Chemotherapy is one type of systemic treatment. This means that once the chemical substances, or drugs, enter the bloodstream, they spread throughout the entire body. While surgery and radiation are considered local treatment methods, drug therapy is systemic affecting the whole body. Patients traditionally refer to it simply as chemo, but today a wide variety of drugs are available, which differ not only in the way that they work, but also in their structure and how they were designed. Therefore, it isn’t correct to label all systemic treatment options as chemotherapy. It’s the oldest, but not the only method. In other sections we’ll also discuss the other methods – hormone therapy, targeted therapy, immunotherapy, biotherapy, virotherapy – that are all similar in that they all affect the entire body.
Objectives of chemotherapy
We can conditionally discuss three objectives of chemotherapy – treatment (curing), disease control (limiting or stopping) or alleviating the situation (usually this means reducing the size of the tumour and its associated symptoms). When your doctor offers this method, it’s very important to understand what he intends to achieve, what your chances are and what are the potential complications. You must also understand that no doctor anywhere in the world can guarantee the success of this therapy. Even if you both agree that a cure is your main objective, you might not succeed. On the other hand, the lower the likelihood of a cure, the more important it is to find a well-tolerated and safe therapy that won’t adversely affect your quality of life, immune system or the normal functioning of your body. You have the right to seek a second opinion if you’re not convinced that the treatment offered is right for you. Unfortunately, today’s so-called multidisciplinary approach to medicine places the cancer patient in an unenviable situation where he lacks a primary care physician. One operates, a second irradiates and another prescribes medication. Each one is a specialist in his field, but the patient lacks a primary doctor who can evaluate the patient overall, which is often called the holistic approach. This means that the patient isn’t just another disease to be cured, but rather a living, breathing individual in body and spirit.
There will be some cases when chemotherapy will genuinely cure the disease, or at least significantly prolong life and slow the recurrence of the disease. However, no one can guarantee that this will happen to you, because the prognosis is the part of the disease, which changes the most. In the Latvian language, this can be rather confusing. People usually assume the word izārstēt (which can mean both to treat and to cure) implies a complete cure, without a recurrence. But it would take many years to verify this. There are certain localised tumours that can be categorised as diseases, which, when detected early enough in combination with a variety of other fortunate circumstances, can be completely cured, in the true sense of the word, with chemotherapy. However, you must also be prepared for a less rosy scenario. Today, chemotherapy can successfully treat onco‐haematological diseases (lymphoma and acute leukaemia), testicular cancer, choriocarcinoma, ovarian cancer and some childhood oncological diseases, where drug therapy has proven over the years to be demonstratively effective. However, studies are one thing and individual cases are another. Average statistical data can be confusing, and, in my experience, many people don’t understand it. Moreover, everyone hopes that they’ll be among the lucky ones who are cured. And why not? Especially if this can be achieved without any serious additional pain, loss of quality of life or severe side effects or complications.
Disease control usually means that chemotherapy can reduce the size of the tumour and inhibit its further growth and dissemination. This is also called adjuvant therapy or preventative chemotherapy. It is usually administered after surgery, if there is a risk that the disease could return. It’s difficult to predict whether or not this will happen. Doctors usually look for specific objective indicators that have proven their potential over the course of many years for an increased risk of metastatic disease. Each individual tumour has its own set of indicators for an increased risk of recurrence. However, exactly how these will affect you specifically is difficult to predict. I often hear the following phrase from my patients – to be on the safe side, let’s do chemotherapy. This is a moment for philosophical reflection when the doctor must assess all the potential risks related to therapy including your overall health, comorbidity, expectations and doubts. Unfortunately, in my experience, if a patient doesn’t have faith in the prescribed therapy, it usually won’t be successful. Therefore, this conversation with your doctor about your upcoming therapy is of paramount importance. Recently, adjuvant or preventative therapy is prescribed for many types of localised tumours and not just for breast, intestinal, lung and bladder tumours. Treatment strategies change as experience is accumulated. Systemic therapy is now often prescribed for situations when it once wasn’t.
Post-operative chemotherapy is usually administered with the objective of eliminating cells that are circulating in the bloodstream or that have already migrated elsewhere in the body where they can’t be detected. The large mass of the tumour was removed during surgery (or treated with radiation), but a hidden enemy could still pose a threat. People often ask me if they should be stimulating their immune systems after an operation instead of weakening it with chemicals. There is no clear answer. There will be cases when a patient should be hopeful, but others when a patient must be persuaded that chemotherapy is the best option, even if it has notable side effects. These days, when so many people write and talk about changing lifestyles, diet, physical fitness and psycho-emotional rehabilitation, it’s perhaps worth listening to their suggestions. They certainly won’t interfere with your chemotherapy or with the maintenance or improvement of your immune system.
Although rare, there are some cases when chemotherapy can relieve certain symptoms related to the disease. By reducing the size of a tumour, especially one that has placed pressure on other structures of the body, you can alleviate symptoms such as pain, shortness of breath and other serious health problems. So-called symptomatic therapy can much more successfully improve quality of life, but chemotherapy can help even in cases that seem hopeless. Ideally, when it is combined with other methods. My colleagues often have a negative attitude toward complementary methods and integrative approaches, which is essentially the acceptance of any additional methods aimed at improving the patient’s condition. I also know that most people are discouraged by the term palliative chemotherapy. It’s true that curing or significantly inhibiting the course of the disease isn’t its objective, but it is meant to improve wellbeing, to reduce symptoms, to generally alleviate the burdens of the disease and to prolong life, if only minimally.
Types of chemotherapy
Sometimes chemotherapy will be the only option your doctor will offer. However, today chemotherapy is most often combined with other treatment methods – radiation, surgery, hormone therapy and targeted therapy.
Neoadjuvant chemotherapy is the prescribing of medication before an operation with the objective of reducing the size of the tumour and of assessing whether or not it’s effective in your specific case. Neoadjuvant chemotherapy is often combined with radiation with the goal of improving future indicators of life expectancy. A typical example would be the initial treatment of breast cancer with drugs. In this case, your own participation is essential, as you’ll have to keep track of any changes to your tumour. If you think that it has continued to grow during neoadjuvant chemotherapy, don’t hesitate to inform your doctor. In many cases, the size of tumours is significantly reduced during neoadjuvant chemotherapy and additional chemotherapy isn’t even necessary after surgery. Neoadjuvant chemotherapy is most often used for somewhat large, localised (with tangible or visible metastases in the regional lymph nodes) tumours.
Adjuvant chemotherapy or preventative therapy is the prescribing of medication after the primary tumour has been removed surgically or treated with radiation and a risk of a recurrence still remains. Over the years, a wide variety of drug combinations and treatment strategies have been developed and tested on most tumours and new drugs are also now available. In any event, if one treatment plan doesn’t work, it can be changed to another. It’s true that just how effective this adjuvant therapy has been and how necessary it was in a specific case is difficult to know. Many years must pass to judge whether or not it was the right choice, because the person still has to be alive years after the disease was first detected. To say that it’s possible that the patient would still be alive even without this therapy is also incorrect, because the prognosis is the most mercurial factor of the disease. Neither the doctor, nor the patient would want to take that risk. However, it should be discussed. A variety of circumstances, conditions and coincidences could lead to a recurrence of the disease after 10, 20 or even 30 years, regardless of the chosen therapy. This is the disease’s biggest problem – its unpredictability.
Palliative chemotherapy usually refers to a widely metastasised tumour, when the cancer cells in the body are too numerous to treat with radiation or surgery. Sometimes systemic palliative chemotherapy can prolong life. It is often combined with other methods. Of course, the doctor will decide if it’s wise to choose intensive therapy if the disease is very aggressive and its treatment can cause more harm than good. It’s very hard to refuse treatment, because the patient is usually willing to believe in miracles and to accept severe side effects to regain hope that they might live. A frank discussion with your doctor is also very important in this situation. I’ve encountered angry patients and relatives who blame the doctor or even the country for not doing anything for them and for not providing expensive, innovative drugs. However, there are situations when treatment can’t continue without significant harm to the patient’s health due to the rapid and widespread progress of the disease. In most cases, people, at least here in Latvia, aren’t ready to accept that our common goal is to ensure the wellbeing of the patient and a good quality of life for as long as possible. Even the Pope can’t guarantee eternal life on earth, never mind a doctor…