Cancer Treatment Modalities

Khalid Alfaqih, RN, MSN,AOCN

Email: [Link]@[Link]
Treatment Modalities Types

• Surgery  Treatment depend on type of cancer

• Radiation therapy and its location and patient condition

• Chemotherapy  Cancer treatment goals

• Biotherapy • Cure
• Control
• Target therapy
• Palliation
• Immunotherapy • prevention
• Hormonal therapy
• Bone marrow/stem cell transplantation
Multimodal Therapy
Combining one or more treatment modalities is
common and can be beneficial.
Therapies can and should have:
• Synergistic effects
• Different mechanisms of action
• Possible delayed drug resistance
• Minimal or no overlapping toxicities.
Factors Affecting Treatment Response
• Tumor burden
• Rate of tumor growth
• Hormone receptor status
• Dose category
• Drug resistance (intrinsic or acquired)
• Cell sanctuaries and cellular residual
• Age, immune status, or poor performance status.
Measuring Tumor Response
• Complete Response: complete disappearance for
at least one month.
• Partial Response: reduction in measurable
tumor mass >50% for one month without new
tumor growth.
• Stable Disease: unchanged without tumor
growth or reduction.
• Progressive Disease: advancing disease in
presence of therapy.
 (new growth) Relapse

Progressive

25% increase or new growth•

Stable response
25% increase> 50% decrease or > Neither •

Partial response
50% decrease tumor mass (one month)v

Complete response
(one month absence of sign and symptomes)•

Tumor before management

Cancer treatment meditates
 Modalities for treatment:
1. Local
a) Surgery:
 Treatment of choice for most solid tumors.
 Can be for prophylactic with patient has high tendency to get cancer
 Can be curative in early stage/localized disease.
 Can be to control, palliative in advanced stage, diagnosis or staging,
and Reconstructive/rehabilitative.
b) Radiotherapy:
 Therapy use high dose of ionizing radiation to damage DNAwithin
cancer cells which lead to kill cancer cell and shrink tumor.
• The most common side effects are: fatigue and skin changes or burn at
site of radiation exposure.
• Radiation therapy Types example: External beam (EBRT),
Brachytherapy (internal), and Gamma.
 Cancer treatment meditates
• IMMUNOTHERAPY
Immunotherapy is a type of cancer treatment that helps the
immune system fight cancer.
• TARGETED THERAPY
Targeted therapy is a type of cancer treatment that targets
the changes in cancer cells that help them grow, divide, and
spread.
• HORMONE THERAPY
Hormone therapy is a treatment that slows or stops the
growth of breast and prostate cancers that use hormones to
grow
Bone Marrow/Stem Cell
Transplantation
• Goal is to empty bone marrow and replace with
new marrow.
• Used to treat leukemia, lymphoma, multiple
myeloma, aplastic anemia, and some solid
tumors.
• High doses of chemotherapy and radiation can
be given concurrently.
Bone Marrow/Stem Cell
Transplantation Process/steps:
• Mobilization - Blood cell stimulants are
administered
• Harvest - Marrow is harvested (collect)
• Conditioning - Cytotoxic treatment is given
• Engraftment - Marrow is reinfused
(Transplantation)
Bone Marrow/Stem Cell
Transplantation types
• Allogeneic
- Usually a sibling or parent; can be related or
matched unrelated
• Syngeneic
- Identical twin
• Autologous
- Most common type
- Donor is recipient.
- Marrow is harvested during disease remission to
be reinfused later.
Cancer Treatment Modalities
Principle, Chemotherapy
Preparation, Handling, and
Administration
INTRODUCTION
 Originally chemotherapy referred to the treatment of disease by
the use of chemical substances or drugs.

 But by mid 1950’s the term was only being used primarily in
reference to drugs which were used to treat cancer.

 So chemotherapy is a type of cancer treatment modalities.

INTRODUCTION

 Most commonly, chemotherapy acts by killing cells that divide

rapidly, one of the main properties of most cancer cells. This
means that it also harms cells that divide rapidly under normal
circumstances “skin, GI tract, Blood cells, Bone marrow” .

 Another terms for chemotherapy “Antineoplastic, Cytotoxic

agent, Antitumor drugs “.
 History Of Chemotherapy

• German physician, Paul Ehrlich Father of

‘‘chemotherapy’’, his laboratory
discovered arsphenamine (Salvarsan), the first
effective medicinal treatment for syphilis.

• Chemotherapy was first developed in 1943.

• During World War II, it was discovered that

people exposed to nitrogen mustard developed
significantly reduced white blood cell counts.

• Based on this finding, Alfred Gilman and Louis

Goodman from Yale university used Nitrogen
Mustard to induced remission of Lymphoma in
mice.
 History Of Chemotherapy

• 1970’s - “Golden Age” of medical oncology.

Development of effective combination chemotherapy regimens.

• New classes of drug developed - anthracyclines, platinum

compounds .

• Cures achieved in some forms of cancer (lymphomas, leukemia's,

testis cancer).

• Significant responses in some common types of cancer (breast,

stomach, small cell lung cancer)

• Effective use of chemotherapy to prevent recurrence in high

risk breast cancer patients.
IT IS EASY TO KILL CANCER
CELLS, BUT THE CHALLENGE
IS KEEPING THE PATIENT
ALIVE AT THE SAME
TIME…..!
 Cure Prevention

Goals of
Chemotherapy

Palliative Control
 Prevention
• Such as Tamoxifen: it is an antagonist of the estrogen
receptor in breast tissue used in prevention of Breast cancer.

• Tamoxifen is the usual endocrine (anti-estrogen) therapy

for..
- Hormone receptor-positive breast cancer in
pre-menopausal women,
- And is also a standard in post-menopausal women.
(National Cancer Institute, 2012).
 Cure
• If possible, chemotherapy is used to eradicate the
cancer, meaning that the cancer disappears and does
not return. However, most doctors do not use the
word “cure”.

• When giving treatment that has a chance of curing a

person’s cancer, the doctor may describe it as
treatment with curative intent. But there are no
guarantees, and though cure may be the goal, it
doesn’t always work out that way. It often takes
many years to know if a person’s cancer is actually
cured.
 Control
• It achieved either through shrinking the tumor size
or stop the cancer from growing. This can help in
increasing the life span.

• Also to decrease the rate of relapse.

• In many cases, the cancer does not completely

go away but is controlled and managed as a
chronic disease, much like heart disease or
diabetes.
 Palliative
• When the cancer is at an advanced stage and can’t
be treated and there is nothing to do to the patient,
chemotherapy drugs may be used to relieve symptoms
caused by the cancer.

• The only goal of a certain treatment is to relief

symptoms and improved quality of life.

• Chemotherapy dose usually reduced to reduce the

toxicity profile.
CHEMOTHERAPY PRINCIPLES

 Chemotherapy regimen/protocol: Defining the drugs

to be used, their dosage, the frequency and duration
of treatments and other considerations.

For example “ ABVD for Hodgkin 's Lymphoma “

Adriamycin, Bleomycin, Vinblastine, Dacarbazine.

 Chemotherapy cycle : A cycle is the time between one

round of treatment until the start of the next.
 We give chemotherapy as a course of treatments over
a few months because:

⚫ It allows the chemotherapy to kill more cancer cells.

⚫ The rest between treatments allows normal cells to

recover and your body to regain its strength.
CHEMOTHERAPY CYCLES
COMBINATION CHEMOTHERAPY

• Combination therapy involves the use of two or more

drugs proven effective against a tumor type.

Aim of combination Chemotherapy

• High kill rate
• Safety
• Minimal chances of resistance
CHEMOTHERAPY TERMS
 Adjuvant chemotherapy - Chemotherapy given to destroy left-
over (microscopic) cells that may be present after the known
tumor is removed by surgery. Adjuvant chemotherapy is given to
prevent a possible cancer reoccurrence.

 Neo adjuvant chemotherapy - Chemotherapy given prior to the

surgical procedure. Neo adjuvant chemotherapy may be given to
attempt to shrink the cancer so that the surgical procedure may
not need to be as extensive.

 Induction chemotherapy - Chemotherapy given at first to induce

a remission. This type of chemotherapy is used for curative
intent .
CHEMOTHERAPY TERMS
 Consolidation chemotherapy - Chemotherapy given once a remission
is achieved over a few days or weeks. The goal of this therapy is
to sustain a remission. The drug that is administered is the same as
the drug that achieved remission.

 Intensification chemotherapy- is identical to consolidation

chemotherapy but a different drug than the induction
chemotherapy is used.

 Maintenance chemotherapy - Chemotherapy given in lower doses to

assist in prolonging a remission, over a long period of time, typically
years.
CHEMOTHERAPY TERMS
 Palliative chemotherapy - Palliative is a type of chemotherapy
that is given specifically to address symptom management without
expecting to significantly reduce the cancer

 First line chemotherapy - Chemotherapy that has, through

research studies and clinical trials, been determined to have the
best probability of treating a given cancer. This may also be
called standard therapy.

 Second line chemotherapy “salvage therapy “ - Chemotherapy

that is given if a disease has not responded or reoccurred after
first line chemotherapy. Second line chemotherapy has, through
research studies and clinical trials, been determined to be
effective in treating a given cancer that has not responded or
reoccurred after standard chemotherapy.
 CLASSIFICATION OF CHEMOTHERAPEUTIC AGENTS

Alkylating Agents
Antitumor
Antimetabolites
Antibiotics

Plants Topoisomerase Hormones

Alkaloids 1 & 2 inhibitors Antagonists

** Classes according to ( Clinical Guide to Antineoplastic Therapy A Chemotherapy Handbook , M. Gullatte, second edition).
SIDE EFFECTS OF CHEMOTHERAPY

Alopecia
Mucositis

Pulmonary fibrosis
Nausea/vomiting
Cardiotoxicity
Diarrhea
Cystitis Local reaction

Sterility Renal failure

Myalgia
Myelosuppression
Neuropathy
Phlebitis
 General toxicity of cytotoxic drugs
Dermatological toxicity Drugs
Alopecia Cyclophosphamide, Ifosfamide
Vincristin ,Methotrexate , Paclitaxel,
Local necrosis- Dactinomycin, Doxorubicin, vinca
extravasation alkaloid

Hyperpigmentation of 5-F U
skin
Gastrointestinal toxicity Drugs
Nausea and vomiting Carmustin,cisplatin,cyclophosphamide,
dacarbazine,cytarabine,lomustine,thiote
pa
Stomatitis Capecitabine,5
FU,methotrexate,mercaptopurine
Diarrhea Irinotecan, 5FU
Constipation Vincristine
 General toxicity of cytotoxic drugs

Toxicity Drugs
Neuropathy Oxaliplatin,Paclitaxel, Cytarabine,5FU,
Renal toxicity Cisplatin, Ifosfamide, Methotrexate
Hemorrhagic cystitis Cyclophosphamide, Ifosphamide
Hepatotoxicity Asparginase, Cytarabine,
Mercaptopurine,Thioguanine,
Methotrexate
Cardio toxicity Daunorubicin, Doxorubicin,Epirubicine,
Mitoxantrone,Transtuzumab,
Bevacizumab
Pulmonary toxicity Bleomycin, Melphalan, Chlorambucil,
Busulphan,
Infertility Alkylating agents
Hypersensitivity Asparginase, Platinum compound,
reaction etoposide
C H E M OTH E RAP Y R OU TE S OF A DMINISTRATION

 Intrathecal/intraventricular (central nervous

system)
 Intraperitoneal (abdominal)

 Intrapleural (lung)

 Intravesicular (bladder)

 Intravenous (peripheral -smallest gauge- or

central line)
 Oral

 Subcutaneous

 Intramuscular

 Intra-arterial (arterial)
IRRITANT VS. VESICANT
 Local inflammatory  Infiltrating surrounding
reaction tissue  blistering
 Intact blood return  May be delayed  6-12 hr
 Short-term injury  Severe necrosis
⚫ Bleomycin
 Absent of blood return
⚫ Platinum
⚫ Anthracyclins
⚫ Doxorubicin (both forms)
⚫ Vinca alkaloids
⚫ Etoposide
⚫ Teniposide
⚫ Ifosfamide
⚫ Streptozocin
 EXTRAVASATION OF CYTOTOXIC
DRUG
 Extravasation
 It is severe tissue damage
 (Complication)
 The incidence is ↓ probably due to:
 improvements in the infusion procedure
 early recognition of drug leakage
 training in management techniques
DOSE CATEGORY
 Standard dose
⚫ Most patients

 High dose
⚫ Dose is potentially sufficient to eradicate tumor &
cause severe side effects that warrant supportive
therapy

 Dose intensification
⚫ Higher than standard dose at shorter than usual
intervals
DOSE DETERMINATION
 Mg/kg of body weight
 used most often in infants <1 yr, <10kg

 Body Surface Area (BSA) mg/m2

⚫ Modifications:
 Obese patient
 Children

 Ascites/ edema

 Pre-existing hepatic dysfunction, renal impairment, poor

performance status, toxicity from prior chemo

weight in kg
height in cm.
CHEMOTHERAPY DOSE
Chemotherapy dose X BSA* (100% ) 

Example: - Cisplatein 400mg/m2 over 2hr 

- BSA=1.7m2
400x 1.7= 680 mg 

DOXORUBICIN 75 mg/m2, BSA=1.3m2 = 97.5 

IV push on Day1 ( cycles 1 to 5 )mg
WHO RESPONSE SCALE TO CHEMOTHERAPY

1. Complete response (CR) – disappearance of

disease on imaging test.

2. Partial response (PR) – size decrease of 50%

or more from original tumor. No new lesions.

3. Stable disease (SD) – less than 50% response

without actual progression of disease.

4. Disease progression (PD) – 25% increase in

the size of the original tumor. Or new lesions
developed.
 Safety precaution
PERSONAL PROTECTIVE EQUIPMENTS

• Double Gloves Gowns

•Eye and Face Protection Check

blood return
- pre-initiation
- every 15 minutes during
administration
- post infusion