Common Cancer Treatment - Assignment Example

Common Cancer Treatment Evaluate the action of one common cancer treatment e.g. chemotherapy, radiotherapy, surgery, immunotherapy, hormone therapy, peripheral stem cell and bone marrow transplants Introduction In this assignment, evaluation of action of 2 cancer treatments: chemotherapy and radiotherapy will be done. I have chosen to look at both the treatments, because the patient is received both the treatments for his cancer. The patient is an elderly male with advanced cancer of the larynx. The reason I choose this patient is to extend my knowledge and to improve my care in managing patients with cancers of head and neck. The assignment will explore patient history, chemo and radiotherapy regime he received and the complications he developed during treatment. Patient history The case under discussion is about a 66 year old male John (name changed to preserve confidentiality as indicated in the NMC 2002 Code of Professional Conduct). John was diagnosed to have carcinoma larynx stage T2 in April 2010. He is a smoker for 15 years and an alcoholic for 30 years. There is no family history of cancer. John initially presented with stiff neck in March 2010. A few days later, he had a visible swelling on the right side of his neck, which was very painful and tender to touch. He assumed that the swelling was because of tonsillitis as he had a bad cold recently. He took himself straight to his local Accident and Emergency (A&E) department. But, then, after examination, he was immediately referred to see the specialist consultant. On arrival at the specialist consultation, John presented with a large swelling on the right side of his neck with red marks over his chest and neck. Apart from occasional sweats, he had no other symptoms. He was admitted to the medical ward, started on intravenous antibiotics and referred to a dermatologist. John’s treatment plan is to have six cycles of chemotherapy followed by radiotherapy. The aims of anti-cancer treatment in him are to control the disease locally and improve survival. The chemotherapy plan for John is to give him a combination of Cisplatin and 5-fluorouracil or 5FU every three weeks. The aim of combination chemotherapy is to maximize the number and type of cancer cells that are targeted with each treatment cycle and because different drugs exert their effect in different ways, a combination of drugs will have a greater effect by tackling different parts of the cell cycle. Also, tumor cells are able to adapt in order to increase their survival potential, therefore a combination of drugs will decrease the chance of drug resistance from the tumor (Barr et al. 2004). The following discussion will examine the treatment provided to John and the complications he suffered from due to those treatments. Discussion Cancers in head and neck are common and the most common type of these is squamous cell carcinoma. In fact, squamous cell carcinoma accounts for more than 90 percent of cancers in head and neck (Campbell and de Torre, 2008). Behavior of the carcinoma in this region depends on the site of origin. More often than not, treatment is done by multiple modalities: surgical therapy, chemotherapy and radiotherapy and adverse effects to these treatments are common. Though cancers in head and neck include various types of diseases, many of which are either rare or uncommon, the services of care are similar to all the diseases of this category. Cancer treatments in this region have permanent impact on the organs leading to difficulties in breathing, eating, speaking and drinking (Campbell and deTorre, 2008). Because of these, most patients need rehabilitation after treatment and many of them need long term care. The aim of any antineoplastic therapy, either surgical, radiotherapeutic or pharmacological is complete elimination of all neoplastic cells, and if this is not possible, atleast to reduce the number of neoplastic cells, so that there is improvement in the symptoms, adequate quality of life is maintained and survival is prolonged. Surgical resection is the best treatment for carcinoma of the larynx (SIGN, 2006). In the initial stages of laryngeal cancer, total or partial laryngectomy is the treatment of choice with adjuvant chemo-radiotherapy. In advanced stages however, when resection is not possible, a combination of chemotherapy and radiotherapy is given for preservation of larynx (Johnson and Christopoulos, 2009) and improvement of long term survival (Yoshio et al, 2006). Since John is an elderly person with many associated problems like residing in hostel, history of alcohol and smoking, malnutrition, increased risk of infection and increased risk of poor care, non-surgical therapy was chosen. In many centers world wide, radiotherapy is the first line of treatment for glottis cancers with staging T1-T2 (Hirasawa et al, 2010). Radiotherapy is however given in combination with chemotherapy. John was first started on chemotherapy and then on radiotherapy. Chemotherapy John received chemotherapy first. Ideally, concurrent chemo-radiotherapy is very useful in carcinoma larynx as studies have shown that is reduces the risk of death by 22 percent (SIGN, 2006). However, concurrent therapy increases the risk of complications like mucositis, hemotological complications and dental problems. Since John has several other risk factors like advanced age, poor nutrition, poor health care, smoking and alcoholism which increase the risk of toxicity, he was started on adjuvant chemotherapy. Chemotherapy sessions were started before radiotherapy sessions. Cisplatin and 5FU were used for chemotherapy in John. In patients like John, who have N3 stage II-IV laryngeal cancer, preservation of larynx can be done without survival compromise by using radical radiotherapy with induction chemotherapy using cisplatin. Single agent therapy with cisplatin is recommended in chemoradiotherapy (SIGN, 2006). According to SIGN (2010),"neoadjuvant cisplatin/5FU followed by radical radiotherapy alone may be used in patients with locally advanced resectable hypopharyngeal cancers who have a complete response to chemotherapy and, the routine use of adjuvant chemotherapy following radiotherapy is not recommended." Taxanes are not considered as useful chemotherapeutic agents for carcinoma of head and neck. In John, a combination of cisplatin and 5FU were given for improved effectiveness of chemotherapy. While preparing plan of action for John, some of the members in the treatment team suggested cetuximab therapy. Some research has shown the effectiveness of cetuximab in the treatment of laryngeal cancer. Cetuximab is a monoclonal antibody of chimeric immunoglobulin B type that basically competes for the binding sites of the epidermal growth factor receptor, thus preventing activation of tyrosine kinase in the cells and leading to apoptosis. The technology is used in combination with radiotherapy. It is associated with some side effects. Side effects like chills, fever, nausea, vomiting, dizziness, head ache or dyspnea are related to infusion. More than 80 percent of the patients develop skin reactions which mainly appear like acne. In some other, dry skin, pruritus, desquamation, nail disorders or even hypertrichosis can occur. Usually, skin problems are seen within 3 weeks of initiation of treatment. The recommended dose is 400mg/m2 body surface area for the initial dose and 250mg/m2 every week thereafter. The course of treatment is 2-8 weeks and the cost of treatment is between £4778 to £5870 (NICE, 2008). Cetuximab is recommended as a treatment in squamous cell carcinoma of head and neck only in combination with radiotherapy, that too only in those with locally advanced cancer and those with Karnofsky performance-status score of atleast 90 percent and in whom platinum based chemoradiotherapy is contraindicated (NICE, 2008). The score in John is 70 percent and he could receive platinum based chemotherapy. John was initiated on cisplatin and 5fluorouracil. Cisplatin is a chemotherapeutic agent that is platinum-based. The platinum complex in the substance binds to DNA and cross links it leading to disruption of mitosis and finally apoptosis. Guanine is the most preferred target of cisplatin. The drug is mainly administered for the treatment of solid tumors like germ cell tumors, sarcomas, head and neck cancers and small cell lung cancer. It is administered intravenously in physiological saline over a short duration. One major problem in using this drug as a single chemotherapeutic agent is the high risk of development of cisplatin resistance either by changes in cellular uptake and reflux, inhibition of apoptosis, detoxification or increased repair of DNA (NICE, 2008). 5FU is a pyramidine analog. It mainly works by non-competitive inhibition of thymidylate synthase. Thus, it is an antimetabolite drug. It is administered with leucovorin. Interruption of thymidylate synthase causes blockage of synthesis of pyrimidine thymidine which is very essential for the replication of DNA. Ultimately cells udergo thymineless death. 5FU is very useful in the treatment of various cancers like colorectal cancer, pancreatic cancer and laryngeal cancer. The effects of this drug are mainly seen in cells which replicate very fast (Liu, 1998). Radiation therapy After chemotherapy, John received radiation therapy, also known as radiotherapy. In this method, ionizing radiation is used to treat cancer, or control the progression of malignancy. It is either used as a curative treatment or, an adjuvant to other forms of treatment like chemotherapy, immunotherapy, hormone therapy and surgical resection. Radiation therapy is usually applied to the malignant tumor. It may also be applied to the lymph nodes draining the tumor in case of risk of subclinical spread. Due to uncertainties in internal movement and internal motion of the tumor, a margin of normal tissue is also irradiated. Radiation therapy causes damage to the DNA of the cancer cells, either by photon energy or by energy from charged particle, leading to apoptosis of cells. Radiotherapy is the most preferred treatment modality for advanced glottis cancer. Infact, there is extensive documentation in literature about its benefits in preserving the function and structure of the larynx (Hirasawa et al, 2010). In a study by Hirasawa et al (2010), it was found that treatment of glottic cancers of grading T1- T2 using radiotherapy, with or without chemotherapy showed high rates of local control and reservation of larynx. John received external beam radiotherapy. Basically, radiotherapy can be either brachytherapy or external beam radiotherapy. In brachytherapy, the source of radiation is placed precisely at the site of cancerous tumor, thus irradiating only cancer cells. Because of this advantage, high doses of irradiation can be used and subsequently, the duration of treatment can be shorter. Shorter duration of radiotherapy is advantageous because, it prevents the chances of growing and dividing of surviving cells between doses of radiotherapy. Brachytherapy is mostly effective in cancers of the skin, breast, tongue, thyroid, cervix and prostate. It is not useful in laryngeal cancer treatment. There is no randomized controlled trial that shows evidence that brachytherapy is superior to external radiation beam therapy. External beam radiotherapy is useful in cancers like larygneal cancer. External beam radiotherapy, also known as teletherapy is the most frequently used type of radiation therapy. The source of radiation is external. Another type of radiation therapy exists, known as systemic radioisotope therapy in which radiation therapy is delivered through radioisotopes given orally or through infusion. Currently intensity modulated radiotherapy has been employed by many centers in the UK. However, no randomized controlled trial has proven its superiority over conventional therapy in the treatment of head and neck cancer (SIGN, 2006). In external beam radiotherapy, an external radiation beam is used to target the tumor. The dose is usually fractionated and the total dose is delivered over a period of time in several small doses. The dose delivered in each setting is dependent on the tolerance of the normal tissues present in the surrounding. The effect of radiotherapy on the cancerous tissue and also on the surrounding normal tissue depends on the total dose that is administered, the size of individual fraction doses and also on the time taken for delivery of total dose (SIGN, 2006). In most cases, each fraction delivers radiotherapy of doses 1.8-2.0 Gy each day, 5 days a week. This ultimately causes total dose accumulation of 10Gy per week. This is the conventional fractionation radiotherapy. However, the dose of fractionation can be either decreased or increased depending on individual requirement. Then it is called non-conventional or modified fractionation radiotherapy. There are 3 types in modified fractionation radiotherapy and they are are hypofractionation, hyperfractionation and accelerated fractionation. In hypofractionation, the dose delivered in each fraction is much above the conventional dose delivered in each fraction. This type of radiotherapy is useful in patients with isolated glottis cancer and leads to excellent control of cancer growth locally. In hyperfractionation, the dose delivered per fraction is much less than the conventional radiotherapy and thus, the dose is delivered over many fractions. By this method the total dose delivered also can be increased. In accelerated fractionation, the dose delivered in each fraction is gradually increased and the total dose per week exceeds more than the conventional radiotherapy. This treatment allows excellent locoregional control. But it increases the risk of developing toxicities (SIGN, 2006). Hyperfractionation radiotherapy is more useful for advanced cancer of head and neck, and therefore John was given this type of radiotherapy. Hyperfractionation therapy reduces the risk of death significantly and enhances the locoregional control when compared to conventional radiotherapy. However, it increases the risk of toxicity which was a major concern in this patient. Side effects After initiation of anti-cancer treatment, John developed several side effects. After the first chemotherapy session, John suffered nausea and vomiting and loss of appetite. He was started on oral ondansetron. However, when his vomiting persisted, he was given intramuscular ondansetron and dexamethasone. Once his vomiting stopped, oral ondansetron was resumed and he was kept on it until chemotherapy sessions were over. His nausea and vomiting were mainly due to cisplatin. Cisplatin is associated with many side effects like nephrotoxicity, neurotoxicity, nausea and vomiting, ototoxicity and electrolyte disturbance. In view of these, side effects, John was monitored thoroughly during chemotherapy sessions. Renal parameters and electrolytes were checked regularly. John also developed mucositis during chemotherapy sessions which worsened when radiotherapy was started. He developed severe itching and dermatitis of the skin, which then became complicated with bacterial infection. He had to be started on topic antibacterial agents. Mucositis and dermatistis were mainly because of 5FU. Main adverse effects to 5FU are mucositis, myelosuppression, dermatitis, cardiac toxicity and diarrhea. and radiation therapy. In mice, studies have shown degeneration of central nervous system even with small doses (Longley et al, 2003). Hence, while on chemotherapy, John's complete blood picture was regularly checked to rule out myeosuppression. Mucositis and dermatitis worsened when John was initiated on radiotherapy. Side effects to radiation therapy occur mainly due to irradiation of surrounding normal tissues and this is unavoidable. The side effects can be acute or late. The most common side effects to treatment are mucositis and xerostomia. Xerostomia contributes to eating difficulties, discomfort, and alteration of taste and increased risk of dental caries that is rampant. When radiotherapy is given after the chemotherapy, the risk of developing mucosal toxicity is increased when compared to fractionation radiotherapy of same dose. Oral rinsing using benzodamine solution decreases the pain, frequency and severity of ulcerative mouth lesions. Hence John was started on this treatment from the initiation of chemotherapy. Until now, there is no specific intervention that is recommended to prevent xerostomia, although some centers continue to use amifostine. Much prior to initiation of anti-cancer treatment, John was educated about the side effects to treatment. There is some evidence that administration of pilocarpine, a parasympathomimetic alkaloid, during the course of radiotherapy into the salivary gland tissue improves salivary gland flow and hence it is hoped that this may prevent, decrease or postpone xerostomia (SIGN, 2006). However, there is no evidence to show that this improves quality of life. John was not started on this treatment because of lacking evidence to start this treatment regularly. Other complications of radiotherapy include dermatitis, skin burns and pruritus. While some recommend administration of aloe vera gel, sucralfate, glycerine gel and aqueous cream to reduce skin toxicity, there is not much evidence to prove this (SIGN, 2006). John however, was started on a combination of aloe vera and glycerine gel, which according to him brough some relief with reference to deramatitis. Other late complications that can be expected in a patient treated with radiotherapy include chondritis, soft tissue fibrosis, poor wound healing and osteoradionecrosis of the mandible. In advanced disease, laryngeal edema, aspiration and persistent dysphagia can occur. 10 percent of patients on radiation therapy will need gastrostomy feeding tubes because of scarring of esophagus (Lydiatt and Lydiatt, 2009). Those who receive concurrent therapy are at increased risk of development of complications (Lydiatt and Lydiatt, 2009). The complication which John suffered the most was mucositis. Mucositis occurs both due to 5FU and radiation therapy to laryngeal area. 5-FU affects the synthesis of DNA in S-phase and hence causes this adverse effect commonly. The incidence and severity of mucositis varies from patient to patient and treatment to treatment. The incidence of mucositis is high and can occur upto 40 percent in those on standard chemotherapy. In those with high doses of chemotherapy or combination of radiotherapy and chemotherapy, the chances of procuring mucositis is as high as 76 percent (Naidu et al, 2004). Though mucositis is not a life threatening condition, it is a distressing condition and increases the number of treatment cycles. Certain factors like advanced age, malnutrition, malignancy of head and neck, depression and poor oral care increase the risk of malignancy (Naidu et al, 2004). John was in high risk of developing mucositis, because of advanced age, malnutrition, laryngeal cancer, combined chemotherapy and radiation therapy including fluorouracil and increased risk of poor oral care because of residence in hostel. Thus nurses have a major role to play to prevent mucositis and detect mucositis in early stages (Eilers and Million, 2007) so that appropriate interventions to prevent the progression of the disease can be instituted. There are several interventions to prevent and detect mucositis in early stages. Since John was identified to be a candidate for increased risk of development of mucositis, oral care education was started in him much before initiation of chemotherapy sessions. John was taught how to brush his teeth and keep his mouth clean and hygienic. He was asked to eat soft and nutritious food without pungent additives. Oral mucopaine gel was given to him to apply on ulcer sites before eating food. Despite all these measures, he developed florid mucositis and had to be started on intravenous drip because he could not eat or drink. John developed grade-3- grade-4 mucositis. There are several grading systems for mucositis, of which, the WHO grading is the most widely used (Naidu et al, 2004). According to the World Health Organization, mucositis is graded from 0-4. "If the patient has no signs and symptoms, it is graded as 0. If the patient has painless ulcers, edema, or mild soreness, it is graded as 1. If there is painful erythema, edema, or ulcers but able to eat, it is graded as 2. If there is painful erythema, edema, or ulcers but unable eat, it is graded as 3. If there a requirement for parenteral or enteral support, it is graded as 4" (Wilkes, 1998). This simple WHO scoring system can help detect mucositis in early stages. According to Eiler (2004), "ongoing assessment and monitoring are critical to the effective management of oral mucositis." Thus, oral care protocols are very essential for management of oral mucositis. John continues to have oral mucositis during radiotherapy. However, because of proper oral care and enteral support, the intensity of mucositis came down from grade-4 to grade-1. Conclusion Laryngeal cancer is one of the most common cancers of head and neck and is significant cause of morbidity and mortality. The treatment of the cancer depends on the site and behavior of the cancer. While surgical resection is the best treatment that can be given for those who have present early, radiotherapy is the preferred treatment because it preserves the anatomy and function of larynx. Radiotherapy is often given in combination with chemotherapy. In the patient under discussion, laryngeal cancer was in advanced stage. He was started on a combination chemotherapy using cisplatin and 5FU. Cetuximab was contemplated in him. However, because of poor response scores to platinum therapy, advanced age, lack of proper care and malnutrition, it was not given. Following chemotherapy, he received external beam radiation therapy with hyper fractionated radiation doses for good local control of disease. John did develop several side effects like nausea, vomiting, mucositis and dermatitis. While his nausea and vomiting responsed to treatment to some extent, he continued to suffer with mucositis and dermatitis despite early identification and intervention. His mucositis subsided only after cessation of anti-cancer treatment. Though the anticancer treatment decreased the progression of the disease, according to him, it did not imporve his quality of life because he suffered from nausea, loss of appetite, itching all over the body and burning sensation and pain in the mouth. References Barr, L. Cowan, R. Nicolson, M. (2004) Larynx Tumours. Oncology. Churchills Pocket Books. Second Edition. Churchill Livingstone. Elsevier Ltd. Campbell, W.J., and de Torre, J. (2008). Head and Neck Cancer-Squamous Cell Carcinoma. Emedicine from WebMD. http://emedicine.medscape.com/article/1289986-overview Eilers, J. (2004). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncol Nurs Forum, 31(4 Suppl), 13-23. Hirasawa, N., Itoh, Y., Ishihara, S., et al. (2010). Radiotherapy with or without chemotherapy for patients with T1-T2 glottic carcinoma: retrospective analysis. Head Neck Oncol., 2, 20. Johnson, J.T., and Christopoulos, A. (2009). Malignant Tumors of the Larynx. Retrieved on 30th November, 2010 from Emedicine from WebMD. http://emedicine.medscape.com/article/848592-overview Lydiatt, W.M., and Lydiatt, D.D. (2009). Glottic Cancer. Emedicine from WebMD. Retrieved on 30th November, 2010 from http://emedicine.medscape.com/article/853055-followup Liu, S.M. (1998). Anti Cancer Agents. Retrieved on 30th November, 2010 from http://www.ch.ic.ac.uk/local/projects/s_liu/Html/Frames.html Laccourreye, O., Brasnu, D., Bassot, V., et al. (1996). Cisplatin-fluorouracil exclusive chemotherapy for T1-T3N0 glottic squamous cell carcinoma complete clinical responders: five-year results. Journal of Clinical Oncology, 14, 2331- 2336. Longley, D.B., Harkin, D.P., and Johnston, P.G. (2003). 5-Fluorouracil: mechanisms of action and clinical strategies. Nature Reviews Cancer 3, 330-338. Naidu, M.U.R., Ramana, G.V., Rani, P.U., et al. (2004). Chemotherapy-Induced and/or Radiation Therapy-Induced Oral Mucositis—Complicating the Treatment of Cancer. Neoplasia, 6(5), 423- 431. NICE. (2004). Improving Outcomes in Head and Neck Cancers. Retrieved on 30th November, 2010 from http://www.nice.org.uk/nicemedia/live/10897/28851/28851.pdf SIGN. (2006). Diagnosis and management of head and neck cancer. Retrieved on 30th November, 2010 from http://www.sign.ac.uk/pdf/sign90.pdf NICE. (2008). Cetuximab for the treatment of recurrent and/or metastatic squamous cell cancer of the head and neck. Retrieved on 30th November, 2010 from http://www.nice.org.uk/TA145 Wilkes, J.D. (1998). Prevention and treatment of oral mucositis following cancer chemotherapy. Semin Oncol., 25(5), 538-51. Yoshio, M., Tomoaki, O., Yosshihiro, I., et al. (2006). Radiotherapy for latyngeal cancer. 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