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Chemotherapy
This chapter was written by Dr. Daniel Rayson MD, who is a medical oncologist at the QEII Health Sciences Centre, in Halifax Nova Scotia. For the complete lecture, given by Dr. Rayson, click here.

A medical oncologist is a physician who specializes in the diagnosis and medical treatment of cancer and its’ complications. Medical oncologists work as part of a team to provide comprehensive cancer care to all patients diagnosed with cancer. Patients are typically referred to a medical oncologist after being diagnosed but occasionally may see one before a cancer is confirmed. They are trained to provide state of the art cancer care and treatment in a safe and supportive environment. Some of the treatments recommended may be to increase the chance of cure or reduce the risk of cancer recurrence when possible, while others may be designed to help control the cancer for a longer period of time. Some of the types of treatments that a medical oncologist may discuss include chemotherapy, biologic therapy, hormonal therapy, targeted therapy and supportive therapies. Each patients’ treatment is individualized depending on the goals of care and the disease situation in the context of a patient’s own medical history, health status and preferences.

An oncologist should;
1) Explain the cancer diagnosis and the possible impact of the disease on health.
2) Explain the disease stage and the goals of treatment.
3) Explain all relevant treatment options available, including clinical trials testing new treatments.
4) Recommend the best course of treatment in the context of a patients’ health history, symptoms and preferences..
5) Deliver optimal safe and supportive care.
6)Supervise and manage treatments designed to increase chance of cure when possible or, if cure is not possible, supervising treatments aimed at controlling/improving symptoms and slowing cancer progression. This is called ‘palliative’ or symptomatic and supportive’ therapy.
7) Initiate and supervise treatments aimed at controlling and improving symptoms such as pain, nausea or loss of appetite when they are a problem. Medical oncologists often work with a different medical team called ‘palliative care’ in order to help provide comprehensive symptom control and improve patients’ quality of life.

It is important to understand that not all pancreatic cancers are the same. Pancreatic Cancer is not one disease that follows one pathway. Different types of pancreatic cancer respond to different treatments and some may not need treatment urgently. To receive the best care you must first find out what type of pancreatic cancer you have. This means that you must advocate strongly for a biopsy. REMEMBER “Tissue is the Issue!” (Dr. Daniel Rayson)

Depending on a patient’s diagnosis and stage of disease, medical oncologists may recommend;
- treatment before surgery (neo adjuvant therapy)
- treatment after surgery (adjuvant therapy)
- treatment for symptom and pain control.

Treatment before surgery is rare but may be recommended when a cancer cannot be removed initially; however surgery may be possible if radiation, chemotherapy or a combination of these treatments could shrink the mass.

Treatment after surgery may be recommended for 3 reasons. a) Your surgeon may not have been able to remove your cancer completely, so treatment may be used to help shrink or control what was left behind. b) Chemotherapy may be used to reduce the risk of the cancer coming back in the future. c) The surgeon was unable to remove the tumour at all.

Therapy for palliation of symptoms and pain management, is also known as palliative or symptomatic and supportive care. If surgery is not possible........what then? The goal is now to control the disease and prolong survival, to minimize or improve the symptoms, improve or maintain function and quality of life, and to minimize problems from the disease as well as problems from the treatment. This process means that the oncologist, patient and caregivers must work together to find a balance. This means finding a treatment that is not worse than the disease itself.

Each individual will respond to treatment differently, so this makes finding a balance extremely difficult. It is important to remember that each individual has different genetics and biochemistry and their own individual disease situation. Due to these factors, there is no way to completely predict how an individual patient will respond to the disease and its’ treatment.

What options are there to find this balance in the treatment and care of patients from a medical oncologist’s perspective?

Observation- Although this is not always a popular choice with patients (depending on the type of pancreatic cancer), monitoring may be suggested and just “makes sense.” This may make sense when;
- surgery is not an option.
- a patient is doing well.
- the patient is experiencing no symptoms.
- treatment will be brought in when the disease has started to advance and when it is most likely be of benefit.

The difficulty with this disease is that it can progress very quickly. One moment a patient can be doing very well and the next moment a patient can become very ill. So patients need to be comfortable, mentally with this approach and be monitored by their oncologist on a regular basis for new symptoms or problems. This monitoring usually involves regular physical examinations and special x-rays like CAT scans, as well as blood tests.

Symptom Control – There are variety of medicines that are available to treat symptoms. Some of these can include:
* Pain Medication- Pain is an issue with pancreatic cancer. (see chapter on pain management)
* Celiac Plexus Nerve Block- The pancreas sits on a nerve bundle that can cause pain. This nerve bundle can be frozen (just like your tooth can be frozen at a dentists’ office),
* Appetite/Energy Stimulants- The pancreas is involved with nutrition, so pancreatic cancer can cause weight loss and malabsorption. There are medications that can stimulate appetite and assist in the absorption of foods.
* Anti-Nauseants- Patients often experience nausea and/or vomiting, making eating a difficult process. There are medications that can prevent feelings of nausea and may prevent vomiting.

Chemotherapy- Chemotherapies are powerful drugs which are typically given, intravenously (I.V) but can now sometimes be administered in pill form or through injections.

Chemotherapy disrupts the “growth program” of cancerous cells BUT it also disrupts the “growth program” of normal cells. It is important to remember that unlike our healthy cells that grow, die and rejuvenate, cancerous cells just continue to grow (they forget how to die). Cancerous cells are not reprogrammed to grow, once they die. If we can get the cancer cells to die, they will stay dead. This is a goal of chemotherapy.......to disrupt this cancer cell growth.

Why can’t chemotherapy cure pancreatic cancer? There are two important answers to this question. First, cancer cells learn. They are the smartest cells around. Even when cancer treatments are going beautifully, they can learn to resist the cancer treatments. In other circumstances, cancerous cells can demonstrate resistance to the cancer drugs, right from the initial start of treatments. Secondly, even if one cancer cell survives, it will start growing and regenerating. Many of our cancer treatments can’t eliminate every single cancer cell. Fact: In a cancer that is only a cubic millimetre in size, there are one billion cancer cells, so even if 99% of the cancer cells are killed, there are still many that remain.

Treatment Options: Patients and caregivers are reminded that these treatment options would probably not be recommended for anyone who is so ill they need considerable help with day to day care. Side effects of treatment may outweigh the possible benefits in this situation.

Treatment options for typical adenocarcinomas of the pancreas:
-Gemcitabine- suggest remove dashes
-FOLFIRINOX
-Gemcitabine + Erlotinib
-Abraxane (2nd line treatment)

Treatment options for uncommon neuroendocrine cancers of the pancreas.
-Temozolomide/Xeloda
- Everolimus
- Sunitinib

Treatment option for rare primary pancreatic lymphomas.
- R-CHOP

All of these treatment options only reinforce the importance of finding out what specific cancer of the pancreas you have, so that the treatment matches your disease.

As well, research into better and more effective treatments for pancreatic cancers continues to progress. Your oncologist may talk to you about participating in a clinical trial testing a new form of treatment or comparing one type of treatment to another. Before a clinical trial is approved, it undergoes rigorous scientific, ethical and clinical review to ensure that safety is maximized and that all patients approached to participate have a chance to benefit. Without clinical trials, and patients who agree to participate, progress in the treatment of pancreatic as well as other cancers would come to a halt. If your oncologist doesn’t mention a clinical trial to you, ask him or her if there is one available to consider. Clinical trials are very picky in who is allowed to participate and so, even if one is available at your medical center, you may not be able to participate due to a host of factors. It never hurts to ask!

It is important to understand that although these treatments for pancreatic adenocarinomas and neuroendocrine cancers can offer tremendous benefits to some patients, they still do not cure pancreatic cancer. The hope is that as research moves forward, options will continue to expand and become available to patients.

In closing, it is important to remember that a medical oncologist is a very important member of your medical team, so it is important to find one who is willing to work with you and your family and who you are comfortable working with. If you are presently working with a medical oncologist that you are not comfortable with, you can ask for a second opinion. This is completed by going back to your family physician, and asking for a second referral. With appropriate advocacy, this second opinion can take place.

Lastly, many medical oncologists work with a primary care nurse. If there are issues that you would like to resolve, you may feel more comfortable speaking with the primary care nurse, who may be able to resolve any concerns you may have as a patient or caregiver.
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