Chemotherapy

A type of cancer treatment that uses drugs to kill cancer cells. It works by killing or stopping the growth of cancer and other fast-growing cells.

It is used for two reasons:

• Treat cancer: can be used to cure cancer, lessen the chance it will return, or stop or slow its growth.
• Ease cancer symptoms: can be used to shrink tumors that are causing pain and other problems.

Chemotherapy may be the only treatment you receive. But mostly, you will have other cancer treatments as options, too. The type of treatment that you need depends on the type of cancer you have, if it has spread and where, and if you have other health problems.

How chemotherapy is used with other cancer treatments:

When used with other treatments, chemotherapy can:

• make a tumor smaller before surgery or radiation therapy, called neoadjuvant chemotherapy
• destroy cancer cells that may remain after surgery or radiation therapy, called adjuvant chemotherapy
• help other treatments work better
• kill cancer cells that have returned or spread to other parts of your body

Side effects:

Chemotherapy also kills or slows the growth of healthy cells that grow and divide quickly.

Examples include cells that line your mouth, intestine, and those that cause our hair to grow. Damage to healthy cells may cause side effects, such as mouth sores, nausea, and hair loss. Side effects often get better or go away after you have finished chemotherapy.

The most common side effect is fatigue, which is feeling exhausted and worn out.

You can prepare for fatigue by:

• asking someone to drive you to and from chemotherapy
• planning time to rest on the day of and the day after chemotherapy
• asking for help with meals and childcare on the day of and at least one day after chemotherapy

How chemotherapy is given:

Common ways include:

• oral: comes in pills, capsules, or liquids that you swallow
• intravenous (IV): goes directly into a vein. The nurse will put the needle in at the start of each treatment and remove it when treatment is over. IV chemotherapy may also be given through catheters or ports, sometimes with the help of a pump. It is advisable to watch for signs of infection around the inserted area.

1. Catheter: a thin, soft tube. It is placed on one end of the catheter in a large vein, often in the chest area. The other end of the catheter stays outside the body. Most catheters stay in place until the chemotherapy treatment is finished. They can also be used to give you other drugs and to draw blood.
2. Port: a small, round disc that is placed under your skin during a minor surgery. A surgeon puts it in place before you begin your course of treatment, and it remains there until you have finished. A catheter connects the port to a large vein, most often in your chest. The nurse can insert a needle into your port to give you chemotherapy or draw blood. This needle can be left in place for chemotherapy treatments that are given for longer than one day.
3. Pump: often attached to catheters or ports. Their function is to control how much and how fast chemotherapy goes into a catheter or port, allowing you to receive your chemotherapy outside of the hospital. They can be internal or external. External pumps remain outside your body. Internal pumps are placed under your skin during surgery.

• intra-arterial (IA): injected directly into the artery that leads to the cancer
• injection: given by a shot in a muscle in your arm, thigh, or hip, or right under the skin in the fatty part of your arm, leg, or belly
• intrathecal: injected into the space between the layers of tissue that cover the brain and spinal cord
• intraperitoneal (IP): goes directly into the peritoneal cavity, which is the area in your body that contains organs such as your intestines, stomach, and liver
• topical: comes in a cream which can be rubbed onto your skin

Everyone is different, and people respond to chemotherapy in different ways.

Costs:

The cost of chemotherapy depends on:

• the types and doses of chemotherapy used
• how long and how often is chemotherapy given
• whether you get chemotherapy at home, in a clinic, or in a hospital stay
• the part of the country where you live

During chemotherapy visits, doctors and nurses will ask you how you feel, do a physical exam, and order medical tests, including blood tests and scans, which might include MRI, CT, or PET.

Some people think that severe side effects mean that chemotherapy is working well, or that no side effects mean that chemotherapy is not working. The truth is that side effects have nothing to do with how well chemotherapy is fighting your cancer.

Hormone therapy

Treatment that slows or stops the growth of cancer that uses hormones to grow is also known as endocrine therapy. It may be used to reduce or prevent symptoms in men with prostate cancer who are not able to have surgery or radiation therapy. It is also used to treat breast cancers that use hormones to grow.

Hormone therapy falls into two broad groups:

1. those that block the body’s ability to produce hormones
2. those that interfere with how hormones behave in the body.

Common side effects:

For men:

• hot flashes
• loss of interest in or ability to have sex
• weakened bones
• diarrhea
• nausea and fatigue
• enlarged and tender breasts

For women:

• hot flashes
• vaginal dryness
• changes in your periods if you have not yet reached menopause
• loss of interest in sex
• nausea and fatigue
• mood changes

How is it given:

• Oral - which come in pills, and you can swallow them
• Injection - given by a shot in a muscle in your arm, thigh, or hip, or right under the skin in the fatty part of your arm, leg, or belly.
• Surgery - to remove hormone-producing organs. In women, the ovaries are removed. In men, the testicles are removed.

How to know if the hormone therapy is working:

For prostate cancer, you will have regular PSA tests. If it is working, your PSA levels will stay the same or may even go down. But if your PSA levels go up, this may be a sign that the treatment is no longer working. If this happens, your doctor will discuss treatment options with you.

For breast cancer, you will have regular check-ups. Checkups usually include an exam of the neck, underarm, chest, and breast areas. You will have regular mammograms, though you probably won’t need a mammogram of a reconstructed breast. Your doctor may also order other imaging procedures or lab tests.

Surgery

A procedure in which a surgeon removes cancer from your body.

Surgeons often use small, thin knives, called scalpels, to cut through your body during surgery, which often requires cuts through skin, muscles, and sometimes bone. After surgery, these cuts can be painful and take some time to heal.

Anesthesia (drugs or other substances that cause you to lose feeling or awareness) keeps you from feeling pain during surgery.

• Local anesthesia causes loss of feeling in one small area of the body.
• Regional anesthesia causes loss of feeling in a part of the body, such as an arm or leg.
• General anesthesia causes loss of feeling and a complete loss of awareness that seems like a very deep sleep.

Other ways of performing surgery not involving cuts with scalpels include:

• Cryosurgery - a type of treatment in which extreme cold produced by liquid nitrogen or argon gas is used to destroy abnormal tissue. It may be used to treat early-stage skin cancer, retinoblastoma, and precancerous growths on the skin and cervix.

• Lasers - a type of treatment in which powerful beams of light are used to cut through tissue. They can focus very accurately on tiny areas, so they can be used for precise surgeries. Lasers can also be used to shrink or destroy tumors or growths that might turn into cancer.

  Lasers are most often used to treat tumors on the surface of the body or on the inside lining of internal organs. Examples include basal cell carcinoma, cervical changes that might turn into cancer, and cervical, vaginal, esophageal, and non-small cell lung cancer.

Types of surgery

There are many types of surgery. The types differ based on the purpose of the surgery, the part of the body that requires surgery, the amount of tissue to be removed, and, in some cases, what the patient prefers.

Surgery may be open or minimally invasive.

• In open surgery, the surgeon makes one large cut to remove the tumor, some healthy tissue, and maybe some nearby lymph nodes
• In minimally invasive surgery, the surgeon makes a few small cuts instead of one large one. They insert a long, thin tube with a tiny camera into one of the small cuts. This tube is called a laparoscope. The camera projects images from the inside of the body onto a monitor, which allows the surgeon to see what they are doing. They use special surgical tools that are inserted through the other small cuts to remove the tumor and some healthy tissue.

Because minimally invasive surgery requires smaller cuts, it takes less time to recover from than open surgery.

Types of cancer treated with surgery:

Surgery works best for solid tumors that are contained in one area. It is a local treatment, meaning that it treats only the part of your body with the cancer. It is not used for leukemia or for cancers that have spread.

Sometimes surgery will be the only treatment you need. But most often, you will also have other cancer treatments.

How surgery works against cancer:

Depending on your type of cancer and how advanced it is, surgery can be used to:

• Remove the entire tumor contained in one area.
• Debulk a tumor - Surgery removes some, but not all, of a cancer tumor. Debulking is used when removing an entire tumor might damage an organ or the body. Removing part of a tumor can help other treatments work better.
• Ease cancer symptoms (removing tumors causing pain)

What to expect before, during, and after surgery?

1. Before surgery

Common tests that you may need, if you have not had them lately, are:

• blood tests, chest x-ray, electrocardiogram (ECG)

2. During surgery

Information has been provided above.

3. After surgery

Once you are ready to go home after surgery, the nurse will tell you how to take care of yourself. They will explain:

• how to control pain
• activities you should and should not do
• how to take care of your wound
• how to spot signs of infection and steps to take if you do
• when you can return to work

Visits to the doctor will have to be consulted with your doctor.

Risks of surgery:

• Pain

  After surgery, most people will have pain in the part of the body that was operated on. How much pain you feel will depend on the extent of the surgery, the part of your body where you had surgery, and how you experience pain.

• Infection

  Infection is another problem that can happen after surgery. To help prevent infection, follow your nurse’s instructions about caring for the area where you had surgery. If you do develop an infection, your doctor can prescribe a medicine (called an antibiotic) to treat it.

  • Other risks of surgery include bleeding, damage to nearby tissues, and reactions to the anesthesia.
  • If you have local or regional anesthesia, you will probably return to your work/more quickly than if you have general anesthesia.

Radiation therapy

**It uses high-energy radiation to kill cancer cells and control tumor growth (**often in conjunction with other treatments like chemotherapy or surgery). 

Treatment can be external, using a machine to deliver beams of radiation to a specific part of the body, or internal (brachytherapy), where a radioactive source is placed inside the body.

How does it work?

• Targeting cancer cells: High-energy radiation, such as X-rays, is used to damage the DNA of cancer cells, which prevents them from growing and dividing. Healthy cells may be damaged along with cancer cells during radiation therapy. But healthy cells can repair themselves more easily than cancer cells.
• Precision: Modern techniques, like image-guided radiation therapy (IGRT) and 3D conformal therapy, use detailed scans to precisely aim the radiation at the tumor and shape the beams to fit it, sparing surrounding healthy tissue.

Types of Radiation Therapy

• External Beam Radiation Therapy (EBRT): A machine, like a linear accelerator, delivers radiation beams from outside the body directly to the tumor.

Forms of EBRT:

1. 3D conformal radiation therapy uses CT scans and computer software to create a 3D model of the tumor. Using the model as a guide, the machine directs radiation beams that target the cancer site while sparing healthy tissue.
2. Intensity-modulated radiation therapy (IMRT) is a more advanced form of radiation therapy. It uses many radiation beams that vary the dose intensity, delivering a higher radiation dose to the tumor and lower doses to healthy tissue.
3. Arc-based radiotherapy is a form of IMRT. It directs energy beams of varying intensity in a rotational arc-like pattern. This method delivers radiation faster than traditional IMRT. Volumetric modulated arc therapy (During treatment, a machine rotates around your body, sending multiple energy beams of varying strengths to kill cancer cells and destroy tumors. It treats various cancers, including prostate cancer, lung cancer, and head and neck cancers, among others. And Tomotherapy (It uses a spiral, rotating beam to precisely target and treat tumors while simultaneously acquiring 3D images of the patient's anatomy. This image-guided approach allows for real-time adjustments to the radiation dose, minimizing damage to surrounding healthy tissues and potentially leading to fewer side effects compared to conventional radiotherapy. are two forms of arc-based radiotherapy.
4. **Image-guided radiotherapy (IGRT)** is a form of EBRT in which the radiation machine obtains a low-dose X-ray or mini CT scan before each treatment. This image helps align the treatment site, resulting in more precise radiation delivery.
5. Particle therapy uses radiation therapy that consists of protons instead of photons (X-rays). For certain people, protons can deliver the same radiation dose to the tumor and reduce radiation dose to healthy tissues.
6. Stereotactic radiosurgery, such as Gamma Knife surgery, uses high doses of focused radiation to destroy small brain tumors with surgical precision. Unlike surgery, it doesn’t require cutting. Typically, this treatment takes one to five days.
7. Stereotactic body radiation therapy uses high doses of focused radiation to destroy tumors outside of your brain. Like stereotactic radiosurgery, it eliminates tumors with surgical precision but without actual surgery.
8. Intraoperative radiation: delivers radiation during surgery. After a tumor has been removed surgically, IORT destroys any remaining cancer cells that aren’t safe to surgically remove.

• Internal radiation therapy places radiation inside your body, close to cancer cells. It treats smaller tumors in your head, neck, breast, cervix, uterus, or prostate.

You can receive internal radiation through a solid source or in liquid form:

1. Brachytherapy implants a solid radioactive source, or “seed,” inside or beside a tumor. The source releases radiation to a small area to kill cancer cells. Some implants release low doses for longer periods (weeks). Others may release high doses for shorter periods (minutes). Some implants used in this treatment are temporary. Others stay in your body forever. Eventually, they stop releasing radiation.
2. Systemic therapy sends liquid radioactive material through your blood to find and destroy cancer cells. Some forms are swallowed. For others, you’ll receive an injection through a vein (IV). Treatments include radionuclide therapy (radioimmunotherapy). With radioimmunotherapy, a radioactive protein recognizes specific cancer cells, attaches to them, and then releases radiation to kill them.

Why is it used?

Radiation therapy can be used:

• As the main treatment: for small tumors or when surgery isn't an option.
• Before surgery: to shrink tumors.
• After surgery: to kill any remaining cancer cells.
• With chemotherapy: (chemoradiation) for a more potent effect.
• To relieve symptoms, like pain or bleeding, from advanced cancer.
• To treat recurrent cancer

Common Side Effects:

Side effects are typically localized to the treated area and can include: Fatigue, Skin irritation in the treatment area, and hair loss in the treated area.

What to Expect?

• Treatment is usually painless and can be relatively quick, allowing patients to often resume normal activities.
• Treatments are delivered in a series of sessions, often five days a week for several weeks, though shorter schedules are also used.
• You will likely receive treatment as an outpatient at a hospital or clinic.

Hyperthermia

 A type of treatment in which body tissue is heated to as high as 113 °F to help damage and kill cancer cells with little or no harm to normal tissue. Many clinical trials have shown that hyperthermia, when used with treatments such as radiation therapy and chemotherapy, helps shrink tumors and may make it easier for them to kill cancer cells. It can help other cancer treatments, such as chemotherapy and radiation therapy, work better.

Techniques include:

• probes that make energy from microwaves
• radiowaves, also called radiofrequency
• lasers
• ultrasound
• perfusion - heating fluids such as blood or chemotherapy drugs and putting them into the body
• placing the entire body in a heated chamber or hot water bath, or wrapping with heated blankets

Why is hyperthermia used?

It is not widely available. However, it has been used to treat a few types of advanced cancers:

• appendix cancer
• bladder
• brain cancer
• breast
• cervical cancer
• esophageal cancer
• head and neck cancer
• liver
• lung cancer
• melanoma
• mesothelioma
• sarcoma
• rectal cancer

How is the treatment given?

During the treatment, the doctor numbs the treatment area and inserts small probes with tiny thermometers (which closely watch the temperature of the tumor and nearby tissue during he treatment). Imaging techniques, such as CT scans, may be used to make sure the probes are in the proper place.

Types of hyperthermia treatment:

Hyperthermia can be used to treat small areas of the body, large areas, or the entire body.

• In local hyperthermia, doctors apply heat to a small area. The local hyperthermia used depends on where the tumor is located.
• External hyperthermia is used to treat tumors that are on or just below the skin. Devices that create heat around or near the treatment area are placed by the doctors.
• Intraluminal or endocavitary hyperthermia - used to treat tumors within or near body cavities, such as the esophagus or rectum. Probes that create heat inside the cavity are inserted into the tumor by the doctors.
• Interstitial hyperthermia is used to treat tumors deep within the body, such as in the brain. This allows the tumor to be heated to higher temperatures than external techniques. While you are under anesthesia, the doctor will insert probes or needles into the tumor. Imaging techniques, like ultrasound, may be used to help make sure the probe is in the right place. The heat source is then inserted into the probe. Radiofrequency ablation is a type of interstitial hyperthermia that uses radio waves to heat and kill cancer cells.

In regional hyperthermia, doctors apply heat to large areas of the body, such as a cavity, organ, or limb. Techniques include deep tissue techniques, regional perfusion, and continuous hyperthermic peritoneal perfusion.

1. Deep tissue techniques treat cancers within the body, such as cervical or bladder cancer. During this procedure, devices that deliver heat are placed around the cavity or organ to be treated and energy is focused on the area to raise its temperature.

2. Regional perfusion techniques treat cancers in the arms and legs, such as melanoma, or in some organs, such as the liver or lung. During this procedure, some of your blood is removed, heated, and then pumped back into the limb or organ. Chemotherapy is often given during this treatment.

3. Continuous hyperthermic peritoneal perfusion treats cancer within the peritoneal cavity, which is the space within the abdomen that contains the intestines, stomach, and liver.

   This treatment is given during surgery. While you are under anesthesia, heated chemotherapy drugs flow from a warming device through your peritoneal cavity, causing the temperature in the area to reach 106 to 108°F.

Whole-body hyperthermia treats cancer that has spread throughout the body. In this type of hyperthermia, you are placed in a thermal chamber or wrapped in hot water blankets that raise your body temperature to 107 or 108 °F for short periods of time.

Hyperthermia side effects

1. Most of the healthy tissue is not damaged during hyperthermia if the temperature stays under 111°F. But different features of different tissues may cause higher temperatures to occur in certain spots. This can cause burns, blisters, discomfort, or pain.
2. Perfusion techniques can cause swelling, blood clots, bleeding, and other damage to the normal tissues in the treated area. But most of these side effects improve after treatment.
3. Diarrhea, nausea, and vomiting are common after whole-body hyperthermia. It can also cause more serious side effects that are not common, including heart and blood vessel problems.

Immunotherapy

A diverse type of therapy that works by harnessing the patient's own immune system to prevent, control, or eliminate disease, most commonly cancer.

It uses biological substances or modified cells to either boost the immune system's natural ability to fight disease or to add lab-made components that mimic natural immune functions. Besides cancer treatment, it's also used for conditions such as autoimmune diseases, allergies, and immunodeficiencies.

It is primarily used for advanced cancer stages (like Stage 3 and Stage 4) but is also increasingly used in earlier stages, even before surgery, for cancers that respond well to it or haven't responded to traditional therapies.

How does it work?

Normally, the immune system detects and destroys abnormal cells and most likely prevents or curbs the growth of many cancers. For instance, immune cells are sometimes found in and around tumors. These cells, called tumor-infiltrating lymphocytes or TILs, are a sign that the immune system is responding to the tumor. People whose tumors contain TILs often do better than people whose tumors don’t contain them.

Even though the immune system can prevent or slow cancer growth, cancer cells have ways to avoid destruction by the immune system.

• Stimulating the Immune System: helps the immune system recognize and attack abnormal cells, such as cancer cells, that it might otherwise overlook.
• Modifying Immune Cells: Some therapies involve removing a patient's immune cells, changing them in a lab to make them more effective at fighting the disease, and then returning them to the body.

Types of Immunotherapy:

• Immune Checkpoint Inhibitors: These drugs block proteins that prevent the immune system from attacking cancer cells, effectively "releasing the brakes" on the immune response.
• T-cell transfer therapy (also called adoptive cell therapy, adoptive immunotherapy, or immune cell therapy): a ****treatment that boosts the natural ability of your T cells to fight cancer. In this treatment, immune cells are taken from your tumor. Those that are most active against your cancer are selected or changed in the lab to better attack your cancer cells, grown in large batches, and put back into your body through a needle in a vein.
• Cancer Vaccines: These therapies train the immune system to recognize and fight cancer cells.
• Cytokines: Lab-made versions of proteins that naturally regulate the immune system.
• cells, such as cancer cells, that it might otherwise overlook.
• Monoclonal Antibodies (therapeutic antibodies): Lab-produced antibodies that can target specific molecules on cancer cells or immune cells to help fight disease.
• Treatment vaccines, which work against cancer by boosting your immune system’s response to cancer cells. They are different from the ones that help prevent disease.
• Immune system modulators, which enhance the body’s immune response against cancer. Some of these agents affect specific parts of the immune system, whereas others affect the immune system in a more general way.

How is immunotherapy given?

• intravenous (IV): The immunotherapy goes directly into a vein
• oral: comes in pills or capsules, which can be swallowed.
• topical: The immunotherapy comes in a cream that you rub onto your skin. This type of immunotherapy can be used for very early skin cancer.
• intravesical: The immunotherapy goes directly into the bladder.

Side effects:

Many side effects happen when the immune system, which is revved up to act against the cancer, also acts against healthy cells and tissues in the body.

Different people have different side effects. They depend on

• how healthy you are before treatment
• type of cancer
• how advanced your cancer is
• the type and dose of immunotherapy you are getting

When on immunotherapy for a long time, side effects can occur at any point during and after treatment. Doctors and nurses cannot know for certain when or if side effects will occur or how serious they will be. So, it is important to talk with your doctors and nurses about what signs to look for and what to do if you start to have problems.

Some common side effects of all types of immunotherapy. For instance, you might have skin reactions at the needle site, which include:

• pain
• swelling
• soreness
• redness
• itchiness
• rash

You may have flu-like symptoms, which include:

• chills or fever
• weakness or fatigue
• dizziness, headache
• nausea or vomiting
• muscle or joint aches
• trouble breathing
• low or high blood pressure

Other side effects might include:

• swelling and weight gain from retaining fluid
• heart palpitations and organ inflammation
• sinus congestion
• diarrhea and infection

Some types of immunotherapy may cause severe or fatal allergic and inflammation-related reactions. But these reactions are rare.

Blood stem cell transplant

Also called a bone marrow transplant or hematopoietic stem cell transplant involves infusing healthy blood-forming stem cells to replace unhealthy or destroyed ones.

These stem cells, which can come from the recipient's own body, a donor's bone marrow, blood, or umbilical cord blood, migrate to the bone marrow to produce new, healthy red blood cells, white blood cells, and platelets. 

How does it work?

• Restores a patient's ability to produce healthy blood cells after treatment with the very high doses of chemotherapy and maybe other treatments.
• The Process: Before the transplant, patients usually receive chemotherapy or radiation to kill diseased cells and malfunctioning bone marrow. Then, healthy stem cells are infused into a vein, much like a blood transfusion.
• Engraftment: The transplanted stem cells travel to the patient's bone marrow, where they ideally begin to produce new blood cells.

In leukemia, the stem cell transplant may work against cancer directly, which happens because of an effect called graft-versus-leukemia, which can occur after transplants that use stem cells from a donor. This effect occurs when white blood cells from your donor (the graft) attack any cancer cells that remain in your body (the tumor or leukemia cells). This effect improves the chances of success of the transplant.

Sources of stem cells:

• Peripheral blood stem cells (PBSCT): Collected from the bloodstream.
• Bone marrow transplant (BMT): Collected from the bone marrow.
• Umbilical cord blood transplant: Collected from the placenta and umbilical cord after a baby is born.

To decide if the stem cells from a donor are a match for you, they will be tested for their HLAs (which stand for human leukocyte antigens), which are sets of proteins, or markers, that you have on most cells in your body. Each person has a different set of HLAs. The more HLAs that you and the donor have in common, the better the chance that your body will accept the donor’s stem cells.

Most often, the best match for an allogeneic stem cell transplant is a brother or sister.

Why is it done?

Stem cell transplants are most often used to treat people with cancers that affect blood cells, such as leukemia, lymphoma, multiple myeloma, and myelodysplastic syndromes. They may also be used for neuroblastoma, Ewing sarcoma, brain tumors that have come back in children, germ cell tumors, and testicular cancer.

• For disorders: It addresses non-cancerous diseases such as aplastic anemia, thalassemia, sickle cell anemia, and immune deficiency syndromes.

Types of transplants:

• Autologous transplant: Uses the patient's own stem cells.
• Allogeneic transplant: Uses stem cells from a donor.
• Syngeneic transplant: Uses stem cells from an identical twin.

With autologous transplants, the transplanted cells will match, but there is a small risk that cancer cells will be transplanted.

With allogeneic transplants, it is important that the cells match closely enough that your immune system won’t see the transplanted blood stem cells as foreign and destroy them.

• Mini-transplants - a type of allogeneic transplant that uses lower doses of cancer treatment than a regular transplant. They do not kill all your blood-forming stem cells, but they still kill some of the cancer cells. This can prevent rejection of the donor’s stem cells by suppressing your immune system.
• Tandem transplants - a type of autologous transplant. During a tandem transplant, you receive a round of high-dose chemotherapy followed by a stem cell transplant. Then after many weeks or months, you have another round of high-dose chemotherapy followed by another stem cell transplant.

Risks and side effects:

• Increased infection risk: The initial treatment weakens the immune system.
• Graft-versus-host disease (GVHD): In an allogeneic transplant, the donor's new cells may attack the patient's body.

They can be acute or chronic. Acute graft-versus-host disease occurs within the first 3 months after transplant. Chronic graft-versus-host disease occurs 3 months after a transplant or later.

Graft-versus-host disease can be treated with steroids or other drugs that suppress your immune system.

• Other effects: Delayed growth (in children), new cancers, and fertility issues can also occur.

The high doses of cancer treatment that you have before a stem cell transplant can cause problems such as:

• bleeding
• increased risk of infection
• feeling tired and exhausted

Short-term problems may include:

• nausea
• vomiting
• fatigue
• loss of appetite
• mouth sores
• hair loss
• skin reactions

Long-term problems of stem cell transplants may include:

• infertility
• cataracts (clouding of the lens of the eye, which causes loss of vision)
• new secondary cancers
• liver, kidney, lung, or heart damage
• bone and muscle weakness

Targeted therapy

A type of cancer treatment that targets proteins that control how cancer cells grow, divide, and spread. It lays the foundation of precision medicine.

Types of targeted therapy:

• Small-molecule drugs enter cells easily and are thus used for targets that are inside cells. They are pills or capsules that you can swallow.
• Monoclonal antibodies, also known as therapeutic antibodies, are proteins produced in the lab. These proteins are designed to attach to specific targets found on cancer cells. Some monoclonal antibodies mark cancer cells so that they can be better seen and destroyed by the immune system. Other monoclonal antibodies directly stop cancer cells from growing or cause them to self-destruct. Still others carry toxins to cancer cells. They are usually given through a needle in a vein.

Who is treated with targeted therapy?

For some types of cancer, such as chronic myelogenous leukemia (also known as CML), most people with that cancer will have a target for a certain drug, so they can be treated with that drug. But most of the time, your tumor will need to be tested to see if it contains targets for which there is a drug. Testing your cancer for targets that could help choose your treatment is called biomarker testing.

A biopsy is a procedure in which your doctor removes a piece of the tumor for testing. There are some risks to having a biopsy.

How does targeted therapy work against cancer?

Interfering with specific proteins that help tumors grow and spread throughout the body is how most types of targeted therapy work. It is different from chemotherapy.

• Help the immune system destroy cancer cells. Certain targeted therapies can mark cancer cells so it is easier for the immune system to find and destroy them. Other targeted therapies help boost your immune system to work better against cancer.
• Stop cancer cells from growing by interrupting signals that cause them to grow and divide without order. Healthy cells in your body usually divide to make new cells only when they receive strong signals to do so. These signals bind to proteins on the cell surface, telling the cells to divide. This process helps new cells form only as your body needs them. But some cancer cells have changes in the proteins on their surface that tell them to divide whether or not signals are present. Some targeted therapies interfere with these proteins, preventing them from telling the cells to divide. This process helps slow cancer’s uncontrolled growth.
• Stop signals that help form blood vessels. To grow beyond a certain size, tumors need to form new blood vessels in a process called angiogenesis. The tumor sends signals that start angiogenesis. Some targeted therapies called angiogenesis inhibitors interfere with these signals to prevent a blood supply from forming. Without a blood supply, tumors stay small. Or, if a tumor already has a blood supply, these treatments can cause blood vessels to die, which causes the tumor to shrink.
• Deliver cell-killing substances to cancer cells. Some monoclonal antibodies are combined with cell-killing substances such as toxins, chemotherapy drugs, etc. Cells die in an orderly manner when they become damaged or are no longer needed. But cancer cells have ways of avoiding this dying process. Some targeted therapies can cause cancer cells to go through this process of cell death, which is called apoptosis.
• Cause cancer cell death. Healthy cells die in an orderly manner when they become damaged or are no longer needed. But cancer cells have ways of avoiding this dying process. Some targeted therapies can cause cancer cells to go through this process of cell death, which is called apoptosis.
• Starve cancer of the hormones it needs to grow. Some breast and prostate cancers require certain hormones to grow. Hormone therapies are a type of targeted therapy that can work in two ways. Some hormone therapies prevent your body from making specific hormones. Others prevent the hormones from acting on your cells, including cancer cells.

Drawbacks:

• Cancer cells can become resistant to targeted therapy. Resistance can happen when the target itself changes and the targeted therapy is not able to interact with it. Or it can happen when cancer cells find new ways to grow that do not depend on the target. Because of resistance, targeted therapy may work best when used with more than one type of targeted therapy or with other cancer treatments, such as chemotherapy and radiation.
• Drugs for some targets are hard to develop. Reasons include the target’s structure, the target’s function in the cell, or both.

What are the side effects of targeted therapy?

When targeted therapy was first developed, scientists thought that it would be less toxic than chemotherapy. But they have learned that targeted therapy can also cause serious side effects. The side effects that you may have depend on the type of targeted therapy you receive and how your body reacts to it.

The most common side effects of targeted therapy include diarrhea and liver problems. Other side effects might include

• problems with blood clotting and wound healing
• high blood pressure and fatigue
• mouth sores
• nail changes
• the loss of hair color
• skin problems, which might include rash or dry skin

Very rarely, a hole might form through the wall of the esophagus, stomach, small intestine, large bowel, rectum, or gallbladder.

There are medicines for many of these side effects. These medicines may prevent side effects from occurring or treat them once they do.

Most side effects of targeted therapy go away after treatment ends.

Photodynamic therapy

A two-stage treatment that combines light energy with a medicine called a photosensitizer, which kills cancerous and precancerous cells when activated by light, usually from a laser. Most often used as a local treatment to treat a specific part of the body.

The photosensitizer is nontoxic until it is activated by light. However, after light activation, the photosensitizer becomes toxic to the targeted tissue.

Studies have shown that this light-based therapy can trigger the body's immune response, providing an additional means for the body to help destroy cancerous and precancerous cells.

Why is it done:

Used to treat a variety of conditions, including:

• Pancreatic cancer.
• Bile duct cancer, also known as cholangiocarcinoma.
• Esophageal cancer.
• Lung cancer.
• Head and neck cancers.
• Certain skin diseases, including acne, psoriasis, nonmelanoma skin cancer and precancerous skin changes, known as actinic keratosis.
• Bacterial, fungal, and viral infections.

The FDA has approved photodynamic therapy to treat:

• actinic keratosis (a thick, scaly patch of skin resulting from prolonged sun exposure that can become a pre-cancerous condition known as squamous cell carcinoma)
• advanced cutaneous T-cell lymphoma
• Barett esophagus
• basal cell skin cancer
• throat cancer
• non-small cell lung cancer (also helps in relieving the symptoms, especially in case of blockage)
• squamous cell skin cancer (Stage 0, also helps in relieving the symptoms, especially in case of blockage)

How does it treat cancer?

When cells that have absorbed photosensitizers are exposed to a specific wavelength of light, the photosensitizer produces a form of oxygen, called an oxygen radical, that kills them.

It may also damage blood vessels in the tumor, which prevents it from receiving the blood it needs to keep growing. And, it may trigger the immune system to attack tumor cells, even in other areas of the body.

How is the therapy given?

Photodynamic therapy is a two-step process.

1. You will first receive a photosensitizer. The drug may be taken by mouth, spread on the skin, or given through an IV, which depends on where the tumor is in the body. After 24 to 72 hours, most of the drug will have left normal cells but will remain in cancer or precancer cells. Then your tumor will be exposed to the light source.
2. How the light is applied depends on where the tumor is. For skin tumors, the light is aimed right at the cancer. For tumors in the throat, airways, and lungs, your doctor will insert an endoscope down your throat.

• An endoscope is a thin, lighted tube that can help the doctor see inside the body. Once the endoscope is in place, a fiber optic cable that transmits light through it to reach the treatment areas is threaded by the doctors.

One type of photodynamic therapy called extracorporeal photopheresis (ECP) is used to treat abnormal WBCs that can cause skin symptoms in people with cutaneous T-cell lymphoma. In ECP, a machine collects your blood cells, treats them with a photosensitizer, exposes them to light, and then returns them to your body through a needle in a vein.

Most often, after the treatment you go home after treatment and do not spend the night in the hospital. You may have photodynamic therapy by itself, or you may have it along with other cancer treatments.

Benefits:

• limits damage to healthy cells because the photosensitizers tend to build up in abnormal cells and the light is focused directly on them.
• does not cause scarring, which makes it good for people with skin cancers and precancers.

Drawbacks and side effects:

1. Can harm normal cells in the treatment area and cause side effects. Damage to normal cells is limited, but photodynamic therapy can still cause burns, swelling, pain, and scarring in the treatment area.

2. The light used in photodynamic therapy can’t pass through more than about 1/3-inch of tissue, or 1 centimeter. Thus, it can only be used to treat tumors that are on or just under the skin or on the lining of internal organs or cavities.

3. Other side effects include:

• cough
• trouble swallowing
• stomach pain
• painful breathing and shortness of breath
• skin problems, such as redness, stinging, swelling, or itching

A type of photosensitizer called porfimer sodium makes the skin and eyes sensitive to light for about 6 weeks. During this time, you should avoid direct sunlight and bright indoor light.

ECP can cause:

• brief periods of low BP, and low blood platelet count
• faster than normal heart rate
• anemia

Side effects improve once treatment is over.

Laser therapy

A minimally invasive technique using laser fibers to deliver high-energy light into a tumor, converting it to heat to destroy cancer cells

It is guided by imaging technologies like MRI or ultrasound. The laser fiber is inserted through a small incision into the tumor, where the focused heat causes irreversible damage and cell death. This method offers a precise way to treat localized tumors in various organs, such as the brain, liver, and prostate, potentially reducing side effects and recovery time compared to conventional surgery.

It is a treatment for:

• abnormal cells that might become cancerous (precancerous cells) - including abnormal cells on the cervix, vulva, or vagina
• abnormal cells on the surface of the skin of the penis, also called penile intraepithelial neoplasia (PeIN)
• basal cell skin cancer, combined with a light-sensitive drug (photodynamic therapy)
• some advanced cancers inside the body - for example, the food pipe (esophagus), stomach, or the windpipe (trachea)

For very early cancers, the laser cuts or burns away the cancerous tissue. However, for more advanced cancers, laser therapy can shrink or destroy tumors. This can help to relieve blockages in the body.

How it works:

1. Energy delivery: A laser is produced with a specific wavelength, then transmitted through a thin, flexible optical fiber into the tumor.
2. Heat conversion: The laser light is absorbed by the tissue, where it is converted into thermal energy.
3. Cell destruction: This heat causes the tumor cells to reach high temperatures, leading to irreversible damage and death.
4. Guidance: The procedure is guided by real-time imaging, like Magnetic Resonance Imaging (MRI) or ultrasound, to precisely position the fiber and monitor the ablation zone.

How is it given?

• directly to your skin - to treat penile intraepithelial neoplasia
• using a speculum to look inside the vagina - to treat abnormal cells on the cervix, vagina or vulva
• through a flexible tube (a scope) - to treat cancers inside your body such as lung or stomach cancer

1. Before you have laser treatment

You usually have treatment at the hospital as an outpatient

You might have a local anaesthetic for treatment to your cervix, vulva or vagina. But some people have this treatment under a general anaesthetic. For other cancers types you might have an injection to make you sleepy (sedation).

Your doctor points the laser beam at the abnormal areas. The laser burns away the abnormal area, so you may notice a slight burning smell during the treatment. This is nothing to worry about. It is just the laser working.

Afterwards, you may go to the day ward to rest for a few hours. You can go home after the nurse has checked that it is safe for you to do so.

Laser therapy can treat cancers in the:

• windpipe (trachea) or lung airway (bronchus)
• food pipe (esophagus)
• stomach
• voice box (larynx)
• head and neck area, such as the tonsil, mouth, and nasal sinuses

To reach internal tumors,, doctors use a tube with a light at one end and an eyepiece at the other end. Endoscopy or Bronchoscopy is also done.

• Having a bronchoscopy

You usually have a general anesthetic, and the doctor uses a long, thin, flexible tube called a bronchoscope. They put this down your throat and into the airway. The doctor passes a small laser down the bronchoscope tube. The doctor burns away as much of the tumor as possible with the laser. They then take out the bronchoscopy tube.

• Having an endoscopy

You usually have medicine to make you sleepy, or a general anesthetic.

Your doctor gently puts a long flexible tube called an endoscope into your mouth. It goes down into your food pipe. The tube has a light and a small camera on the end so your doctor can see inside your food pipe and stomach.

• Relieving symptoms of a blockage (laser ablation)

The doctors position the end of the tube close to the tumor and direct the laser at it. This heats up the cancer cells and burns them away. This reduces the blockage or gets rid of it completely.

• Removing early stage cancers (endoscopic resection) - The surgeons use the laser to cut away the areas of cancer. This type of laser therapy might be called endoscopic resection.

Benefits:

• Minimally invasive, avoiding large surgical cuts.
• Reduced side effects such as urinary incontinence and erectile dysfunction, compared to whole-gland therapies.
• Faster recovery: Patients often experience quicker recovery and can sometimes go home the same day.
• Precision: It allows for the precise targeting of tumors, including those in sensitive areas like the brain.
• Repeatable: The treatment can be repeated if needed to treat recurrent tumors.

Laser ablation is used for various cancers, including:

• Brain and spinal tumors: To treat tumors deep within the brain with a low risk of infection or stroke.
• Liver tumors: To reduce tumor burden, potentially making patients eligible for a liver transplant.
• Prostate cancer: As a focal therapy to eradicate low-risk prostate cancers while preserving quality of life.
• Lung and other metastases: To treat metastatic lesions in organs like the lungs.

Considerations:

• While effective, there are limitations on the size of treatable tumors.
• More research and long-term data are needed to fully understand the potential of laser ablation as a long-term cancer treatment.

Side effects of laser treatment:

The side effects depend on the area of your body that you're having treatment to. They also depend on whether the laser is for surgery or to destroy cancer cells.

Cryoablation

A treatment that uses extreme cold directly on cancer cells, causing them to die. During cryoablation, thin metal probes are placed into the area where the cancer is located. The probes are filled with a gas that freezes nearby tissue.

*Typically used when surgery isn't an option (*For example, it may be recommended when cancer is too large to be surgically removed. Or it may be useful for people who have other health conditions that make surgery unsafe.) It may be used to ease pain and other symptoms caused by cancer that has spread. It does not require open surgery with large cuts through the skin and thus is a minimally invasive procedure.

Why it's done?

It freezes cancer cells, causing those cells to die.

Cryoablation can be a helpful treatment for many types of cancer, including:

• Bone cancer.
• Cervical cancer.
• Breast cancer.
• Kidney cancer.
• Liver cancer.
• Lung cancer.
• Prostate cancer.
• Sarcomas

When would a healthcare provider recommend cryoablation?

• An early-stage or small tumor that a provider can reach without making incisions
• A tumor that can’t be removed safely with surgery. This might be because the tumor is very large or there’s a chance that surgery could damage nearby organs
• Cancer that’s spread to other areas of your body that affects nearby organs or causes pain. Your provider could use cryotherapy to shrink the cancerous tumor or help with the pain (palliative cryoablation).

Risks:

• These risks include bleeding, blood clots and infection. A bad reaction to anesthetics is also a possibility.
• Pain in the treated area that lasts, and injury to healthy organs and tissue.
• Some people have an illness called post-ablation syndrome that happens several days after cryoablation. Typically, it involves a fever and other symptoms that are similar to the flu. In general, post-ablation syndrome lasts about five days. But in some people, it may not go away for 2 to 3 weeks.
• Rarely, a condition called cryoreaction can happen soon after cryoablation, causing chills, fever, a fast heartbeat, and fast, shallow breathing. It may also lead to kidney damage. But that damage often is temporary.
• Cryoshock - a life-threatening condition that can lead to organ failure. What causes cryoshock is not clear, but it happens most often when cryoablation is used to treat liver cancer.

What to expect?

1. During cryoablation for cancer

It is done in a hospital. You may be given a general anesthetic to put you in a sleep-like state or a regional anesthetic is used so that you'll be aware of your surroundings, but you won't feel anything in the area that's being treated.

Once the anesthetic takes effect, your healthcare professional:

• Inserts thin metal probes or needles into the area where the cancer is located.

• Watches images made by an ultrasound,  or to make sure the probes or needles are in the right place.

  CT

  MRI

• Releases a gas to circulate through the probes or needles that causes freezing in the tissue.

• Watches and controls the temperature of the needles and the amount of freezing within the tissue.

2. After cryoablation for cancer

You might be able to go home the day of the procedure, or you may need to spend the night in the hospital. An antibiotic to prevent infection may be given.

After the procedure, you may have some soreness and bruising for several days where the probes or needles were placed.

Regular follow-up exams, along with imaging scans and laboratory tests, to check how the cancer is responding to treatment is necessary.