Treating cancer remains difficult simply because the cancer cells have evolved and survived many obstacles — they are survivors! This is worst when the diagnosis occurs at a late stage when the cancer is well established and has overwhelmed your defenses and depleted your resources. Cancer therefore calls for a rational plan of management.
After a thorough understanding of the diagnosis, you will be presented with several treatment options to consider. You have a central role to play in this decision and your treatment plan needs to balance the oncologist’s recommendations versus your beliefs, intuitions and your own wishes about what is best for you. Therefore, it is crucial for you at this stage to know the different treatment options for your type and stage of cancer.
Broadly, cancer treatment can be approached from three fronts: destruction (targeted) based, healing based and integrative.
Classification of the treatment modalities
(A) Destruction based or conventional treatments — Also known as allopathic, western, mainstream and orthodox treatments, this is the most widely recognized, accepted and practiced. It relies on medical intervention and ‘targets’ the cancer cells with the purpose of destroying and killing it. Conventional treatments utilize state of the art technology in diagnostics, imaging, radiation, surgery and drugs.
There are a number of treatments that are deployed to target and destroy the cancer cells. The choice of therapy again depends very much on the location, the stage of the disease, as well as the general status of the patient. Cancer treatment may consist of a single therapy or a combination of therapies. The primary treatment modalities are:
Þ Surgery — removal of cancer cells using surgery (cut),
Þ Radiotherapy — destruction of cancer cells using ionizing radiation,
Þ Chemotherapy — destruction of cancer cells using cytotoxic drugs (drugs that are toxic to the cells)
(B) Healing based treatments — This treatment approach is to target the root causes of cancer in addition to directly targeting the cancer cells. The various methods employed are aimed at restoring normal body function and to support the body’s internal mechanisms in switching off cancer. These are collectively known as complementary and alternative medical therapies (CAM). There are a multitude of modalities available and this will be used as appropriate for the situation.
(C) Integrative based treatments — This approach is the combination of A and B (as appropriate) in order to increase the chances of overcoming the disease.
Note: Your oncologist may not be offering you B and/or C healing options, therefore do ask about this. It is your right to find out all the options available to you.
3.1 Conventional treatment options
Cancer surgery is an operation to remove a part of your body to diagnose or treat cancer. It can also be used to relieve the symptoms it causes rather than to treat the cancer for example to relieve pain caused by a tumor that's pressing on a nerve or bone. Traditionally, it was the first weapon used against cancer and is still the frontline treatment especially when the tumor is well localized and diagnosed at an early stage. It is frequently used to remove cancerous growths or obtain small samples of tissue for examination.
When removing a cancer, the specialist will try to remove as much of the cancer as possible the goal of which is to remove the entire tumor or in some cases the entire affected organ (example mastectomy – the removal of breast). For several types of cancer, surgery alone may be sufficient to effect a cure, especially those that have not spread to other parts of the body.
Sometimes surgery may also be used to remove as much of the cancer as possible (debulking) to make chemotherapy or radiation therapy more effective. The limitation of surgery is that it cannot eliminate all cancerous cells in the body especially the microfoci containing small undetected tumors. It is now well recognized that even small cancers give rise to Circulating Cancer Stem cells which under the right conditions can be triggered to proliferate (grow).
If you need to have your cancer removed surgically, the decision as to who actually performs the procedure is important. Cancer surgery is generally considered complex surgery therefore make sure you get the expertise of a Surgical Oncologist. Surgical Oncologists are doctors who have undergone additional specialty training in cancer surgery and they offer a very high degree of specialization. There are only a handful around so be sure to ask.
Radiation therapy (also known as radiotherapy, X-ray therapy or irradiation).
The goal of radiation is to kill cancer cells and shrink the tumor directly by damaging them with high energy ionizing radiation beams while avoiding as much healthy tissue as possible. The effects are localized and confined to the region being treated. Radiation therapy injures or destroys cells in the area being treated by damaging their genetic material, making it impossible for these cells to continue to grow and divide. Unfortunately this therapy damages both cancer cells and a variable number of adjacent normal cells. The consolation is that most normal cells can recover from the effects of radiation and regain varying degree of normal function.
To compensate for the damages on healthy cells, radiation therapy is given in many fractions, allowing healthy tissue time to recover between fractions. It may be given before surgery to shrink a tumor or after surgery to stop the growth of cancer cells that may remain. It can also be given before, during or after chemotherapy to improve overall results.
Side effects associated with radiation is largely due to the high doses of radiation used to destroy cancer cells which damage the healthy cells and tissues located near the treatment area. The severity of the side effect varies, with some not having any side effects at all. Common side effects that happen during or shortly after treatment are fatigue (tiredness or exhaustion), appetite lost and skin changes (dry, itchy, tanned, sunburned), nausea and diarrhea.
Internal radiation is also becoming more common now, where radioactive material is surgically implanted on or into the area to be treated. Another advanced type of radiation treatment is one that uses a beam of protons to deliver radiation directly to the tumor, thus destroying the cancer cells while sparing healthy tissues. Because the technology is expensive, it is only found at major cancer centers.
Radiation therapy requires precision, therefore to maximize your opportunity for receiving excellent care choose a certified radiation oncologist.
Chemotherapy — Chemotherapy is the use of a wide array of cytotoxic drugs. It may be used alone or in combination with surgery and radiation therapy. Some chemotherapy drugs kill dividing cells by damaging the part of the cell's control center that makes it divide while others interrupt chemical processes involved in cell division.
Most forms of chemotherapy target all rapidly dividing cells and are not specific to cancer cells. As such it has the potential of harming healthy cells as well, especially those that are constantly dividing such as blood-forming cells in the bone marrow; hair follicles; and cells in the mouth, stomach and intestines (mucosa layers).
Unlike radiation and surgery, chemotherapy affects the entire body (the drugs travel in the bloodstream throughout the body - refer to figure on the right), which increases the risk of side effects. The treatment can be a long-term process involving multiple courses of therapy given over time resulting in longer periods of experiencing physical side effects, and diminished quality of life. Chemotherapy has been found to be very effective in treating some cancers eg. acute lymphocytic leukemia of children and Hodgkin's disease, as well as a few others. For other kinds of cancer, there could be good responses in the initial stage but often punctuated by recurrences and subsequent treatment 2nd or 3rd line drugs far less promising.
Potential side effects include:
¨ Toxicity to normal healthy cells
¨ Drop of immune cell (white blood cells) thereby increases the risk for infection
¨ Decrease in red blood cell and platelet counts, resulting in anemia and bleeding tendencies
¨ Stomach and intestinal problems, such as nausea, inflammation to the gastric mucosa, vomiting, diarrhea, and dehydration
¨ Damage to the nervous system - Refer to insert on ‘Chemo brain’ on the next page.
Chemo brain or Post-chemotherapy cognitive impairment (PCCI)
Most people have heard about the undesirable side effects that chemotherapy has on the body such as hair loss, fatigue and loss of appetite, but few are aware of the chemotherapy’s effects on the brain.
Cancer survivors have long reported of memory loss, an inability to concentrate, trouble remembering details and other cognitive dysfunctions, yet these observations were generally dismissed as insignificant. The issue however eventually received due attention when a large number of breast cancer survivors complained of changes in their memory, cognitive and motor abilities after undergoing chemotherapy. Since then, this ‘post chemotherapy’ impairment has been a subject of much research and also debate.
‘Chemo brain’ occurs when a person has trouble processing information, which includes mental tasks related to attention span, thinking, and short-term memory. These difficulties usually vary in severity.
Here are just a few examples of ‘chemo brain’ as provided by the American Cancer Society:
¨ Forgetting things that they usually have no trouble recalling (memory lapses)
¨ Trouble concentrating (they can’t focus on what they’re doing, have a short attention span, and appear “spaced out”)
¨ Trouble remembering details like names, dates, and sometimes larger events
¨ Trouble multi-tasking, like answering the phone while cooking, without losing track of one task (they are less able to do more than one thing at a time)
¨ Taking longer to finish things (disorganized, slower thinking and processing)
¨ Trouble remembering common words (unable to find the right words to finish a sentence)
Similar symptoms have also been reported by those undergoing radiation treatment especially to the head and neck or total body irradiation, and also those undergoing brain surgery.
A survey was jointly conducted by Princess Margaret Hospital in Toronto and the University of Sydney to gather information from cancer survivors about their experience with chemotherapy-related cognitive changes and how it affected their ability to function in daily life. 471 men and women diagnosed with various types of cancers participated. The highlights of the survey included the following:
Journal of National Cancer Institute; Hede K (2008). "Chemobrain is real but may need new name".
Another concern with chemotherapy is the fact that when cancer cells are not eradicated, they can become more aggressive and more difficult to treat. In general all cancers diminish in size (commonly referred to as responding to treatment), but all too often they develop resistance and recur over time, and this time around more aggressive.
The other types of conventional medical treatment modalities increasingly being used are:
- Hormonal therapy which is used in cancers that depend on hormones for their growth. If the cancer cells have hormone receptors, you may be prescribed hormonal therapy , which are blockers or inhibitors. Both types of drugs help to destroy cancer cells by cutting off their hormonal support vital for their growth
- Immunotherapy — a therapy that attempts to enhance the body’s own immune function.
3.2 Complementary and alternative medical therapies (CAM)
Complementary, alternative and traditional cancer treatments are often grouped together, referring to a diverse group of medical and health care practices, which are not considered part of conventional or mainstream medicine.
- Complementary therapy is generally used in addition to or complementing the conventional therapy. It refers to using a non-mainstream approach (eg. acupuncture or massage) together with conventional medicine.
- Alternative Medicine is the term widely used to describe treatment modalities using a non-mainstream approach in place of conventional medicine. These are treatments used instead of mainstream oncology treatments.
Traditional medicine falls under this category, which includes well documented therapies that are the accumulated experience of many traditional health care practitioners over the world and over an extended period of time – some as far back as 3000 years ago. Notable ones are the ancient Ayurvedic Medicine (one of the world’s oldest medical systems promoting the use of herbal compounds, special diets, massages, balance of mind, body and spirit and other unique health practices: Chinese medicine which uses acupuncture, Chinese herbology, massage, exercise and nutritional therapy, the Western herbal medicine, Homeopathic medicine and the Unani or the Islamic medicine set up by Islamic physicians about 1000 years ago.
The newer alternative approaches for cancer treatments are like the Gerson Therapy, Cellect-Budwig protocol, Laetrile, Photo Dynamic Therapy, Electromagnetic therapy, Hyperthermia Therapy, Insulin Potentiated Chemotherapy - IPT and Dendritic vaccines just to name a few.
CAM treatments include the use of herbal, nutritional and mineral supplements, hypnotherapy, metabolic therapies, as well as physical and psychological interventions such as exercise, relaxation, massage and prayer.
Increasingly, the boundaries between complementary and conventional medicine overlap and change. Most people use some form of CAM therapies along with conventional treatments.
The use of CAM for cancer treatment is gaining in popularity and becoming more widespread. One large survey of cancer survivors reported on the use of complementary therapies, and the therapies used most often were prayer and spiritual practice (61%), relaxation (44%), faith and spiritual healing (42%), and nutritional supplements and vitamins (40%). CAM therapies are used by 31-84% of children with cancer 3.
- American Cancer Society website at: http://www.cancer.org/treatment/treatmentsandsideeffects/
- Cancer Research UK website at: http://www.cancerresearchuk.org/cancer-help/about-cancer/treatment/
- American Cancer Society's studies of cancer survivors. Cancer 113 (5): 1048-57, 2008
3.3 Integrated therapies
It is often not enough to have a strategy to kill cancer cells – the body needs to be supported. While conventional cancer treatments often remove much of the disease burden, this is only half of the battle.
Integrative oncology is an emerging field of medical practice which blends the best of Western (conventional) medicine with practices from various complementary and alternative schools of thought to facilitate healing. It is a philosophy that does not reject conventional medicine nor accepts alternative medicine uncritically, but is informed by evidence. It recognizes that good medicine should be based on good science, inquiry driven, and open to new paradigms.
The basic principles of integrative therapies are as follows:
* Considers healing of the whole patient, including mind-body (including how you handle stress), spirituality, nutritional, toxicity, immunity, social and physical dimensions. Each of these can enhance or undermine your health.
* It is a Partnership between the patient and the practitioner
* It is a systematic and rational approach to the causes and treatment of cancer using all appropriate therapies utilizing not only the conventional cancer treatment but also other treatment modalities to maximize the efficacy of the treatment.
* Boosting your ‘anti-cancer’ biology - the body’s internal environment either encourages the growth and spread of cancer or thwarts them. The internal biochemistry includes levels of oxidation and inflammation and the state of your immune system.
* Aimed to improve the patient’s quality of life by minimizing toxicity and side effects.
There is a growing awareness of the role of integrative approaches to achieve a more holistic and effective cancer cure. While conventional Oncology (cancer treatment) is very much disease centered, integrative oncology seeks to promote the broader concept of health and the prevention of illness as well as the treatment of disease. Being healing based, it provides this support by changing the ‘microenvironment’ in the body, strengthen the immune system and support the body’s healing ability.
3.4 Deciding on the treatment to pursue
Before you decide on your treatment options make sure you have:
* asked your oncologist to explain the specific treatment options as briefly highlighted earlier.
* Understood the terms ‘remission, cures, extend life, or improve quality of life—these are the outcomes by which you must measure all treatments - be it conventional, alternative or integrative.
* Know what you can expect and what not to expect - and what can be possibly achieved with the different treatments, including the side effects.
3.5 Choose your treatment team
Another important consideration in deciding the treatment options is your confidence level in the treatment team — or the one who will be carrying out the treatment.
It is important that you do not feel intimidated by your oncologist; conventional or integrative. It is our belief that the oncologists are trying their utmost to represent your best interests in achieving a cure.
Other than the professional certification, most of the criteria in evaluating the suitability of your oncologist to work with you in your healing journey are subjective you really need to let your intuition gauge your confidence level. Evaluate your confidence level following your consultation with your medical team. If you have any doubt either in the treatment or the person undertaking the task then it is
Ä time to change your confidence level (do more research, ask for second/ third / forth opinions or
Ä change your oncologist.
Good Medicine — Open Communication and trust
Clear communication is the fundamental of all healthy relationships, clarity and honesty are as important. Trust on the other hand, is the therapeutic bond and agent that make the doctor-patient relationship a healing power.
3.6 Make an informed choice
Once you possess the necessary information, you are in a better position to make an informed choice. Again don’t be rushed into making a decision — take your time to analyze and reflect on those information that you have acquired. The critical questions that you should ask yourself are:
- Do I believe that this is the right thing to do?
- Am I just taking the path of least resistance?
- Does the treatment program have my conviction?
- What are the long term implications?
Answer the above truthfully as it is important that you have peace with your decision. Then consider who will be your potential partner in the healing/ treatment journey. The power of decision is in your hands. Thus far you have been gathering information and doing your homework and now is the time to decide. Until a decision is made nothing happens.
Making a decision takes courage but you have to make this inevitable task and make a full commitment. There is definitely risk, but there is greater risk in not making a decision. Decision frees you from any uncertainties caused by fear, doubt and anxiety.
Be optimistic. This is the moment to say, “this is how I am going to do it — now let’s get started”.
“The hardest thing about the road not taken is that you never know where it might have led.”