Chemotherapy

From Dark beginnings and into the Light

In the 1940s, a chemical gas called Nitrogen Mustard is being used as a weapon of mass destruction- wiping out almost an Entire Nation’s population in World War II.
An incident that depicts this is the air raid on Bari, Italy, which led to the release of mustard gas that affected several hundred soldiers and innocent civilians.

As all this is happening, in a laboratory at the Yale School of Medicine, Alfred Gilman and Louis Goodman look at it in a different way.
They’re working on the Mustard’s effects on human cells called lymphocytes (which are cells involved in defence against infection).

In August 1942, Gilman and Goodman would treat their first chemotherapy patient– “JD”, with lymphosarcoma of the neck.

Notes entered in the medical record on August 25, 1942, read: “The patient’s outlook is utterly hopeless on the present radiation regimen. Because the end seems near he should be in the hospital.”

On August 27, at 10 a.m., the first of ten daily doses of chemotherapy is given. Four days later the patient said he could sleep, eat, and move better. By September 6 he had greatly improved.


Come the late 90s, and Scientists have successfully tamed these agents of chemical warfare for the benefit of mankind, using them to destroy cancers while limiting and managing their adverse effects.

The same Nitrogen Mustards, were the first ones used for the treatment of lymphoma- a type of cancer affecting the immune cells of the body, leading to a significant reduction in tumor burden and giving birth to this field called “Chemotherapy“.

Ever since then the practice of chemotherapy has been constantly evolving showing an improvement in efficacy and a reduction in adverse effects.

Currently, a wide range of chemotherapeutic agents are available each having its own importance in different cancers.

Chemotherapy uses cytotoxic (chemicals that are toxic to living cells) agents that kill growing cancer cells. These drugs work by different mechanisms to slow down and destroy proliferating tumor cells.

When would my Doctor prescribe Chemotherapy?

Chemotherapy is given with 3 main aims in mind:

  • To reduce tumor burden
  • To reduce current symptoms
  • To reduce chance of tumor spreading to distant sites.

It may be given for curative purposes or as a part of palliation.
Some patients with terminal disease may have symptoms such as pain, difficulty in breathing due to lung metastases, liver issues due to distant metastases.

In such patients palliative chemotherapy is given to reduce tumor burden at various sites and relieve the patient from symptoms.

Neoadjuvant, Adjuvant or Concurrent Chemotherapy?

When chemotherapy is given before the definitive treatment it is termed as neoadjuvant chemotherapy.

When Chemotherapy is given after the definitive treatment it is termed as adjuvant chemotherapy.

When chemotherapy is given along with the definitive treatment it is termed as concurrent chemotherapy, such as cisplatin given along with definitive radiation in a case of cervical cancer.

In curative cases the tumour shrinks to a size small enough after chemotherapy making it easier to operate upon or irradiate.

Patients may be receive chemotherapy as the primary form of treatment, such as lymphomas and testicular cancer.
Or chemotherapy may be given in addition to radiation such as in Ca Cervix cases, or may be given in addition to surgery such as adjuvant chemotherapy given after breast surgery.

In some cases chemotherapy is used as an adjunct to other modes of treatment. For example Temozolamide tablets sensitize glioblastoma tumor cells to radiation or cisplatin sensitizes cancer cervix cells to radiation.

These decisions are based various standard protocols for different Cancers, and the medical team expertise.

How is Chemotherapy given?

The patient is first explained the benefits and the Ill effects of chemotherapy. The patient can be given chemotherapy only after a well informed consent from the patient after an individual decision or a joint decision from the family.

Before prescribing chemotherapy the patient requires a thorough workup. The exact stage of the disease must be known and other factors such as biological properties of the tumor, tumor markers and tumor differentiation must be known.

Chemotherapy always requires a biopsy confirmation of malignancy before it is started.

Once the initial workup is done two main factors that are mandatory to look for before starting any type of chemotherapy are ‘age‘ and ‘the performance status of the patient‘.

It is known that most chemotherapy drugs are excreted through kidneys. Elderly patients usually show a decline in kidney function and hence chemotherapy, specially the nephrotoxic ones are avoided in the elderly. In elderly patients many other bodily functions besides kidney functions tend to decline and because of that chemotherapy is avoided.

Another factor we look for before administering chemotherapy is ‘Performance Status of the Patient‘. In simpler words performance status is whether the patient will be able to bear the brunt of chemotherapy or not. Things like ‘is the patient able to walk without support’ , ‘how much time does the patient spend in bed’, ‘is the patient able to perform routine activities like eat, brush teeth etc.’- All these factors cumulatively give us an idea of whether the patient will be able to tolerate chemotherapy.

The next step is to carry out blood tests.

Three blood tests are mandatory before starting every chemotherapy- Complete blood count, kidney function tests and liver function tests. An adequately functioning liver and kidney are required before starting chemotherapy. There should be no underlying infection and the haemoglobin levels have to be adequate for proper action of the drug. Haemoglobin is important for proper functioning of the drug. Chemotherapy require free radicals to perform their actions within the tumor. These free radicals require oxygenation to form. Therefore adequate blood supply and haemoglobin levels are required for adequate oxygen delivery. 

After all these steps are carried out the patient is admitted on a daycare basis– if the chemo lasts for less than a day; or admitted in the wards if the chemo lasts for a day or more.

Different cancers have different regimens, which may last for varying durations. Vitals are monitored and chemo is started.

Chemo maybe administered either through IV Cannula, through a PICC line or through a Chemo port.

The patient may be discharged once Chemo is complete.

How should you Prepare for Chemo?

Before starting chemotherapy it is important for patients to be mentally prepared and physically fit. Cardiac fitness in the form of 2D- ECHO should be carried out, since some such as Doxorubicin are cardiotoxic.

Patients should also visit the Dentist before starting chemotherapy.
Most chemotherapy are known to cause immunosupression. The oral cavity contains a variety of flora and fauna and can act as a source of infection, which may flare up during chemotherapy.

Once chemotherapy is started it is mandatory that patients consume only well cooked home food. Food available outside should be avoided, as they may be unhygeinic. Fruits must also be avoided since they can act as a source of infection and must be consumed only if the fruits are fresh and after having them peeled.

Vegetables and high fibre food* should be consumed. Patients should have an adequate fluid intake and stay well hydrated. Dry fruits can be consumed as they are a rich source of vitamins and antioxidants.

*avoid high fiber is gastrointestinal cancers as it can be painful.

Every patient who is about to be started on chemotherapy needs to be well informed about the drugs he will be started on along with their side effect profile and their cost. It is important for the patient to know the cost of these drugs, so that appropriated decisions can be made regarding the purchase of drugs. The doctor can suggest cheaper alternative in case of unaffordability of the patient.

Unnecessary contact with people must be avoided, to avoid infection. In crowded places patients can wear a mask and gloves to avoid exposure to these infections.

What adverse effects can the patient experience?

Patients on Chemotherapy experience adverse effects.
Some common ones are listed below.

Hair loss

One of the most common side effects of chemotherapy.
The lost hair is usually replaced, although the texture may not be the same as before.

But the risk of hair loss should not stop a patient from receiving chemotherapy (lost hair will usually come back)

Nails too may become brittle.

Nausea and Vomiting

Another common side effect of Chemoterapy. These symptoms may be caused as a direct effect of chemotherapy or as a result of treatment anxiety. But this should not stop a patient from receiving chemotherapy if required. These symptoms can very well be controlled by safe drugs such as ondansetron and metoclopramide. Anxiety can be treated using a mild sedative.

Fatigue

Patients who undergo chemotherapy usually have issues such as tiredness.
In these cases the patient requires an adequate amount of rest.
Patients must avoid strenous activities if they’re feeling fatigued.

Bone marrow suppression

Some chemotherapeutic agents are known to cause bone marrow suppression. Neutropenia is a condition where the absolute granulocyte count declines putting the patient at risk of infection and sepsis that can be life threatening.

But with the right care and regular monitoring of blood counts the patient will soon recover. Granulocyte stimulating factors are available which are given to replenish neutrophils.

Sometimes, although not as common as neutropenia, chemotherapy can also cause a fall in platelets, a condition known as thrombocytopenia.

These patients may have bleeding conditions. But then again with the right care and monitoring, patient will recover.

Mucositis

Sometimes chemotherapy can cause damage and death of cells lining the mucous membranes, resulting in pain, bleeding and risk of infection. If the mucositis is within the oral cavity patient will find swallowing a problem. If it’s in the gut patient will experience diarrhoea and sometimes even blood in stools.

In these conditions chemotherapy is usually stopped and the gap between the two cycles is increased till the patient recovers.

Neuropathy

Drugs such as cisplatin, oxaliplatin, vincristine are know to cause peripheral neuropathy. Patients under this type of chemotherapy often experience tingling and numbness of hands and feet. Sometimes this condition may be debilitating for the patient.

Under these conditions the drug is usually changed.
Patients are kept on multivitamin tablets and B12 supplements. The patient eventually, over time begins to recover from this condition, albeit being a slow recovery.

Mental issues

When a patient is on chemotherapy there may be a range of issues extending from depression to anxiety. These conditions may require care from a Psychiatrist. But most of the time these symptoms are mild and can often be tackled by a simple, lively and motivating conversation with the patient.

Loss of Appetite

Most patients experience a loss of apetite during chemotherapy.

The patients can be asked to take 2 hourly small meals instead of three large meals, as 2 hourly small meals can be ingested easily and also provides adequate nutrition. If the patient is given the food of his personal preference he may like it.

A Final Word

The fact is that although there has been in the past as well as present so much hype created around chemotherapy and its side effects, it is common to find patients refusing treatment by chemotherapy. But that shouldn’t be the case. The benefits offered by chemotherapy far outweigh the risks in most cases.

In some cases there may not be a response as expected but the patient may experience side effects. In these cases the drug is either changed or chemotherapy is stopped completely.

And in those cases patients who are on chemotherapy and are showing an excellent response to therapy the drug should be continued inspite of the side effects. It has been mentioned earlier that these side effects are in most cases manageable without compromising on the quality of life of the patient.

So it should be clear that if chemotherapy is indicated for a particular cancer the patient should definitely go for it (provided the above mentioned prerequisites before starting therapy and during therapy are all satisfied).

Response is checked using clinical examination or imaging after the first few cycles. If patient is showing a good response, chemo should be continued. If side effects are minor they will be managed easily; If major, Chemo will be stopped for some time and restarted once the patient is fine.