Introduction

There are a number of treatments used to remove, reduce, halt the growth of a cancer or reduce the symptoms that may result from a cancer. The main treatments explored in the following chapters are identified in Figure 8.1.

Fig 8.1 Cancer treatment options

Making a decision regarding which treatment to offer an individual diagnosed with cancer is complex and has changed over the past few hundred years, and especially in the past few decades, as knowledge and skills have developed. There are many holistic considerations to make to ensure that the decision-making process reflects the wishes of patients, as well as giving them the best possible outcome in terms of life expectancy and quality of life. The decision to use a treatment is influenced by the cancer itself, the patient, treatments available and environmental and ethical factors, all of which will be discussed in turn.

Disease-related factors

Over time we have gained a better understanding of how cancer cells develop, how cancer cells behave, why surgery alone does not remove all cancer cells and why cancer recurs. Each type of cancer has been studied in detail and we now have an understanding of the likely progression and outcome of most cancers. For instance, some cancers spread to distant sites very early; others very late; others never spread.

The size and anatomical location of the cancer may dictate the treatment plan. It may be too big to remove surgically or the position of the cancer may make surgery difficult. For instance, if the cancer is too large or is too close to a major or sensitive organ/tissue, the surgeon may not be able to remove it completely.

The type of tissue is important as some tissues are more sensitive to chemotherapy or radiotherapy than others. Therefore, the histology taken from biopsies is crucial.

Ethical-related factors

All patients have the right to make their own decisions regarding treatment and healthcare professionals must respect this autonomy. It is the multidisciplinary team’s role to appraise all the relevant treatment options and the lead medical consultant’s responsibility to present the options and consequences of each option in a balanced and unbiased manner. The patient has the right to information in terms that they can understand, at appropriate times, and the opportunity to ask questions in order to make an informed decision and consent to treatment.

Although most patients wish to receive information regarding treatment options and many want to be involved in the decision-making process in varying degrees, some want to make the decision themselves while other patients would rather the consultant decides for them (the patient may think the consultant has more knowledge/experience). Some patients feel that the responsibility and pressure is too great; others feel overwhelmed by the trauma of a cancer diagnosis to make an objective choice; others want to be involved but view the decision as a joint decision between themselves and the healthcare team. No matter what their involvement in the ultimate decision, patients require tailor-made, accurate information so that they can make a balanced decision and give informed consent. Although the depth and amount may vary depending on the individual, healthcare professionals need to provide information regarding the type and extent of the cancer; what the possible treatment options are; what advantages might be encountered; and what the long-term effects of treatment might be. This information may need repeating several times and patients should be given an opportunity to ask questions. Encouraging patients and family members to write questions down helps them to remember what they want to ask about. Written information is particularly useful for referral at a later date.

All patients have the right to access cancer treatments fairly. However, in the UK, the availability of cancer treatments has not been equal for all patients. Prior to the Calman Hine report (DH 1995) and The NHS Cancer Plan (DH 2000), there was a great deal of regional variation regarding access to cancer treatments, quality of care and healthcare expertise. Each local health authority decided which cancer treatments would be available based on financial budget, immaterial of the effectiveness of drugs or the needs of patients. This resulted in spending variations, known as the ‘postcode lottery’, which may have contributed to higher death rates in some areas (although this was never proven). As a consequence of The NHS Cancer Plan (DH 2000), NICE was set up to review the clinical research trial evidence for each type of cancer and decide which treatments were effective and financially affordable. These two concepts are often in conflict and create ethical debate. Although there has been a reduction in regional inconsistencies and improved national access to research-based and cost-effective treatments, not all treatments are approved by NICE, and those that are approved are still sometimes unavailable and inaccessible by some patients.

Patient-related factors

The patients’ level of education and previous experience in the health service may affect the treatment options as they may be able to comprehend more complex information, may understand the healthcare system and may seek alternative opinions. As well as knowledge, patients’ financial circumstances may allow them access to treatment not available on the NHS.

Patients’ values and beliefs about cancer and treatment may also influence their decisions. These may be based on previous experiences and beliefs. For example, a patient who is a Jehovah’s Witness may refuse a haematological transplant, as this will involve the transfusion of blood products (Holland & Hogg 2001).

Although a patient’s age will not necessarily directly influence the treatment they receive, the older the patient is, the more likely it is that they may have other medical conditions (co-morbidity) such arthritis, diabetes, etc., which may affect the body’s ability to cope with cancer treatment. To measure a patient’s general wellbeing objectively, assessment tools are used such as the Karnofsky scoring system and the World Health Organisation (WHO)/Eastern Cooperative Oncology Group (ECOG) score (Table 8.1, p.82). This is used to determine whether a patient is fit enough to tolerate treatment.

Table 8.1 ECOG performance status (Oken et al 1982)

In addition, an individual’s situation or stage of life may influence their treatment choice. For example, if a patient considers that they have done everything in their life that they wanted to do or if their spouse is already deceased, they may not wish to undergo aggressive treatment. However, this is personal to every individual and healthcare professionals must be careful not to make assumptions. Just because a person may be considered older does not mean they have done everything they wish or do not want aggressive, fully active treatment. Patients’ perception of their current and potential quality of life and projected life expectancy may also sway their decisions. Again, these are difficult to quantify and predict by the most experienced clinician, so must also be gauged carefully. It is therefore essential that a patient is supported to make an informed decision regarding their treatment.

Treatment-related factors

As well as financial resources restricting access to cancer treatment, treatment may be restricted by the experience and knowledge of the treatment team, the available clinical research trial results and the complications and potential mortality rates from treatment. A patient’s previous cancer treatment may affect future treatment options. For instance, if an area of the body has already received radiotherapy then it may not be safe to give more. Similarly, some cytotoxic drugs have a maximum lifetime dose limit (Table 8.2).

Table 8.2 Advantages and disadvantages of cancer treatment options

In order to achieve the best possible outcome, patients often undergo several treatments (multimodality), highlighted in Figure 8.2. In most cases, the idea of this is to remove the primary cancer and treat any potential secondary metastatic spread.

Fig 8.2 Example of multimodality treatment: breast cancer pathway

The sequence of treatments can be done in several ways. Sometimes patients receive either radiotherapy or chemotherapy before undergoing surgery; this is known as neoadjuvant treatment. This approach reduces the size of the cancer, which may allow better surgical margins and/or better long-term functioning and/or better cosmetic appearance. Neoadjuvant treatment is used particularly when cancers are positioned close to other major organs or where there is not a vast amount of tissue to take a clear margin, for example in head and neck cancers.

The most common sequencing of cancer treatment is adjuvant treatment. Surgery is performed initially, followed by chemotherapy and/or radiotherapy and/or biological therapy and/or endocrine therapy. This way, the main primary cancer is removed and then any possible metastatic spread can be treated.

Ideally, the goal of cancer treatment is to remove both the primary and secondary disease. However, if the primary cancer cannot be removed completely then treatment may still be given with the intention to reduce the symptoms a patient might experience and, where possible, to prolong life. This is known as palliative treatment.

Some treatments are experimental. These are known as clinical trials, and they test out new techniques, drugs and combinations to see how treatments can be improved or to find new ones. Patients may be offered a clinical trial at any point in their disease and they may or may not have any benefit from the treatment. There are different types of trials, known as ‘phases’. A phase 1 trial investigates a new treatment to identify a safe dose, what the side effects might be and if the cancer shrinks. These trials involve a small number of patients and are often used once conventional/tried and tested treatments have failed. Phase 3 trials compare existing treatments against new ones to see if the new treatment or a different dose is better than the standard treatment in use. These trials are often randomised controlled trials (RCTs). In an RCT, patients are randomly split into two groups: one gets the conventional treatment, the other the new one. Sometimes patients do not know which group they have been placed in and they receive a placebo – this is known as a blind trial. At other times, neither the patient nor the clinician knows which group the patient is placed in – this is known as a double blind trial.

Although there is little guarantee in terms of treatment success for individual patients on the trial, and it takes many years before the results of a trial are known, some patients may benefit (physically and psychologically) from taking part in the trial. Clinical trials have transformed cancer treatments and symptom management as well as survival rates, and are essential to the future development of treating cancer.

Many patients you meet and care for during your cancer/palliative care placement will be receiving, or will have undergone, one or a number of these treatments. In addition, you may meet individuals with cancer in many healthcare settings who have a suspected or actual cancer diagnosis. For instance, while on an acute medical placement, you may meet patients who are being investigated for lung cancer, and on a surgical placement, you may meet patients being treated for colorectal cancer. Whatever the clinical environment, as a healthcare professional you should be able to explain how cancer treatments work and what patients should expect while on treatment, as well as being able to answer any questions patients or their families might have. This knowledge will also assist you to identify, assess and manage any side effects, ensuring you deliver high-quality, evidence-based care. The following chapters explore the principles of each of the following cancer treatments, identifying the possible side effects and care required: surgery, cytotoxic therapy, haemopoietic stem cell transplant, biological therapy, radiotherapy and endocrine therapy.