What is Chemotherapy?

Chemotherapy is defined as the use of drugs to treat disease. The term most often refers to drugs used to treat cancer.

Why is Chemotherapy used?

While surgery and radiation therapy destroy or damage cancer cells in a specific location in the body, chemotherapy works throughout the entire body. Chemotherapy drugs can kill cancer cells that have metastasized or spread to other parts of the body far away from the primary (original) tumor.

The use of chemotherapy depends on your type of cancer, how large it is, and how far it may have spread. Chemotherapy can be used for several reasons:

• Relieve symptoms caused by the cancer
• Kill cancer cells that may have spread to other parts of the body from the original tumor
• Slow cancer growth
• Keep the cancer from spreading
• In some cases with specific cancers we are able to cure the disease

What are the different kinds of Chemotherapy?

There are more than 100 chemotherapy drugs used in various combinations for the treatment of cancer. Although you could receive a single chemotherapy drug to treat cancer, generally the chemotherapy drugs are more powerful when used in combination with other drugs. Your chemotherapy treatment probably will consist of more than one drug, called combination chemotherapy. This combination of drugs, all with different purposes and actions, will work together to kill more cancer cells.

Chemotherapy drugs are divided into several categories based on how they affect specific chemical substances within cancer cells, which cellular activities or processes the drug interferes with, and which specific phases of the cell cycle the drug affects. Knowing this helps oncologists decide which drugs are likely to work well together and, if more than one drug will be used, plan exactly when each of the drugs should be given (in which order and how often). Courtesy: American Cancer Society

CHEMOTHERAPY AGENTS

Alkylating Agents

Alkylating agents work directly on DNA to prevent the cancer cell from reproducing. As a class of drugs, these agents are not phase-specific (in other words, they work in all phases of the cell cycle). These drugs are active against chronic leukemias, non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma, and certain cancers of the lung, breast, and ovary.

Examples of alkylating agents include busulfan, cisplatin, carboplatin, chlorambucil, cyclophosphamide, ifosfamide, dacarbazine (DTIC), mechlorethamine (nitrogen mustard), and melphalan .

Antimetabolites

Antimetabolites are a class of drugs that interfere with DNA and RNA growth. These agents work during the S phase and are used to treat chronic leukemias as well as tumors of the breast, ovary, and the gastrointestinal tract.  Examples of antimetabolites include 5-fluorouracil, capecitabine, methotrexate, gemcitabine, cytarabine (ara -C), and fludarabine .

Antitumor Antibiotics

Antitumor antibiotics interfere with DNA by stopping enzymes and mitosis or altering the membranes that surround cells. (They are not the same as antibiotics used to treat infections.) These agents work in all phases of the cell cycle. Thus, they are widely used for a variety of cancers.

Examples of antitumor antibiotics include dactinomycin, daunorubicin, doxorubicin (Adriamycin), idarubicin, and mitoxantrone .

Mitotic Inhibitors

Mitotic inhibitors are plant alkaloids and other compounds derived from natural products. They can inhibit, or stop, mitosis or inhibit enzymes for making proteins needed for reproduction of the cell. These work during the M phase of the cell cycle.

Examples of mitotic inhibitors include paclitaxel, docetaxel, etoposide (VP-16), vinblastine, vincristine, and vinorelbine .

Nitrosoureas

Nitrosoureas act in a similar way to alkylating agents. They interfere with enzymes that help repair DNA . These agents are able to travel to the brain so they are used to treat brain tumors as well as non-Hodgkin's lymphomas, multiple myeloma, and malignant melanoma.

Examples of nitrosoureas include carmustine (BCNU) and lomustine (CCNU).

NON CHEMOTHERAPY AGENTS

Targeted therapy/Monoclonal Antibodies:

Monoclonal antibodies have been developed for the treatment of cancer. Monoclonal antibodies are different from traditional chemotherapy. Chemotherapies are chemicals that kill rapidly dividing cells. Monoclonal antibodies target specific kinds of cells with markers on their surfaces and kill only those cells. Both chemotherapies and monoclonal antibodies can kill good cells as well as cancer cells, the effect on the normal cells cause side effects. The side effects associated with monoclonal antibody therapies are generally considered to be more manageable than side effects associated with chemotherapy and radiation. There is the potential although rare occurrence for allergic or anaphylactic reactions that can be severe or even life-threatening. Monoclonal antibodies are not available for all types of cancer and are currently being used for treatment of colon, breast, lung, Non-Hodgkin’s lymphoma and some forms of leukemia. Hopefully in the future we will have this kind of treatment available for ovarian, pancreas and other solid tumors.

Corticosteroid Hormones

Steroids are natural hormones and hormone-like drugs that are useful in treating some types of cancer (lymphoma, leukemias, and multiple myeloma) as well as other illnesses. When these drugs are used to kill cancer cells or slow their growth, they are considered chemotherapy drugs. They are often combined with other types of chemotherapy drugs to increase their effectiveness.

Examples include prednisone and dexamethasone.

Hormonal Therapies

Hhormonal therapies, or hormone-like drugs, alter the action or production of female or male hormones. They are used to slow the growth of breast, prostate, and endometrial (lining of the uterus) cancers, which normally grow in response to hormone levels in the body. These hormones do not work in the same ways as standard chemotherapy drugs.

Examples include anti-estrogens (tamoxifen, fulvestrant), aromatase inhibitors (anastrozole, letrozole), progestins (megestrol acetate), anti-androgens (bicalutamide, flutamide), and LHRH agonists (leuprolide, goserelin).

Immunotherapy

Some drugs are given to people with cancer to stimulate their immune systems to more effectively recognize and attack cancer cells. These drugs offer a unique method of treatment, and are often considered to be separate from "chemotherapy."

You and your doctor will decide which drug or combination of drugs, dosages, route of administration, frequency and length of treatment are best for you. All of these decisions will depend on your specific type of cancer, the location, the extent of its growth, how it is affecting your normal body functions, and your overall general health.

Supportive Care

Biophosphonates:

Biophosphonates (Zometa, Aredia) slow the bone-destroying activity that occurs with bone metastases. They are used to help improve bone strength and reduce bone complications such as bone fracture. Biophosphonates are given to patients with solid tumors and multiple myeloma that have spread to the bones.

Growth factors

Supportive care is available for patients that experience side effects like neutropenia (low white count) and anemia (low hemoglobin).Growth factors are given to increase the white blood count and hemoglobin.

How is Chemotherapy administered?

Drugs used in chemotherapy regimens can be given in many ways. The most common routes of administration include:

• Oral (by mouth or PO)
• Topical (on top of the skin as a cream or lotion)
• Intravenous (into a vein or IV)
• Intramuscular (into a muscle or IM)
• Subcutaneous (under the skin or SQ)

The IV route is the most common form of administration. The IV route gets the drug dispersed quickly throughout the body. IV therapy may be given through a vein in the arm or hand or through a vascular access device (VAD), which includes a catheter implanted into a larger vein in the chest, neck, or arm. The advantages of the VADs include: to give several drugs at one time, for long-term therapy, for continuous infusion chemotherapy, and more stable access in a larger vein thus reducing the risk of drug leaking outside of the vein.

Nurses may wear special gloves and gowns when preparing and giving you the chemotherapy drugs. Additionally, nurses prepare the drugs in areas with special ventilation systems.

pecial procedures are used for disposing of materials after mixing and administering the drugs. There are separate plastic containers to dispose of sharp items, syringes, IV tubing, and medication bags. Gowns and gloves are disposed of in special bags. If any drug leaks or spills, special precautions are used to clean up the drugs.

How often is chemotherapy given?

Chemotherapy is generally given at regular intervals called cycles . A cycle may involve one dose followed by several days or weeks without treatment. This allows normal tissues time to recover from the drug's side effects. Alternatively, doses may be given several days in a row, or every other day for several days, followed by a period of rest. Some drugs work best when given continuously over several days.

If more than one drug is used, the treatment plan will specify how often and exactly when each drug should be given. The number of cycles you receive may be determined before treatment starts (based on the type and stage of cancer) or may be flexible, in order to take into account how quickly the tumor is shrinking.

Certain serious side effects may also require doctors to adjust chemotherapy plans (dosage or schedule) to allow you time to recover.

What happens before, during and after treatment?

Before you can begin treatment, your doctors must first run tests to determine what type of cancer you have and if it has spread to other parts of the body. Once the diagnosis has been made, you will probably talk with your primary care physician along with several oncology specialists, such as a surgeon, a medical oncologist and a radiation oncologist, to discuss your treatment choices. Often, these specialists will work together to help recommend the best treatment for you. In some cases, your cancer will need to be attacked by using more than one type of treatment. For example, if you have breast cancer, you might have surgery to remove the tumor (by a surgeon), then have radiation therapy to destroy any remaining cancer cells in or near your breast (by a radiation oncologist). You also might receive chemotherapy (by a medical oncologist) to destroy any remaining cancer cells that have traveled to other parts of the body.

Before Treatment

Consultation With a Medical Oncologist
If you are considering chemotherapy, you must first schedule a visit with a medical oncologist to see if chemotherapy is right for you. During your initial visit, the doctor will evaluate your need for chemotherapy and its likely results. This includes reviewing your current medical problems, past medical history, past surgical history, family history, medications, allergies and lifestyle. The doctor will also perform a physical examination to assess the extent of your disease and judge your general physical condition. After reviewing your medical tests, including CT scans, MR scans and positron emission tomography scans (PET scans), and completing a thorough examination, your medical oncologist will fully discuss with you the potential benefits and risks of chemotherapy and answer your questions.

During Treatment

Once your chemotherapy treatment plan has been prescribed by the Medical Oncologist, the nurses will coordinate your chemotherapy treatment schedule with you, as well as any necessary laboratory or radiology tests that need to be performed on an ongoing basis.

Depending on your specific chemotherapy drugs prescribed, the drugs will be mixed prior to your treatment and administered by the oncology trained nurses according to the administration method dictated by the physician. Throughout the chemotherapy administration, the nurses will be monitoring you and your vital signs often. The length of your treatment can vary from several minutes to several hours, again depending on the type of chemotherapy you are receiving.

During your chemotherapy cycle, your medical oncologist and nurse will see you regularly to follow your progress, evaluate whether you are having any side effects, recommend treatments for those side effects (such as medication) and address any concerns you may have. As treatment progresses, your doctor may make changes in the schedule or treatment plan depending on your response or reaction to the therapy. Your medical oncology team may gather on a regular basis with other healthcare professionals to review your case to ensure your treatment is proceeding as planned. During this session, all the members of the team discuss your progress, as well as any concerns.

After Treatment

Follow Up
After treatment is completed, follow up appointments will be scheduled so that your medical oncologist can make sure your recovery is proceeding normally and can continue to monitor your health status. Your medical oncologist may also order additional diagnostic tests. Reports on your treatment can be sent to your other physicians. As time goes on, the frequency of your visits will decrease, but you most likely will always follow up with the medical oncologist on a regular basis. However, you should know that your medical oncology team will always be available should you need to speak to someone about your treatment.

Who are the members of the Medical Oncology Team?

A team of highly trained medical professionals will be involved in your care during chemotherapy. This team is led by a medical oncologist, a doctor who specializes in treating cancer.

Medical Oncologists
Medical oncologists are the doctors who will oversee your chemotherapy treatments. These physicians work with the other members of the medical oncology team to develop and prescribe your treatment plan and make sure that each treatment is accurately given. Your medical oncologist will also monitor your progress and adjust the treatment as necessary to make sure you get the best care throughout the course of treatment. Medical oncologists help identify and treat any side effects that may occur due to the chemotherapy. They work closely with other physicians, including radiation oncologists and surgeons, and all members of the medical oncology team.

Medical oncologists have completed at least four years of college, four years of medical school, 3 years of residency (specialty) training in medicine and then 2 years of fellowship in medical oncology training. They have extensive training in cancer medicine and the use of chemotherapy to treat disease.

Medical Oncology Nurses
Medical oncology nurses work with medical oncologists to care for you and your family at the time of consultation, while you are receiving treatment and during your follow-up care. They will explain the possible side effects you may experience and will describe how you can manage them. They will assess how you are doing throughout treatment and will help you cope with the changes you are experiencing. They will also provide support and counseling to you and your family.

Medical oncology nurses are licensed registered nurses and many registered nurses in medical oncology have additional accreditation in the specialty of oncology nursing. Advanced practice nurses, including clinical nurse specialists and nurse practitioners, have completed a Master's degree program.

During your treatment, you may work with a number of other healthcare professionals while undergoing chemotherapy. These specialists ensure that all of your physical, psychological and financial needs are met during your treatment.

Social Workers
Social workers are available to provide a variety of supportive services to you and your family. They can provide counseling to help you and your family cope with the diagnosis of cancer and evaluate your treatment options. They may also help arrange for home healthcare and other services.

Nutritionists
Nutritionists, also called dietitians, work with patients to help them maintain proper nutrition during their treatments. They will help you modify your eating plan if the side effects of treatment are affecting your appetite and what you can eat, and can provide recipes, menu suggestions and information on ready-to-use nutritional supplements. They address dietary issues and current developments that may affect cancer treatment outcomes.

Physical Therapists
Physical therapists use therapeutic exercises to ensure that your body functions properly while you are undergoing treatment. These exercises are used to help manage side effects, alleviate pain and keep you healthy.

Financial Couselors
The Financial Counselors are available to discuss your insurance benefits relating to your treatments and will answer any questions you may have relating to coverage verification, necessary referrals, payment plans, and balances for which you are responsible.

Are there any side effects?

Chemotherapy drugs are made to kill fast-growing cells, but because these drugs travel throughout the entire body, they can affect normal, healthy cells as well. It is the damage to healthy tissue that causes the side effects. Most likely to be damaged are normal cells that divide rapidly including: Bone marrow/blood cells, hair follicles cells, and cells in the reproductive and digestive tracts.

Side effects are different for each person, for each chemotherapy drug, and they also differ based on the dosage, the route the drug is given, and how the drug affects you individually. The most common side effects of chemotherapy include: nausea and vomiting, hair loss, fatigue, an increased chance of bruising and bleeding, and getting an infection.

Most side effects gradually disappear after treatment ends because the healthy cells recover quickly. The time it takes to get over some side effects and regain energy varies from person to person and depends on many factors, including your overall health and the specific drugs you are receiving.