How Cancer is Treated

Bone Marrow & Stem Cells

Bone marrow is the spongy tissue located inside of bones that is used to create blood cells. Bone marrow contains cells known as hematopoietic stem cells that have the ability to turn into a range of other cell types, including any type of blood cell, or more bone marrow cells. These cells are essential for the maintenance of a healthy body. When a cancer negatively effects these cells, you may need what is known as a stem cell transplant to allow your body to continue to make healthy blood cells.

Bone Marrow Transplants

Bone marrow transplants, or stem cell transplants are the treatment types used to treat certain types of cancers. Previously, bone marrow transplants were called as such as stem cells were collected from the marrow. Today, doctors and scientists have developed advancements that allow them to take stem cells directly from the blood. There are two main types of transplants: Autologous and allogenic transplants. Depending on your type of disease and other factors relating to your health, your oncology team will recommend either an autologous or allogenic transplant. Read more about the two types of transplants bellow.

Autologous transplant

An AUTO transplant involves the process of collecting a person’s stem cells, which doctors will proceed to freeze. A patient will then be treated, generally by chemotherapy, following which your oncology team will thaw your stem cells and return them to your body via an IV tube. Typically, it takes 24 hours for the stem cells to return to the bone marrow, where if successful, they will once again begin to produce healthy blood cells.

There are typically four steps in an AUTO transplant.

1. The collection of stem cells: At the beginning of your treatment, your doctor or nurse will administer medication to increase the number of stem cells within your body. Once your numbers have been boosted, your oncology team will extract your stem cells, typically via an IV or catheter. This process generally takes a several days, over which you will not be restrained to stay within the hospital.
2. Treatment: With your healthy stem cells removed you will receive high doses of chemotherapy. This generally takes up to 10 days, and you will typically be required to stay at the hospital or transplant centre throughout the transplant process, which takes around 3 weeks.
3. Returning stem cells: Once you have fully received your chemotherapy, your stem cells will be returned to your body, typically via your transplant catheter. This process is called a stem cell infusion. This is a short process, that typically takes up to 30 minutes, and may be repeated more than once in some cases.
4. Recovery: once your stem cells have been replaced within your body, you will be administered antibiotics, and be placed under observation for further intervention, such as blood transfusions or the management of side effects. Generally, it is best for you to remain in hospital or the transplant clinic for 2 weeks following this process.

Side Effects

As with all procedures, there are specific side effects that may occur after an AUTO transplant.

• Infection: Following the procedure of a transplant, patients are generally at a higher risk of infection due to treatments such as chemotherapy which weaken your immune system. The highest risk of infection is typically within the first month after a transplant, which is why doctors administer antibiotics following the procedure.
• Immediate side effects: These can include nausea, fatigue, low platelet levels, low blood cell count, diarrhea and/or mouth sores.
• Long–term side effects: The long-term side effects of an ALLO transplant can be severe. This can include infertility, early menopause in women, thyroid issues, cataracts, bone damage, lung damage, and the higher risk of developing a new cancer.

Allogenic Transplant

The second transplant option is an allogenic transplant, or ALLO. In this transplant, you receive stem cells from a donor. This process is more complicated, as your bone marrow must be a match to that of the donors, otherwise, there is potential for a serious medical condition known as graft-versus-host disease. In this condition, your own cells within your body are attacked by the healthy cells, making you quite sick. By finding a matching donor, such as a sibling or family member, the proteins in your white blood cells known as human leukocyte (HLA) are more likely to match, and the transplant will be successful. If you cannot be matched with an adult donor in your family, there are other two options available. The first option is the umbilical cord blood transplant. This is a tested method, in which stem cells from the blood of umbilical cords are extracted for transplants. This option is practiced worldwide. The second option is what is known as a parent-child and haplotype mismatched transplant. This more common practice uses the stem cells of family members such as a child or parent, who may be a 50% match, rather than 100%.

Depending on the health, age and disease being treated, there are two different types of ALLO transplants to chose from: Ablative (high-doses of chemotherapy), or reduced intensity (low-doses of chemotherapy).

There are typically four steps in an ALLO transplant.

• 1. The collection: Your donor will be given medication to increase their white blood cells. Depending on the situation, donors may donate bone marrow through a surgical procedure. The time on this process varies, depending on the process of collection.
  2. Treatment: The patient with cancer is given chemotherapy (in most cases). This process can take up to a week and is conducted in a hospital.
  3. Returning stem cells: The process of receiving your donors stem cells is known as a stem cell infusion. This process can take up to 1 hour, as the cells are transplanted via a catheter, which remains in after treatment.
  4. Recovery: The patient will receive antibiotics, and if necessary, further blood transfusions. The time in hospital varies, but a patient can expect to be in hospital for 1-4 weeks, depending on their situation.

Side Effects

As with all procedures, an ALLO transplant includes the risk of side effects. These can range from the chemotherapy to the transplant itself.

• Infection: Following an ALLO transplant, you have a higher risk of infection throughout your life. Your doctor may administer chemotherapy and other drugs to help your immune system accept the new stem cells, but these treatments also affect your body’s ability to fight infection.
• Graft-versus host disease (GVHD): This is the process of your newly implemented stem cells attacking your body. There are two types of GVHD that can occur, even if your donor is a 100% match. The first is acute GVHD. Acute GVHD will typically affect the skin, intestines and liver, and will typically occur within the first 3 months following an ALLO transplant. The treatment for acute GVHD is a medication designed to stop T cells – the white blood cells that keep your immune system functioning. In the case of acute GVHD, the T cells often attack the body’s own cells rather than simply infections. Chronic GVHD includes a range of symptoms (or none at all), such as an irritated liver, dryness in the mouth and/or eyes, a condition known as scleroderma, in which the skin loses its ability to stretch, as well as joint pain, weight loss and infection. Chronic GVHD typically occurs 3 months after an ALLO transplant and can last a lifetime. It is typically treated with medication such as corticosteroids, or a range of immune suppressing drugs.
• Immediate side effects: These can include nausea, fatigue, low platelet levels, low blood cell count, diarrhea and/or mouth sores.
• Long–term side effects: The long-term side effects of an ALLO transplant can be severe. This can include infertility, early menopause in women, thyroid issues, cataracts, bone damage, lung damage, and the higher risk of developing a new cancer.

A Successful Transplant

There are many different definitions of the word “successful” in the world of cancer. In relation to transplants, there are two milestones that indicate a successful transplant. The first, is the return of your blood count to safe levels. During the transplant process, your blood count – made up of red cells, white cells and platelets – becomes very low, which can leave you exposed to infection, bleeding and tiredness. This is why antibiotics are important following your transplant. As your newly transplanted stem cells begin to multiply, your blood count improves, indicating success.

The second measure of a successful transplant is the control of cancer. Occasionally, oncologists use stem cell transplants as a means of curing a disease. This is possible for some cancers of the blood. While a cure is not always possible, stem cell transplants are also able to send a patient into remission, which means they have no signs of cancer. If this is the desired outcome, it is essential to conduct regular check ups to watch for any signs that the cancer has returned.

Choosing the Right Transplant

Choosing between an AUTO and an ALLO transplant is difficult, but with the right knowledge base and a strong oncology team behind you, the choice can be simpler. Ensure you ask as many questions as possible. These can include:

• What is your recommended transplant option and why?
• If an ALLO transplant is recommended, how will we go about finding a donor?
• What are the treatment options before the transplant takes place?
• How long will I be in hospital?
• Will the transplant disrupt by regular life?
• How long until we will know if the transplant is successful, and what if it doesn’t work?
• Are there any side-effects?
• Are there any long-term effects?
• What ongoing testing will be needed?
• What is the cost for these treatments? Is there any cost difference between an AUTO and an ALLO transplant?

Choosing the Right Treatment for You.

The overwhelming feeling following a cancer diagnosis is often exacerbated by the sheer amount of decisions a patient will need to make in regards to their treatment moving forward. Where possible, it is essential to do your research and take time to consider your options. The first step is to fully understand your diagnosis, and what this means moving forward. Ask your oncology team for information, or a starting point for accurate online information. You don’t want to read inaccurate information that causes you further anxiety, so ensure it is verified.

There are several different options moving forward, depending on your type of cancer, and the advice from your oncology team. These can include a combination of:

• Surgery
• Chemotherapy
• Radiation
• Hormone therapy
• Targeted therapy
• Immunotherapy
• Palliative care
• Clinical trials

Before You Decide

As we have mentioned, it is important to undergo research to find out everything you can in regard to your disease and your options. Consider the following:

• The goal of your treatment: Not all patients with cancer can expect the same goals in their treatment plan. Your goal to fully recover from cancer may be different that the goal of living the rest of your life comfortably.
• Side effects: Different cancer treatments cause different side effects that have a range of different impacts on your life. Ensure you understand the side effects of each treatment by discussing them with your oncology team.
• Make a pro con list: Weigh out the positives versus the negatives of each treatment plan and consider what is the best option long-term.
• A second opinion: It is always recommended to find a second opinion from another oncologist before committing to your treatment plan. You may find that they have an alternative option, or experience in something another doctor may not.
• The cost: One of the biggest challenges with cancer treatments is the cost. Find out what your health cover will cover before proceeding.
• Consult guidelines: There are published guidelines available that help with the decision of treatments such as those published by The American Society of Clinical Oncology that are worth looking into when making your treatment decision.
• Ask your friends and family: While it is ultimately your decision, it is important to speak with your loved ones to consider their opinion, particularly those who will be going through this will you, such as a spouse. 

Chemotherapy

Chemotherapy is the most well known cancer treatment, but few know what chemotherapy actually entails. Chemotherapy is the use of drugs that works to kill cancer cells, stopping them from growing and dividing. Since cancer spreads through rapid division of cells, chemotherapy is effective at stopping this. There are three types of chemotherapy: standard chemotherapy, traditional chemotherapy and cytotoxic chemotherapy. Unfortunately, as the drugs being used to kill the unhealthy cells are so potent, they can also kill healthy cells, leading to the side-effects commonly associated with chemotherapy. 

Chemotherapy Goals

As with all cases, the goals of a person’s cancer treatment depends entirely on the individual needs of the patient. Chemotherapy can be used to shrink and slow cancer, or it can be used to remove cancer all together. Chemotherapy can be given in the hospital via an IV, or some types may be administered by tablet which may be taken at home.

Your chemotherapy plan is something that should be discussed with your oncology team. They will help you to determine your chemotherapy goals and expectations moving forward. This will depend on:

• Your cancer type
• The size of your tumour and its location
• The stage of cancer
• Your overall health
• Your reaction to side effects
• Previous cancer treatments

How is Chemotherapy Administered?

• Intravenous Chemotherapy (IV): An IV is a therapy that delivers fluid directly into a patient’s vein. IV chemotherapy can take anywhere between minutes to hours, and some chemotherapy treatments work best when received over several weeks. In this case, a patient is required to wear a small pump which will administer the chemotherapy over time, which is known as continuous infusion chemotherapy.
• Injected chemotherapy: This type of chemotherapy is administered as an injection which is typically injected into the arm, leg or abdomen.
• Oral chemotherapy: Some chemotherapy’s may be in the form of a tablet or a capsule. Oral cancer treatments are becoming frequently more common and are typically taken daily over a set amount of time.
• Chemotherapy into an artery: An artery – the blood vessel that carries blood from your heart throughout your body – is occasionally used as the injection site for some chemotherapies. This is known as IA chemotherapy.
• Chemotherapy into the abdomen: For cancers that involve the peritoneum – the surface of the abdomen and the intestines, stomach and liver -, medication that is administered directly into the abdomen is necessary.
• Topical chemotherapy: Topical chemotherapy is administered as a cream to the skin.

Alternative Options

With advancements in technology, scientists have created new methods in which to treat cancer. Some of these alternative options are best when used in conjunction with chemotherapy. These can include:

• Hormonal therapy: Used to change the number of hormones active in your body. By changing the number of hormones, doctors are more able to control the hormone levels that are linked to certain cancer types such as breast cancer.
• Targeted therapy: Used to disable genes and/or proteins that are located within cancer cells that cause growth.
• Immunotherapy: Used to boost your body’s natural defence system to fight off cancer.
  

What is the Time Period for Chemotherapy?

Before you begin your treatment, you will often be told how long to expect your treatment to go for. This can take anywhere from 6-12 months, or it can continue as long as the treatment works for. Because of the intense side effects of chemotherapy, it is typically administered over a set time period with scheduled breaks in between. This is in order to allow your body time to heal. This time frame will depend on the type of chemotherapy, and severity of your cancer.

Your Chemotherapy Team

When you undergo chemotherapy, you will find a whole team of professionals will be alongside of you throughout this journey. The two main professionals will be a medical oncologist, a doctor who is in charge of your treatments, and an oncology nurse, who will look after your health and manage your side effects.

IV Treatment

The most common chemotherapy administered is IV chemotherapy. Before you can begin chemotherapy, you will need to speak at length with your doctor about the risks and benefits and best options for your individual needs moving forward. you will then be required to sign a consent form before you proceed, stating that you understand what will and may happen moving forward and that your doctor has explained this.

At the time of your first treatment, you will meet your chemotherapy team, and you will have a range of tests completed to check your overall health, and you will have blood samples taken. One of the most important steps in this process is the placement of an IV tube into your arm. In some cases, you may receive a “port” through a minor surgery. This port is a round disk that allows an IV to be inserted easily, meaning a nurse does not need to insert a needle into your vein for every treatment you undertake. You will then be administered your IV chemotherapy through your IV and into your system.

After your chemotherapy has been administered, your IV will be removed, but your port (if you have one) will remain for future use. You will then be given a physical examination, as you received before the treatment, and you will be briefed on the possible side effects to be ready for. You may also be given strict rules, such as to avoid people with colds, drink plenty of fluids, and rest for several days following your chemotherapy.

Side effects associated with Chemotherapy

• Loss of appetite: You may find yourself unable to eat during chemotherapy. It is always best to try and eat something, as this can lead to muscle loss which is hard to recover.
• Blood disorders: During chemotherapy, your bone marrow cannot make the appropriate number of blood cells and this can lead to serious complications. To avoid this, doctors will often undergo routine complete blood counts and platelet counts to ensure your blood count levels are at the appropriate number. Doctors can change chemotherapy doses to ensure these stable levels are maintained.
• Constipation: Certain chemotherapies can cause difficult bowel movements.
• Changes in thinking and memory: After chemotherapy, some patients have noted difficulty concentrating and thinking clearly. This is known as cognitive dysfunction.
• Diarrhea: Certain chemotherapies can cause watery bowel movements. It is important to replenish your fluids and remain hydrated for your overall health if this occurs.
• Fatigue: Feeling exhausted most of the time.
• Fertility complications: Chemotherapy has been known to affect fertility in both men and women. Chemotherapy can also affect an unborn baby.
• Hair loss: Many types of chemotherapy induce full body hair loss. This typically takes place at around one month after treatment begins. Your doctor may be able to shed some light into whether or not you can expect hair loss, depending on your chemotherapy and dosage.
• Mouth sores: Chemotherapy has been known to affect the cells found inside a patients throat and mouth. These sores are known as mucositis, which typically disappear when your chemotherapy is over.
• Nausea: Chemotherapy can lead to nausea can occur when the medication levels have not been used properly. It can take time to find the right levels.
• Nervous system changes: Survivors of cancer are more likely to have a second cancer later in life, and children may develop chemotherapy side effects several years after their treatment. These are both due to changes in a person’s nervous system after chemotherapy.
• Nervous system effects: Some chemotherapies can lead to nerve damage.
• Pain: This can include muscle pain, headaches, nerve pain and/or stomach pain. Pain can be treated by your doctor through medication, blocking pain signals from the nerves and/or adjusting chemotherapy doses.

Side effects can be treated, and this process is known as palliative care. Your palliative care team will work with your chemotherapy team to combat, reduce and remove your side-effects.

After Care

As with all cancer treatments, aftercare is essential to restore and maintain a patient’s health. You should ensure that your oncology team schedules regular testing, examinations and regular check-ups to ensure you are able to minimise long-term side effects and any late effects moving forward.

Integrative Medicine

The combination of cancer treatments and complementary therapies are known as integrative medicine. This combination is typically used to compact the symptoms and side effects of treatment. This is sometimes known as “complementary therapies”.

Complementary Therapies

It is important to note that complimentary therapies are not an alternative treatment path, but an addition to standard cancer treatments. These alternatives should only be used in addition the treatments you have discussed with your oncology team, and with doctor permission. Taking alternative medicines as a complete alternative without the consent of a doctor can be very dangerous.

Complementary therapies can be helpful when used correctly, and often include physical activity, nutrition guidelines, acupuncture, and mindfulness activities. While these therapies are natural and have been proven to boost a person’s overall health in particular situations, they should never be used in place of recognised cancer treatments.

• Physical activity: This can help build strength, reduce stress levels, reduce depression and anxiety and increase the overall health of a patient. Discuss physical activity plans with your oncologist before proceeding.
• Nutrition: By speaking with a professional nutritionist, patients are able to create a meal plan that can help them manage their weight changes during their treatment, cope with nausea, learn the foods to remove from their diet to stop interference with their treatments, and boost the overall health of a patient.
• Acupuncture: Is an ancient therapy that uses tiny needles to release chemicals in the brain to help with pain relief. Acupuncture has also been proven to help reduce nausea related to chemotherapy, can relieve dry mouth and hot flushes, fatigue and insomnia, headaches and appetite loss.
• Mindfulness: mindfulness is an important skill to have during cancer treatment. With a strong and clear mind, a patient has a better chance at recovery. Mindfulness activities can include yoga, tai chi, meditation, music therapy, art therapy and/or massage.

Each of these complementary therapies have been proven to help reduce pain and stress levels on cancer patients, but as will everything, this will vary from patient to patient.

Alternative Therapies and the Risks Attached

• Your cancer may worsen whilst using an alternative method of therapy, as other methods cannot stop the growth of cancer. This may lesson your treatment options in the future.
• You may be subject to worsening side effects from the alternative method.
• The alternative method may inhibit your treatments from working

Questions to Consider

When discussing your option with your oncology team, it is important to ask about complementary therapies, so you know what your options are moving forward. Some questions may include:

• What therapies can I use with my treatments?
• What is the purpose of the complementary therapy?
• Are there side effects to this?
• Will the use of this therapy affect my uses of standard treatment in the future?
• Is there research available to substantiate the complementary therapy?
• Are there clinical trials for this therapy available?

Clinical Trials

After a cancer diagnosis, it is recommended of patients conduct research into their treatment options. One option that you may come across are clinical trials. A clinical trial is a study that aims to study different types of cancer and treatments available. These are conducted with volunteer patients with these specific diseases.

Should I Enter a Clinical Trial?

Like all treatments, clinical trials are an option worth considering. A clinical trial may:

• Allow you access to treatments that are otherwise unavailable
• Help to minimise side effects
• To help improve the treatments available for all cancer patients

Questions to Consider

No two clinical trials are the same, but it is important to ask questions that help you chose whether or not this is a suitable treatment option for you. Some things to consider are discussed below.

Do you have to have tried all other treatments before the trial?

This depends on the trial. Some clinical trials require patients who have not completed any treatments, while others need patients who have tried them all. This is specific to each individual trial.

What is being studied?

Typically, clinical trials operate with the purpose of finding a better way of treating and/or curing cancer. A trial could be testing a new drug, a new method of transmitting a drug, new combinations of drugs and/or methods in which to reduce side-effects to name a few.

Is it safe?

There are strict rules in place when it comes to clinical trials. There are a number of government implemented rules that doctors are required to follow.

Will my insurance cover it?

Depending on the trial, the costs are often covered by the clinical team.

The Pros and Cons of Clinical Trials

Pros

• Trial of new treatments
• Access to the care of medical experts in leading hospitals
• Helping the future of cancer research
• Potential to benefit from the treatment

Cons

• You may experience new side effects
• Being in a trial means you need further testing and it can take more time
• It can be difficult to get into a clinical trial

Personalised and Targeted Therapies

By studying a patient’s genetic makeup, oncology teams are able to determine effective strategies for the prevention, screening and treatment of a specific cancer. This is done through the genetic testing of both healthy cells and cancer cells in order to create a customized treatment plan for the individual patient. Personalised therapies are becoming more common as scientists have found that genetic differences in people determine the effectiveness of a cancer treatment. Today, it is common for a patient to receive standard treatments with modifications to suit their individual needs.

Targeted Treatments

Personalised treatments are designed to target the specific genes and proteins found within a tumour that help the cancer to grow. While not all cancer types are able to have targeted treatments, the following can:

– Breast cancer

– Colorectal cancer

– Gastrointestinal stromal tumour

– Kidney cancer

– Lung cancer

– Melanoma

– Multiple myeloma

– leukemia and lymphoma

– Some childhood cancers

Targeted therapies are not always possible, and every case depends on the specific tumour and patient being treated. To determine the most effective path forward, an oncology team needs to examine the tumour through the lens of pharmacogenomics. Pharmacogenomics examines the ways in which genes react to specific drugs, and this determines the treatment method moving forward.

Personalised treatments are not offered under all circumstances. Often, this is only available during clinical trials, or at a large cost of money. Scientific investigation is still being undertaken, and the future is likely to see personalised treatment methods as the standardised norm of treating cancer.

Questions to Consider asking your Oncology Team

– What are my treatment options?

– Are there clinical trials available to me?

– Am I able to undergo genetic testing?

– Is my treatment plan considered as personalised?

– Will I benefit from this treatment? How?

– What are the side effects?

– Will this help my chance of recovery?

What is the “Target”?

In order to understand targeted therapy, you must first understand how cancer grows and spreads. Cancer grows when healthy cells change and begin to multiply at a rapid rate. This is known as a mutation. When a mutation occurs, this rapid multiplication creates a tumour. Targeted therapy works when scientists are able to use a drug that can stop the signals in your body that tell your cells to continue growing, keeping your cells from living for too long and by destroying the cancer cells completely.

Targeted Therapy Types

There are two typical types of targeted therapy.

• Monoclonal antibodies: These drugs are typically administered via an IV, and work to stop a specific target around the outside of a cancer. Monoclonal antibodies work to keep the cancer contained, as well as sends toxic substances into the cancer cells.
• Small-molecule drugs: These small-molecule drugs work to block the process that allows cancer cells to multiply and are typically taken orally as pills. This therapy uses angiogenesis inhibitors to stop the production of blood vessels around the tumour, starving the tumour and thus stopping the spread and growth of the cancer itself.

Finding the Right Treatment

Targeted treatment will not work for everyone and not all targeted therapies work for all cancers. In order to determine the best path forward, it is likely that your oncology team will conduct a range of tests to understand the proteins, genes and other information about your tumour.

There are certain cancers that have been known to have responded well to targeted therapies. These include breast cancer, colorectal cancer, lung cancer and melanoma. There are other cancers that can utilise targeted therapies, and researchers are adding more options to the list each day. Even if your type of cancer is on this list, it is important to remember that targeted therapy may not be the best option for your own treatment, and you should discuss this with your oncology team.

Remember:

– If the tumour does not have a target, the treatment cannot work.

– If a target exists within the tumour, this does not guarantee it will respond to the drug.

– Any response to a drug may be short term.

– You may experience more severe side effects.

– Targeted therapy works best in conjunction with traditional therapies.

Surgery

When a person receives surgery for cancer, they undergo an operation in which a surgical oncologist removes the tumour and nearby tissue from your body. Surgery is one of the oldest cancer treatments and is still effective today. Surgery can be used to diagnose and locate cancer, remove cancer, relieve the side effects of cancer or to investigate the potential spread of a cancer.

The Surgical Team

If you require surgery, it is likely that you will be taken care of by a full team of oncology professionals.

• You will have a lead surgical oncologist within your team. Depending on your cancer, your surgical oncologist will have a certain specialty. For example, neurosurgeons specialise in brain cancer.
• An anaesthesiologist is the medical professional who is in charge of your anaesthesia, the drug that block your pain senses during surgery. An anaesthesiologist will also monitor your vital signs and identify the rest of the team of any complications during surgery.
• Operating room nurses are essential to the assistance of surgeons during your surgery. You will also be looked after by recovery room nurses following the completion of your surgery while you remain in hospital to recover.

Surgery Types

It is not uncommon for people to feel anxious before their surgery. To relive this, it is important to understand what you may expect as your surgery approaches.

Surgery can be used for different purposes.

• Diagnostic surgery is the process where a surgeon removes all or part of a tumour in order to biopsy it. The biopsy is then examined by a pathologist who determines whether the cells, tissues and/or organs have cancer. A pathology report is then written to diagnose the type of tumour found.
• Staging surgery is used to investigate whether or not the tumour has spread, and where it has spread to. During this surgery, the surgeon will often remove a small number of lymph nodes surrounding the cancer to determine the spread.
• Tumour removal is the removal of a tumour and the nearby tissue. Tumour removal is often used in conjunction with other treatments such as chemotherapy or may be used alone.
• Debulking is the process where a surgeon removes as much of a tumour as possible without damaging the rest of the body. This is typically used in conjunction with other treatments such as chemotherapy.
• Palliative surgery is used to relive the side effects that may be caused by a tumour. This can include pain relieve if a tumour is pressing on a nerve, for example, to stop bleeding when cancers are in or near areas that are susceptible to bleeding or where bleeding is a side effect of a treatment. Surgery can also be used to insert a feeding tube into a patient in order to keep them sustained when treatment makes it difficult to eat, and to prevent broken bones that are caused by treatments through the insertion of a metal rod into certain parts of the patient’s body.
• Reconstructive surgery is used following the removal of a tumour to restore either the function or appearance of the patient’s body. This surgery can be conducted either at the time of the original surgery, or at a later date, depending on the individual situation.
• Preventative surgery is undergone when a person is at risk of developing cancer in order to prevent it. For example, women with an extensive family history of breast cancer may chose to have a mastectomy to prevent themselves developing the cancer. While preventative surgery cannot guarantee the patient will never develop cancer, it significantly lowers a patient’s risk.

Minimally Invasive Surgery

The majority of the surgeries mentioned above involve a surgeon making large incisions to the body in order to achieve their goal, however this is not the only method of surgery. Minimally invasive surgery is the use of small incisions made by surgeons. This type of surgery often have less recovery time and less instances of pain following surgery.

Some minimally invasive surgeries and procedures are:

• Laparoscopic surgery: Where a surgeon makes a small cut in the skin using a small lighted tube with a camera. Laparoscopic surgery takes place in the abdomen and is sometimes done with the aid of a robot controlled by a doctor. Both mediastinoscopy and thoracoscopy are similar types of surgery to a laparoscopic surgery, however they are conducted within the chest.
• Laser surgery: The removal of cancer through the use of a narrow beam of high-intensity light.
• Cryosurgery: The use of liquid nitrogen in order to freeze and thus kill cancerous cells.
• Mohs micrographic surgery: Conducted by a dermatologist, skin cancer is shaved off one later at a time until all cells within a layer of skin look healthy.
• Endoscopy: The incision of a thin and flexible tube that has a light and camera attached to the tip within the body. This tube can be inserted via the mouth, rectum or vagina to view and closely inspect the insides of a patient. During this procedure, doctors may also be able to take a small sample of tissues or cells for further investigation.

Maintenance Therapy

Maintenance therapy is the use of medication following an initial round of treatment. This may include the use of chemotherapy, hormonal therapy or targeted therapy.

Maintenance therapy may be beneficial in order to:

• Delay or prevent the return of cancer if a patient is in complete remission.
• If a cancer is advanced following initial treatment, maintenance therapy may be used to slow the growth. This is not used as a cure, but to prolong life.

Advancements in Maintenance Therapy

Maintenance therapy is not a new concept, but advances in technology have increase the use of the therapy in modern medicine. This is related to:

• The increase of studies conducted on cancer drugs and the finding of drugs that do not aid in curing cancer but can be used effectively as maintenance therapy.
• New therapy drugs often have less side effects than those older ones, meaning people can use them for longer.
• Maintenance therapy is an effective method of lengthening life in certain situations, which is becoming increasingly more widespread.
• Maintenance therapy typically involves a single drug rather than several, meaning there are fewer side effects.
• Maintenance therapies may last for months or years depending on the type of cancer, the drugs being used and how well it works, thus allowing a patient to live a more normal life.
• Maintenance therapy is often used to lower the risk of cancer returning for patient’s in remission.
• Maintenance therapy may slow and help to control advanced cancer in order to help patient’s live longer.

Questions to Consider Asking your Oncology Team

• Is maintenance therapy the best option for my cancer?
• What therapy would you recommend?
• Are there any risks to this therapy?
• What is the cost involved?
• How long would I undergo this therapy?
• Are there any clinical trials available for this therapy?
• Should I watch and wait before beginning maintenance therapy?

Radiation Therapy

The use of high-energy x-rays to kill cancer cells is known as radiation therapy. This type of treatment is conducted by a radiation oncologist over a set regime of treatments to be determined based on your individual needs. Radiation therapy is quite common, with over half of patients with cancer receiving the therapy in one form or another. For some, radiation therapy is the only treatment needed, whereas for others, they may use it in conjunction with other treatments.

The Goals of Radiation Therapy

Typically, the goal of radiation is to destroy cancerous cells within the body in order to stop the spread of a tumour without causing damage to healthy cells within the body. Depending on your cancer, your oncologist may recommend radiation therapy as your first treatment, or they may recommend using radiation therapy as “adjuvant” therapy, meaning it is used following surgery or chemotherapy in order to target any remaining cancer cells following the initial treatment.

In some instances, oncologists may not be able to remove all cancer cells and will use radiation therapy as a means to shrink a tumour instead of removing it. This is known as palliative radiation therapy, and may help to reduce pain, pressure and any other symptoms of your cancer. The goal here is not to cure the body of cancer, but to improve a patient’s quality of life whilst living with cancer.

External-beam Radiation Therapy

External-beam radiation therapy is the most common type of radiation therapy received. It works by delivering radiation via a machine known as a “linear accelerator” to the outside of the body, treating large areas if necessary. The machine works by creating a beam of radiation, whose size and shape is adjusted by computer software for the individual needs of a patient in order to avoid damaging healthy cells. External-beam radiation is typically administered each day for several weeks. The different types of external-beam radiation therapies are:

• Three-dimensional conformal radiation therapy (3D-CRT): The process where a detailed, 3D image of a cancer is created, allowing oncologists to create a treatment plan that directly targets the tumour without damaging the healthy cells around it. This allows doctors to use higher levels of radiation whilst being more effective, as well as lowering the risk of side effects.
• Intensity modulated radiation therapy (IMRT). Similar to the 3D-CRT, an IMRT is a more sophisticated form of radiation therapy. Rather than using the same intensity in each beam such as within the 3D-CRT, the IMRT varies the intensity within each of its beams allowing for more accuracy during treatment.
• Proton beam therapy: This is a sophisticated a new age therapy that requires specialist equipment and only works on certain types of cancer. Rather than the use of x-rays, proton beam therapy uses protons – a particle that is positively changed. When used at high levels of energy, protons are able to destroy cancer cells that are targeted within a tumour, administering high levels of radiation. This is a highly targeted treatment and is less likely to damage surrounding healthy cells.
• Image-guided radiation therapy (IGRT): This type of therapy allows the doctor to take images of a patient throughout treatment. These images can then be compared to the images used to plan treatment. It allows better targeting of the tumor and helps reduce damage to healthy tissue.
• Stereotactic radiation therapy: This therapy delivers large and precise doses of radiation to a small tumour area. Stereotactic radiation is often limited to a single treatment.
• Internal radiation therapy: Also known as brachytherapy, this is when radioactive material is implanted within a cancer as either a permanent or temporary implant that deliver the radiation directly to the surrounding cells.
• Intraoperative radiation therapy (IORT): The delivery of radiation via an external-beam or internal radiation therapy during surgery. This allows surgeons to directly target unhealthy tissue whilst minimising the exposure of heathy tissue.
• Systemic radiation therapy: A treatment that requires a patient to swallow or have an injection of radioactive material. This material targets and kills cancerous cells. It can be dangerous however, as the radioactive material exits the body via saliva, sweat and urine.
• Radioimmunotherapy: A systemic therapy that uses monoclonal antibodies that deliver radiation to cancer cells via low doses of radiation without effecting noncancerous cells.

Safety Precautions

It is a misconception that following radiation therapy, a patient becomes radioactive. This is untrue for external-beam therapies, however there is a chance that internal therapy and permanent implants can cause a patient emit radiation from their body. As a precaution, patients should:

• Not come into contact with children under 18
• Not come into contact with pregnant women
• Be at least 6 feet from all visitors
• Allow visitors to stay for up to 30 minutes only each day

For patients who have received systemic radiation therapy, for the first week you should:

• Thoroughly clean your hands after using the bathroom
• Use distinctly separate utensils
• Use distinctly separate towels
• Drink a larger amount of water
• Avoid sexual contact with your partner
• Do not accept visits from children or pregnant women.

The Radiation Team

As with all treatments, you will have a specifically designed medical team working towards creating a treatment plan for you. This team will likely consist of:

• A radiation oncologist is the doctor who specialises in radiation therapy. This doctor will oversee all treatments and work with other members of the team to create a specialised treatment plan.
• A radiation oncology nurse works specifically with patients receiving radiation therapy.
• A medical radiation physicist is an expert in operating radiation equipment.
• A dosimetrist calculates the perfect dose of radiation for your treatment
• A radiation therapist operates the treatment machines

The Treatment

Before you begin your radiation treatments, you must first meet with your oncologist and discuss your options and best path forward. Once you and your doctor have agreed upon this, you must sign a consent form indicating that you understand the process moving forward. You will then undergo a series of tests and trials to locate the tumour such as a CT scan, an MRI or an x-ray. The oncology team will mark your skin to identify the location of your tumour, allowing greater ease when you undergo your treatment. Depending on your treatment plan, is also possible that you will be fittest for an immobilization device to hold you still during your treatment.

For those undergoing external-beam radiation therapy, sessions are short and painless, only lasting on average 15 minutes. This treatment type is typically carried out 5 times a week for up to 9 weeks, depending on your treatment plan.

For those undergoing internal radiation therapy – the temporary or permanent placement of a radioactive source – sessions are typically repeated for a scheduled number of days and/or weeks, and potentially require a short hospital stay. If you receive an implant, you will need to take care about protecting others from radiation until the implant is either removed or loses its radioactivity.

Following Your Treatment

Upon the conclusion of your treatment, you can expect to have regular check-ups with your radiation oncologist. These check-ups will ensure that your recovery is on track, and to diagnose and treat any side effects that you may begin to develop. As time passes and if your recovery is going well, you will need fewer check-ups.

Radiation Therapy and Side Effects

As with all treatments, radiation can cause side effects. This is typically due to damage causes by healthy tissues and cells surrounding the treatment area. While side effects have become fewer due to more precise treatments being developed by researchers, patients may still find that they have side effects during their second or third week of treatment, while others experience no side effects at all. Those who do experience treatments are typically found in areas located near the treatment site.

Some side effects can include:

Full body:

• Skin problems
• Fatigue
• Radiation recall – a rare rash that resembles severe sunburn

Head and neck:

• Hair loss
• Dry mouth
• Mouth sores
• Difficulty swallowing
• Nausea
• Tooth decay

Chest:

• Shortness of breath
• Sore breasts
• Stiff shoulders
• Radiation pneumonitis
• Radiation fibrosis

Stomach:

• Nausea
• Diarrhea

Pelvis:

• Diarrhea
• Bleeding of the rectum
• Bladder irritation or incontinence

In women:

• Menstrual changes
• Infertility
• Menopausal symptoms

In men:

• Erectile dysfunction
• Lower sperm count

Side effects can be treated and/or minimised through palliative care.

Proton Therapy

As discussed earlier, proton therapy involves the use of high energy protons. These protons are sped up in a machine known as a synchrotron. They are then placed into targeted locations within the patient’s body to inject the tumour with a dose of radiation.

The Treatment

Before you receive proton therapy, you will typically undergo testing such as a CT or an MRI that need to be specific in their data collection. As such, you will generally be fitted with a device to keep you still and as comfortable as possible. The type of device will depend on the location of the tumour and will be custom fitted to each patient. The patient will also wear this during other tests and/or treatments. These devices are set to precise measurements both to the operating table and to your body in order for your treatments to be completely accurate and no healthy tissue is damaged. Similar to radiation x-rays, you will also receive a small mark on your body to indicate where the tumour is located.

Proton therapy is typically administered during an outpatient setting, meaning you will not necessarily need to be treated within a hospital. This depends on your specific cancer and your oncology team’s recommendations. Proton therapy can be administered in under 5 treatments, with larger doses of radiation being administered the fewer visits you have planned. The time needed for each session will vary depending on the scans you need at each session. You will first be placed into the personally fitted device to hold you perfectly still on the treatment table or chair. You will then be given a CT or x-ray scan at the beginning of each session to verify the exact location of the tumour. Occasionally, a treatment room will also be fitted with a machine known as a gantry. The gantry rotates around the patient, providing different angles in which to view the tumour.

Once the patient has been properly positioned, the treatment team will relocate to the delivery controls on the outside of the room which is joined by a glass window and fitted with video and microphones for the patient to communicate with the team.

The protons are then released from the machine and are directed by magnets into the tumour. The treatment process itself takes from 15 to 30 minutes, however the scanning and fitting process can add a greater length of time to your visit. This time frame will also depend on the intensity of your treatments, and how many treatments you will be receiving. Typically, most centres will only hold one proton machine, so you may need to wait for another patient to be treated before you can receive your treatment.

Side Effects

Following proton therapy, you may find yourself fatigued, though the treatment process itself is painless. You may also experience skin problems such as swelling, redness, blistering or general irritation from the treatment.

If you are also receiving other treatments such as chemotherapy, you may experience side effects. This may depend on the location of the tumour being treated. Your oncology team will be able to highlight some of the side effects that you could be at risk for.

Cancers That May be Treated with Proton Therapy

While not all cancers can be treated with proton therapy, in many cases tumours that are located near important parts of the patient’s body, such as the spinal cord. Proton therapy is also recommended to children with cancer as it is less invasive and lowers the risk of harming healthy cells.

Cancers that may be treated via proton therapy:

• Cancer of the eye
• Cancer of the central nervous system
• Cancer located in the head or neck
• Lung cancer
• Liver cancer
• Prostate cancer
• Cancers occurring within the soft-tissue
• Cancers occurring within the bone
• Noncancerous brain tumours

Positives and Negatives

When considering the differences between x-ray radiation therapy and proton therapy, there are several positives and negatives to consider.

Proton therapy positives:

• Typically delivers around 60% less radiation to surrounding healthy tissues, lowering the risk of damage.
• Operates at higher doses of radiation, increasing the likelihood that the tumour will be destroyed.
• May cause fewer side-effects

Proton therapy negatives:

• It can be costly and requires specific, advanced technology
• It does not work on all cancers
• Insurance companies may not cover the cost
• It is still undergoing significant studies

If Your Treatment Does Not Work the First Time Around

When you have cancer, everything can seem overwhelming. You will work closely with an oncology team to create the best treatment plan for your cancer which has the best potential to treat you whilst providing you with the fewest side effects. The first treatment that a patient will undergo is known as the first-line treatment and is typically chosen as it has worked best for people with similar characteristics to the patient within clinical trials. Unfortunately, this does not always mean that it will work for every patient.

If a first-line treatment fails, causes severe side effects, or starts to work but then stops, your oncologist is likely to suggest a second-line treatment. Similarly, it this does not work, you may move onto a third-line treatment.

Looking into and Alternative Treatment Option

If your oncologist suggests that you require a second-line treatment, this does not mean that the first-line treatment was wrong or that you cannot be cured. Second-line treatment can be successful depending on the type of cancer you have. The success rate of a second-line therapy will also depend on:

• The stage of a cancer
• The results of the first-line treatment
• The time between your treatments
• The side effects of the first-line treatment
• Your overall health
• The goal of the treatment

Your oncology team may suggest that trying an alternative treatment option is not the best path forward. This is a difficult decision to make, but it can allow you to focus on a better quality of life when living with cancer. This is known as palliative care.

Questions to Consider

It is essential to have an open line of communication with your oncology team. This will ensure you understand the process that you are undertaking and make you feel more confident in your choice of treatment.

Some questions that you may wish to ask are:

• What changes have occurred within my cancer from my first treatment?
• Should we be looking at other treatment options?
• Are there any clinical trials available?
• Is it wise to consider stopping my treatments?
• Is there financial help available to me?

If your doctor recommends second-line treatment, you should consider asking the following questions:

• What is the difference between the first-line treatment and the second-line treatment?
• What is the overall goal of this new treatment?
• What are the possible side effects?
• What is the success rate for this new treatment?
• What is the timeframe for this new treatment?
• When will I begin my second-line treatment?
• Where will this treatment be administered?
• Do I need to see a different oncology specialist for this treatment?
• Do you have any further information?
• What are the costs involved?

Dealing with a New Treatment

When you are told that you need to move on from your first-line treatment to alternative treatment options you may experience anxiety, depression, guilt anger or shock. This is a normal response to a difficult situation. It is important to have a support system in place when you undergo any treatment, but in this situation, it can be important to:

• Share your feelings with family, friends or support groups
• Connect with people that have experienced a second-line treatment to share in their experiences
• Try writing your feelings down, or drawing some images to express your feelings
• Try practicing mindfulness
• Spend some time outside
• Try music therapy
• Spend some time doing something just for you

When to Call Your Doctor

There are many reasons to call your doctor during your treatment. This can be due to unexpected or new side effects that you are concerned about but deciding when to call the doctor can be difficult. You should discuss this concern with your doctor once you decide on your treatment options, and he/she should provide you with a list of signs and symptoms that require immediate medical attention. Some of these are explored below.

Infection

When undergoing cancer treatments, your immune system is often lowered, meaning you are more susceptible to infection. There are many common types of infections that require medical attention including pneumonia, urinary tract infection, infections in the mouth, throat, stomach, oesophagus, anus or intestines and blood infections.

Some symptoms of infection that require immediate attention are:

• A persistent fever of or over 100.5° F
• Chills that are accompanied by shaking
• Chest pain
• Shortness of breath
• Confusion
• Headache with a stiff neck
• Bloody urine

In certain instances, any of these infections can be life threatening for a patient receiving cancer treatment. Speak with your oncology team to determine who you need to call and when.

Some symptoms of infection that require prompt care are:

• A cough or sore throat
• Swelling
• Redness
• Tooth or gum pain
• Ear pain
• Headache
• Stiff or sore neck
• Stomach pain
• Rash
• Diarrhea
• Bloody urine
• Pain whilst urinating
• Vaginal discharge
• An overall feeling of being unwell

There are certain precautions to take in order to prevent infections following treatment.

These can include:

• Washing your hands with antibacterial soap
• Avoid contact with sick people
• Avoid large crowds of people
• Avoid sharing food
• Shower daily
• Avoid cuts
• Avoid handling any form of animal waste
• Keep any wounds or opening clean
• Follow any food guidelines
• Sleep well
• Maintain physical activity when possible

Deep Vein Thrombosis and Pulmonary Embolism

Both deep vein thrombosis (DTV) – a blood clot, and a pulmonary embolism (PE) – a blood clot located in the lung, are potentially life threatening side effects. While a normal blood clot may naturally disappear, a DVT requires a drug known as an anticoagulant to prevent the clot from traveling to the lungs and causing a PE. A PE is a life threatening condition. Many patients are not aware of a DVT until it has moved on to the lungs.

Symptoms of a DVT may include:

• Leg or arm swelling along a vein
• Pain in the leg, particularly when standing
• Arm pain that limits movement
• Increased warmth within a swollen arm or leg
• Discoloration of the leg or arm

Symptoms of a PE may include:

• Shortness of breath that is unexplained
• Chest pain
• Coughing up blood
• Rapid heart rate
• Rapid breathing rate

Some people may have a higher change of developing a DVT. This could include:

• Surgery
• Chemotherapy
• Adenocarcinoma
• Hormonal therapy
• The inability to move for an extended period of time
• Family history of blood clots
• Heart or lung disease
• Advanced age
• Smoking

Blood clots may be prevented by:

• Moving as much as physically possible after treatments
• If you have a higher risk or a history of DVT, your doctor may suggest blood thinners or compression socks if you are travelling

Tumour Lysis Syndrome

Tumour lysis syndrome (TLS) is a life threatening injury to a vital organ and is considered a medical emergency. TLS is more likely to occur following chemotherapy for fast-growing cancer, and when a cancer does not have a solid tumour. TLS is caused by the quick death of cancerous cells during treatment, which release their potassium, phosphate and tumour DNA into the blood stream. This creates a chemical imbalance within the patient’s body and can damage vital organs.

Cancers with the highest risk of developing TLS include:

• Burkitt lymphoma
• Large-cell lymphoma
• Acute lymphocytic leukemia
• Acute myeloid leukemia
• Chronic lymphocytic leukemia
• Small cell lung cancer

Further risk factors can include:

• Having a high white blood cell count
• Having a high blood uric acid level
• Kidney problems
• Dehydration
• Late stage of cancer
• Large tumour

Symptoms of TLS may include:

• Nausea
• Diarrhea
• Swelling
• Shallow breath
• Irregular heartbeat
• Low blood pressure
• Blood in the urine
• Low urine output
• Back pain
• Low energy
• Seizures
• Muscle spasms
• Joint pain
• Sudden death

Often, people with the largest risk of developing TLS will be treated within the hospital in order for doctors to monitor them closely. These patients will often be administered IV fluids and other medications that may prevent the onset of TLS.

Questions to Consider

• What are the potential side effects related to my cancer and/or my treatment?
• Which side effects should I call my doctor about and which should I call emergency services for?
• Are there any other reasons that I should call my doctor?
• Will I be provided with a list of contacts?
• Is there an afterhours number?
• Is email a preferred method of communication?

Immunotherapy

The cancer treatment known as immunotherapy works by boosting the body’s natural defences in order to fight cancer. This therapy works through the use of substances made either within the body or by a laboratory to boost the immune functions of a patient.

Immunotherapy can work by:

• Slowing the growth of cancerous cells
• Stopping the spread of cancer
• Boosting the immune system to better fight cancerous cells

Immunotherapy works by attacking cancer cells and stopping the spread to healthy parts of the body. Occasionally, immunotherapy results in the immune system attacking heathy cells, thus leading to side effects. The side effects of immunotherapy can range from mild to severe.

Side effects may include:

• Skin redness, blistering or dryness
• Flu-like symptoms
• Muscle aches
• Shortness of breath
• Leg swelling
• Sinus congestion
• Headaches
• Weight gain
• Diarrhea
• Hormone changes

Most side effects can be treated though palliative care. Palliative care should be a part of your overall cancer treatment plan, so discuss this with your oncology team for further information.

There are many different types of immunotherapy treatments.

Oncolytic Virus Therapy

Oncolytic virus therapy, first approved in 2015, makes use of genetically modified viruses in order to kill cancerous cells. The virus is injected into the tumour, causing the cancer cells to burst and die. As these cancer cells die, they release a substance known as antigens which the body’s immune system targets and kills.

Side effects of oncolytic virus therapy may include:

• Fatigue
• Fever
• Chills
• Nausea
• Flu-like symptoms
• Pain at the injection site

Monoclonal Antibodies and Tumour-Agnostic Therapies

When the body detects a harmful substance within the body, it produces antibodies to get rid of any impending infection. Scientists have used this concept in the creation of laboratory-made monoclonal antibodies. These are often used to target any abnormal proteins within the body that allow cancer to spread. Immunotherapy is also used alongside of monoclonal antibodies in order to highlight specific cells for the immune system to locate and destroy.

Monoclonal antibody clinical trials are currently ongoing. The use of checkpoint inhibitors known as tumour-agnostic treatments are used to treat tumours throughout the body by focusing on specific gene changes. One current FDA approved monoclonal antibody is the ‘pembrolizumab’, which is used to treat metastatic tumours. This treatment can only be used with tumours with the specific genetic change known as microsatellite instability-high (MSI-H), or DNA mismatch repair deficiency (dMMR). Tumours with these conditions for not allow for DNA to repair, and thus making it easy for immune cells to attack the tumour.

Non-specific immunotherapies

Similar to monoclonal antibodies, non-specific immunotherapies also work to aid the immune system in the destruction of cancer cells. Typically, non-specific immunotherapies are administered at the same time as other cancer treatments. In some instances, non-specific immunotherapies are administered as the only cancer treatment.

There are two common non-specific immunotherapies:

• Interferons work to slow the growth of cancerous cells whilst aiding the immune system in fighting cancer. The most common interferon is the laboratory-made ‘interferon alpha’.
• Interleukins work to help the immune system produce cells that are able to destroy cancer cells. The most common interleukin is the laboratory-made ‘interleukin-2’, which can be used to treat kidney cancer or certain types of skin cancer.

T-Cell Therapy

T-cells are the immune cells within a body that fight off infection. When undergoing T-cell therapy, these cells are removed from the patient’s blood and transformed in a laboratory to have receptors (proteins) placed within them and then are returned to the patient’s body. This process allows the body to recognise cancer cells and destroy them. This is known as chimeric antigen receptor (CAR) T-cell therapy. This method has been particularly successful in treating certain blood cancers.

Cancer vaccines

Doctors and researchers are beginning to create cancer prevention vaccines to stop healthy people developing certain cancers. Cancer vaccines have been developed to expose the body’s immune system to a particular antigen – a substance that is not normally a part of the body. This exposure will prompt the immune system to recognise this particular antigen and proceed to destroy any related materials that it recognises. The immune system is left with what is known as a “memory” and will respond the same way when this antigen is detected in the future.

In some instances, cancer vaccines are made specifically for a patient from their tumour sample. In order to do this, surgery is first needed to gather a large enough tumour sample to create the vaccine. For those who are given more generic cancer vaccines, these are used to target specific antigens that have been located within the tumour.

Generally speaking, most cancer treatment vaccines are only available through clinical trials, however an FDA approved treatment for metastatic prostate cancer was created in 2010, known as sipuleucel-T (Provenge). Sipuleucel-T is created for individual patients through the following steps:

1. White blood cells are collected from the patient’s blood
2. These white cells are modified to target prostate cancer cells
3. These modified cells are injected into the patient, similar to a blood transfusion.
4. The modified cells pass this “memory” on to the rest of the immune system in order to locate and destroy prostate cancer cells.

There are currently only two FDA approved cancer prevention vaccines available:

• The Human papillomavirus (HPV) vaccine has been used to prevent cervical, vaginal and vulvar cancer, anal cancer and genital warts. The HPV vaccine may also work to prevent oral cancer, although this is yet to be FDA approved.
• The Hepatitis B vaccine has been used to prevent hepatitis b (HBV) infection, which can lead to liver cancer if it is within the body for an extended length of time.

Current Limitations

Developing cancer vaccines is a difficult process because:

• Cancer cells work by supressing the immune system, which enables it to grow and spread.
• Cancer cells develop from the healthy cells of a person’s body. As they are “natural” the immune system may not recognise them as harmful and does not attack them.
• Advanced tumours are more difficult to remove.
• Patients with weaker immune systems cannot produce a strong immune response following a vaccination. This severely limits the strength of a vaccine making it difficult to aid in the cancer treatment.

It is for these reasons that small or early-stage cancers are better suited to cancer treatment vaccines.

Questions to Consider

• Do you recommend immunotherapy and which type do you recommend?
• What are the long term goals of this treatment?
• Will this be my only treatment path?
• What is the treatment schedule?
• What are the side effects, both long and short term?
• How will this affect my daily life?
• Are there any available clinical trials?
• Do you have further information?