Is chemo needed for all cancers?

Chemotherapy – with its body-wide side effects – no longer stands as the standard treatment for some cancer patients.

The rise of targeted therapy, hormone therapy and immunotherapy are reducing reliance on chemotherapy for patients with some cancers, especially those of the breast and lung, and melanoma, said Edward J. Wyluda, DO, hematologist and medical oncologist at Cape Cod Hospital’s Davenport-Mugar Cancer Center in Hyannis. Sometimes these treatments are used with chemotherapy, or in place of it, in addition to surgery and radiation.

These therapies are “more tolerable, have less toxicity and fewer side effects” than chemotherapy, or “chemo,” he said.

The majority of patients getting these treatments have advanced cancer that has spread, or metastasized, to other parts of their body, and aren’t likely to be cured. In some cases, these less harsh treatments may be more effective than chemo and extend lifespan. Alternatives to chemotherapy can be a boon to older patients, who are more likely to be frail or have multiple health conditions, Dr. Wyluda said.

“We’re finding therapies that can be more tolerated, provide a better quality of life,” he said.

Types of Cancer Therapies

Standard chemotherapy doesn’t attack just cancer cells, but kills rapidly growing cells throughout your body, according to the American Society of Clinical Oncology (ASCO). This can lead to hair loss, pain, fatigue, decreased blood cells, sores in your mouth and throat, nausea, vomiting and diarrhea, as well as nerve, muscle, heart and fertility problems. Some types may cause long-term or permanent damage. Anti-nausea drugs and steroids can help counter some of the ill effects, Dr. Wyluda said.

Targeted therapy focuses on cancer cells. It may seek out specific proteins or mutations in cancer cells, inhibit growth of blood vessels that feed tumors, interfere with chemical signals needed for cancer cell growth and division, or transport chemicals to kill only cancer cells, according to the American Cancer Society. Side effects may include skin rashes or photosensitivity, hand-foot syndrome, changes in your hair, sores around your nails and irritated and swollen eyes.

Immunotherapy employs your body’s immune system to attack cancer. Some types may be considered targeted therapy, including monoclonal antibodies that block specific proteins or genes in cancer cells or allow your immune system to attack cancer cells, according to ASCO. Some are non-specific or systemic, such as interferons and interleukins, which promote your immune system to respond to cancer.

Other forms of immunotherapy include:

• T-cell therapy, in which immune cells are removed from your blood, treated to detect cancer cells and injected back into you to destroy cancer cells.
• Oncolytic virus therapy, which uses a genetically altered virus injected into a tumor to kill it.
• Cancer vaccines, which teach your immune system to recognize and attack cancer cells.

Side effects of immunotherapy can include skin problems, fatigue, muscle aches, diarrhea, fluid retention and hormonal changes.

Hormone or endocrine therapy may be used for breast, prostate, endometrial and other hormone-sensitive cancers to shrink tumors, lessen symptoms and reduce the risk of cancer recurring, according to the National Cancer Institute. These drugs hinder your body’s production of a hormone or block a hormone’s actions in your body. In some breast cancer patients, Dr. Wyluda said he has seen a 40-50 percent reduction of the chance of recurrence with hormone therapy. Most of his patients have breast cancer.

Hormone therapy helps breast cancer patients whose cancers have receptors for estrogen or progesterone. That’s about two-thirds of breast cancer cases, according to the American Cancer Society. For these women, estrogen fuels tumor growth. Therapy often starts after tumor removal surgery to reduce the risk of recurrence but may start before.

There are several forms of hormone therapy for breast cancer, and some are restricted only to women who have gone through menopause. Some can cause side effects, such as bone thinning, muscle or bone pain, hot flashes and night sweats, or rare increased risks of blood clots, stroke and uterine cancer. Side effects vary with the type of drug used.

Many women with early stage breast cancer that has not spread to lymph nodes may not need chemo at all after surgery, only hormone therapy, according to the American Cancer Society, citing a 2018 federally-funded study.

Advances in Testing and Treatment

As health experts learn more about genetic mutations that cause some cancers and the biochemical characteristics of tumors, more tests have been developed to determine how best to treat an individual’s cancer.

“For advanced lung cancer, we can run certain tests right after surgery is performed,” Dr. Wyluda said.

Samples of tumor tissue, called biopsies, can be analyzed by a pathologist for cancer type, cell and tissue structure, degree of abnormality and likelihood of growing and spreading. Blood samples can also be used, as “a tumor basically sheds,” he continued.

“We’re able to do genetic testing here and get answers here,” Dr. Wyluda said. Testing and treatment “can be done locally and not have to go to Boston.”

Genetic tests that can’t be performed locally can be sent off for analysis. Cape Cod Healthcare’s membership in Dana-Farber Cancer Care Collaborative increases the available expertise, including tumor board reviews of cases and patient visits by Dana-Farber oncologists, Dr. Wyluda said.

One test used to decide whether immunotherapy may be useful checks tumor expression of PD-L1, Dr. Wyluda said. Some cancer cells possess large amount of this protein, which limits the immune system’s reaction to them – protecting them from attack. Monoclonal antibodies can stop this protection by targeting either PD-LI or PD-1, the checkpoint protein on immune system T cells that binds to PD-L1, according to the American Cancer Society.

“Immunotherapy is becoming more widespread, in terms of certain kinds of medications,” he said.

In addition to lung and breast cancer, it’s also being used to treat melanoma and some instances of esophageal cancer, Dr. Wyluda said.

Use of targeted therapy also is expanding with greater understanding of cancer.

“I think it’s going to continue to expand further,” he said, ticking off cancers where it’s being applied: “Breast, ovarian, kidney – to name a few. It’s pretty prominent in all solid tumors.”

Fear of ill effects may make patients anxious about any type of cancer treatment, Dr. Wyluda said, but “once they get started, that fear of the unknown” fades. He said he tells patients he’ll take a gradual approach, adjusting dosage if necessary.

“We’re going to give it some time,” he said.” Give it a couple of months, repeat imaging, get an idea of where it’s going.”