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The three primary methods to treat a cancer are surgery, radiation and chemotherapy. In treating gynecologic cancers sometimes all three are used, and often two are combined depending upon the cancer and how far it may have spread at the time of diagnosis. Immunotherapy has a far lesser role and is mostly in experimental phases, although there has been a resurgence of interest in more recent findings.

There are also four treatment goals in cancer management. First and foremost is prevention. Failing that goal, the rest are cure, prolongation of life, and palliation. Palliation means that treatment is given to help alleviate a symptom of the cancer rather than trying to cure the cancer. This might mean elimination or reduction of bleeding from a uterine cancer (e.g. hysterectomy) which has already spread or reduction of pain from treating an area where cancer is pressing on or involving nerves (e.g. radiation or chemotherapy).

SURGERY
Surgery alone can cure many gynecologic cancers, IF and only IF, the cancer is still contained in the area that it started; this is otherwise known as localized disease and usually means it is in an early stage. The organ the cancer started to grow in, like the uterus or ovary, must be easily removable with no sign of the cancer spreading beyond that organ into surrounding supportive tissues. The chance of cure with surgery alone is best then the type of cancer (how it looks like under the microscope) is not one that microscopically spreads early by the blood or lymphatic system. The best example of this situation is the common form of uterine or endometrial cancer.

lymph nodes in the area of the organ involved by cancer are usually removed during surgery. This is done for the purpose of staging. Very simply, a way to determine if the cancer has spread beyond the organ it started in. Again, if the cancer is fairly small inside the organ it started in, and the lymph nodes removed have no cancer cells found in them (i.e. no metastases), surgery alone can result in a cure. In many cases, surgery is preceded by or followed by additional treatment in the form of radiation or chemotherapy or both. This is called neo-adjuvant (before) or adjuvant (after) therapy. The role of surgery in these cases is to more accurately determine if the cancer has spread and remove the bulk of the tumor.

RADIATION THERAPY
Radiation therapy is otherwise known as X-ray therapy and is delivered to the patient several different ways. Generally, this form of treatment is given when an entire area or region of the body must be treated. For example, when a surgery for endometrial cancer uncovers the presence of cancer cells in the pelvic lymph nodes, the entire area or region of the pelvis is treated. This relatively large area is usually treated with external radiation treatment, otherwise known as teletherapy. This means that X-ray beams are given to this pelvic area. This external X-ray treatment only takes a few minutes a day while the patient lays on a table and is repeated every day Monday through Friday. This is repeated approximately 20-25 times and MUST follow this schedule without skipped days, otherwise the result is not as good. On occasion a day or two of delay is unavoidable due to severe side effects. X-rays pass through the skin and are focused on the area requiring therapy which is located much deeper. At that area of interest, the maximum amount of energy is deposited. This results in damage to the genetic structure of cells, killing them before they can reproduce. Unfortunately, some cancer cells are more resistant than others and can repair themselves more readily than others. However, upon daily radiation, most are eventually killed. Normal cells in surrounding non-cancerous areas are also affected but have better mechanisms of repair. Radiation doctors and physicists take all of this into account in planning treatment dose and timing so that the treatment is most likely to kill the cancer cells and limit severe damage to normal cells in the area.

The rad (Radiation Absorbed Dose) is measurement of the amount of radiation dose delivered to the cancer cells. You should be aware that the newer term for this is the CentiGray (cGy), which is equivalent to the rad. Both are used in medical jargon. Typically, 200 rad is delivered per day (same as 200cGy). One hundred rad or cGy is referred to as a Gray(Gy). Therefore a typical weekly Monday through Friday regimen of 200cgy per day for 5 weeks often totals to 5000rad or cGy (same as 50 Gy).

Another common way radiation therapy is administered is by way of using implants, and is called brachytherapy. You may hear or read about other terms for this, including intra-cavitary or interstitial implant, radium implant, cesium implant, high dose rate insertion, or needle implant. In addition, some implants are named after the physician who developed the technique, notably the Syed interstitial implant. These various kinds of implants are all placed into the cancer itself or right next to it, and a radioactive element (Cesium or Radium) is placed into the implant (called after-loading). The implant is then left in place for several hours (called high dose rate) or several days (called low dose rate) and then removed. Brachytherapy is used to deliver very high doses of radiation to a smaller area involved by cancer while limiting damage to surrounding organs and tissues, like the bladder and rectum. While this form of radiation delivery is sometimes used alone, it is more often used in combination with the external form or radiation (teletherapy) to complete the total dose to an area affected by cancer. The amount of each is determined using very specialized radiographic and computerized techniques (called simulation), in order to optimize the probability of eliminating the cancer cells and minimizing radiation damage to normal surrounding organs. The total amount of radiation given is limited by the tolerance of the normal organs and tissues in the cancer afflicted area. The total dose to an area cannot exceed the tolerance of normal organs or severe complications will result. On the other hand, unless the radiation dose is optimized to a cancerous area, there is a danger that the treatment will be incompletely effective. Again, this is all taken into very serious consideration during the treatment planning and simulation process. For any given general situation, standard doses have been developed which then require consideration of the specific patient’s anatomy and other health factors. There is always a risk vs. benefit trade off. Specifically, it is the probability of cure vs. the risk of complications.

CHEMOTHERAPY
Chemotherapy is the administration of anti-cancer drugs, usually by an intravenous injection or infusion. Second most common administration is by pill. Since the drugs travel by bloodstream to almost all parts of the body, this type of treatment can affect cancer in almost all parts of the body. Because of this, chemotherapy may also result in temporary loss of hair or other “systemic” side effects. Although these side effects are common they are not inevitable and vary depending upon the drugs used.

Almost all chemotherapeutic agents act by interfering with cell division. Since cancer is the result of uncontrolled cell division, if cancer cells can be prevented from dividing then the cancer cannot grow. Normal cells also must divide to replace those lost through wear and tear as well as to repair tissue injuries. These normal cells are also affected by the chemotherapy. Those which divide fastest are the ones most affected, hence hair loss and some intestinal side effects. Both of those areas have cells which normally divide rapidly. Chemotherapy is also referred to as cyto-toxic therapy. This is simply another way of saying cell-toxic therapy. Administration of all chemotherapeutic agents can lead to some form of side effects. Often these side effects are specific to the drug which is being given. Some can affect the heart, many can affect the kidneys, and some can damage nerves. Almost all of these drugs are toxic to the bone marrow which produces the white (infection fighting) and the red (oxygen carrying) blood cells and the platelets(help blood clotting). Chemotherapy drugs are toxic to bone marrow and cause a drop in the white cell and platelet count after each chemotherapy administration. red cells are not affected as much, but tend to drop over time after multiple chemo treatments. The lowest white cell and platelet count, which usually occurs about 7-14 days after treatment, is called the nadir count. This low count can persist for 3-10 days, but usually the white blood cells and platelets “recover” or come back up in time for the next treatment. After multiple administrations the recovery can be slow, resulting in delays of treatment unless certain bone marrow supportive drugs are given to help accelerate recovery, thereby minimizing delays.

If the white cell count gets too low, then infections can occur which may be fatal. If the platelet count gets too low then spontaneous bleeding can occur in various parts of the body. Sometimes this bleeding may be detectable (rectal or vaginal bleeding) but sometimes it can occur in enclosed organs like the brain, resulting in a stroke. Over a period of time there may also be a drop in the red cell count which could cause symptoms of fatigue. For this a transfusion may be required, or bone marrow support drugs can be given to keep the red blood cells count up.

Many drugs can cause nausea and sometimes vomiting. However, the medications used to prevent this have improved immensely to the point that some patients experience minimal to no nausea. Since chemotherapy affects the lining of the mouth, stomach and intestine, irritation and sores can occur in any of these areas causing pain, possible bleeding and diarrhea. A disturbing side effect is nerve sensation changes at the fingers or toes from taxanes, cisplatin, or altretamine. In the worst cases, this can alter the ability to use hands for fine movements. While this often resolves at least partially, it can persist for long periods of time or indefinitely. Some of the drugs can affect the kidneys and bladder, but prevention via administration of lots of fluids or medications is usually very successful. Some drugs affect the skin, and often increase sensitivity to sunlight. In the case of Doxil (a common drug used in ovarian cancer), skin rashes may develop. While other side effects can occur they are usually more rare. However, a full discussion with your treating physician should address what might be expected with the particular drug treatment that is planned.

Chemotherapy might be administered to you under the supervision of either a medical oncologist or a gynecologic oncologist. Both are certified to safely administer chemotherapy and handle the complications thereof. Medical oncologists administer chemotherapy to patients with many kinds of malignancies, while gynecologic oncologists restrict their practice to gynecologic cancers only. Therefore, in seeking opinions, it is important to know what the level of expertise is in managing you particular kind of cancer. Some medical oncologists take a special interest in gynecologic cancers, otherwise it is a prudent idea to seek the opinion of a board certified or fellowship trained board eligible gynecologic oncologist for the overall treatment plan.

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