How to treat sarcomas: Chemotherapy

How is chemotherapy administered?

They are intravenous compounds administered through droppers. Usually it is not necessary to stay at the hospital. Specialized nursing staff dedicated only to the administration of chemotherapy works at the day hospital.

Although there are other similar oral drugs, the majority are intravenous compounds managed with droppers. Usually it is not necessary to stay at the hospital. The hospitals that provide cancer care have specific facilities for administrating the chemotherapy called day hospitals. In general terms, the procedure usually runs in the following way; the patient goes early to the hospital to take a blood test. The oncologist needs to know the levels of red and white blood cells and platelets to adjust the dose of the treatment, so there is no choice but to wait for the results. Meanwhile, the specialist visits the patient so that he can tell him his complaints to get an overview of the course taken by the disease, ask for the necessary diagnostic tests and establish the following appointments.

Once the blood test results have arrived and the oncologist has seen the patient in his office, the patient goes to the day hospital, where the specialist indicates the pharmaceutical composition and exact dose of chemotherapy he wants to apply. Nowadays, this is typically done using a type of software equipped with safety mechanisms to prevent prescribing inadequate doses or incompatible combinations by mistake. A specialized nursing staff dedicated only to the administration of chemotherapy works in day hospitals. A thin plastic catheter is placed in a vein in the back of the hand or the arm (only some patients use specific catheters permanently implanted) and starts dropping the treatment. Generally, before the chemotherapy itself, other drugs are applied to prevent the occurrence of adverse effects, such as nauseas or allergic reactions. Some chemotherapy schemes are dispensed in a few minutes while others may require several hours. The chemo is given while the patient sits in an anatomical armchair, which are similar to the ones used in halls of blood donation. When the dropper is empty, the patient can go home.

Chemotherapy is never provided in a single administration, but in cycles. A chemotherapy cycle comprises the day or the days of Administration (may be two or three), followed by a rest period. This varies between one and four weeks, according to the scheme and requirements of each patient. At the end of the rest period, the procedure starts again, coming back to the oncologist office to receive the next cycle. It depends on each case, but a typical and complete treatment of chemotherapy takes around six months.

It is true that chemotherapy drags a very bad reputation since its first steps, back to the forties of the last century. This black legend is only partially true. No one should deny that we are talking about some toxic drugs. It has nothing to do to be treated with chemotherapy with taking drugs for high blood pressure or diabetes. On the other hand, this field of medicine has developed a lot in these 70 years of history. The drugs we use today are much less toxic than in the past, and we have very effective means to prevent and combat many of those adverse effects.

What are chemotherapy adverse effects?

Anyone receiving chemotherapy visits the oncologist regularly and takes periodic blood tests so that the coming problems are easy to foresee and that it is possible to solve them with simple measures.

The chemotherapy is a family that includes dozens of very different medications. What almost all of them have in common is that they are toxic to the cells dividing rapidly, since this is the key feature of cancer cells. Now, there is also normal tissue composed of cells in constant division. Most of the chemotherapy’s toxicity is due to its effect on those tissues.

The loss of hair (alopecia) is the first image that comes to your mind when you think of chemotherapy. It is obvious that the hair grows, and this is due to the cells in continuous division located in the hair roots. The interruption of that growth at the root is the reason why chemotherapy makes the hair fall. In this issue, we must admit that we have come short. Chemotherapy patients still suffer from alopecia, without any practical way to prevent it. The hair loss often happens between two and four weeks after the first dose of chemotherapy and it is a delicate moment for mood. Alopecia caused by chemotherapy is reversible and hair grows again. One or two months after the last administration, the head will already be completely covered by sparse hair. Some chemotherapy will not make it fall.

After the hair loss, nausea and vomiting are the most characteristic of chemo’s undesirable effect. In this case we have improved a lot. For starters, as it happens with alopecia; some chemotherapeutic agents that can provoke a lot of vomiting (but only if no remedy is put!), others totally lack that problem. Vomiting of chemotherapy may be due to the effect on the mucous membrane of the stomach, which is also composed of dividing cells. However, the main cause is the direct stimulation of a couple of areas of the brain that serve, precisely, to coordinate the vomiting. There are various drugs that act directly on these nerve centers. Thanks to them, a lot of people treated with chemotherapy already do not vomit at all or rarely do it. Moreover, patients can do several things to avoid the nauseas. 

The blood cells are the red blood cells (erythrocytes or RBCs), white blood cells (leukocytes) and platelets. Red blood cells are used to transport oxygen from the lungs to the tissues. White blood cells defend us from infections and platelets deal with the blood clotting and bleeding control. All those cells erode and die while performing their functions, so it is necessary to replace them continuously. The marrow, which is what doctors call the bone marrow is the place where all those cells are manufactured. This factory is very sensitive to chemotherapy, so the blood can impoverish from any of these cells because of the treatment. That's why a blood test must be performed before each cycle. What the oncologist aims to is to ensure that all blood cells are in a suitable shape to withstand the impact of a new round of chemotherapy. If any of them is too low, they will wait a week or two for it to recover, or the oncologist will prescribe a subcutaneous injection treatment. We have the drugs necessary to quickly recover blood cells, or stop them from decreasing too much.

The list of the adverse effects of chemotherapy is much longer. It could also affect the functioning of the kidneys or the heart, or cause allergic reactions. All of this is extremely uncommon, predictable (except for the allergies) and reversible. Anyone receiving chemotherapy will visit the oncologist regularly and take periodic blood tests, so that the coming problems are easy solve with simple measures. There will always be exceptional cases suffering from very serious complications from chemotherapy, but that can also be said of antibiotics, anesthesia, or aspirin.

The most important thing. What is chemotherapy for?

Preoperative or neoadjuvant chemotherapy: chemotherapy can be used to reduce the volume of the disease, so as to enable a proper surgery.

Chemotherapy can be applied with different goals. It does not need the patient to know the exact composition of the scheme that is being administered to him, but he should have a very clear idea about what the treatment aims for in your particular case.

Sometimes, a sarcoma may be too large to operate directly, or it could be so close to vital organs that it would be very difficult to operate on it with the appropriate margins. Then, you can use chemotherapy to reduce the volume of the disease so as to enable a proper surgery. This modality is usually called neo-adjuvant or preoperative chemotherapy.

Adjuvant chemotherapy: the chemotherapy is administered after the surgery.

When the chemotherapy is administered after the surgery, it is called adjuvant chemotherapy, which is a very different approach from the previous case. Unfortunately, sometimes a patient is intervened for a Sarcoma with all the guarantees, but over time, metastases or ramifications appear in distant organs. The place that is most frequently affected by sarcomas are the lungs, but it can also be the skeleton, liver or brain, among others. This happens because these metastases already existed when the sarcoma was intervened, but they had a microscopic and undetectable size. The micro metastasis can remain hidden for months or years. Adjuvant chemotherapy consists in destroying them before they develop, thus, avoiding a relapse. Adjuvant chemotherapy acts as a vaccine. Therefore, it is impossible to refine its efficacy in specific patients. If a patient is operated on a sarcoma, receives adjuvant chemotherapy and never relapses, we will never know if the cure was due to chemotherapy or, anyway he didn't have micro metastases and was going to heal anyway. The effectiveness of the adjuvant treatments can only be found out by clinical trials, gathering statistics of hundreds of patients and their evolution over the years.

Adjuvant chemotherapy is very well established against malignant tumors such as breast or intestine. In the world of sarcomas, things are not so clear because chemotherapy is not that effective, or because due to the rarity of the disease, it is difficult to conduct clinical trials with sufficient number of subjects to get reliable statistics. However, the efficacy of adjuvant chemotherapy is beyond doubt in some types of sarcomas. Osteosarcomas, rhabdomyosarcomas and Ewing Sarcoma must necessarily receive chemotherapy plus surgery if they want to reach the best expectations of being cured. In other varieties of sarcoma, the particular characteristics of the patient and disease should be taken into account. Many sarcomas do not require adjuvant chemotherapy, because the odds of a cure with surgery are very high or because the preventive efficacy of the treatment is very dubious.

Curative chemotherapy: when the disease has spread, chemotherapy constitutes the main form of treatment.

When there are already metastases, i.e., when the disease has spread, chemotherapy constitutes the main form of treatment. Some cancers can be cured with chemotherapy, although the disease has spread much, one speaks then of curative chemotherapy. Unfortunately, this situation occurs very rarely in the case of sarcomas, almost always in children and teenagers and in very specific types of sarcoma, as of the bone, rhabdomyosarcomas and Ewing Sarcoma. 

Most of the metastatic cases of sarcoma are incurable. Then, the chemotherapy’s aim is palliative, because it is used to relieve symptoms, delay or avoid appearance of those who are not yet present, and to extend the life without diminishing its quality, if possible. Palliative chemotherapy moves in a delicate balance between the efficiency expected of it and its adverse effects. It must not fall into the error of administering chemotherapy after another, without stopping to reflect on their true effectiveness, and only so that the doctor, family and the own patient have the feeling to be doing something. This attitude always affects the patient. Palliative chemotherapy administered with common sense can be very useful, but should never lose sight of what it is trying to get and at what price. In the interest of sarcoma patients, there is also to know how to judge when it comes the time to abandon chemotherapy and comply with ameliorating the symptoms with simple medications.

What drugs are used to treat sarcomas?

There are various chemotherapeutic agents used for the treatment of sarcomas. The most common are the Adriamycin or doxorubicin, ifosfamide and trabectedin. Others are docetaxel, the Dacarbazine or DTIC, Gemcitabine, cisplatin, the CPT11 or irinotecan, methotrexate, vincristine... Research through clinical trials is getting more drugs into the hands of oncologists. It is okay that the patient and their families are interested and informed about the treatments they receive. However, the exact composition of chemotherapy schemes is something so specific that even most of the physicians who are oncologists do not know more about it than people without any medical training. Probably, it is way more interesting for the patient to know the names and doses of the medicines, the intention with which the doctor recommends chemotherapy, and the way and time expected to evaluate whether the treatment meets or not the planned expectations.