The Ferocity of Chemotherapy: Does The End Justify The Means?
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Nov 13, 2020.
Empower Yourself: Learn About Cancer
Cancer. It's one of the most dreaded words in the English language. You might shy away from learning about health conditions that scare you, like cancer.
But knowledge of cancer and its treatments will empower you to help prevent its occurrence, understand your options and maybe even save your life.
Here are 5 of the top cancers that occur in the U.S. You probably know a person who has been affected by at least one.
Cancer is Complicated, So You Need a Helping Hand
Cancer is a large group of diseases with many differences, but they all have one thing in common: abnormal cells growing out of control.
As the cells multiply unchecked, they create a malignant tumor, more commonly called cancer. Tumors aren't always solid - they can be in the blood, too.
There are multiple types of cancer medications: either chemotherapy, targeted drug treatments or immunotherapy.
- Some cancers, if caught early, are easy to treat, while others may require any combination of radiation, surgery, or drug treatment.
- Finding a knowledgeable and compassionate cancer healthcare team is important. Doctors who treat cancer are called oncologists.
- Rely on your family and friends for support, too.
Is Cancer Always Due to Genetics?
When something alters the cell DNA, cancer cells can begin to grow. A genetic predisposition for cancer is one of the most common risk factors for developing cancer. For example, if your mother had breast cancer, your chances of developing it may be higher, and in some cases, (i.e., with BRCA mutations), significantly higher.
Other non-genetic cancer risk factors include:
- Estrogen exposure in women
- Too much ionizing radiation, like x-rays or nuclear
- Too much ultraviolet radiation, like UVB rays from the sun
- Cancer causing chemicals, like asbestos or benzene
- Tobacco smoke, heavy use of alcohol
What is Chemotherapy?
Chemotherapy (often just called 'chemo') is the use of anti-cancer drugs which kill rapidly-dividing cells in different ways -- for example, by damaging DNA, halting cell division, or blocking cell metabolism.
Chemotherapy can be given:
- intravenously into a vein
- by mouth
- by injection into a muscle
- applied to the skin
- in other ways.
Many types of chemotherapy can be given at home or in an outpatient setting by a nurse.
Chemotherapy is usually given in cycles according to a protocol. One or several chemo drugs may be given over a period of time, (daily, weekly or monthly) with rest periods between treatment when no medicine is received.
Is Chemotherapy Always Needed to Treat Cancer?
There are many different options for cancer treatment, and your doctor will have the knowledge to direct you to your best choices.
Many cancers are treatable and patients go on to live cancer-free for the rest of their lives. Your decision to have chemotherapy or other treatments should be based on sound knowledge of your cancer, the cancer stage at your diagnosis (in other words, how far it has advanced), the recommended therapy and side effects, and your prognosis - with or without chemotherapy.
Chemotherapy Has a Bad Rap. Are the Side Effects Controllable?
Chemotherapy works by destroying cancer cells, but many treatments affect the healthy cells, too.
Side effects of chemotherapy are usually due to the drugs effect on the healthy cells.
You have probably heard about many of these side effects:
- hair loss
- nausea and vomiting
- increased risk of infections
However, years of research have allowed health care professionals to know how to help you cope with the side effects of chemotherapy. Plus, there are treatments your doctor can use to reduce many of the side effects.
Does Everyone Lose Their Hair With Chemotherapy?
Hair loss is one of the most dreaded aspects of chemotherapy, even though other side effects may be more severe from a biological aspect. Hair loss can affect self-confidence, lower mood, and cause stress and embarrassment for many.
- There is some good news - not all cancer drugs lead to hair loss.
- For those that do, it may range from thinning to complete baldness and may not affect all areas of the body with hair.
- The other good news, hair loss due to chemo is not permanent.
- Hair usually begins to grow back 2 to 3 weeks after the last treatment.
- Many patients prefer to cut their hair short before treatment begins to lessen the psychological impact of hair loss.
As reported by the FDA "cooling caps" helped 66% of patients with solid tumors and undergoing chemotherapy to minimize hair loss.
- Cooling the scalp constricts blood vessels and reduces the amount of chemotherapy that reaches cells in the hair follicles. Patients put on a tight scalp cooling cap for a half hour before chemotherapy, and leave it on for up to 120 minutes after treatment.
- However, the devices are expensive. Discuss this with your physician, as long-term effects are not known yet, and your insurance may not pay for it.
How Can You Avoid Chemotherapy-Induced Nausea and Vomiting?
Chemotherapy results in the release of chemicals such as serotonin (5-HT3) in the intestine which can lead to nausea and vomiting.
- Chemotherapy-induced nausea and vomiting (CINV) can occur quickly, within the first 24 hours of chemotherapy, or it can be delayed (after 24 hours).
- The goal is to prevent chemo-induced nausea and vomiting before it starts, or to minimize it as best as possible.
- You might also have anticipatory nausea and vomiting even before your treatments start. This occurs because of previous events of nausea and vomiting after your chemo treatment. Your brain "anticipates" the nausea and vomiting, and it can happen while preparing for your next treatment, during treatment, or after chemo. This is one reason why it's important to prevent it from the start.
Considering joining the Chemotherapy-Induced Nausea and Vomiting Support Group to keep up with the latest approvals, news, and group chats.
5-HT3 (serotonin or 5-hydroxytryptamine) Inhibitors
The 5-HT3 inhibitors are a common drug class used for patients to prevent CINV. They are also used for other types of nausea and vomiting, such as with surgery or radiation.
5-HT3 inhibitors work by preventing the binding of serotonin to the 5-HT3 receptor in the small intestine and/or the brain to reduce the occurrence of nausea and vomiting due to chemotherapy. Depending on the drug and use they can be used in adults or children, and can be given by mouth, injection, or via a transdermal patch worn on the skin.
5-HT3 inhibitors include:
Neurokinin-1 (NK1) receptor antagonists
Neurokinin-1 (NK1) receptor antagonists are also used to help prevent immediate or delayed nausea and vomiting due to chemotherapy. Some are used to prevent nausea and vomiting that may be caused by surgery in adults, too. How do they work?
- NK1 receptors are found in the gastrointestinal tract and in areas of the brain that govern the vomiting reflex.
- The NK1 receptor antagonist binds to the NK1 receptor and blocks the binding of substance P.
- Blocking substance P (a neuropepetide) prevents the emetic (vomiting) signal from being transmitted.
- NK1 receptor antagonists can be used in combination with 5-HT3-receptor antagonists and corticosteroids (like dexamethasone) to enhance their effect.
These medications can be given either by mouth or by intravenous (IV) injection. They are used with dexamethasone to help boost the anti-nausea and anti-vomiting effect. They may also be used with a 5HT3 antagonist such as ondansetron (Zofran).
Common examples of NK1 antagonists include:
Safety of 5-HT3 and NK1 Inhibitors
In general, the 5-HT3 inhibitors are well tolerated and have less side effects than older medicines given for nausea and vomiting, like promethazine (Phenergan). Tell your doctor if you've had an allergic reaction to any 5-HT3 inhibitor drug in the past. You can view sides effects for any specific drug you take here.
The most common side effects with 5-HT3 inhibitors, using ondansetron (Zofran) as an example, might include:
- fast heartbeat
- shortness of breath
With 5-HT3 inhibitors, you may have an increased risk for a very rare side effect called serotonin syndrome, so be sure to have a drug interaction review with a healthcare provider for any drugs you combine with medication for nausea and vomiting.
The NK1 inhibitors common reactions, using aprepitant (Emend) as an example, may include:
- stomach pain, heartburn, loss of appetite
- diarrhea or constipation
- abnormal liver enzyme tests
Other Chemo Side Effects: An Increased Risk for Infections
Avoiding infections while you are receiving strong chemotherapy is important because infections can interrupt the cancer treatment cycle.
Chemotherapy can cause neutropenia, an abnormally low level of a white blood cell called neutrophils, which increases a patient’s risk of infection.
Neutropenia can be prevented through the use of white blood cell boosters such as:
- pegfilgrastim (Fulphila, Neulasta, Neulasta Onpro, Nyvepria, Udenyca, Ziextenzo)
- filgrastim (Neupogen, Nivestym, Zarxio)
- tbo-filgrastim (Granix)
- sargramostim (Leukine).
These drugs stimulate the stem cells in the bone marrow to produce more white blood cells that migrate to the blood to help fight infections. These drugs are classified as colony stimulating factors.
Biosimilars are now approved for several colony stimulating factors.
Combat Low Blood Oxygen From Chemotherapy
Anemia is a common problem encountered by cancer patients, either due to chemotherapy or the cancer itself.
Anemia, defined as a low level of red blood cells, reduces the amount of oxygen that can be carried to the body. As a result, symptoms of anemia include:
- trouble breathing
- chest pain
- pale skin.
Correction of anemia is important to improve overall health and to allow chemotherapy to continue on schedule. Anemia can be treated with:
The agents are usually used in conjunction with supplemental iron. Blood transfusions may be an option, too.
What is the Future of Chemotherapy?
Many cancer therapies are now ‘targeted’ treatments -- immuno-oncology therapies that interfere with specific cancer-causing molecular targets that promote cancer growth.
Although researchers expect targeted therapies to be easier to tolerate than traditional chemotherapies, there are still significant side effects, like diarrhea, skin problems and liver toxicity. In contrast, traditional chemotherapy acts against all cells that are growing and dividing - normal cells and cancerous cells.
Immunotherapies are one example of next-generation cancer treatments. Options such as Keytruda (pembrolizumab) and Opdivo (nivolumab) have already been FDA-approved and are used to treat many types cancers, including those that previously had poor options, like melanoma (skin cancer) and lung cancer.
Targeted therapies are known as personalized medicines or precision medicine, as they work in conjunction with a person’s individual genetics to target cancer. Examples include lenvatinib (Lenvima) and axitinib (Inlyta) that are classified as VEGF/VEGFR inhibitors.
Which Cancers Do Targeted Therapies Treat?
There have been many FDA-approvals for targeted and immunotherapy therapies, most drugs treat many different types of cancer, and many may be used in combination.
Targeted therapies + immunotherapy combinations are extending survival, too, as seen in studies combining Keytruda with Inlyta for renal cell carcinoma (kidney cancer).
These drugs are used across many different types of cancer, not just for one specific type. Examples of cancers that many of these drugs can treat include: melanoma (skin cancer), leukemia and lymphoma (blood cancers), brain cancer, colorectal cancer, endometrial cancer, liver cancer, kidney cancer, head and neck cancer, rectal cancer, bladder cancer, thyroid cancer, stomach cancer, cancer of the cervix, ovary or fallopian tube cancer, and lung cancer.
You've no doubt heard of at least a few of these drugs. FDA immuno-oncology approvals include:
- Avastin (bevacizumab)
- Mvasi (bevacizumab-awwb)
- Yervoy (ipilimumab)
- Opdivo (nivolumab)
- Gleevec (imatinib)
- Nexavar (sorafenib)
- Keytruda (pembrolizumab)
- Tecentriq (atezolizumab)
- Libtayo (cemiplimab-rwlc)
- Bavencio (avelumab)
- Imfinzi (durvalumab)
And the list will go on. If you are diagnosed with cancer, talk to your doctor about these therapies to weigh the risks and benefits of your options.
Finished: The Ferocity of Chemotherapy - Does The End Justify The Means?
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- FDA Approves Cinvanti (aprepitant) Injectable Emulsion for the Prevention of Acute and Delayed Chemotherapy-Induced Nausea and Vomiting (CINV). Drugs.com. Accessed November 13, 2020 at https://www.drugs.com/newdrugs/fda-approves-cinvanti-aprepitant-injectable-emulsion-prevention-acute-delayed-chemotherapy-induced-4630.html
- FDA clears expanded use of cooling cap to reduce hair loss during chemotherapy. US Food and Drug Administration (FDA). Accessed Nov. 13, 2020 at https://www.fda.gov/news-events/press-announcements/fda-clears-expanded-use-cooling-cap-reduce-hair-loss-during-chemotherapy
- Side Effects of Cancer Treatment. NIH. National Cancer Institute. Accessed Nov. 13, 2020 at https://www.cancer.gov/about-cancer/treatment/side-effects
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- Anemia. Drugs.com. Accessed Nov. 13, 2020 at https://www.drugs.com/mcd/anemia
- National Cancer Institute. Breast Cancer. Accessed Nov. 13, 2020 at https://www.cancer.gov/types/breast