What criteria does a doctor use when choosing chemotherapy?
Whether a doctor chooses one drug (monotherapy) for you, a number of different drugs (combined chemotherapy) or successive changes to your chemotherapy regime depends on a number of factors. First, doctors are directed by European, American or Latvian treatment guidelines for specific tumours, adjusting them to local circumstances (mainly the availability of state-subsidised drugs). These guidelines have been compiled based on the experience gained from numerous clinical studies. It’s true, however, that patients were chosen for these studies who met certain criteria, so when extrapolating (transferring) these data to real patients in general, the results may differ slightly. The guidelines usually recommend a number of solutions with a variety of drug combinations or monotherapy. There is no one correct path. The type of chemotherapy depends on each individual situation and can differ from patient to patient, so you have to discuss this with your doctor. If one specific drug (usually a new and expensive one) isn’t available, that doesn’t mean that there are no other treatment options. There are no miracle drugs in oncology. Take a look at the NCCN or ESMO guidelines and you’ll see that among the available drugs are also long-standing drugs, which no one plans on removing from the list as they are still effective.
A no less important factor when choosing a specific drug or a combination of drugs is your own personal experience, that of your colleagues or possibly what you’ve read in scientific literature about its efficacy, toxicity and safety. You may find that a drug or a combination of drugs offered to you have helped (the size of the tumour was reduced, or it completely disappeared) 40% of patients involved in a research study. No one can foresee whether this treatment will help you. If the specific drug helped 40% of patients in the study, then it’s possible that only 30% were helped in real life. So, you should count on a 30% chance that the drug will help and a 70% chance that it won’t be successful. Everyone has the right to hope for the best scenario and perhaps it will also come to fruition, but be prepared. If there’s a chance that the treatment won’t help (with metastatic tumours you’ll have to wait at least three months to know) and the chosen therapy is toxic, not well-tolerated and has serious side effects, then definitely talk to your doctor about other options (other drug combinations or monotherapy). On the other hand, we can only be sure of the efficacy of adjuvant or preventative therapy after several years have passed. The five-year survival rate is often considered a benchmark for a chosen therapy’s efficacy. If nothing bad has happened within those five years, then you’re most likely healthy. However, five-year survival rates only show if the patient is still alive. But is he healthy? Moreover, it’s possible that the disease can also return 10, 15 and 20 years later. The remission period, or time between the onset of the disease or the beginning of therapy and the first metastases or recurrence, is also commonly used as an indicator of the efficacy of adjuvant therapy. It’s convenient to use in clinical trials, because you don’t have to wait for years and years.
Another factor that is also often taken into account is the experienced remission time with a specific chemotherapy method. To put it another way, it’s a measurement of how much the drug or combination of drugs helped to eliminate or reduce the effect of the disease until the next metastases or recurrence. Everything can be reduced to numbers, but we must take into account that every person is unique and that it’s, unfortunately, impossible to predict just how effective a combination of drugs will be on you.
The choice of treatment also depends on your overall health, comorbidity and the medication that you’re taking. Age isn’t the only obstacle to receiving an effective treatment. Naturally, as we age our immune systems and the capacity of our organs to function properly is reduced, which can have a negative effect, for example, on how well toxic substances are expelled from our bodies. But everything must be looked at in the context of both existing health problems and the potential toxicity of chemotherapy. It wouldn’t be wise to prescribe severe and toxic chemotherapy that is not well-tolerated, if your quality of life will be significantly reduced.
Therefore, I can say that there is no one correct set of criteria that should be used when choosing chemotherapy. Each strategy has its own pluses and minuses that must be considered. In addition, it’s possible that you’ll need to change drugs or their combination over the course of your therapy. You should also understand that the chemotherapy that helped in the beginning may not work later if the disease progresses.
Doctors are happy to prescribe the latest drugs or combinations of those drugs and patients tend to believe that they’re better than the old ones. However, this is not always the case, because it’s impossible to predict your tumour’s sensitivity to the most modern, widely-marketed drugs beforehand, despite all of the refined genetic and molecular biological methods of investigation now available to us. Don’t despair if you can’t afford one of the widely advertised life-saving drugs. It’s possible that it would have done more harm than good in your specific case. However, you have the right to choose the drug you want, and hope is always the last thing to die. Good luck!
If I’m not offered chemo…
It’s possible that you have a tumour that doesn’t really respond to chemotherapy, so there’s no point in prescribing it. You’ll most likely be offered other options (radiation, hormone therapy, immune modulating therapy, targeted therapy, oncological virotherapy or observation).
Severe side effects (liver or kidney failure, poorly adjusted chronic diseases) and complications from prior treatments (such as bone marrow suppression with inadequate blood cell production) can serve as reasons why chemotherapy hasn’t been offered or it has, but with relaxed treatment conditions. These could include lower doses or less aggressive drugs. Your therapy might also be suspended, delayed or refused entirely, but this is all done for your benefit, taking into account your current health status.
You also shouldn’t be confused if your hospital roommate with the same diagnosis received a different treatment. That doesn’t mean that you’re getting worse or less intensive treatment. Each treatment regime is chosen according to your body’s current condition.
How to prepare for chemotherapy?
Before beginning chemotherapy, I recommend you do some preparation work. If you have time, visit a dentist and have any problems fixed. Because chemotherapy can last for several months during which there’s a large risk of infection, it would be good to eliminate any infections in your mouth. Your teeth shouldn’t be fixed or removed during chemotherapy.
If you’re of a certain age and you’re expecting an invitation for a gynaecological screening, then do it before chemotherapy or delay it for another six months until the course of chemo has been completed. During chemotherapy it’s possible to receive a false positive (the mucous membrane cells change), which will only worry you unnecessarily.
If your doctor has warned you about hair loss, then I recommend you cut your hair short and buy a wig ahead of time. The reason I suggest this is because it can be less traumatic then waking up in the morning and seeing handfuls of hair on your pillow. This will also allow your friends and relatives to get used to your new appearance. You should also choose a wig with a shorter length. Naturally, a wig isn’t mandatory. Many women choose to shave their heads or to wear head scarves.
Think about transport and how you’ll get to and from your chemotherapy procedures. I know that many patients drive themselves or take public transport, but it’s possible that you’ll be too tired or lack the energy afterward. It would be wise if someone drove you at least to the first few procedures.
Wear comfortable clothes made from breathable fabrics for chemotherapy. Think carefully about your sleeves. Therapy is usually introduced via your elbow vein, so you should have sleeves that can be easily rolled up, perhaps with buttons to make it easier to access your arm. Many women prefer separate garments – trousers and skirts with a blouse or shirt.
Chemotherapy can last for several hours (find out exactly how long you’ll be attached to an IV), so think about what you might want to bring with you to pass the time. A book is one option, but I suggest listening to music with earbuds. You can ask someone to make you a relaxing playlist. Obviously, YouTube is another option. Look for relaxation, bedtime or music in general that’s soothing for the brain. This could be classical music, but also any music that you like or that’s in tune with your mood. These days you can also watch movies, opera or ballet, or lectures on your smartphone or even learn a new language or hobby. Always use headphones or earbuds, so you don’t bother other patients. This is another way that your friends and loved ones can help and support you.
Definitely speak to your supervisor or manager at work. It’s possible that you can schedule chemotherapy for a Friday afternoon and be ready to return to work on Monday. You might also be able to tolerate the therapy well and you might not even need to take time off from work. But this is hard to predict, which is why it would be good if you warned your employer about the possibility that you’ll require time off from work. From experience, I know that colleagues are generally well-meaning and supportive at work. But it’s another thing if you don’t want to share this with them. Think carefully about this and leave yourself a little wiggle room in case the chemotherapy isn’t well tolerated. You are definitely entitled to disability (in Latvia), which you should use if necessary. Also, I know from experience that many women use this time off to do a variety of household chores or to take their kids out, but I urge you not to expend too much of your energy. You should use this time to relax and to recover your strength.
Definitely consider accepting help from others. This could mean looking after your children, your home and shopping. Some women believe that they can move heaven and earth during chemotherapy and don’t even entertain the thought of asking for help. This is simply wrong. You definitely need assistance, because a lot of energy is expended during chemotherapy. The body needs to replace damaged or destroyed cells with healthy ones and this requires additional energy resources, which are finite during your illness. Even before chemotherapy you should consider who can help you and with what. For example, shopping, preparing meals, driving your kids to school or other activities, etc. Sometimes, delegating various duties to your loved ones can bring a family closer together, but it will also make your kids grow up quicker. Don’t push them away, but rather give them a chance to take on new responsibilities and to help around the house. Many times, you’ll be nauseous and may even vomit after chemotherapy, so you definitely won’t even want to think about eating or preparing a meal. It would be good to prepare and freeze small portions of food that you can heat up later. Then you won’t have to worry about standing in front of a stove. Another option is to have someone else cook while you’re away from home, because the smell of food can often trigger bouts of nausea and a negative view of food. Eating is very important during chemotherapy. You shouldn’t eat heavy foods (fatty or fried) at this time, but rather dishes such as vegetable casseroles, softened fruits and a variety of salads with oil, crushed nuts (if there’s no inflammation of the mucous membranes), seeds and herbs.