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Title: Cancer palliative treatment
1- What do you understand by palliate cancer treatment (50%).
2- Give examples of what treatment modality can be used for palliation (30%).
3- Give one example of a cancer where palliative treatment is used (20%)
The World Health Organisation defines (WHO) cancer as the major cause of death globally and estimates that 7.6 million people died of cancer in 2005. (1) Another estimate in the United States shows that by 2030 almost 20% of their population will be 65 years of age and older including those with cancer who will require comprehensive health assessment and symptoms management without compromising their quality of life. (2)
Palliative cancer treatment and care is one of the four basic components of cancer control effective programmes implemented by the WHO to reduce the cancer morbidity, mortality rate and improve the quality of life in cancer patients.
Palliative care is defined by the WHO as ‘’ an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’’ (3).
There are two aspects in cancer palliation; palliative treatment and palliative care. (4,5)
(A) Palliative Cancer Treatment:
The aim of palliative cancer treatment is to improve the quality of life by relieving symptoms caused by cancer illness or side effects of cancer treatments and to prolong number of living years even in non-curable cases. (4,6) The treatment can be introduced at any stage during an illness to relief symptoms of sickness or pain such as Dexamethasone in Moderate Emetic Chemotherapy (7) and Opioids in treating cancer pain (8). In addition, palliative treatment can also be used in treating symptoms for example reducing the size of tumour mass by localised radiotherapy or surgery to relief pressure symptoms (4).
Palliative Cancer Treatments include the following:
• Palliative Chemotherapy:
Is the treatment with cytotoxic drugs to kill tumour cells, can be administered intravenously (IV), intramuscularly, orally or topically in some cases of skin cancer. Mainly the IV route of administration is associated with severe side effects while given in cycles followed by recovery period. Due to the aggressive blood cells destruction by cytotoxic drugs and rapid cell division of digestive tract, patient may develop signs of infections, bleeding, nausea and vomiting, hair loss or mouth ulcers. These symptoms are treated by prescribed medicines and tend to gradually ease during the recovery period or after the treatment is complete. Bone marrow transplantation and peripheral cell support to replace cell production could be considered in some cases following chemotherapy and/or radiotherapy. (9)
In many cases where chemotherapy is the curative therapy, patients are willing to accept the treatment side effects and compromise their quality of life in order to be cured. Examples of cancers cured by chemotherapy are: stage IV testicular cancer, early stage breast cancer and colon cancers, Hodgkin’s Disease, acute leukaemia and localised cervical cancer (10). However, the same strategy applies when the goal is palliative for example in cases like advanced breast cancer and colon cancers, lung cancer, pancreatic cancer and metastatic prostate cancer where the patient have no option but to adhere to the same treatment and suffer the same side effects in order to live longer and perhaps increase their quality of life.
• Palliative Radiotherapy:
Is a localised therapy of ionizing radiation in treating disease, it is also used to damage cancer cells in high frequency/energy rays to stop cells growth and division. Palliative radiotherapy is recommended when other treatments such as surgical tumour removal cannot be used. It helps in reducing symptoms associated of pain, bleeding and decreased function caused by tumour pressure for example brain tumour, spinal tumour and tumour near the oesophagus. It can be combined with chemotherapy, surgery or both. It is usually a one-time unrepeated course of treatment, the treatment plan include three treatments on day 0, 7, and 21. (11)
Side effects depend on the treatment dose and the treated part of the body. In most cases they are not permanent and controllable. Patient may experience skin reactions, loss of appetite and neutropenia. (9)
• Hormone Therapy:
Hormones help some types of cancer cells to grow, such as breast cancer and prostate cancer. In other cases, hormones can kill cancer cells, make cancer cells grow more slowly or stop them from growing. Hormone therapy as a cancer treatment may involve taking medications that interfere with the activity of the hormone or stop the production of the hormones. It may also involve surgically removing a gland that is producing the hormones. The type of hormone therapy depends upon many factors, such as the type and size of the tumor, patient’s age, the presence of hormone receptors on the tumor. (12,13)
Tamoxifen (Nolvadex®) is the medication of choice to treat breast cancer by blocking the effects of estrogen on the growth of malignant cells in breast tissue. However, tamoxifen does not stop the production of estrogen. (13)
Side effects may be severe, mild or absent and may include Headaches, Nausea and/or vomiting, Skin rash, Impotence and Decrease in sexual interest
• Biological Therapy:
This type of therapy uses the body’s immune system to fight cancer. It’s designed to boost the immune system, either directly or indirectly, by Making cancer cells more recognizable by the immune system, and therefore more susceptible to destruction. (13.14)
Types of biological therapies used include(13,14):
1. Nonspecific immunomodulating agents: stimulate the immune system to produce more cytokines and antibodies.
2. Biological response modifiers: produced in a laboratory and given to patients. Drugs used include interferons, interleukins, colony-stimulating factors, monoclonal antibodies, cytokine therapy and vaccines.
Side effects may include fever, chills, aches and fatigue. Other side effects include a rash or swelling at the injection site.
(B) Palliative Cancer Care:
Palliative cancer care is usually implemented from the time of diagnosis, during and after cancer treatment and end of life care. It is the total focus of care when cancer treatment is no longer effective. Palliative care take place in hospitals and cancer centres under responsibilities of trained health care professionals who work as part of a multidisciplinary team to coordinate care. It may also be offered in hospice for patients with terminal stage of cancer usually life expectancy of 6 months or less and approaching end of life (5).
Although it shares the same principle of palliative treatment of improving the patient’s quality of life, palliative care goal is not to cure but to support and comfort. Family members and relatives are usually affected in terms of extra responsibilities placed upon them, stress, emotional instability and uncertainty, they may also be included as part of the emotional and spiritual support provided in palliative care. (15)
Treatment modality can be described as Combined Modality Therapy when more than one therapy is prescribed such as combination of radiotherapy and chemotherapy. When the treatment is given after the primary cancer treatment is completed to improve the chance of a cure then it is described as Adjuvant Therapy. It is also known as Neoadjuvant Therapy when more than one therapy are used especially when cancer treatment is given before the primary therapy to contribute to the effectiveness of the primary therapy. (16,17)
Examples of combined-modality treatment for palliation (17):
• Radiotherapy followed by Surgery:
Removal of neck lymph nodes by neck dissection after radiation therapy for cancers of the mouth or throat region. The operation is done to reduce the risk of recurrence in the neck and improve the chance of cure.
Adjuvant radiation therapy given before surgery for rectal cancer to reduce the risk of recurrence, increase the likelihood of cure, and reduce the likelihood that the patient will require a permanent colostomy.
• Chemotherapy followed by radiotherapy:
In Hodgkin’s disease chemotherapy is administered into two to three cycles before radiation therapy to improve the probability of cure.
• Surgery followed by chemotherapy and radiotherapy:
In moderate to advance stages of breast cancer where subtotal mastectomy or radical mastectomy is the first choice of treatment followed by chemotherapy and/or radiotherapy according to the tumour grading/staging and extend of metastasis aiming to cure or increase survival rate. Hormonal therapy may be introduced at some stage. The same strategy applies to thyroid cancer.
• Drug modality:
A study on the colorectal cancer treatment showed that the combination of COLO 205 cells with metformin and silibinin would decrease cell survival resulting in the expression of activated caspase 3 and apoptosis inducing factor, followed by apoptosis when applied at a dose insufficient to influence the non-malignant cells [Human colonic epithelial cells (HCoEpiC)]. This shows a potential drug modality method for the treatment of colorectal cancer. (18)
• anti-angiogenic therapy:
Angiogenesis inhibitor is the chemical that interferes with the signals to form new blood vessels in order to cut blood and oxygen supply from cancer cells, thus preventing metastasis. Bevacizumab (Avastin) became the first anti-angiogenesis drug to be approved for treating cancer. (18)
Hyperthermia is heat therapy. Heat can be applied to a very small area or to an organ or limb. It is usually used with chemotherapy, radiation therapy and other treatment therapies.
Complementary medicine: used combination with other alternative treatments or standard/conventional medicine to relief symptoms and improve quality of life, this include massage therapy, dietary and herbal supplements, physical exercise and hypnosis. (13)
Example of a cancer where palliative treatment is used:
Is one of the unpredictable types of cancers that may turn into an aggressive form after being dormant for more than 20 years.
A small study that included smokers, ex-smokers and people who had never smoked found that after the first genetic mutations that can cause cancer had been triggered, the disease can exist for many years before additional genetic faults cause it to suddenly flare up. (19)
More than 43,000 people in the UK are diagnosed with lung cancer each year and, despite some positive steps being made against the disease, it remains one of the biggest challenges in cancer research, with fewer than 10% surviving for at least 5 years after diagnosis. (19)
Two-thirds of patients are diagnosed with advanced forms of lung cancer when treatments are less likely to be successful.
The most common type of lung cancers is non-small-cell lung cancer (NSCC), accounting for around 80% of all cases.
Non-small-cell lung cancer is divided into three types: squamous cell carcinoma, adenocarcinoma and large-cell carcinoma.
The symptoms depend on the primary tumour’s size, its location in the lung, the surrounding areas affected by the tumour, and the sites of tumour metastasis, if any. Symptoms related to the primary tumour may include any of the following (19)
Cough, Shortness of breath, Difficulty taking a deep breath, wheezing, haemoptysis, pneumonia or other recurrent respiratory infection, pain in the chest, side, or back, hoarseness, difficulty swallowing, or other symptoms in the face, neck, or arms due to infiltration by a tumour
Symptoms of metastatic lung tumours, which have spread from the lung, depend on location and size. Lung cancer most often spreads to the liver, the adrenal glands, the bones, and the brain. About 30-40% of people with lung cancer have some symptoms or signs of metastatic disease. (19,20)
The goals of treatment for non-small-cell lung cancer are to remove or shrink the tumour, and to kill all remaining tumour cells.
Treatment options will depend on the staging, spread and locations of tumours, and include (19,20):
• Surgery: which involves tumour surgical removal such as lobectomy, pneumonectomy or segmentectomy. Lymph nodes excision is also common.
• Chemotherapy: Because of its tendency to spread extensively, small-cell lung cancer is typically treated with combination chemotherapy – which is the use of more than one drug – and often in conjunction with radiotherapy.
• Radiotherapy: After lung cancer surgery, radiotherapy and chemotherapy may be necessary to kill remaining cancer cells, but is usually delayed for at least a month while the surgical wound heals. Non-small-cell lung cancers that cannot be treated with surgery are usually treated with radiotherapy and chemotherapy.
• Laser therapy: A narrow beam of intense light called a laser is used to kill cancer cells.
• Biological therapy.
Inoperable NSCLC is treated with chemotherapy or a combination of chemotherapy and radiotherapy. Biological therapies may also be used