| In 1987, Dr. Wilson Mertens was walking toward the hospital he was working at when he saw a man running out the door so fast that his gown was flowing behind him.He was dismayed to discover it was one of his patients, who was scheduled to receive a session of chemotherapy. The man was terrified, because the previous treatment had resulted in violent nausea and vomiting. “Years ago, people often started vomiting while the chemotherapy was being administered and occasionally before,” said Mertens, medical director of cancer services for Baystate Regional Cancer Program. “Back then, dealing with nausea and vomiting was a big challenge.”
But today, advances in medicine have all but eliminated such side effects and patients are given much more personal support. “People can come in, get a treatment and go right back to work. It’s not universal, but is very common,” Mertens said. “Most patients experience no nausea or vomiting from their cancer therapy, which allows them much more lifestyle flexibility as well as a better quality of life.”
There are also new drugs that target specific types of cancer, and although “personalized medicine” has yet to be realized, “there are entire classes of chemotherapy drugs that weren’t available 10 or 15 years ago and many new medications that can be used to treat a variety of cancers,” said Mertens. “Chemotherapy can do incredible things today that we couldn’t have imagined 15 years ago.”
Dr. Sean Mullally agrees.
“Twenty years ago there were very few chemotherapy drugs available and they certainly were much more toxic than they are today. New drugs have been developed that have fewer side effects, along with drugs that are used to ameliorate side effects,” said Mullally, medical director for Cooley Dickinson Hospital’s Cancer Care program. “People are often surprised after their first treatment how well they tolerate it.”
That’s an enormous difference from the experience people had 20 or more years ago, when studies were done to determine whether a person’s quality of life was better with or without chemotherapy. “Now, studies show that chemotherapy is the better option in terms of quality of life. It has evolved significantly from therapy that targets cancers but also affects the rest of the body,” Mullally said, adding that drugs have been developed to mitigate side effects such as mouth sores and neuropathy or tingling and/or numbness in the fingers and toes that can result from chemotherapy.
New medications include enzyme blockers that are given in pill form to treat kidney cancer as well as certain types of thyroid cancer. “Molecular technology has allowed us to treat some categories of cancer in different ways,” Mertens told HCN. And ongoing research shows patients don’t need as many treatments as they did in the past to reap the maximum benefits.
Inner Workings
Traditional chemotherapy works by killing cells. “The drugs are incorporated into the DNA of cells, and when they divide, they die,” Mullally explained, adding, that cancer cells divide much more rapidly than normal cells. The reason for side effects such as hair loss and mouth sores is that hair follicles and the tissue in the mouth are made up of rapidly dividing cells.
Unfortunately, healthy cells can also be damaged, but are less likely to be affected because they don’t divide as quickly.
As researchers discover more about the causes of cancer, they have been able to develop therapies that target specific genes on chromosomes, usually oncogenes. Mertens said mutated oncogenes are the genes that are stuck “in the ’on’ position and are the targets being sought.”
He uses the analogy of an accelerator pedal in a car to describe targeted therapy.
“Normal cells regulate themselves according to what they need to do in the body,” he said. “But cancer cells have an accelerator problem; it’s like the accelerator is stuck and there is no restraint. In the old days, we would apply the brakes, or perhaps use nail strips on the ground to slow it down. But now we are trying to fix the accelerator.”
This is accomplished when researchers identify a specific mutation for a type of cancer, then develop a treatment for it. But such cutting-edge therapy is very specific and cannot be used for everyone. For example, researchers have found two or three “accelerators” for lung cancer, but only about 7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of people with the disease have the specific molecular mutations that can be targeted with the pills that treat it.
Still, other drugs have been developed that have revolutionized the treatment of some types of cancer, such as chronic myelogenous leukemia. A drug named Gleevec, or imatinib, which targets the leukemic cells, dramatically alters the course of the disease.
“It was literally a miraculous discovery and the first of its kind,” Mullally explained, adding that the drug is given in pill form and has few side effects. “There are a few other cancers that also respond remarkably well to it, including a rare type of tumor in the gastrointestinal tract.”
Another effective targeted drug used to treat lymphoma (cancer of the lymph system) is rituximab. “There is a molecule on the cell’s surface, and the drug bonds to it; it kills the lymphoma but spares the rest of the body from side effects,” Mullally said. “The trend is to develop pills rather than intravenous treatments. In many cases these targeted therapies are more effective and spare people from experiencing side effects.”
Although these medications can shrink tumors and keep cancer under control for years, eventually they stop working. “Clinical data shows that targeted therapy may not be sustainable. So while it is an advance, it’s not a cure,” Mertens said. “It would be a dream if researchers were able to find specific mututations and be able to turn off the cancer.”
But cancer cells find a way to develop resistance, he contined. “Cancers are not made up of normal cells, and if you look at their chromosome structure, they often have a snowstorm of problems.”
However, some types of cancer can be completely eradicated by chemotherapy, including a type of leukemia seen in very young children, testicular cancer, and many types of lymphomas.
Mind, Body and Spirit
When people are told they need chemotherapy, they often become anxious. “When patients come into my office they are terrified of the diagnosis and the potential side effects of treatment. But after counseling, they usually become more open to it,” Mullally said.
Reanne Burke agrees, and said that patient education makes a significant difference.
“People often feel vulnerable when they come in for their first treatment because they feel they have lost all control over their lives,” said Burke, regional nursing manager of cancer services for Baystate Regional Cancer Program. “Once people become knowledgable about chemotherapy and have the support of an entire oncology team, they are able to overcome their fears. The ultimate goal is a cure, even though everyone is not cured. And there are many medications that can be used. Some have minimal side effects, while others have more substantial effects.”
But great care is taken to ensure that everything goes well. The day before a patient receives chemotherapy at the D’Amour Center for Cancer Care, a clinical review of the prescription is undertaken to ensure that the person is getting the right drugs for their condition as well as for their height and weight.
“Nothing is ever rushed,” said Pharmacy Supervisor Scott Gray, adding that the review takes about 15 minutes and another 20 minutes is spent putting the drugs into intravenous bags, which is done right before the infusion.
The work is done inside an enclosed chamber. Pharmacists don special gloves, then put their hands through a type of netting and handle the medicines inside. This is done for their own protection, since the drugs are toxic, as well as to ensure sterility.
The cost of chemotherapy drugs can vary from $10 to $30,000 per dose, and shortages are so common across the U.S. that Baystate has had people call from Boston and a variety of other institutions seeking medication.
“But we have not had a patient miss a session of therapy due to these shortages,” Gray said, adding that Baystate has taken a very aggressive approach to keeping an adequate supply in stock. “If someone misses an infusion session, it definitely affects the outcome.”
Proven Efficacy
Mullaly said fatigue, pain, and depression, along with physical anexoria, weight loss, and a progressive decline can result from cancer that goes untreated.
And experts agree that people who cannot be cured can still benefit from chemotherapy. In fact, patients in Stage 4 sometimes receive treatments to shrink tumors that are pressing on other organs, which causes pain.
“In the majority of situations, chemotherapy, even in terminal disease, will improve the quality of life. The side effects are not as bad as the side effects caused by the cancer growing,” Mullally said. “I tell people with lung cancer, which is the most common fatal malignancy, that if they have chemotherapy they will live twice as long on average and have a better quality of life. And even if the cancer returns, they will have a period of time when they feel better because their body is not being ravaged by the cancer.”
Mertens concurred. “There is good evidence that even when cancer can’t be cured, chemotherapy can improve survival and the quality of life. If you can shrink the cancer you can reduce pain or organ failure,” he said, adding that even if a patient is too weak to receive treatment, data shows palliative care makes a difference.
That finding has made a dramatic difference in both the quality of life and how long people live.
Mertens said he remembers attending an annual conference of the American Society of Clinical Oncologists in 1988. “They only had four posters in a stairwell that addressed palliative care,” he said, explaining that, “today there has been a radical change on the part of oncologists to look at research and delivery systems to provide adequate patient support. Cancer treatments will come and go, but we will continue to advance in the ways we can support people; It’s a permanent and real attitudinal change.”
Hope for the Future
There are many types of cancers that can be cured by administering chemotherapy in combination with radiation. “And there are more advances coming due to studies being done to ensure better treatments and outcomes for patients,” Gray told HCN.
There is also so much support that side effects such as hair loss are not as bad as they were in the past. “The quality of wigs has improved dramatically over the last 20 years,” Burke said.
And in today’s world, physicians welcome conversations with patients about their treatment. “In the past there was a lot of passivity. But now, treatments really have to fit the person and their way of life, particularly their social support structure,” said Mertens. “We would rather craft an appropriate treatment plan initially than have to change it halfway through because it proved impractical; there are guidelines available to patients as well as oncologists that evaluate the evidence and appropriateness of different approaches. This allows patients the opportunity to receive the best care for their cancer and their situation.”
Mullally agrees that the news about today’s chemotherapy is encouraging. “There are drugs available that are amazing, effective, and well tolerated,” he said.
All this is a world away from the treatments of the past, where the cure seemed almost as bad as the disease and people were literally running away from it. |
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