Pearlman Cancer Center

Preventive surgery is used to keep cancer from occurring. Many colon cancers can be prevented by removing precancerous polyps before they become malignant. A woman at very high risk for breast cancer may decide to have her breasts removed rather than worry about getting breast cancer later in life.

Diagnostic surgery is also known as a biopsy. In this procedure, the surgeon removes some or all of a tumor for examination to determine if the growth is cancerous. A biopsy can be done in several ways, such as:

• Fine Needle Aspiration (FNA):a needle is inserted into the tumor and material is drawn out for inspection under a microscope.
• Incisional or Excisional Biopsy:the patient is put under local or regional anesthesia, which numbs the area, and a small incision is made in the skin. The surgeon either removes a piece of a large tumor (incisional), or the entire mass (excisional), for further examination. If the tumor is in the chest or abdomen, general anesthesia is used.

Staging surgery is used to determine the extent of a cancer. This procedure can sometimes be done without an incision by using tiny cameras (scopes) attached to a flexible tube, which are inserted into natural body openings. An endoscope is used in hollow body cavities and organs such as the lungs, intestinal tract and urinary tract. Besides allowing surgeons to view the suspicious area, these devices can take a tissue sample. A laparascope is used to view the abdominal cavity. Laparotomy involves a small incision in the abdominal cavity, done under general anesthesia. Laparotomies are used when the suspicious area cannot be examined by less invasive procedures.

Curative surgery involves removal of a cancerous tumor. It works best on localized cancers that have not yet spread to other parts of the body, and is often followed by radiation therapy or chemotherapy to destroy cancerous cells that have not been removed.

Supportive surgery is used to help with other cancer treatments. For example, some chemotherapy requires a port (a semi-permanent IV) to be inserted under the skin into a vein.

Restorative surgery returns the body to a more normal appearance or function following cancer treatment. The most common restorative surgery is reconstruction of a breast after a mastectomy. Facial reconstruction and testicular implants are also examples of restorative surgery.

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Radiation Therapy

Radiation therapy uses large doses of high-energy beams or particles to destroy cancer cells in a specifically targeted area. It may be used before surgery to shrink a cancerous tumor, or after surgery to eliminate any remaining cancer cells. Radiation can also be used by itself, or with chemotherapeutic agents to destroy a malignant tumor. It is very effective when used to treat certain types of localized cancers like malignant tumors of the lymph nodes or vocal cords. Like surgery, radiation therapy is unlikely to be successful if the cancer has spread throughout the body.

There are two basic types of radiation therapy:

• External Beam Radiation uses specialized machines to administer a high dose of radiation directly to the cancer site and to a small amount of healthy tissue surrounding the tumor. Different machines are used for tumors of various types or in different locations in the body. In 1948, M. D. Anderson scientists created the first machine to use a radioactive material called cobalt-60, a technology that is still in use today. Other radiation machines use X-rays or electron beams.
• Internal Radiation, also known as brachytherapy, involves radioactive material that is implanted in the body at the cancer site. Radiation implants are small tubes, seeds or capsules filled with different types of radioactive material and sealed. Sometimes, implants are used at a tumor site after its removal, to kill any lingering cancer cells.

Side effects are usually limited to the radiation site, although many patients will experience overall fatigue. Normal cells that may be affected by radiation therapy will usually repair themselves. Patients receiving radiotherapy in the abdomen may have nausea, while radiation to the pelvis may trigger diarrhea. Skin in the target area may become irritated, change color or become overly sensitive. These effects usually fade after several weeks. Hair loss at the radiation site can sometimes be permanent. Always make your cancer specialist aware of any side effects, no matter how minor they seem.

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IMRT/IGRT

Intensity modulated radiation therapy (IMRT) is an ongoing development in radiation therapy. This technology takes conformal radiation therapy one step farther. With IMRT, the intensity of the radiation beam is varied (modulated) across the treatment field. Instead of a single, large uniform beam of radiation, the patient is treated with hundreds of very small beams. Each of the beams can have a different intensity-some stronger, some weaker.

SGMC's new IGRT technology enhances the delivery of conformal and intensity modulated radiation fields by addressing the uncertainties arising from the motion of internal organs during
daily patient set-up. With the old system, patients were imaged at the very beginning of their treatment cycle. From this one image, the treatment parameters were established for the weeks of treatments that were to come. This time factor, coupled with the constant internal motion of the body, made highly accurate dosage delivery quite challenging. IGRT adjusts for this variation.

Image guided radiation therapy, or IGRT, makes it possible to take high-resolution digital images on the linear accelerator while the patient is being treated. This ability to image and treat at the same time with enhanced precision has enabled more aggressive treatment of tumors while minimizing damage to surrounding healthy tissue. According to Dr. Devine, the benefits of IMRT with IGRT include reduced side effects and complications of radiation therapy, and in some cases, an increased dose of radiation to the tumor, thus increasing the probability of cure.

"This technology has shown to be effective in reducing side effects in treating prostate, breast, head and neck cancers and gastrointestinal malignancies," he reported. "It allows better control of the radiation dose to the many organs located around these tumors." According to Dr. Devine, before the IGRT equipment was developed, cancer patients went through a clinical process called “simulation” prior to beginning actual radiation therapy. A treatment planning simulator was used with a computed tomography (CT) scan to determine the size of the tumor and the treatment area. The diameter of the treatment area was increased by two centimeters to allow for the motion of internal organs.

"The new technology is so precise, we don't have to increase the size of the treatment field to allow for internal organ movement," Dr. Devine explained. "IGRT lets you locate the tumor before each dose of radiation is administered, while the patient is in the treatment position." This minimized exposure to healthy tissue can possibly reduce the number of treatments and better protect the surrounding tissue from being harmed. IMRT and IGRT patients typically experience fewer side effects from high-dose radiation, which helps them remain stronger and more able to lead normal lifestyles during the course of their treatment.

Chemotherapy

Chemotherapy is the treatment of choice for some malignancies, and it is often used to treat cancers when surgery or radiation therapy is not possible. Chemotherapy can be used in addition to surgery and/or radiation therapy to kill cancer cells. Chemotherapy often involves using a group of different drugs that work together to kill cancer cells. The patient's oncologist decides which drug or combination of drugs will work best according to the kind of cancer, its location, whether it has spread, how it affects the body's ability to function normally, and the patient's overall health.

Depending on the specific drugs used, chemotherapy can produce various side effects. However, many advances have been made recently to manage and control these side effects more effectively. Drugs can manage the side effects of nausea and vomiting, for instance. Drugs to boost the bone marrow can help lower the chance of secondary infections. Each patient's oncologist and oncology nurse can explain more about the specific drugs the patient will be receiving and what side effects to expect.

During chemotherapy or any cancer treatment, patients will need support to cope with fear of the unknown, treatment side effects, and disruption in daily routines and personal relationships. Patients are encouraged to talk with their doctors and other health care providers about these concerns.

Chemotherapy is administered in three ways:

Intravenous (IV) is by far the most common method. A needle is inserted into a vein and attached with tubing to a plastic bag holding the chemotherapy drugs. The needle is taken out at the end of each treatment for one day treatments but may be left in over several days for multiple day treatments.

For some patients who undergo several chemotherapy sessions, a catheter, another type of plastic tubing, is inserted into one of the large veins and left in place during the entire chemotherapy regimen. Some patients have a metal or plastic disc known as a "port" implanted under the skin, to serve as an IV connection device. This device spares the veins in the patient’s arms, which can be damaged by repeated use. IV bags are attached to a tall metal stand with wheels, providing some mobility. Some patients wear a small pump outside the body, with minimal interference to their normal routine. Other patients may have a drug pump surgically inserted into their body.

Oral chemotherapy drugs are given in pill or liquid form.

Injections are administered into the muscle, under the skin, or directly into a cancer lesion, depending on the type or location of the cancer.

Side effects vary from patient to patient and with the type of drugs used. The good news is that there are therapies to help you cope with some side effects, and hair lost as a result of treatment does grow back, although sometimes in a different color or texture. The most common side effects of chemotherapy include:

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Immunotherapy

This is a method of treatment that doctors use to enhance the body's natural immune system to fight cancer cells. Immunotherapy involves the use of biologic agents which mimic chemicals that are normally produced by white blood cells. Until recently, the results of immunotherapy against cancer were disappointing, but researchers have begun to have more and more success controlling specific types of cancer with this form of treatment (for example, melanoma and lymphoma).

Immunotherapy can also be used to lessen the side effects of other cancer treatments.

Some immunotherapies have already received approval from the Food and Drug Administration for certain types of cancer. Others are being tested in clinical trials. Biological response modifiers are another name for immunotherapy drugs.

Side effects of immunotherapies can vary, but most exhibit similar symptoms, including fatigue, a rash or swelling at the injection site, and flu-like symptoms including nausea, diarrhea and fever.

There are five general types of biological response modifiers. They can be used alone or in combination with each other, or they can be used in addition to other cancer treatments.

Interferons are a group of proteins released by white blood cells in reaction to invading organisms. They have been shown to stop cell growth and strengthen the immune system's response to cancer. They can now be manufactured in laboratories for wide-spread use in cancer and other chronic illnesses. Interferon alpha is approved for treatment of some cancers, including melanoma and chronic myeloid leukemia, but is being studied for use on other cancers.

Interleukins are proteins that increase growth and activity in the body's immune cells. Many interleukins have been identified, but only IL-2 is approved as an anti-cancer treatment for kidney cancers and melanomas that have metastasized (spread) to other regions of the body.

Monoclonal Antibodies are created in the laboratory by fusing two different types of cells together. Monoclonal antibodies are designed to attack specific areas on the surface of cells known as antigens. Antigens help the body identify cells that are foreign, like germs or cancer cells, and stimulate an immune response. Monoclonal antibodies show promise both as a cancer treatment and a diagnostic tool. Two such medications are already approved for use in lymphoma and breast cancer.

Vaccines help the body recognize cancer cells and trigger the immune system to destroy them. There are several types of cancer vaccines. Some contain cancer cells that have been inactivated so they cannot produce new tumors. Others contain lab-produced antigens designed to attach themselves to cancer cells, giving the immune system a target to attack. Cancer vaccines are being used experimentally to either kill tumor cells or keep cancers from returning.

Colony Stimulating Factors work in the bone marrow, where red and white blood cells and platelets are produced. Colony Stimulating Factors increase the production of all blood cells, which helps patients fight infection, bleeding, and fatigue. These drugs also allow patients to endure higher doses of chemotherapy drugs.

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Palliative Treatment

When curing cancer is not possible, doctors use palliative treatment to make the patient more comfortable by shrinking tumors and reducing pressure, bleeding, pain and other symptoms of cancer. Palliative treatment can take many forms, including radiation therapy, surgery, or medication.

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Surgery
Radiation Therapy
IMRT/IGRT
Chemotherapy  
Immunotherapy
Palliative Treatment