best or most appropriate type of treatment will to some extent be individualised to you, and will depend on the tumour and its stage, and your own medical state.
The members of your medical team will match you up with the therapy, or combination of therapies, that offers you the highest chance of success with the lowest chance of side effects. That means that even if you have friends and neighbours with the same diagnosis, they may be receiving different types of treatment from you. If you have cancer of the breast, say, there may be reasons that hormone tablets are not recommended to you, while they are for your neighbour who also has breast cancer.
This section will set out some of the criteria by which these treatment options are recommended.
What’s the best kind of cancer treatment? It completely depends on your particular situation. Because there are hundreds of different clinical situations—depending on the type of the cancer, the stage, the part of the body that the tumour is in and so on—there are hundreds of facts that need to be considered in the selection of treatment for any one person.
In your case, your medical team may recommend one, some, or even all of these treatment methods. That is why it is extremely important that you discuss the individual treatment approach with your medical team.
Surgery
Surgery is the oldest method of treating any type of cancer and there are records of surgical techniques going back many hundreds of years.
The important point to realise here is that surgery is treatment for the local disease, that is, the disease in one particular part of the body. Sometimes that’s all that is needed, but sometimes it’s not enough. You can help yourself to ask the right kind of question by focusing on the following four topics:
Which area of the body is involved? This largely determines what the surgery is going to be like: if it is going to be a big operation or a small one, and what the effect will be on nearby organs. After surgery in the abdomen, for example, how quickly will bowel function return; in the lungs what will your breathing be like afterwards, and so on?
After the surgery, will additional local therapy be required? In other words, is the chance of the cancer recurring in the same area high, or low, or moderate? If it’s moderate or high, often radiotherapy will be recommended to reduce that chance of a local recurrence.
After the surgery, will additional systemic treatment—such as chemotherapy, hormone, or biologic therapy, that reaches all areas of the body—be recommended?
Are there alternatives to surgery or alternatives to big surgery? For example, in prostate cancer, what are the risks and benefits of using radiotherapy instead of surgery? In breast cancer, what are the risks and benefits of using radiotherapy after lumpectomy, compared to the bigger operation, mastectomy, which removes the entire breast?
In thinking about and discussing these topics with your surgical team, remember one important point (often a source of confusion, and even doubt). Whether or not further treatment is required after surgery depends on the type of cancer and on the way it is likely to behave, not on the personal skill of your surgeon!
In other words, the need for chemotherapy and/or radiotherapy after surgery does not mean that your surgeon didn’t succeed or did not do a good job. It means that in your particular case, the cancer itself poses a significant risk of recurring or spreading. It is very common for the surgery to be successful, meaning that all the visible tumour was removed and the phrase ‘we got it all’ is accurate about the local cancer, but there may still be a significant chance of recurrence or spread. For that reason, further therapy may be recommended after surgery.
This occurs often, and there can be some confusion on the patient’s part about whether the right operation was done or was performed properly. Hopefully what I am saying here will clear up that common sense of confusion!
Radiotherapy (radiation oncology)
Radiotherapy is treatment in which an area of the body is given a high dose of radiation—rays that are similar in some respects to x-rays but different in that they are produced with the intention of damaging any growing cells in the area exposed to them.
These rays are usually created in specific machines called linear accelerators and are very closely controlled and monitored by highly specialised systems.
It is important to realise that radiation, like surgery, is a local treatment. In other words, it treats the area that gets the radiation only, and has little or no effect on any cancer cells outside the area being treated. Although many people know this, it can still be confusing, and some patients are really perplexed when it is recommended that they have radiotherapy after their chemotherapy, for example after a lumpectomy for breast cancer.
The single most important feature of radiotherapy is that the radiation passes through normal structures—such as the skin or lungs or bowel or spinal cord, depending on the area of the body involved.
Nowadays it is possible to ‘focus’ the radiation very precisely in the cancer area, and to reduce the damage to normal structures in front of or behind that area. There are several ways to do this:
By using several different directions (or fields), each of which is concentrated on the cancer, but each of which affects different areas (say, of the skin or bowel).
By using radiation that has the appropriate properties for a particular cancer—for example, radiation that gives out much of its energy near the skin surface and doesn’t penetrate very far is good for superficial cancers, whereas radiation that gives most of its energy deep in the tissues does less damage to the skin.
And finally, by using tailor-made radiation fields that are ‘trimmed’ to include all of the tumour mass and very little of the surrounding normal tissues.
Obviously, the planning of radiation treatment is a major and important procedure. Nowadays, the actual imaging of the cancer area can be done with greater and greater accuracy. Although it’s a tricky and somewhat exacting process—and probably quite boring for you!—it’s crucially important because it drastically affects how much damage can be done to the cancer cells while avoiding the normal cells in the area.
Chemotherapy
Chemotherapy involves the treatment of cancers by drugs that, to some extent, damage all growing cells. Chemotherapy drugs work in the treatment of the cancers because, overall, they do much more damage to cancer cells than they do to normal cells.
A cancer mass has many more growing cells inside it than normal tissue does, and that is why chemotherapy agents generally do more extensive damage to cancers than they do to normal tissues.
However, by their very nature most chemotherapy agents do some damage to all growing cells. That is why many of them cause your hair to fall out (temporarily), because they damage the growing cells at the hair root. Similarly, they may cause mouth sores by damaging the growing cells in the mouth. More importantly, they can affect the growing cells in the bone marrow, which are responsible for making the various components of blood. Hence, many (but not all) chemotherapy agents can reduce your white cells count (a condition called neutropenia) making you more susceptible to infections and fevers. They can also reduce your platelets (a condition caused thrombocytopenia) which are important in helping blood to clot. Hence you may develop bruises or bleeding. Chemotherapy can also affect the red cells (causing anaemia) that contain haemoglobin and this would cause you to look pale and to feel tired and short of breath.
Most chemotherapy agents also cause some nausea and vomiting, and although this is a common side effect of most of the drugs, it isn’t directly related to their ability to damage growing cells. In fact it appears that there are certain centres in the brain which are particularly sensitive to certain types of chemicals in the bloodstream. These centres are called the chemotactic trigger zone (CTZ) and the vomiting centre (VC).