women with a history of having sexually transmitted disease.
  •  Women who have multiple sexual partners.
  •  Women whose partners have had multiple sexual partners or who have had sexually transmitted disease.
  •  Women from low socioeconomic status (due to poor hygiene).
  • Women undergoing treatment involving suppression of the immune system from steroids, other diseases or HIV

Symptoms

  •  Abnormal vaginal bleeding between periods, after intercourse or after menopause Persistent white, brown or blood stained, foul smelling vaginal discharge
  •  Loss of appetite
  •  Unexplained weight loss
  •  Involuntary loss of urine or fecal matter

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 normally 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:

Class I Negative, normal smear with no abnormal cells.

Class II Early dysplasia, slightly atypical. This includes all minor cell changes including inflammation and infection.

Class III Suspicious, mild to moderate dysplasia, cancer precursor, cervical intraepithelial neoplasia (CIN). These are then rated as CIN 1 or 2 according to the proportion of abnormal cells present as well as the degree of change. They may or may not be precancerous.

Class IV Highly suspicious, severe dysplasia. Carcinoma in-situ (cancer of the surface of the cervix) cannot definitely be called positive for cancer, may or may not be malignant.

Class V Positive for cancer, suggests need for further diagnostic testing.

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 gynaecologits on a regular basis. For women over 40, the visit becomes even less frequent. In a survey done by CARF, it was found that most women have last visited their gynaecologits when they were last pregnant. This is one reason why 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.