CANCER TREATMENT: Chemotherapy

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1 CANCER TREATMENT: Chemotherapy Chemotherapy, often called chemo, is the use of drugs to treat a disease. The term chemotherapy is now most often used to describe a type of cancer treatment. Dr. Khuri: to check and make sure that don't have any swelling in your joints or " The goal of chemotherapy can be to cure cancer, to cause cancer to go into remission, or to improve the quality of life for patients. Dr. Khuri: Chemotherapy kills cells that are dividing. The cells that are most actively dividing in your body are almost always the cancer cells. Our bodies are made up of trillions of cells. These cells make up the organs that perform our body's functions. The lungs, brain, skin, and liver are some examples of organs. Most cells in our body are not dividing or making copies of themselves, they are just performing their normal jobs. When new cells are needed, signals are sent that cause the right cells to divide. On the other hand, the cells that lead to cancer are damaged, so they no longer obey the rules of the body. In fact, they divide without the need for signals and in an unregulated manner. Essentially, they are out of control. Dr. Khuri: Cells that are dividing, multiplying, and metastasizing, or spreading those are the target cells for chemotherapy." To better understand how this works, it may be useful to imagine a single cell as if it were a car. Just like a car, a cell is made up of many different pieces that must work together to function properly. Imagine if something damages a car's brakes, the car may not stop properly. In the same manner, if something damages a part of a cell, it may not function properly. Chemotherapy drugs work by targeting damaged cells, those without the proper brakes, and eventually cause them to die. Chemotherapy drugs come from many sources; some are derived from plants and minerals, while others are entirely man- made, and are created in laboratories. Some chemotherapy drugs are used to treat several different kinds of cancer, while others are designed to target only one or a few specific cancer types. There are more than 100 chemotherapy drugs, and they have one thing in common, they all work to kill cancer cells. Dr. Khuri: Mr. David Taylor?" David Taylor (patient): Yes." Dr. Khuri: Hi, Fadlo Khuri. Nice to meet you."

2 David Taylor (patient): Pleasure to meet you doctor." Dr. Khuri: How are you doing today?" David Taylor (patient): I'm actually feeling okay." Chemotherapy can be given different ways depending on the type and location of the cancer, the type of chemotherapy drug, and the overall health of the patient. Dr. Khuri: Chemotherapy can be given before surgery, that's called neo- adjuvant or induction chemotherapy. It can also be given after surgery, that's called adjuvant therapy." It can also be combined with other treatments, such as radiation therapy or surgery. Dr. Khuri: We can also give high doses of chemotherapy, for stem cell and bone marrow transplants for blood cancers. And finally, we can give chemotherapy for metastatic disease to try to prolong life and maintain quality of life." The most common way patients receive chemotherapy is by intravenous or IV injection. Dr. Khuri: Two most common ways that its given are by a vein, intravenously, either through an IV or though a port or a central venous catheter. That's one way. And the other is oral; there are many chemotherapies that are oral these days." Other common ways that chemotherapy drugs are given include: injecting the drugs into a blood vessel that feeds the tumor; injecting the drugs directly into the tumor; placing the drugs in the space containing the abdominal organs, such as the stomach, intestines, and bladder; or, using a cream that is rubbed onto the skin. Often for a long- term therapy, central venous catheters, such as PICC- lines or implanted ports, are used to deliver the medication to the patient. The catheters remain in the patient for the duration of the treatment, and they make it easier to deliver medications and reduce the number of needle sticks that the patient has to get. IV delivery of chemotherapy medications can take several hours, and during this time, patients are monitored closely. Dr. Khuri: Usually the first cycle of chemotherapy, we and our nursing colleagues and our nurse practitioner colleagues tend to watch the patients. Once a week, we have them come in, get blood counts; we see them; we see how they're tolerating chemotherapy; we call them; we keep in touch. If they tolerate the chemotherapy very well, then we tend to see them every 3 to 4 weeks and get blood counts in between to make sure they haven't dropped too much."

3 There are several places patients can go to get treatment. It can be given at the doctor's office, a hospital, or an infusion center, which is a treatment center, specialized in giving chemotherapy; some drugs may even be taken at home. Chemotherapy is typically given in cycles. Dr. Khuri: So here's how we give you the chemotherapy, we give you one combination of chemotherapy, 2 drugs, with anti- nausea medicines, with medicines designed to prevent the other side effects every three weeks in the infusion center. The average chemotherapy will last between 4 to 6 hours depending on what we chose to be your treatment. The rest of that 3 to 4 week period is really time for your and your body and your white cells, in particular, to recover from that last dose of chemotherapy. So even though you're not down in the infusion center, that whole 3 to 4 week period, depending on your recovery time, constitutes a cycle; that's a cycle of chemotherapy." The cycle of treatment and rest is then repeated, up to 8 times. The entire process may take several months, and is called a course of chemotherapy. Each patient follows a schedule designed to increase the success of their particular treatment and limit the side effects. How much of the chemotherapy drug is given, or the dosage, is dependent on the patient s weight, height, general health and other factors. The doctor will determine the proper amount in each cycle, but may increase or decrease the dosage during the course of treatment based on the patient's reaction to the drugs. Dr. Khuri: So we're going to give you chemotherapy to try to eliminate any possible circulating cancer cells that may still be there." Chemotherapy is best at killing cells that are rapidly dividing or reproducing. Because most cells in our body are not dividing, they are left alone. But some cells, like cells in our bone marrow, cells that line our digestive tract, and cells that form hair are normally dividing, and may be damaged or killed by chemotherapy. This happens because the drugs cannot tell the difference between the normal dividing cells and cancer cells. Dr. Khuri: Chemotherapy targets all dividing cells. So you can expect that you will have some side effects, some patients actually experience none. But, let's go through the type of side effects that you can experience and when you might experience those side effects. While you're getting the infusion, the most serious side effect that we worry about is an allergic reaction. That happens in one in several thousand patients, and we tend to make sure we take care of that on- site. That's why we have the oncology nurses and doctors all around patients while they are getting the chemotherapy. The other side effects that can happen while patients are actually receiving their infusion can be changes in blood pressure and some nausea, and in some extreme cases, but not all that commonly, vomiting. Once

4 you've completed the actual chemotherapy infusion, and you've left the infusion area, we worry about other side effects. The side effects that may occur during treatment include: fatigue, nausea, vomiting, mouth sores, diarrhea or constipation, decreased blood counts, numbness or tingling of the hands and feet, decreased appetite, memory problems, and a reduced sex drive. Dr. Khuri: And then there are long- term side effects of certain chemotherapy drugs. These could include everything from worsening kidney function, worsening heart function, and the extremes of those, of course, are heart failure and kidney failure. The single most serious long- term side effect, which is rare, from chemotherapy, but does happen, is the development of a second cance; and the most common type of second cancer is a blood cancer, a leukemia. While that's rare, that's one of the reasons we keep following patient's blood tests for years after we finish chemotherapy." It's important to remember that each patient has different side effects based on their chemotherapy and the way their body reacts to the treatment. Side effects may also be different from day to day. Dr. Khuri: Most patients, when they get chemotherapy, are pleasantly surprised that it's not what they fear. That's because we have much more effective drugs to control nausea, vomiting and other side effects. The patient and doctor should discuss the most likely side effects of chemotherapy treatment being used. Behr Champana (survivor): The experiences of everybody with cancer are a little different. You need to understand what are your particulars of your disease. I think this was all part of my growth as a person, as a human being. I took it as a lesson. I didn't take it as a tragedy. I got closer to my family. I appreciate life a lot fuller." There are some things a patient and their caretaker can do to reduce the chances of any serious complications. Patients should keep their doctors informed about any problems they are having. Dr. Khuri: So we tell the patients if you're experiencing side effects, even side effects that we haven't described. Please call us so we can work with you to make you feel better, because many of these symptoms that you're experiencing we can help you manage, and help make you feel better." It is important that patients go to all of their doctors' appointments and get all scheduled tests done. They also need to make sure to take proper care of themselves.

5 Dr. Khuri: There are some precautionary measures, some things we tell you to be careful about. First of all, particularly in the period when your blood counts are at their lowest, so between 10 days after you start your chemotherapy and 17 days roughly in that period, please try to avoid any raw or uncooked vegetables. It goes without saying; don't eat any raw or uncooked meats." Also patients should avoid sick people and crowds. Dr. Khuri: If you see someone around you who's coughing or sneezing or has a virus or if you're exposed to very young children, be careful. But with regard to having to wear a mask every place you go out, not with this sort of standard chemotherapy. You can go out, you can eat, just, again, be careful with what you're eating." Behr Champana (survivor): I continued with my proper diet. I continued taking care of myself, and maybe that has contributed tremendously to the fact that I didn't have any long- term side effects. Actually, my hair grew back darker and I'm quite stronger in all aspects." While surgery and radiation are targeted at specific locations, chemotherapy drugs travel throughout the body and kill cancer cells wherever they are located. Ultimately, chemotherapy is a very effective treatment for many types of cancer. Dr. Khuri: One thing to understand about chemotherapy, is that it is a component of your total cancer care. Your oncologist, or your cancer specialist, is trying to give you total care for your disease. Again that includes a number of components: psychological, social, nutritional, dental, if need be. That's a major step forward for cancer medicine, treating the whole patient as opposed to just the tumor." For more information, contact your healthcare provider or visit the American Cancer Society s website at