Cancer Today Origins, Prevention, and Treatment (1984) / Chapter Skim
Currently Skimming:
Cancer Treatment
Cancer Treatment
Pages 81-116
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From page 81... ...
Once the cancer has metastasized, a surgical cure is impossible and This chapter is based on the presentation given by Emil Frei III, Dana-Farber Cancer Institute, at the 1983 annual meeting of the Institute of Medicine.
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From page 82... ...
For some types of cancer, the gains have been particularly dramatic. The survival rate for acute lymphocytic leukemia, a childhood cancer, has climbed from 4 to 60 percent since 1955, due largely to new chemotherapeutic regimens.
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From page 83... ...
Largely through trial and error, the clinical investigators learned which drugs to give in combination and at what dose -- an enormously complex question. Soon after they began, the clinical researchers learned that cancer cells are notoriously recalcitrant.
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From page 84... ...
Childhood Leukemia Much of the early work in chemotherapy was on a childhood cancer, acute lymphocytic leukemia, as well as on some of the other leukemias and lymphomas, which are malignancies of the organs that produce the blood, such as bone marrow and lymph nodes. In the mid-1950s, clinical researchers had three compounds that they thought might be effective in treating these cancers -- prednisone, methotrexate, and 6-mercaptopurine.
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From page 85... ...
"That was our first insight into the refractoriness of the cancer cell, which we now know to be specific tumor cell resistance," says Emil Frei of the Harvard Medical School and director and physician-in-chief of the affiliated Dana-Farber Cancer Institute. He and the other clinical researchers realized that they would have to continue chemotherapy during remission, a procedure known as maintenance, using still other agents to combat drug resistance.
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From page 86... ...
By 1965, the therapeutic approach was in place: combination therapy to induce complete remission, followed by maintenance chemotherapy and central nervous system prophylaxis. The survival rate for acute lymphocytic leukemia climbed dramatically.
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From page 87... ...
In the late 1960s, several investigators reasoned that chemotherapy might be effective if it were used immediately following radiation therapy or surgery to kill any disseminated cancer cells before they massed into a tumor. This approach is called adjuvant chemotherapy, and has been tested in clinical trials on women with advanced cancer who are at high risk of having a disseminated disease.
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From page 88... ...
Head and Neck Cancer In the past five years, Emil Frei and his colleagues at Harvard have been trying to adapt the strategy of adjuvant chemotherapy to treat head and neck carcinoma. This is a particularly virulent cancer, afflicting some 37,000 people a year in the United States.
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From page 89... ...
Investigations on a molecular level are beginning to reveal the biological basis of drug resistance, and new strategies are under development to combat it. In addition, investigators are learning how to modulate the activity of cancer drugs with normal metabolites (substances produced by natural chemical changes in the body)
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From page 90... ...
These are antibodies of unparalleled specificity, developed and cloned through immunologic techniques. It may be possible to target them to destroy specific cancer cells or carry existing cytotoxic drugs to only one type of cancer cell, leaving all other cells unharmed.
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From page 91... ...
In the past 20 years, the 5-year survival rate for all cancers combined has climbed steadily. On another front, basic researchers have begun to unravel the biological basis of cancer -- the molecular changes within a cell that give rise to malignant growth.
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From page 92... ...
The obvious starting point, when research began in the early 1970s, was to find ways to relieve the emotional turmoil of the cancer patient -- the anger, fear, and the often debilitating depression. Since this work began, counseling and other psychological services have become an integral part of cancer care.
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From page 93... ...
Holland and a number of other clinical researchers from several institutions have collaborated to study this and other problems. Recently, these researchers, known as the Psychosocial Collaborative Oncology Group, set out to measure the prevalence of severe emotional distress among cancer patients.
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From page 94... ...
Yet remarkably few patients in the past have been given antidepressants, according to Holland. In a study conducted seven years ago, the Psychosocial Collaborative Oncology Group found that only 1 percent of the drugs ordered for 800 cancer patients were antidepressants.
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From page 95... ...
This, too, warrants clinical trials, says Holland. Chronic Stress When the acute stress accompanying diagnosis subsides, it is often replaced by lower-level, chronic stress that lasts throughout the course of treatment.
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From page 96... ...
The few studies that have been conducted to date suggest that oncologists (the physicians who treat cancer patients) may also experience chronic stress, Holland says, probably more severely than physicians in other specialities.
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From page 97... ...
These numbers reflect one of the great successes of contemporary medicine -- of diagnostic techniques, surgery, radiation therapy, and chemotherapy. Nonetheless, these patients' troubles do not end when they leave the hospital or when they cross the 5-year line.
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From page 98... ...
Some former cancer patients repeatedly seek medical reassurance. Others go to the opposite extreme, avoiding physicians entirely and neglecting essential health monitoring and maintenance programs.
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From page 99... ...
For some patients, there is also the possibility of physical rehabilitation, such as breast reconstruction. In a study conducted with her colleagues at Sloan-Kettering, Holland has found that breast reconstruction can significantly reduce the emotional distress resulting from mastectomy and may help to overcome the reluctance of some women to have this life-saving but emotionally distressing operation.
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From page 100... ...
One unfortunate consequence of these two forms of discrimination is that the individual becomes reluctant to switch jobs, and personal and career growth may suffer. Bereavement Despite the remarkable progress in cancer care in the past few years, slightly more than half of all cancer patients succumb to the disease.
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From page 101... ...
Nonetheless, Holland and others believe that sufficient evidence exists to extend the concept of cancer care to the family and staff, as well as to the patient.
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From page 103... ...
The hospital, geared to treat acute diseases of the body, seemed cold, impersonal, and poorly equipped to handle the more chronic problems confronting a terminal cancer patient. He and Saunders envisioned a different kind of place, a special center for treatment of dying patients that would tend to the emotional and spiritual needs of the patients as well as the physical; that would relieve their pain, assuage their fears, and help them come to terms with dying.
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From page 104... ...
Indeed, pain relief is the hallmark of Saunders' approach to care for the terminally ill. She objects to the practice of giving pain medication only as needed, the standard hospital procedure that arose from fear of fostering drug dependency.
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From page 105... ...
hospices are used almost exclusively by terminal cancer patients; 105
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From page 106... ...
Assessing Hospice Care In the past decade, many claims have been made about hospice care. Hospices promise better relief of pain than can be achieved by conventional cancer treatment, more emotional comfort and relief for patients and their families, and, given the reliance on home care and the minimal use of medical intervention, lower costs.
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From page 107... ...
By contrast, hospital-based hospice patients averaged 18.2 days in an inpatient facility. Examined in another way, over 99 percent of the home-care hospice patients spent some of their time in the home, while that was true of only 67 percent of the hosoitalbased hospice patients; that is, one-third of all hospital-based hospice patients spent all their time in an inpatient setting.
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From page 108... ...
The study revealed that, indeed, during the last two to five weeks of life, hospice patients were significantly less likely to receive any kind of intensive medical intervention -- such as radiation, chemotherapy, or surgery -- than were patients in conventional care facilities. Hospice patients were also less likely to receive blood tests, X rays, and other diagnostic tests, regardless of the type of hospice (see Figures 10-1 and 10-2)
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From page 109... ...
HOSPICE HOME-CARE HOSPICE HOSPITAL-BASED CONVENTIONAL CARE 37.7% 135.7% 25 60 PERCENT 72.4% 75 FIGURE 10-2 Patients receiving diagnostic blood tests, X rays, or scans as last measure prior to death. (SOURCE: National Hospice Study, Preliminary Final Report, 1983.)
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From page 110... ...
He suspects that families are reluctant to administer narcotics. As a result, home-care hospice patients received fewer and smaller doses of pain medication than did their counterparts in the hospital-based hospice.
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From page 111... ...
To evaluate overall quality of life in the hospices and conventional care settings, the National Hospice Study investigators used several different indices that measured, among others, perceived health, outlook, family support, functional performance, loneliness, depression, emotional comfort, and patient awareness. Contrary to some of the anecdotal claims about hospices, they found that the quality of life 111
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From page 112... ...
Again, patients in all three systems reported a high level of social involvement. While patients in home-care hospices actually received more hours of instrumental care and visits, the reports of the primary care persons suggested that patients in the conventional setting had a slightly higher social quality of life than did hospice patients.
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From page 113... ...
There was a rise in illness among family members; in the first few months after the patient's death, the family made twice the average number of doctor visits. Nonetheless, despite the signs of strain, these families did not seem to regret their decision; they BEST 10 r 6 -- - Home-Care Hospice - -- -- Hospital-Based Hospice -^ -- Conventional Care WORST 0 5 3 WEEKS PRIOR TO DEATH FIGURE 10-5 Mean score on quality of life index for "average" hospice patient as death approached.
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From page 114... ...
Further, when home-care hospice patients were hospitalized, the hospice had less control over the ancillary medical services. Consequently, the cost of inpatient care for home-care hospice patients was higher than it was for hospital-based hospice patients.
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From page 115... ...
There is some evidence that pain control is better in the hospital-based hospice than in conventional care setting, although such information is difficult to obtain from critically ill patients. However, despite claims of hospice advocates, neither type of hospice offers an advantage in terms of the patient's quality of life.
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From page 116... ...
Much of this agonizing was done in collaboration with hospice representatives. Yet as a man who has visited hospices across the length and breadth of the nations, I can say that there is something going on in them, something emotionally and spiritually inspiring and invigorating, that is not measurable using current techniques and that cannot even be described, except perhaps by the best of our poets." Medicare reimbursement will make hospice care available to a wider number of people.
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