adjuvant chemotherapy

Chemotherapy Learn what to expect, and what can be done to improve the experience.

(medicine) Chemotherapy that is used to destroy suspected undetectable residual tumor after surgery or radiation treatment has eradicated all detectable tumor; effective in the treatment of breast and colon cancer.

Definition

Adjuvant chemotherapy is cancer treatment that is administered after the primary therapy. For example, when the primary therapy to treat a cancerous tumor is surgery, chemotherapy would be an adjuvant therapy.

Purpose

Even if there is no clear sign that the cancer has spread, adjuvant chemotherapy is administered to prevent the chance of a recurrence by killing any cancer cells that may have spread. The rationale behind adjuvant chemotherapy is that the chemotherapy drugs are more effective when they are given immediately after the tumor has been removed and any remaining cancer is in small amounts.

For some cancers, especially breast and colorectal cancers, adjuvant chemotherapy has been shown to decrease the chance the cancer will return. In addition, cancer patients who received adjuvant chemotherapy tend to live longer than those who do not receive the treatment.

Description

Patient Selection

Patients selected for adjuvant chemotherapy are usually considered to have a high risk of recurrence. In order to determine the chance of recurrence, physicians look at the prognostic factors, which means they study the characteristics of the tumor. Tumor size, histology, and the proliferation rates are three prognostic factors that help determine the necessity for adjuvant chemotherapy. For example, patients with small tumors (2 centimeters or less) have a better prognosis, in general, than patients with large tumors (5 centimeters or more). Histology (or histologic grade) refers tow hat the tumor cells look like under a microscope. In other words, are the cells close to normal or are they far from normal. The term used to describe them is differentiated. When a tumor is well differentiated, the prognosis is better, because the cells closely resemble normal cells. When a tumor is poorly differentiated, the prognosis is considered to be not as good because the cells look very little like normal cells. A high proliferation rate refers to the rate in which cancer cells divide to make more cells. When the cancer cells are multiplying quickly, the cancer is described as aggressive, which often means adjuvant chemotherapy is needed.

Other prognostic factors may need to be considered, depending on the cancer type. For example, the degree of lymph node involvement is an important consideration when the patient has breast cancer. During the tumor surgery, physicians often remove some of the underarm lymph nodes to see if they contain any cancerous cells. Positive lymph nodes indicate a higher risk of recurrence, because research shows if the cancer has spread to the lymph nodes, it may have spread to other parts of the body. Hormone receptor status (high levels of estrogen or progesterone that affect cell growth) may also impact the decision whether or not to treat a patient with adjuvant chemotherapy. It should be noted, however, that a panel of experts at a conference sponsored by the National Institutes of Science concluded that "adjuvant chemotherapy improves survival [of breast cancer patients] and should be offered to most women with primary breast cancers (larger than 1 centimeter in diameter) regardless of tumor involvement in the lymph nodes under the arm, menopausal status, or hormone receptor status." Despite the value of analyzing prognostic factors, physicians cannot predict with 100% certainty what the outcome of adjuvant chemotherapy will be. Treatment decisions must be made on an individual basis, taking into account the patient's general health, as well as his or her preferences.

Treatment Specifics

In general, adjuvant chemotherapy is started as soon as possible after surgery. In the case of colorectal cancer patients, for example, physicians don't like to wait more than six weeks after surgery to begin adjuvant chemotherapy. Chemotherapy regimes generally include more than one drug, but not always. The drug combinations are selected based on the kind of cancer being treated and individual patient considerations.

Adjuvant chemotherapy treatments are usually given over a period of months in cycles, meaning a treatment is followed by a recovery period. The treatments can be administered orally, intravenously (through a vein), by injection, or by a patch on the skin. Most patients receive adjuvant chemotherapy as an outpatient in a hospital or clinic, but, in some cases, the treatments can be given at home.

Preparation

Each patient should talk with his or her doctor regarding any preparations that need to be made prior to treatment. Patients who work outside the home might want to plan, if possible, to take the entire day off from work on the day the chemotherapy is given. Depending on how a patient responds to treatment, the patient may need the next day off as well. The laws vary from state to state regarding employee rights, but many states have specific laws that address what the obligations of an employer are to an employee who is seriously ill. Patients concerned that they might be treated unfairly should consult an attorney.

Many patients prefer to have someone with them when they receive chemotherapy treatments, especially with regard to driving them home. Some cancer treatment centers insist that a patient have someone provide transportation. Patients who do not have friends or family available to help them can call the American Cancer Society. They manage a volunteer program that provides cancer patients with rides to and from the hospital or clinical where they will receive their treatments. For patients that live over 30 miles away from the nearest treatment center or hospital, the American Cancer Society also tries to arrange free-of-charge hotel rooms for cancer patients.

Patients with children may want to arrange to have someone stay with them while they are having chemotherapy, especially the day of or the day after the treatments. Patients should ask their physicians what local support groups exist in their area that specialize in this type of assistance. Church groups often have volunteers who will be willing to lend a hand as well. In addition, the hospital or cancer treatment center is likely to have a list of available services from a variety of sources.

Aftercare

Patients can expect to have some side effects associated with chemotherapy, although the particular side effects will vary depending on the patient and the drug combinations. Most patients lose their hair during chemotherapy treatment. Patients can also expect to be more prone to infection and feel fatigued, even for a period of time after the therapy is all done. For example, patients whose gums tend to bleed when they brush their teeth may be advised to brush their teeth gently and use a soft brush. Other cautions may be to avoid crowds and people who patients know are sick. Other common side effects are nausea, vomiting, diarrhea, and mouth sores.

Chemotherapy doses can be adjusted and medication can be prescribed to help the patient overcome nausea. Patients should refrain from taking any medications (over-the-counter or prescription) without first talking to their oncologist (a physician who specializes in cancer treatment). In general, it is a good idea for patients to talk with all their treatment team regarding the toxic effects associated with adjuvant chemotherapy.

Risks

There is some concern that woman over 70 years of age, for example, are more likely to develop severe side effects than younger women. However, in a large randomized clinical trial conducted by Muss and colleagues, which was published in the Journal of the American Medical Association, it was concluded that age alone was not a significant enough reason to avoid treating elderly women with adjuvant chemotherapy. In the study, the researchers tracked 6,487 breast cancer patients, all of whom had a high risk of recurrence, to see how they responded to high doses of chemotherapy. The study included 542 patients who were 65 years of age or older and 159 of them were 70 years of age and older. Although the researchers found that older patients did have a slightly higher risk of bad reactions to the chemotherapy, the researchers concluded that the risks did not outweigh the benefits of treatment.

Questions to Ask Your Doctor

• Will I need assistance performing my daily tasks?
• Are there certain food limitations associated with chemotherapy treatment?
• What other options do I have if this treatment doesn't work?
• How soon will I be able to return to work?
• Are there any clinical trials I should join?

Results

Treatment results vary from patient to patient, depending on a variety of factors. However, research shows that the benefits of adjuvant chemotherapy often outweigh the risks, especially for patients with breast or colorectal cancers. A patient's physician will perform various tests to determine if the treatment is working, such as blood tests and physical examinations. Some patients think that the side effects provide some indication as to how the treatment is working. The truth is, however, that the severity or lack of severity of the side effects has nothing to do with the effectiveness of the treatment.

Resources

Periodicals

Muss, H. B., Woolf, S., Berry, D., et al. "Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer." Journal of the American Medical Association 293 (2005): 1118–1120.

Other

American Cancer Society. "Older Women Less Likely To Be Offered Adjuvant Chemotherapy." American Cancer Society 9 May 2003 American Cancer Society. 24 Feb 2005 .

National Cancer Institute "Adjuvant Therapy for Breast Cancer: Questions and Answers. National Cancer Institute 13 May 2002 National Cancer Institute. 24 Feb. 2005 .

Susan G. Komen Breast Cancer Foundation. "Recommendations for Adjuvant Therapy for Breast Cancer Updated by the National Institute of Health Consensus Panel." Susan G. Komen Breast Cancer Foundation 2 Jan 2001 Susan G. Komen Breast Cancer Foundation. 19 March 2005

Susan G. Komen Breast Cancer Foundation. "Adjuvant Therapy Improves Survival for Women with Fast Growing Localized Breast Cancer." Susan G. Komen Breast Cancer Foundation 2 Feb 2002 Susan G. Komen Breast Cancer Foundation. 19 March 2005

—Lee Ann Paradise