Cancer Treatment

Depending on your diagnosis, many treatment options are available that may be used alone or in combination. Not every cancer responds the same way to every treatment, so you and your doctor will work together to determine the best treatment based on a variety of factors, such as your specific type of cancer, tumor characteristics, treatment history and general health.

Your primary treatment is the definitive treatment designed to eliminate the disease. It is sometimes referred to as “standard of care.” In some cases, your treatment plan also may include neoadjuvant or adjuvant therapy. Neoadjuvant therapy is given before primary treatment to help shrink a tumor, often in an effort to make it easier to remove surgically. Adjuvant therapy is given after primary treatment to destroy any cancer cells that may remain and that may be too small for laboratory testing or imaging studies to detect. This follow-up treatment decreases the risk of your cancer recurring (coming back).

Recently, researchers have noticed certain differences in tumors, even when they begin in the same site in the body. This understanding has led to an increased focus on personalized medicine, which uses information about a person’s genes, as well as the behavior of certain proteins, to prevent, diagnose and treat disease.

Personalized medicine includes the use of highly targeted therapies, drugs and other substances (such as biologics) that block the growth and spread of cancer. They do this by interfering with specific molecules — as well as critical communication pathways within and between cells — involved in tumor growth. Specific types of therapy can be based on the detection of tumor biomarkers (substances made by certain cells) expressed in a patient’s own cancer. This is a major advancement in cancer management because it means a targeted therapy is more likely to be effective when given to a person who has specific biomarkers of the cancer. This approach benefits people who don’t have those biomarkers because they are not given treatments that are less likely to work.

Research through clinical trials continues to advance existing strategies and make newer treatment drugs and methods available.

Surgery

The primary treatment for most people with a solid tumor is surgery. Removing a tumor using a surgical procedure typically offers the best chance for cure, especially if cancer cells have not spread beyond the original site to other parts of the body. Surgery also may help your doctor stage the cancer as well as relieve or prevent symptoms that might otherwise occur later. Many advances in the types of surgical techniques used to remove tumors, including minimally invasive approaches such as laparoscopy and robotic surgery, are contributing to the likelihood of a shorter recovery time with fewer side effects.

Chemotherapy

Chemotherapy is a type of systemic therapy (one that travels throughout the body) that uses powerful drugs to kill rapidly multiplying cells. It may be given intravenously through a small tube inserted into a vein, or taken orally as a pill. A chemotherapy regimen is typically delivered in cycles, with treatment periods followed by rest periods to give your body time to recover. Treatment may consist of a single chemotherapy drug or a combination, given simultaneously or one after another. Chemotherapy may be used alone or combined with other forms of treatment.

Targeted therapy

Targeted therapy blocks the growth and progression of cancer by interfering with specific molecules involved in tumor growth and progression. The targeted therapy agents block or modify the molecules on or inside cancer cells that alter signaling pathways, which are complex systems that direct basic cell functions such as cell division and death.

Targeted therapy is used for a wide variety of cancer types, including breast, lung, colon and kidney cancers, as well as certain types of leukemia. Many targeted therapy drugs are oral medications and are usually given in combination with conventional chemotherapy.

Most targeted therapy drugs are either small-molecule drugs or monoclonal antibodies. Both types are made in a laboratory and are designed to locate and bind to specific substances inside or on the cancer cells. Small-molecule drugs can pass through the cell membrane and act on a target inside the cell. Many small-molecule drugs are tyrosine kinase inhibitors (TKIs), which act against specific pathways involved in tumor growth.

Some monoclonal antibodies target proteins involved in developing blood vessels within a tumor. Targeting these proteins blocks the growth of new blood vessels, thereby cutting off the blood supply to the tumor. Without a blood supply, the tumor cannot grow. The formation of new blood vessels is known as angiogenesis, and these drugs are known as antiangiogenic agents.

Hormone therapy

Hormones that occur naturally drive the growth of some cancers. For example, estrogen fuels the growth of some breast cancers, and testosterone aids in the growth of prostate cancer. Hormone therapy acts to block the stimulating effect of hormones, thereby slowing or stopping the growth of cancer.

Hormone therapy for breast cancer, also known as endocrine therapy, includes tamoxifen and aromatase inhibitors, such as anastrozole (Arimidex), exemestane (Aromasin) and letrozole (Femara). These drugs are called antiestrogen agents because they inhibit the production of estrogen or interfere with its action.

Hormone therapy for prostate cancer involves either surgery or drugs and is often called androgen-deprivation therapy. Surgical removal of the testicles eliminates the source of about 90 percent of testosterone. Alternatively, several drugs are available to interfere with the production of testosterone.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow the growth of and kill cancer cells. To do so, the immune system uses substances made either by the body or in a laboratory to find and destroy cancer cells, much like it fights off foreign bacteria (see figure below). Immunotherapy typically involves destroying only specific cancer cells, which may result in fewer side effects.

Immunotherapy is effective for some people but not for others, even when they have the same cancer. Doctors and scientists continue to study this unusual characteristic, along with how to improve existing therapies and develop new ones, through clinical trials. If immunotherapy is not an option for you, your doctor will recommend one or more of the approved treatments considered “standard of care.”

Immunotherapy engages the immune system using these different types of treatment:

  • Monoclonal antibodies may be combined with other therapeutic agents, such as chemotherapy or radiation therapy, and work by delivering potent anticancer treatments directly to specific cancer cells. Several monoclonal antibodies have been approved to treat many different cancer types.
  • Immune checkpoint inhibitors (a type of monoclonal antibody) prevent the immune system response from shutting down, which results in a stronger, longer-lasting fight against the cancer. Currently, ipilimumab (Yervoy) is approved to treat certain types of melanoma; nivolumab (Opdivo) is approved to treat unresectable or metastatic melanoma, metastatic squamous non-small cell lung cancer, advanced renal cell carcinoma and classic Hodgkin lymphoma; pembrolizumab (Keytruda) is approved to treat unresectable or metastatic melanoma, metastatic non-small cell lung cancers and head and neck squamous cell carcinoma; and atezolizumab (Tecentriq) is approved to treat advanced urothelial carcinoma (a type of bladder cancer) and metastatic non-small cell lung cancer.
  • Oncolytic virus immunotherapy involves injecting an oncolytic virus (a virus that infects and kills cancer cells) directly into a tumor. Talimogene laherparepvec (Imlygic) is the first FDA-approved oncolytic virus immunotherapy, and it's used to treat advanced melanoma.
  • Cancer vaccinations work by targeting a specific protein on the surface of a cell and then attacking all of the cells that have that protein. Sipuleucel-T (Provenge) is FDA-approved to treat certain prostate cancers and targets a protein expressed by most prostate cancer cells.
  • Cytokines function as messengers between immune cells, and cytokine immunotherapy involves laboratory-made versions introduced to the immune system to promote certain responses. Interleukin-2 (Proleukin) and interferon alfa (Intron A) are two types of cytokine immunotherapy that have been approved for treating metastatic melanoma, metastatic kidney cancer, hairy cell leukemia and follicular lymphoma.

Radiation therapy

Radiation therapy is the use of high-energy X-rays or proton beams to destroy or damage cancer cells. These treatments are given either externally with radiation machines, or internally with radioactive material that is swallowed, injected or implanted in the body.

External-beam radiation therapy (EBRT) is the most common type and is used for a wide variety of cancers. This type of treatment is similar to a conventional X-ray, except the radiation beams are strong enough to kill cancer cells. Developments in EBRT and newer delivery techniques, such as proton-beam therapy, enable doctors to more precisely target radiation at the tumor, causing less damage to healthy tissue. For example, protons are atomic particles that are easier to control than X-rays, enabling this therapy to be delivered to a much more precise location and more accurately account for the size of the tumor during treatment. Proton-beam therapy is ideal for treating oddly-shaped tumors or tumors located in vital areas, such as the brain.

Internal types of radiation therapy include brachytherapy. During brachytherapy, radiation is delivered through radioactive seeds implanted in or near a tumor, or in the area from which a tumor was removed. The radioactive seeds may be placed either temporarily or permanently. Temporary radioactive seeds are implanted and removed using a catheter inserted into the part of the body with the tumor. Permanent seeds are inserted into tissues and will stop giving off radiation after a few weeks or months. Brachytherapy is done most often for prostate, head and neck, gynecologic and lung cancers, and for some early-stage breast cancers.

Radiopharmaceuticals are another type of internal radiation therapy. These substances, which can be swallowed or injected, include a radioactive component, such as radioactive iodine, that destroys cancer cells. Radiopharmaceuticals are used most often for bone and thyroid cancers as well as lymphomas.

A new form of radiation therapy, selective internal radiation therapy (SIRT), also called radioembolization, is a type of internal radiation therapy for inoperable liver tumors. SIRT, which can be used alone or with chemotherapy, is used to treat tumors and as palliative care to relieve symptoms.

Stem cell transplantation

Stem cell transplantation helps the body produce new blood cells. Stem cells are found in the bone marrow, and they have a special feature that enables them to develop into any one of the three types of blood cells. There are two types of stem cell transplantation: autologous and allogeneic.

In an autologous stem cell transplantation, a person’s own stem cells are removed and preserved so that high doses of chemotherapy and/or radiation therapy can be given to attack cancer cells without destroying the stem cells. After the intensive therapy, the person’s stem cells are infused back into the body. Allogeneic stem cell transplantation establishes a new immune system for the recipient with stem cells obtained from a donor with healthy bone marrow whose stem cells are a close match. Stem cell transplantation and high-dose chemotherapy and/or radiation therapy are used most often for leukemias, lymphomas, multiple myeloma, germ cell tumors and pediatric tumors.

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