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Q. What is medical oncology?

Medical oncology is the youngest branch of oncology and it deals with treatment of cancer using medicines and is also the most rapidly developing branch with new breakthroughs coming almost every day.

The specialty primarily originated from the identification of cytotoxic chemicals developed as part of chemical warfare. The "mustard" gases developed around World War II were found to be strongly cytotoxic to human beings with very strong effects on the hematopoietic system. It was this observation that led to attempts to use these agents and their derivatives in hematological malignancies first and solid cancers later.

With intensive drug discovery programs undertaken by many government agencies in USA and multinational pharmaceutical corporations, the super specialty first grew in USA. Medical Oncology has taken a major leap and now forms a very important part of multimodality management of almost all cancers and specially hematological malignancies.

Initially developed for the administration of cytotoxic agents, the specialty has expanded its scope remarkably with newer agents that use many different mechanisms to treat cancer.

Q. What is the role of medical oncology in treatment of cancer?

Haematologic malignancies such as leukemia's (blood cancers), lymphoma and multiple myeloma are treated primarily with medicines.

Some of the solid cancers are potentially curable with chemotherapy. Examples of this include germ cell tumors and gestational trophoblastic disease. In such cases, chemotherapy has become the prime modality of treatment and may be complemented by limited surgery.

Adjuvant chemotherapy has become an important modality in the treatment of many solid cancers such as breast cancer, clolorectal cancer, etc. Adjuvant use of chemotherapy is based on the concept of micrometastases that can not be identified with any current imaging modalities but are responsible for the majority of recurrences after potentially curative local therapy.

Neoadjuvant chemotherapy is chemotherapy administered up front to achieve downstaging of tumor, before use of a local modality such as surgery or radiation. Neoadjuvant chemotherapy can be used to make the disease operable if it was inoperable before or permit the use of limited local therapy. In breast cancer, neoadjuvant chemotherapy can be used in locally advanced breast cancer to make the tumors operable. In early disease, it is used to increase the chances of breast conservation surgery. Recently Organ preservation surgery is the target. This can be achieved by Neo-adjuvant chemotherapy.

In a number of situations, chemotherapy and radiotherapy are being used at the same time (not one after another) to treat malignancies. Chemotherapy here serves to enhance the efficacy of radiation and thus lead to improved loco-regional control rates. In some cases, this approach permits the use of organ conservation strategies. This has been used adequately at DHRC for cancer sites like head and neck cancers, cervix, lung and oesophagd.

Palliative chemotherapy is a very important modality to improve the quality of life of a large proportion of cancer patients who present with advanced disease that is not amenable to curative treatment with surgery and/ or radiotherapy. Here, chemotherapy can improve distressing symptoms and also lead to some prolongation of survival with good quality of life.

Q. What are the medicines used in medical oncology?

Cytotoxic chemotherapy

Conventional chemotherapy drugs that kill dividing (Replicating) cells in the body. Since cancer cells are almost always rapidly dividing, they are preferentially killed.

Hormones and hormone antagonists

Hormonal antagonists and agonists have been very useful in the management of breast cancer in women and prostate cancer in men. A number of exciting new agents are becoming available that are enhancing the role of such interventions.

High dose chemotherapy

High dose chemotherapy is the use of more than the standard doses of chemotherapy and it is used in the management of more aggressive, relapsed, or advanced cancers that are often non-responsive to standard dose of chemotherapy.

Biological agents e.g. interferons, interleukins, etc

A number of biological agents such as interferons and interleukins have been found to have activity against some cancers. These agents have been particularly useful in the management of chronic myeloid leukemia, cancer of the kidney, superficial bladder cancers (follicular), non-Hodgkin lymphoma (follicular), Hairy cell leukemia, etc.

Immunotherapy: monoclonal antibodies.

A promising new field where exciting advances are taking place. Many monoclonal antibodies are available in the country (Trastuzumab or Herceptin for breast cancer, and rituximab or Mabthera for hematological malignancies). Radio labeled monoclonal antibodies for Accurate Leukemias, Lymphomas etc.

Gene therapy

Gene mutations are at the root of all cancers. Interventions at the genetic level are thus very attractive. Lot of research work has been going on and some products are expected to come into clinical practice soon.

Signal transduction inhibitors (Target Therapy)

Drugs such as tyrosine kinase inhibitors, anti angiogenesis drugs, farnesyl transferase inhibitors, etc are very tempting because they have the promise of being effective with oral administration and have negligible systemic toxicity. One of the top success stories is a new drug Gleevac (Imatinib) that has shown very high efficacy in chronic myeloid leukemia in all phases of disease.

Vascular access devices (ports / central lines) Arterial and Venous Pumps (elastomeric and / or electronic pumps) Growth factors to take care of low blood counts (febrile neutropenia) Blood component therapy including single donor platelets Chemo and radiation - protectors and sensitizers

Q. What are the newer methods of chemotherapy drug delivery?

Conventionally chemotherapy is administered by peripheral intravenous route. Some drugs can be given by bolus administration but majority of drugs are given by intravenous infusion over a variable period of time. Some agents are also available for oral administration and can be used as and when required.

There are newer approaches being used for drug delivery to make it more comfortable to the patients. One of the major problems in chemotherapy is development of chemical thrombophlebitis that leads to occlusion of the veins (thrombosis). Due to this, there is a problem of venous access in later courses of chemotherapy. This problem can be bypassed by the use of long term central venous access. This can be achieved through central venous catheters (single or multi-lumen), implanted venous ports, and peripherally inserted central catheters (PICC).

Another approach that is being used nowadays is the administration of prolonged, continuous infusions of chemotherapy drugs. For this, electronic pumps and elastomeric pumps are being used at DHRC.

Q. What is regional chemotherapy?

Besides systemic chemotherapy, regional administration of chemotherapy is another area that is generating great interest world over due to certain potential advantages. Regional administration means administration of the drug to a limited body area and this can be achieved by many means:

Isolated limb perfusion

Administration in body cavities

Intra-arterial administration (hepatic artery infusion)

Intra-pleural (space around the lungs)

Intra-pericardial (space around the heart)

Intra-pericardial (in the abdominal cavity)

Intra-thecal (space around the spinal cord)

Intra-vesical (space in the urinary bladder)

One of the main advantages of regional chemotherapy is achieving a high dose of the drug at the target area while minimizing the systemic toxicity e.g. loss of hair (alopecia) and neutropenia (fall in WBC count). This may also increase the response rates and permit delivery of drug to areas where the reach of the drug is limited if administered by intravenous route.

Dharamshila Hospital And Research Centre has been at the forefront of this and is using regional chemotherapy in most forms e.g. hepatocellular carcinoma and colorectal malignancies. It is the first centre in Northern India where hepatic arterial ports have been placed and electronic pump used for regional, continuous, prolonged chemotherapy to liver tumors.

Q. What are the side effects of chemotherapy?

One of the major fears in the minds of people is that chemotherapy is a very toxic or painful modality of treatment. Due to this fear, many people are reluctant to undergo chemotherapy and thus miss a chance to cure the disease.

It is worthwhile to point out that significant progress has taken place in the last half century and these fears can be called unfounded today. The problem of nausea and vomiting induced by chemotherapy has been conquered with the availability of newer anti-emetic drugs and their combinations.

Hair loss with chemotherapy agents is a common problem and is very disturbing to women, Firstly, hair loss occurs to a variable extent depending upon the drugs used. Secondly, all hair loss secondary to chemotherapy is reversible and the hair start growing back the moment chemotherapy treatment is complete.

Effect on blood forming cells is common leading to fall in white cell counts, fall in platelet counts and anemia. Growth factors are now available to take care of fall in white cell counts (G-CSF and GM-CSF) and anemia (erythropoietin). Fall in platelet counts is not very severe except in few situations and thrombopoietin, a platelet growth factor is likely to be commercially available in near future to take care of this. Single donor platelet transfusions can be used in these situations.

Q. What precautions should be taken by a patient undergoing chemotherapy?

Take freshly cooked home food. Avoid the use of outside food or stale food. Do not consume raw / uncooked vegetables. Thick skinned fruits can be taken. Milk and dairy products should also be taken only after boiling / cooking.

For bathing use pre boiled, cooled water at or just below body temperature. Bathe with soft soaps. After bath and during dry season apply body moisturing lotion / cream, Vaseline, oil over skin, (except radiation field) to prevent dry skin.

Care of skin, nails and other body parts should be taken to avoid development of superficial infections that can spread.

Use oral mouth wash after every major meal to maintain oral hygiene.

Avoid dirt, dust and smoke. Avoid public gatherings and excessive visitors at home. Avoid excessive exposure to extremes of environment.

Ladies during child bearing aged should use approved contraceptives during chemotherapy and three months after chemotherapy to avoid pregnancy.

Undergo investigations as and when advised from time to time.

Please contact your doctor if body temperature is 100'F or more, persistent vomiting / loose motions, unusual bleeding from any site (bleeding gums, bleeding under the skin leading to red or blue spots, etc.), skin rashes, severe headache, neck stiffness; chills and rigors; low blood pressure, or oral intake is very poor etc.

Attend Emergency OPD at Hospital for acute problems. Don't wait for Regular OPD days in such conditions.

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