Treatment choices
Clinical Nurse Specialist Linda Pellerin has witnessed many improvements in patient care.
Chemotherapy, often given as combinations of drugs, remains a standard weapon for attacking cancer cells or reducing pain caused by tumors. But this treatment is more effective and less toxic nowadays, and there are much better medications to control symptoms so the treatments are more tolerable (see related story: Easing the burden). More infusions can therefore be given in the ambulatory clinic, rather than the hospital. "The therapies we give outpatients are so much more complex than they used to be," says Clinical Nurse Specialist Linda Pellerin, RN, MSN, OCN, who remembers sedating hospitalized patients for several days if they were likely to have extreme nausea from their cancer regimens.
Knowledge about the molecular workings of cancer has led to newer treatment approaches since Farber's day, including stem cell transplants, hormone therapy (such as tamoxifen and aromatase inhibitors), and chemotherapy given in pill form, rather than as fluids injected into the bloodstream. Another development is the new class of "smart" drugs, which target specific pathways that cause and sustain cancer.
These include angiogenic inhibitors, which starve tumors of their blood supply, and tyrosine kinase inhibitors, which block overactive cell growth signals. Still other "smart" therapies, cancer vaccines, harness the power of the body's immune system against the disease.
Radiation therapy, a crucial component of multidisciplinary cancer treatment, is delivered with more precision today than in the past. This is due to multiple technological advances, including the routine use of CT scans, often combined with PET or MRI for treatment planning, and new techniques such as intensity-modulated radiation therapy, image-guided radiation therapy, and stereotactic body radiation therapy. These approaches aim to maximize the dose to the tumor while minimizing exposure to the surrounding normal tissue. "The biggest advance is making our radiation as conformal as possible – that is, directed at a specific area, just enough to treat the tumor," explains Barbara Kalinowski, RN, MSN, nurse manager for Radiation Oncology at Dana-Farber/Brigham and Women's Cancer Center.
Surgery, a mainstay of treatment for solid tumors such as colon cancer and sarcoma, is also less physically taxing than it used to be – as is the anesthesia that accompanies it. Tumors are more likely to be removed when they are smaller, thanks to earlier detection and drugs that shrink them before they're taken out. Perhaps the best-known example of these improvements is in breast cancer, where minimal, tissue-sparing surgery (such as lumpectomies) is now often the approach of choice. Gone is the disfiguring Halstead radical mastectomy, which removed the breast, underlying muscle, and nearby lymph nodes in an attempt to stop the disease from spreading. The procedure was abandoned in the mid-1970s, according to Nathan, after scientists learned that it didn't accomplish its goal and that minimal surgery, combination chemotherapy, and estrogen blockers were much more effective and less disabling.
Not only have treatments improved, so have the tools for diagnosing disease and monitoring the effectiveness of treatments. Dana-Farber, for example, has two PET/CT scanners that can assess tumors' response to some drugs as early as one day after starting treatment. It plans to upgrade its CT machines to include three "64-slice scanners," which can show blood flow within the vessels feeding a tumor, as well as the impact of treatments on these vessels. The addition of a high-field MRI machine will also enable faster, clearer scans and allow staff to chemically analyze and characterize malignant tumors and their response to various therapies.
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