The realities of a cancer diagnosis are still present, but treatment options are advancing rapidly. Learn some of the incredible new technologies and methods that make cancer treatment safer than ever before.
Recently, the American Medical Association (AMA) predicted that, within 20 years, 90 percent of patients will not die because of their cancers.
The reason: In the past 50 years, cancer treatment has advanced tremendously. Not only has surgery improved – for centuries it was the only treatment – but oncologists also have been given an arsenal of medical weapons with which to fight the disease in its many forms. Instead of a solo role, surgeons are teaming up with the appropriate oncologists to provide patient-specific treatments.
Surgery: Still Important
Dr. Pierre Charles, a board-certified general surgeon for Beloit Health System, says that in many cases, surgery is still the primary treatment for cancer, often with curative results. Charles specializes in abdominal, thoracic and vascular procedures, and says that, when caught early enough, cancers such as those in the skin, breast and colon may be cured with surgery.
“Surgery plays a major role in treating breast cancers,” he says. “About 99 percent of breast cancer patients undergo some form of surgery. Conversely, very few patients with lung or pancreatic cancer are eligible for curative surgery. Usually, by the time these cancers are diagnosed, they’re at a very advanced stage.”
Charles says many people don’t realize that cancer is not something they catch but is a result of unchecked cell growth within our bodies. This unchecked cell growth may be secondary to external factors, such as exposure to cigarette smoke, asbestos, ultraviolet radiation, or other chemical agents.
“From the time of conception on, our cells are constantly dividing,” Charles says. “The division of cells is usually very precise, but occasionally, a ‘rogue cell’ develops. All of our cells, including cancer cells, come from the same DNA, but evolve to perform different functions. All of us have naturally occurring cancer-suppressing cells, which have the sole function of seeking out and destroying cancer cells. The trouble comes when cancer cells begin to ignore the body’s natural rules and behave abnormally, or when the cancer-fighting cells are overwhelmed and unable to perform their role.”
For centuries, surgery was the sole means of treating cancer. “But today, surgery plays a shared role with other modes of treatment, as technology and medicine have advanced,” Charles says. “What cancers we can’t completely cure with surgery, we treat with chemotherapy, radiation therapy, hormonal therapy and immunotherapies. The important factor is early detection. That’s why consistent health screenings, such as mammograms, PSA tests, chest x-rays and visual examinations, are vital in the early detection of cancer.”
The role of the surgeon isn’t only to remove the tumor but also to evaluate the cancer’s stage and whether or not it has spread to other parts of the body. A low-grade cancer grows slowly, while a high-grade cancer grows more rapidly. Sometimes, surgery is the only way to be absolutely certain.
Charles and his colleagues study these cancers to learn more about how they progress, and the best ways to treat them. But surgery isn’t part of the treatment for bloodborne cancers such as leukemia, and isn’t effective for bone marrow or lymph node cancers. These are treated with non-invasive medical therapies.
“The question I hear most from patients is, ‘Will my cancer come back?’” Charles says. “The answer is that it really depends on the stage in which the cancer was diagnosed. For more-advanced stages, the best way to handle the possibility of recurrence is to look at the cancer as one would diabetes or high blood pressure. It may not be curable, but it is certainly treatable. The goal, then, is long-term, disease-free intervals. I tell them to take care of themselves and to get as much out of life as they can. And as their surgeon, I remind them that I’m here to help them with the journey.”
Chemotherapy, now commonly used to fight cancer cells, was initially a toxic cocktail of drugs that attacked cancer on a broad-based scale. It targeted adversely affected DNA, but also caused severe nausea and low blood counts, which often led to infections. According to Dr. Michael Huie, a board-certified University of Wisconsin medical oncologist treating cancer patients at Monroe Clinic and Hospital, today’s chemotherapy consists of new drugs that not only refine treatment but also target specific cancers.
“We’ve been using chemotherapy since the 1960s,” Huie says. “Not only do we have more supportive drugs to control nausea and other side effects, but we also have an enlarged arsenal, ten times what was available 40 to 50 years ago. In fact, the number has increased five times since I began practicing more than 10 years ago.”
Molecular targeting helps to make chemotherapy more tolerable than ever, along with refined dosages and exacting standards, Huie explains. Through the past decade, extensive research and studies have helped to develop optimal medicines that allow patients to retain quality of life, including working while undergoing treatment.
“Every cancer is as different as the patient,” Huie says. “While there are some cancers that chemo doesn’t effectively treat, such as brain tumors, it’s effective for early-stage cancers. For late stages or recurring cancers, chemo is likely to be less effective.”
Still, while modern chemotherapy is tremendously improved, Huie says that one of his first priorities is to ease the concerns patients have because of preconceptions about its side effects. These misconceptions are formed by the stories of those who underwent chemo in the past, or have older family members and friends who did so.
“We need to educate patients in advance, so when they do have to come in for chemo, they’re better prepared, in general, and understand it’s better now,” Huie says. “Chemo treatment programs are more subtle, advanced and targeted now.”
Today, patients receive chemotherapy infusions in a variety of ways. Some can be delivered in an hour or two, outpatient style. Others may take up to six hours and require a hospital stay. Some patients receive their treatment at home, via a portable chemotherapy pump which they carry in a holster or pouch.
“Quality of life is every bit as important to us as curing or managing the cancer,” Huie says. “We don’t expect to cure every cancer, but we can help patients to live with it, while reducing the fear factor and giving them the chance to continue their lives as undisturbed as possible.”
Radiation is a third weapon against cancer and has been in common use for about 50 years.
“Actually, doctors started using radiation as a means of treating cancer around 100 years ago,” says Dr. Iftekhar U. Ahmad, a board-certified radiation oncologist at OSF Saint Anthony Medical Center. “The University of Chicago pioneered its use for breast cancer. Today, radiation is part of cancer treatment in between 60 and 65 percent of patients.”
Radiation works best in cases where the cancer is located in a tissue-based organ, such as the breast or prostate. It typically isn’t the first line of treatment for bloodborne cancers such as leukemia. Theoretically, however, radiation can be effective in controlling symptoms for any cancer.
“For example, in the majority of colon cancers, radiation isn’t used in conjunction with chemotherapy,” Ahmad says. “However, if the cancer spreads into the patient’s bones, radiation is useful as a palliative measure to reduce pain. It won’t cure the cancer, but it will help the patient cope.”
In prostate cancer, radiation is the only treatment used and is usually curative. In other cases, radiation is combined with surgery either before or after the operation. Depending on the type and location of the cancer, both radiation and chemotherapy may be used first, followed by surgery. Or, chemotherapy may be given prior to surgery, with radiation treatment as a follow-up.
“With patients, there is no cookie-cutter remedy,” Ahmad adds. “While we use standards of treatment as guidelines, there’s no such thing as a formula for cancer treatment. We assess the patient’s specific needs, carefully calculate treatments and dosages, and employ best-practice criteria.”
Newer techniques, such as intraoperative radiation therapy, which is used to irradiate breast cancer sites during surgery, to remove single tumors, can be applied to other cancers. According to Ahmad, however, it’s too soon to evaluate its effectiveness in treating breast cancers.
“In brain surgery, it might be possible, but it would be difficult to measure the exact site and develop a dosage plan, because there’s no easy way to create an image,” he explains. “I believe it is possible, but not ready for mainstream cancer treatment.”
Ahmad and his colleagues are able to do more with radiation now than they did just five short years ago, because of the constant advancements and breakthroughs being made in this technology-driven treatment.
“The biggest challenge we face isn’t treating the cancer, but avoiding collateral damage to healthy tissue,” says Ahmad. “Recently, stereotactic radiosurgery (SRS) has been developed, which enables us to form a 3-D coordinated image of the brain. This allows us to see the tumor and incrementally irradiate it with high doses, in a single treatment confined to a small, exact area. This is cutting-edge technology available to OSF Saint Anthony, so patients no longer need to travel to Madison or Chicago for treatment.”
OSF Saint Anthony has expanded its stereotactic program to include other disease sites, including lung cancer for patients who are unable to have surgery, and in the treatment of metastatic disease.
Yet another new advancement is the use of the TrueBeam linear accelerator, a machine that allows for arc therapy that transcends common technology. By providing a 360-degree treatment of cancer, instead of the traditional angle shot treatment with limited or fixed views, arc therapy allows treatment from all angles and constantly applies tiny doses of radiation molded to the target, while avoiding nearby healthy tissue.
“With arc therapy on TrueBeam, normal tissues are better avoided while patients enjoy a quicker treatment,” Ahmad says. “Arc therapy is convenient, faster, and supports the patient’s sense of well-being. When we use technologies like these, we’re not just treating the disease, but we’re also caring for all of the patient’s needs.”
Ahmad includes delivering brachytherapy with the MammoSite radiotherapy system on his list of cancer treatment advances. With brachytherapy, breast cancer patients are given internal radiation therapy at the surgery site.
“A balloon is inserted through the incision, and tiny radiation seeds are implanted,” Ahmad explains. “The lead is left in place, and the patient is given two more treatments daily for one week, as opposed to the traditional daily treatments for six weeks. So far, we’ve learned that brachytherapy offers the same recurrence probability as traditional radiation.”
Ahmad points out that his colleague, Dr. George Bryan of OSF Saint Anthony, and Dr. Jeffrey Barteau of the Rockford Surgical Service, pioneered breast brachytherapy in this region, beginning in 2006, giving breast cancer patients much-needed relief from the inconvenience of longer traditional courses.
“Brachytherapy can potentially be applied to other common cancers,” Ahmad says. “Everything depends on how comfortable the oncologist is with using it, as well as the patient’s particular needs. We don’t want to just be able to do it, we want to do it right. And along with the technique, we focus on extensive quality control, calculate and recalculate dosages, double-check everything. The bottom line is patient safety.”
Other Systemic Therapies
More recently, cancer management has taken on greater significance, in light of the AMA’s prediction of drastically lower cancer mortality rates. According to Dr. Fauzia Khattak, a board-certified medical oncologist with SwedishAmerican Hospital in Rockford, different kinds of treatment can be used to manage different kinds of cancers. In general, options include localized treatments, such as surgery or radiation, and systemic treatments, such as chemotherapy, endocrine therapy and immunotherapy. Being a medical oncologist allows Khattak to focus on discussing the systemic treatment options available.
The decision to go ahead with cytotoxic treatment like chemotherapy is usually made after the oncologist determines that the benefits outweigh the risks, in terms of decreasing recurrence or prolonging survival, says Khattak. Current standards of care, which follow national guidelines, are kept in mind, along with data from clinical trials.
“Commonly, when we sit with our patients and discuss the pros and cons of chemotherapy, they may have certain preconceived ideas about chemotherapy and be influenced by either a relative’s or friend’s good or bad experience,” Khattak says. “Chemotherapy, in this day and age, is much better tolerated than it used to be. This is because we have good medications to prevent or treat complications like nausea and vomiting. We rarely see uncontrolled nausea and vomiting with chemotherapy today. Fatigue is unavoidable, but a positive attitude always helps get over any kind of side effect. I encourage patients to make a decision about chemotherapy after carefully thinking about it and having all their questions answered.”
Self-education on the disease process is helpful, but patients should tell their doctor which side effects they’re most worried about and ask what can be done about them.“For example, hair loss with chemotherapy is an important deciding factor for some patients,” Khattak explains. “There are chemotherapeutic drugs which may not cause hair loss, although the use of those drugs may or may not be the best option for the patient. This can be clarified with open discussion between patients and oncologists.”
Endocrine therapy is sometimes a treatment option, for cancers such as breast, prostate, uterine and ovarian. National guidelines are used to determine use of endocrine therapy in early- or late-stage cancer.
“Endocrine therapy is, in general, a well-tolerated treatment, without the significant cytotoxicities associated with chemotherapy,” Khattak says. “Usually, in Stage 4 cancers, when cure is not an option, we try to exhaust less-cytotoxic options like endocrine therapy, before resorting to more toxic treatments like chemotherapy. There are other factors involved in making this decision, however, including age, how symptomatic the patient is and presence of other comorbidities. Patients may not be candidates for endocrine therapy when the estrogen and progesterone receptor status in breast cancer is negative. This simply means that there is no target for the endocrine therapy to work.”
Other forms of systemic therapy, including immunotherapy and vaccine therapy, attempt to use the body’s own immune system to destroy foreign cancer cells. According to Khattak, progress has been made using these therapies to treat certain cancers like melanoma and prostate cancer. Clinical trials are ongoing. “Immunotherapy, sometimes called biologic therapy or biotherapy, uses certain parts of the immune system to fight diseases such as cancer,” she says.
Immune therapy can involve stimulating the patient’s immune system to work harder or smarter to attack cancer cells. It can also involve prescribing components such as man-made immune system proteins. Doctors long suspected that the immune system impacted certain cancers, even before it was proven, according to the American Cancer Society.
Dr. William Coley, a surgeon who practiced in New York in the late 1800s, first noted that getting an infection after surgery seemed to help some cancer patients, according to historical records of the National Institutes of Health. He began treating cancer patients by infecting them with certain kinds of bacteria, which came to be known as Coley toxins. Although he had some success, his technique was overshadowed when other forms of cancer treatment, such as radiation therapy, came into use.
Since then, doctors have learned a great deal about the immune system. This has led to research into how it can be used to treat cancer. In the past few decades, immunotherapy has become an important part of treating several cancers, although it seems to be more effective for some types than others. It’s the sole treatment for some cancers.
Khattak believes that consistent public education is vital to help future patients better understand and appreciate modern cancer treatments and to make the best possible decisions about their health.
Given the incredible improvements in all available cancer treatments, and the potential for even more and better medications in the future, it’s conceivable that cancer will lose its position as the second most deadly disease, after heart disease. And when that tipping point occurs, all people, everywhere, will be winners.