CHEMOTHERAPY
60% to 70%
of all cancer patients develop distant metastases. In the
majority of patients metastatic disease is incurable, and the
realistic aim of any chemotherapy treatment is palliation
(control of symptoms and improved survival).
Tumor response may be:
High dose
chemotherapy regimes are used to treat sensitive tumors in the
hope of cure. Tumors that are usually curable by
chemotherapy include Hodgkin’s Disease, testicular cancer,
choriocarcinoma, Burkitt’s lymphoma, childhood leukemias and
nephroblastoma. Tumors that are sometimes curable
include non-Hodgkin’s lymphomas, sarcomas, ovarian cancer, neuroblastomas and acute leukemias.
Most
solid tumors (bronchus, breast, esophagus, stomach,
pancreas, colon, bladder, etc.) respond poorly to
chemotherapy. High dose regimes therefore have little place in
palliation of solid tumors. The tumor cells will not be
eradicated and survival is rarely prolonged, and is sometimes
shortened by toxic effects. Chemotherapy that produces toxic
side effects is not justified when the main aim is symptom
control. Metastatic small (oat) cell cancer of the bronchus
is an exception. Combined chemotherapy can reduce symptoms
and prolong survival from a few weeks up to 12 months (and
occasionally 2 to 3 years). Three courses of combined
chemotherapy will produce improvement in 75% of patients.
In breast
cancer 50% of patients with soft tissue and lung metastases
respond after three courses of combined chemotherapy, but only
occasional patients achieve prolonged survival.
In
adenocarcinomas of the stomach, pancreas and colon 20% of
patients respond to single agent treatment with fluorouracil,
and combined chemotherapy does not increase the response rate.
Metastases
from non-small cell lung cancer, melanoma, or from an unknown
primary site respond very poorly to chemotherapy.
In patients
who do respond and achieve a stable remission of disease, the
next question is whether the patient should receive
maintenance therapy. All chemotherapy has side effects,
and maintenance therapy has no proven benefit in terms of
survival.
«
It is important to control symptoms simultaneously, and not to
wait to see if chemotherapy will produce a response which may
take weeks.
Chemotherapy-related side effects can develop after the course
of treatment, the usual time scale being:
|
Nausea |
during, and 1 to 2 days later |
|
Bone
marrow suppression |
7
to 10 days later |
|
Malaise |
7
to 14 days later |
|
Neuropathies |
Several weeks later |
|
Lung
fibrosis |
Several weeks later |
Stopping
chemotherapy – When chemotherapy fails to control disease,
treatment becomes a burden. A decision clearly and kindly
explained to change the focus of care to symptom control, and
to stop inappropriate chemotherapy, usually brings welcome
relief to patient and family.
Patients
are often more realistic than their physicians, who sometimes
tend to prolong chemotherapy unrealistically because they
wrongly assume that stopping treatment will make the patient
feel helpless, or because they have invested personal
emotional energy in the treatment.
Stopping
treatment can be explained to patients in terms of the
principle that “chemotherapy that is not doing you good is
doing you harm”. When this is not explained the patient may
continue with debilitating treatment (“so I don’t let my
family down”) and endure unnecessary suffering.
Timely
consultation with colleagues who understand the principles of
hospice and palliative care can help change treatment goals to
restore control to the patient and to maximize his remaining
potential. This reduces the feeling of helplessness, and helps
to restore morale.
«
Teaching doctors about symptom control, communication skills
and spiritual support empowers them to help patients without
resorting to inappropriate therapy.
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.
