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From the UpToDate article on multiple myeloma:
In most people, chemotherapy partially controls multiple myeloma; rarely, chemotherapy leads to complete remission.
Transplantation, when successful, prolongs survival, leads to a remission, and, infrequently, cures multiple myeloma. However, transplantation has several limitations. The high-dose chemotherapy given before transplantation usually fails to kill all of the plasma cells, allowing the condition to relapse after transplantation. Such treatment also puts the patient at risk for serious infections and bleeding, which can be fatal.
UpToDate is used by 700,000+ physicians worldwide; it's not alternative medicine. Thus, if even mainstream medicine recognizes the relative ineffectiveness of chemo and transplantation for multiple myeloma, why do they do it?
To long for a comment: Its more an ethical thing I would say. I do research which is connected to melanoma - a cancer which is notoriously treatment resistant, once it started moving. Until very recently there was only one chemotherapeuticum which has pretty low (around 20%) response rates. It was usually tried anyway because its possible that the patients belong to this 20% which respond. If not, treatment was usually not prolonged.
I think its something similiar here. The other problem for chemotherapy is that it is cytotoxic (until we got the small molecule inhibitors which are tested and used today) and the problem is to kill the cancer cells (all when possible) while you leave the rest of the body as unaffected as possible. To get this balance is hard (people tend to react differently to chemotherapy). The other problem is that cancers are not homogenous. So its possible that 99.9% of the cells present respond to chemotherapy and get killed, while a few acquired an additional mutation, which gives them an advantage. The conditions of chemotherapy are very selective.
End-of-Life Care for People Who Have Cancer
What does end-of-life care mean for people who have cancer?
When a cancer patient’s health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the person’s care continues, with an emphasis on improving their quality of life and that of their loved ones, and making them comfortable for the following weeks or months.
Medicines and treatments people receive at the end of life can control pain and other symptoms, such as constipation, nausea, and shortness of breath. Some people remain at home while receiving these treatments, whereas others enter a hospital or other facility. Either way, services are available to help patients and their families with the medical, psychological, social, and spiritual issues around dying. Hospice programs are the most comprehensive and coordinated providers of these services.
The period at the end of life is different for each person. The signs and symptoms people have vary as their illness continues, and each person has unique needs for information and support. Questions and concerns that family members have about the end of life should be discussed with each other, as well as with the health care team, as they arise.
Communication about end-of-life care and decision making during the final months of a person’s life are very important. Research has shown that if a person who has advanced cancer discusses his or her options for care with a doctor early on, that person’s level of stress decreases and their ability to cope with illness increases. Studies also show that patients prefer an open and honest conversation with their doctor about choices for end-of-life care early in the course of their disease, and are more satisfied when they have this talk.
Experts strongly encourage patients to complete advance directives, which are documents stating a person’s wishes for care. They also designate who the patient chooses as the decision-maker for their care when they are unable to decide. It’s important for people with cancer to have these decisions made before they become too sick to make them. However, if a person does become too sick before they have completed an advance directive, it’s helpful for family caregivers to know what type of care their loved one would want to receive. More information about advance directives can be found below in the Related Resources section of this fact sheet.
How do doctors know how long a person will continue to live?
Patients and their family members often want to know how long a person who has cancer will continue to live. It’s normal to want to be prepared for the future. But predicting how long someone will continue to live is a hard question to answer. A number of factors, including the type of cancer, its location, and whether the patient has other illnesses, can affect what will happen.
Although doctors may be able to estimate the amount of time someone will continue to live based on what they know about that person, they might be hesitant to do so. They may be concerned about over- or under-estimating the person’s remaining life span. They also might be fearful of giving false hope or destroying a person's will to live.
When should someone call for professional help if they’re caring for a person who has cancer at home?
People caring for patients at home should ask them if they’re comfortable, if they feel any pain, and if they’re having any other physical problems.
There may be times when the caregiver needs assistance from the patient's health care team. A caregiver can contact the patient's doctor or nurse for help in any of the following situations:
- The patient is in pain that is not relieved by the prescribed dose of pain medication.
- The patient is experiencing onset of new symptoms, such as nausea, vomiting, increasing confusion, anxiety or restlessness.
- The patient is experiencing symptoms that were previously well controlled.
- The patient shows discomfort, such as by grimacing or moaning.
- The patient is having trouble breathing and seems upset.
- The patient is unable to urinate or empty the bowels.
- The patient has fallen.
- The patient is very depressed or talking about suicide.
- The caregiver has difficulty giving medicines to the patient.
- The caregiver is overwhelmed by caring for the patient, is too sad, or is afraid to be with the patient.
- The caregiver doesn’t know how to handle a certain situation.
Keep in mind that palliative care experts can be called upon by the patient’s physician at any point in the person’s illness to help with these issues. They are increasingly available not only in the hospital, but also in the outpatient setting.
When is the right time to use hospice care?
Many people believe that hospice care is only appropriate in the last days or weeks of life. Yet Medicare states that it can be used as much as 6 months before death is anticipated. And those who have lost loved ones say that they wish they had called in hospice care sooner.
Research has shown that patients and families who use hospice services report a higher quality of life than those who don’t. Hospice care offers many helpful services, including medical care, counseling, and respite care. People usually qualify for hospice when their doctor signs a statement saying that patients with their type and stage of disease, on average, aren’t likely to survive beyond 6 months. More information about hospice can be found below in the Related Resources section of this fact sheet.
What are some ways to provide emotional support to a person who is living with and dying of cancer?
Everyone has different needs, but some worries are common to most dying patients. Two of these concerns are fear of abandonment and fear of being a burden. People who are dying also have concerns about loss of dignity and loss of control. Some ways caregivers can provide comfort to a person with these worries are listed below:
- Keep the person company. Talk, watch movies, read, or just be with him or her.
- Allow the person to express fears and concerns about dying, such as leaving family and friends behind. Be prepared to listen.
- Be willing to reminisce about the person's life.
- Avoid withholding difficult information. Most patients prefer to be included in discussions about issues that concern them.
- Reassure the patient that you will honor advance directives, such as living wills.
- Ask if there is anything you can do.
- Respect the person's need for privacy.
- Support the person’s spirituality. Let them talk about what has meaning for them, pray with them if they’d like, and arrange visits by spiritual leaders and church members, if appropriate. Keep objects that are meaningful to the person close at hand.
What other issues should caregivers be aware of?
It’s just as important for caregivers to take care of their own health at this time. Family caregivers are affected by their loved one’s health more than they realize. Taking care of a sick person often causes physical and emotional fatigue, stress, depression, and anxiety. Because of this, it’s important for caregivers to take care of their own body, mind, and spirit. Helping themselves will give them more energy, help them cope with stress, and cause them to be better caregivers as a result.
It’s also helpful if caregivers ask for support from friends and family members. Such help is important to help lessen the many tasks involved in taking care of a loved one who is sick or dying.
What are some topics patients and family members can talk about?
For many people, it’s hard to know what to say to someone at the end of life. It’s normal to want to be upbeat and positive, rather than talk about death. And yet, it’s important to be realistic about how sick the person may be. Caregivers can encourage their loved one without giving false hope. Although it can be a time for grieving and accepting loss, the end of life can also be a time for looking for meaning and rethinking what’s important.
During this period, many people tend to look back and reflect on life, legacies created, and loved ones who will be left behind. Some questions to explore with a patient at the end of life are the following:
- What are the happiest and saddest times we have shared together?
- What are the defining or most important moments of our life together?
- What are we most proud of?
- What have we taught each other?
Patients with serious, life-threatening illness have stated that being positive or adding humor remains an important outlet for them. Even at this challenging moment, laughter may still be the best medicine.
How should caregivers talk to their children about advanced cancer?
Children deserve to be told the truth about a family member’s prognosis so they can be prepared if their loved one dies. It’s important to answer all of their questions gently and honestly so they don’t imagine things that are worse than reality. They need to be reassured that they will be taken care of no matter what happens.
Caregivers need to be prepared to answer tough questions. To do this, they should know what their own feelings and thoughts are about the situation. They need to be able to show children how to hope for the best while preparing for and accepting that their loved one may die.
How does cancer cause death?
Every patient is different, and the way cancer causes death varies. The process can depend on the type of cancer, where it is in the body, and how fast it’s growing.
For some people, the cancer can’t be controlled anymore and spreads to healthy tissues and organs. Cancer cells take up the needed space and nutrients that the healthy organs would use. As a result, the healthy organs can no longer function. For other people, complications from treatment can cause death.
During the final stages of cancer, problems may occur in several parts of the body.
- Digestive system: If cancer is in the digestive system (e.g., stomach, pancreas, or colon), food or waste may not be able to pass through, causing bloating, nausea, or vomiting. If the cancer prevents food from being digested or absorbed, patients can also become malnourished.
- Lungs: If too little healthy lung tissue is left, or if cancer blocks off part of the lung, the person may have trouble breathing and getting enough oxygen. Or, if the lung collapses, it may become infected, which may be too hard for someone with advanced cancer to fight.
- Bones: If cancer is in the bones, too much calcium may go into the bloodstream, which can cause unconsciousness and death. Bones with tumors may also break and not heal.
- Liver: The liver removes toxins from the blood, helps digest food, and converts food into substances needed to live. If there isn’t enough healthy liver tissue, the body’s chemical balance is upset. The person may eventually go into a coma.
- Bone marrow: When cancer is in the bone marrow, the body can’t make enough healthy blood cells. A lack of red blood cells will cause anemia, and the body won’t have enough oxygen in the blood. A low white blood cell count will make it hard to fight infection. And a drop in platelets will prevent the blood from clotting, making it hard to control abnormal bleeding.
- Brain: A large tumor in the brain may cause memory problems, balance problems, bleeding in the brain, or loss of function in another body part, which may eventually lead to a coma.
In some cases, the exact cause can’t be pinpointed and patients simply decline slowly, becoming weaker and weaker until they succumb to the cancer.
Again, every patient is different and all processes have different stages and rates in which they advance. And some conditions have treatments that can help slow the process or make the patient more comfortable. It’s very important to keep having conversations with the patient’s health care team.
What are the signs that death is approaching, and what can the caregiver do to make the person comfortable during this time?
Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. However, each person’s experience at the end of life is different. What may happen to one person may not happen for another. Also, the presence of one or more of these symptoms doesn’t necessarily mean that the patient is close to death. A member of the health care team can give family members and caregivers more information about what to expect.
Withdrawal from friends and family:
- People often focus inward during the last weeks of life. This doesn’t necessarily mean that patients are angry or depressed or that they don’t love their caregivers. It could be caused by decreased oxygen to the brain, decreased blood flow, and/or mental preparation for dying.
- They may lose interest in things they used to enjoy, such as favorite TV shows, friends, or pets.
- Caregivers can let the patient know they are there for support. The person may be aware and able to hear, even if they are unable to respond. Experts advise that giving them permission to “let go” may be helpful. If they do feel like talking, they may want to reminisce about joys and sorrows, or tie up loose ends.
- People may have drowsiness, increased sleep, intermittent sleep, or confusion when they first wake up.
- Worries or concerns may keep patients up at night. Caregivers can ask them if they would like to sit in the room with them while they fall asleep.
- Patients may sleep more and more as time passes. Caregivers should continue to talk to them, even if they’re unconscious, for the patient may still hear them.
- It may become harder to control pain as the cancer gets worse. It’s important to provide pain medication regularly. Caregivers should ask to see a palliative care doctor or a pain specialist for advice on the correct medicines and doses. It may be helpful to explore other pain control methods such as massage and relaxation techniques.
- Weakness and fatigue will increase over time. The patient may have good days and bad days, so they may need more help with daily personal care and getting around.
- Caregivers can help patients save energy for the things that are most important to them.
- As the body naturally shuts down, the person with cancer will often need and want less food. The loss of appetite is caused by the body’s need to conserve energy and its decreasing ability to use food and fluids properly.
- Patients should be allowed to choose whether and when to eat or drink. Caregivers can offer small amounts of the foods the patient enjoys. Since chewing takes energy, they may prefer milkshakes, ice cream, or pudding. If the patient doesn’t have trouble with swallowing, offer sips of fluids and use a flexible straw if they can’t sit up. If a person can no longer swallow, offer ice chips. Keep their lips moist with lip balm and their mouth clean with a soft, damp cloth.
- Near the end of life, people often have episodes of confusion or waking dreams. They may get confused about time, place, and the identity of loved ones. Caregivers can gently remind patients where they are and who is with them. They should be calm and reassuring. But if the patient is agitated, they should not attempt to restrain them. Let the health care providers know if significant agitation occurs, as there are treatments available to help control or reverse it.
- Sometimes patients report seeing or speaking with loved ones who have died. They may talk about going on a trip, seeing lights, butterflies, or other symbols of reality we can’t see. As long as these things aren’t disturbing to the patient, caregivers can ask them to say more. They can let them share their visions and dreams, not trying to talk them out of what they believe they see.
- There may be a loss of bladder or bowel control due to the muscles relaxing in the pelvis. Caregivers should continue to provide clean, dry bedding and gentle personal care. They can place disposable pads on the bed under the patient and remove them when soiled. Also, due to a slowing of kidney function and/or decreased fluid intake, there may be a decrease in the amount of urine. It may be dark and smell strong.
- Breathing patterns may become slower or faster, in cycles. The patient may not notice, but caregivers should let the doctor know if they are worried about the changes. There may be rattling or gurgling sounds that are caused by saliva and fluids collecting in the throat and upper airways. Although this can be very disturbing for caregivers, at this stage the patient is generally not experiencing any distress. Breathing may be easier if a person’s body is turned to the side and pillows are placed behind the back and beneath the head. Caregivers can also ask the health care team about using a humidifier or external source of oxygen to make it easier for the patient to breathe, if the patient is short of breath.
- Skin may become bluish in color and feel cool as blood flow slows down. This is not painful or uncomfortable for the patient. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns. However, they may keep the patient covered with a light blanket.
What are the signs that the person has died?
- The person is no longer breathing and doesn’t have a pulse.
- Their eyes don’t move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open.
- The jaw is relaxed and the mouth is slightly open.
- The body releases the bowel and bladder contents.
- The person doesn’t respond to being touched or spoken to.
- The person’s skin is very pale and cool to the touch.
What needs to be done after the person has died?
After the person has died, there is no need to hurry with arrangements. Family members and caregivers may wish to sit with the body, to talk, or to pray. When the family is ready, the following steps can be taken.
For patients who have just had a stem cell transplant or received CAR T-cell therapy, who are typically receiving immunosuppressive therapy, we recommend that they delay COVID-19 vaccination until at least 3 months after they’ve completed treatment. That’s based on data that [other] vaccines have had limited efficacy during periods when these patients are their most immunosuppressed.
The data are a little less clear for patients who are getting aggressive chemotherapy, but for those who are receiving more intensive treatment regimens—for example, those starting initial therapy for leukemia—we recommend that they delay vaccination until their cell counts recover.
Those are the two main groups where I think there is agreement that they should delay COVID-19 vaccination, at least initially.
Why do doctors do chemo or transplantation for cancers that don't respond well to these treatments? - Biology
When you have cancer, your doctor will recommend a treatment plan that is most likely to have the greatest benefits and the fewest risks or side effects. A doctor who treats people with cancer is called an oncologist. The initial treatment is referred to as first-line treatment or first-line therapy. This treatment is usually what worked best in clinical trials for people with the same type and stage of cancer.
How well your treatment works often varies. Your first-line treatment may not work, may start but then stop working, or may cause serious side effects. Your doctor may then suggest a second-line treatment, also called second-line therapy. It is a different treatment that is likely to be effective. Depending on the type of cancer you have and the available drugs, you may be able to have third-line therapy or additional rounds of treatment after that.
Considering a different treatment option
If you need a second-line treatment, this does not mean that you did not get the right treatment the first time or that there are not more treatments to try. But the chance that second-line treatment or more rounds of treatment will have good results is usually lower than with first-line treatment.
The chance that second-line treatment will be successful depends on the type of cancer you have. Second-line treatment often works very well for certain types of cancer. People with other types of cancer may have only a small chance that second-line treatment will work.
Other factors that affect whether second-line therapy may work include:
How well and how long the first-line treatment worked
How long it has been since first-line treatment ended. Second-line treatment may be more successful if a year or more has passed between the 2 treatments.
The side effects you had during first-line treatment
Your age and general health
Before second-line treatment starts, talk with your doctor about the goal of any suggested new treatments. Also talk about your chance of getting better. You and your doctor may decide that receiving a new treatment is not the best choice. This may happen if the treatment has unpleasant or serious side effects or if the chance for success is small. This tough decision allows you and your doctor to focus more on caring for the symptoms of your cancer. This type of treatment is known as palliative care or supportive care.
Talking with your health care team
It is important to talk with your health care team about your care throughout the treatment process. Being an informed, involved patient, asking questions, and talking about your preferences will help you and your health care team work together better. Also, it will make you feel more confident about your treatment choices.
Bring a list of questions to your visits to help guide the talk. It will help you make sure your doctor addresses all of your concerns. You may want to print the list below or download Cancer.Net’s free mobile app for an e-list and other tools to use during your visit.
Here are examples of the types of questions you may want to ask:
What is the current status of the cancer?
Has the cancer grown and/or spread since my first treatment?
Are other treatment options available?
Would you recommend starting a new treatment?
Would you recommend participating in a clinical trial?
Should I consider not having a new type of treatment at this time?
What will happen if I choose not to have another type of treatment?
Who can help me if I’m worried about managing the costs related to my cancer care?
Who can help me understand what parts of my care are covered by my insurance?
If you and your doctor decide on second-line treatment, you may consider asking the following questions:
How is this treatment different from the first-line treatment I had?
What is the goal of this treatment? Is it to remove all of the cancer, help me feel better, or both?
What are the potential risks and benefits of the treatment?
What are the possible side effects of this treatment, both in the short term and the long term?
What success rate does this second-line treatment have for my type of cancer?
What is the expected timeline for my treatment plan?
Do I need to start treatment right away?
What is the chance my cancer will come back after this treatment?
Will I need to receive this treatment in the hospital, or can I receive it in a doctor’s office or clinic?
How much experience do you have using this treatment for my type of cancer?
Where can I find more information about the treatment you are recommending?
Considering a clinical trial
At any point during your treatment, you may consider asking your doctor whether a clinical trial is an option. A clinical trial is a research study that tests a new treatment in people. It proves that it is safe, effective, and possibly better than the standard treatment you may already have had. Many clinical trials require that you have few or no previous treatments. Because of this, it is best to ask about clinical trials early in the treatment process. Joining a clinical trial may be a better option for your second-line treatment than a standard treatment. Your health care team can help you review all clinical trial options that are open to you.
Coping with a new treatment
Learning your first-line treatment did not work can be scary. You may also feel a wide range of other emotions, such as anger, fear, shock, grief, and anxiety. You may wonder if you and your doctor should have chosen another option for your first treatment. You may worry about whether you have the strength to go through a new treatment. These are all normal reactions. But it is important to seek the support you need to get through this difficult time. Some strategies include:
Sharing your fears and anxieties with family, friends, clergy, or support groups, in-person or online
Connecting with someone else who has had second-line treatment and understands the emotions you are experiencing
Expressing your feelings in a journal or a blog
Spending time outside or around nature
Watching or listening to programs or shows that make you laugh
You may continue to feel anxious or depressed or find it hard to focus or make decisions. If so, consider asking your health care team for help finding a counselor. Even if you do not have severe anxiety or depression, it may be helpful to talk with a counselor or a cancer social worker. It can help you develop healthy ways to understand and respond to your needs and concerns.
Why do doctors do chemo or transplantation for cancers that don't respond well to these treatments? - Biology
Cancer treatment can be more challenging and complicated for older adults. This is because older adults are more likely to have chronic health conditions, such as diabetes or heart disease. Even when you are healthy, your body will most likely respond differently to treatment than a younger person’s body. For example, older adults are more likely to have serious side effects from chemotherapy.
But age should not be the only factor in your treatment decisions. Cancer treatment can help people of any age. This article helps you think about making treatment decisions.
Why your decisions matter
In the past, doctors sometimes made decisions without talking with patients. Today, the situation is different. Your health care team wants to know your concerns and answer your questions. They also believe that you have the right to make your own decisions. Working with your health care team to make a treatment plan can help you feel more in control.
What to consider
Before making any treatment decisions, talk with your health care team about:
The type of cancer, if it has spread, and how far
All your treatment options, and the risks and benefits of each one
Any other medical conditions that might cause problems with treatment or increase your risk of side effects
How cancer treatment can affect your physical health, emotional health, and lifestyle
Thinking about your personal situation is also very important. You might want to consider:
Possible emotional and social challenges. Who can help with your care and provide emotional support? If you live alone, will you feel lonely or cut off from other people? How can you get support during treatment?
Financial challenges. Older adults are more likely to have a limited budget, live on a fixed income, or both. But costs of treatment vary based on several factors. And there are resources to help people with the costs of care. Ask your health care team about ways to get financial help with cancer treatment.
Also consider what your life will be like physically, emotionally, and socially. These factors put together are called quality of life. Think about each of the areas listed below:
Ability to keep taking care of yourself, do usual activities, or live independently
Your ideas about a dignified or peaceful death
It is important to talk honestly with your health care team about what quality of life means to you. Sometimes, managing side effects from treatment can make an important difference in your quality of life.
Your cancer treatment goals
Your cancer treatment goals depend on many factors. For example, the type of cancer and whether it has spread will factor into your goals.
Living longer, even with cancer
Having fewer symptoms from cancer and side effects from its treatment
Maintaining physical and emotional strength
Having a certain quality of life
Your goals might be different from a younger person’s. For example, a healthy younger person's goal might be to cure the cancer even if treatment is very difficult. Some people are able to have aggressive treatment. This might not be true for you.
Depending on your age and general health, you might care more about feeling well than curing cancer permanently. This might be especially true if you have a chronic health condition or you feel that your quality of life is poor.
But if you are very healthy and enjoy many activities, you might want aggressive treatment. You might have plans many years in the future. If so, you might want your health care team to do everything possible for a cure.
If you and your family do not agree
Family members, friends, and caregivers might have different ideas about your treatment. They might want you to have more aggressive treatment. Or they might try to keep you from having certain treatments.
If this happens, your health care team can help you talk with your family and friends. Sometimes, it is best if your family and closest friends meet with you and your doctor to talk about the best treatment plan. Remember that you always have the right to make your own treatment decisions.
Cancer treatment options for older adults
You may have just one type of treatment or a combination of treatments. The main cancer treatments for people of all ages are:
Chemotherapy or targeted therapy
How cancer surgery can affect older adults
Like other treatments, surgery has risks. The risks can be higher when you are older because your body does not always work as well as it did. Before surgery, you and your doctor should think about the following:
Heart function. Surgery may make heart problems worse. It is important to consider your heart function before you have surgery. Older adults have heart disease or an irregular heartbeat more often than younger people. Also, your heart might not tolerate changes in blood pressure as well. This can happen during surgery.
Kidney function. Surgery can involve many drugs. You might also get a lot of fluids to keep your body working. Your kidneys need to process the drugs and fluids. If your kidneys do not work as well as they used to, surgery can cause problems.
Liver function. As you get older, less blood flows to your liver to help it work. Your liver breaks down drugs. If it does not work as well as it should, you are more likely to have a reaction to the drugs needed for surgery.
Lung function. As you get older, your lungs do not hold as much air. And they might not work as well to move air in and out of your body. If you have a lung condition such as emphysema or chronic obstructive pulmonary disease (COPD), you may have problems recovering from anesthesia. This includes medications you get before and during surgery. Lung problems raise your risk of getting pneumonia after surgery, which can be very serious.
Considering surgery risks and benefits
It is important to talk with your health care team about the risks and benefits of cancer surgery. If surgery is risky for you, talk about other treatments.
If you have any health problems, or your doctor is concerned about the risks, you may need to have other tests done before your surgery. These may include blood tests, electrocardiograms (called an ECG or EKG), lung function tests, and x-rays.
You might also want to see a type of doctor called a geriatrician. This is a specialist who cares for older adults. This doctor can check your general health and talk with you about surgery risks and benefits.
Planning for after surgery
Talk with your health care team about the care you need after surgery. Depending on your health, you might need different care than a younger person. Ask if you might need:
Recommendations for help in your community
Planning for your after-surgery care is important. Having a detailed plan makes a successful recovery more likely.
How chemotherapy can affect older adults
Unlike surgery, chemotherapy can take a long time. Doctors often give chemotherapy in many treatments spread over a few weeks or months. Then, you might take a break and have more treatments later. Even with breaks, having many treatments can lead to longer periods of weakness. If you are an older adult, chemotherapy might affect you differently than someone younger. For example, older adults have a greater risk of physical side effects from chemotherapy, which can affect your quality of life.
Side effects of chemotherapy
Unlike radiation therapy and surgery, chemotherapy affects your whole body. This increases the risk of side effects. Older and younger patients have similar side effects, but older adults usually get them more often. Sometimes older adults with cancer go to the hospital because of a reaction to chemotherapy.
Fewer blood cells, also called low blood counts. You may have fewer white blood cells, red blood cells, or a type of blood cell called platelets. Low blood counts increase your risk of infection, anemia, bleeding, and bruising. Anemia is when you have low levels of red blood cells. It can make you tired and cause other problems.
Stomach and digestive problems. These can include nausea, vomiting, diarrhea, and dehydration. Dehydration is not having enough fluids for your body to work well.
Nervous system damage. This can affect a person’s thinking or judgment. It can also increase memory loss, make you tired, and cause nerve damage.
To make these side effects less severe, or less likely, your doctor can:
Check for health problems before you start chemotherapy
Change the dose or type of drug
Chemotherapy and your other medications
Older adults are more likely than younger people to take regular medications for other health conditions. These medications might affect the chemotherapy you receive. Or chemotherapy might affect how your regular medications work.
To help prevent problems, make a list of all your medications. This includes those that are taken without a prescription as well as vitamins, supplements, and herbs. Be sure every medication is listed, even medications that are not taken daily. Share this list with your health care team.
How radiation therapy can affect older adults
Radiation therapy might be your only treatment. Or you might have it in addition to surgery or chemotherapy. You usually do not stay in the hospital for radiation therapy. But you might need to go for treatment often, sometimes every day for several weeks.
Radiation therapy can come from a machine outside the body. Or your doctor may put tiny pieces of radioactive material inside your body, near the tumor.
Considering radiation risks and benefits
Talk with your health care team about:
If you need to be away from home
How to keep a healthy diet during treatment
Depending on your health, your doctor might recommend less intense treatment for a shorter time than for someone younger.
Older adults usually do well with radiation therapy. The side effects depend on the type and dose of radiation therapy and where the cancer is. For example, radiation therapy for prostate cancer can cause different side effects than radiation therapy for head and neck cancer. Learn more about radiation therapy for specific types of cancer types.
Clinical trials are research studies that involve people. The people in clinical trials volunteer to help researchers learn more about new drugs and treatments.
Because 60% of people with cancer are older than 65, it is very important for research studies to include older adults. Doctors need to learn which treatments work best in older adults. They also need to learn if those treatments might work differently than in younger people. Talk with your health care team about available clinical trials and how they differ from standard treatment.
Other types of cancer treatment
Relieving a person’s symptoms and side effects is an important part of cancer care. This is called palliative care or supportive care. It can be especially important for older adults. This is because older adults can have more side effects, especially from chemotherapy. Or your body may not recover as quickly from surgery as someone younger, which can cause more symptoms.
Palliative care also includes getting all the support you and your family need during cancer. Anyone can receive palliative care at any time. It is important to ask for support when you need it.
Advanced cancer care
Advanced cancer is cancer that doctors cannot cure. It is also called end-stage cancer or terminal cancer. Even though your health care team cannot cure advanced cancer, they can treat it. And you can still have a good quality of life.
Advanced cancer treatment options include:
Standard treatment. The current or most effective treatment available.
Clinical trials. Research studies that test new drugs and treatments.
Palliative care. Care that helps you live as comfortably as possible.
Hospice Care. This is care to help you and your family cope with death and dying. It is available when you are no longer having treatment to cure your cancer.
Understanding these types of care can help you and your health care team plan for your needs, goals, and wishes. Learn more about advanced cancer.
Questions to ask the health care team
After you learn about your treatment options and your general health, you might need more information. Consider asking your health care team the following:
What is my chance of recovery?
What are all of my treatment options?
What is the goal of each treatment?
What treatment do you recommend? Why?
How does this treatment help me?
What are some risks and potential side effects of this treatment?
Will I need to be in the hospital for treatment? Or can I stay home and come to the hospital or clinic during the day?
How long will each treatment last?
How will this treatment affect my daily life? Will I be able to perform my usual activities?
If I am worried about managing the costs related to my cancer care, who can help me with these concerns?
Putting it all together
It’s not just the quacks, though. Articles in mainstream news sources reported this study with headlines like “Chemotherapy could cause cancer to SPREAD and grow back even more aggressive, new study claims.” OK, that’s The Daily Mail , which is to science as The Weekly World News is to, well, news. But other stories had headlines like “Chemotherapy could spread cancer cells and lead to more advanced tumours, says study” and “Chemotherapy before breast cancer surgery might fuel metastasis.” Far better is a headline like “Neoadjuvant Chemotherapy Treatment May Increase Risk Of Breast Cancer Spreading In Some Patients“, which more accurately assesses the results of the study. In fairness, I know that editors, not reporters, determine headlines and most of the mainstream articles I mentioned did point out some of the caveats that I discussed, but the impression most people take away comes from the headline, and that impression was only marginally less scary than the headlines coming from Sayer Ji’s and Mike Adams’ websites.
More importantly, if you’re a woman considering neoadjuvant chemotherapy to treat breast cancer, don’t let the spin on this study frighten you out of it. The benefits of neoadjuvant chemotherapy include not only improved survival but the possibility of breast conserving surgery, and, as I mentioned before, there is no detectable difference in overall survival whether chemotherapy is administered before or after surgery.
As for the future, research like this could lead the way to better neoadjuvant chemotherapy. For example, a woman undergoing neoadjuvant chemotherapy might some day have biopsies done part way through the chemotherapy. If her tumor’s TMEM score has increased markedly, then I could envision the addition of a TIE2 inhibitor or other inhibitor of TMEM function being added to her chemotherapy to block the increased level of circulating tumor cells and reverse whatever increased risk of metastasis that might be attributable to neoadjuvant chemotherapy in order to produce better outcomes. That’s how SBM improves, in contrast to alternative medicine, in which no therapies are abandoned when demonstrated to be ineffective and/or dangerous and no therapies are ever improved upon.
A study sheds new light
In the past, if only one in 10 patients responded to a new drug, researchers assumed the therapy wasn&rsquot effective for that cancer type and would discontinue that line of research. But a study published in 2012 changed conventional thinking on exceptional responders. The study noted that an advanced bladder cancer patient participating in a clinical trial had such an &ldquoimpressive response&rdquo to a targeted therapy that she stood out starkly from the other 44 trial participants. So the researchers decided to dig deeper. After performing molecular testing on the DNA of the woman&rsquos tumor, researchers discovered two genetic mutations that are uncommon in most bladder cancer patients. But when the mutations are present, they make the tumor more receptive to treatment. The study, the first to delve into the biology of an exceptional responder, prompted the National Cancer Institute to launch the Exceptional Responders Initiative, a pilot study focused on researching how specific genetic features in exceptional responders&rsquo tumors could help advance cancer treatment.
Already, researchers have learned that between 10 percent and 20 percent of tumors in exceptional responders have unusually high numbers of genetic mutations, which may make the tumors more likely to respond to immunotherapy drugs. That means that identifying predictive biomarkers, or unique DNA mutations in the tumor cells of exceptional responders, may help researchers design drugs to target those same mutations in other patients&rsquo tumor, regardless of where the tumor is located in the body. &ldquoWe now know that when your tumor has a certain feature, you&rsquore more likely to respond to immunotherapy, and you&rsquore going to do much better because of that,&rdquo Dr. Bonilla says. &ldquoPatients have this advantage that they didn&rsquot have before.&rdquo
How is immunotherapy administered?
Patients usually receive immunotherapy treatment at an outpatient oncology center via infusion through a port or intravenous therapy (IV). The dosage and frequency depend on the specific medicine. Therapy intervals may range between every two weeks to every four weeks. In April, however, the FDA approved a six-week dosing regimen for the immunotherapy drug, pembrolizumab (KEYTRUDA ® ), a monoclonal antibody.
Currently, there&rsquos no designated end to immunotherapy treatment. You may continue on the regimen as long as you continue to have a good response.
Patients sometimes ask to take a break from treatment. They may be experiencing side effects or want a break for a personal reason. When that happens, we monitor the patient with scans and tests every three months or so. We don&rsquot fully understand why yet, but some&mdashnot all&mdashcontinue to have a good response after stopping therapy. One possibility is that for those patients, immunotherapy may work like a light switch: Once it&rsquos been turned on, it stays on.
For example, one recent study showed patients with PD-L1‒expressing advanced non‒small-cell lung cancer who were treated for at least two years with pembrolizumab continued to experience long-term benefits of treatment, even after taking a break from treatment. Researchers and oncologists are trying to figure out who may be able to stop immunotherapy indefinitely and still maintain the benefits.
An oncologist can prescribe FDA-approved uses of immunotherapy drugs as long as treatment guidelines support it. But, you may have to go to a larger cancer center or an academic hospital for access to genomic testing, clinical trials and combination therapies that aren&rsquot available elsewhere.
Myelodysplastic Syndrome Research Leads the Way
Physician scientists with the Kimmel Cancer Center at Johns Hopkins have led the way in two approaches to MDS:
(1) The first uses medications that target epigenetic changes – changes affecting gene expression within cells – with the idea to get MDS to behave more normally. One such drug tested at Johns Hopkins and other centers, called 5-aza-cytidine, has been approved by the U.S. Food and Drug Administration for clinical use in MDS patients.
(2) Another method, done through clinical trials, aims to get cancer cells to behave more normally through medications that help the cells mature correctly.
At the Johns Hopkins Kimmel Cancer Center, researchers currently are testing new approaches to help MDS patients, including:
Eyes On New Treatments Beyond Chemotherapy in Diffuse Large B-cell Lymphoma
Almost three years to the day since doctors told Cheryl Williams she was in remission from diffuse large B-cell lymphoma (DLBCL), a routine mammogram in 2014 revealed the cancer’s return.
“They called me back to redo the mammogram, then they wanted an ultrasound, and then later a breast biopsy. In a few days, my primary care doctor called to confirm that it was the same type of lymphoma again,” recalls Williams, a 60-year-old retired early childhood educator in Chicago.
After her initial stage 4 diagnosis in 2011, Williams received standard chemotherapy,
a protocol referred to as R-CHOP — Rituxan (rituximab), Cytoxan (cyclophosphamide), Adriamycin (doxorubicin), Oncovin (vincristine sulfate) and prednisone — and went into remission. During her relapse, she received another round of chemotherapy followed by a stem cell transplant. November 2019 marked five years of remission.
During those five years, Williams underwent numerous scans, blood tests and other follow-ups to confirm her cancer-free status. “I used to worry about every single scan and blood test, but I don’t do that as much anymore,” she says. And, if Williams were to relapse, she would have more options than she did following her first diagnosis.
A large percentage of patients with DLBCL respond to initial treatment, and 71% survive more than five years. For those who don’t respond or later relapse, the condition has been harder to treat. But, in recent years, new therapies have brought hope and promising outlooks.
“This is extremely encouraging,” says Dr. Stephen Ansell, a researcher and consultant in the division of hematology at Mayo Clinic in Rochester, Minnesota. “There are now multiple therapies becoming available for patients who have had the misfortune of having the disease return.”
AGGRESSIVE DISEASE, EFFECTIVE TREATMENT
DLBCL, the most common type of non-Hodgkin lymphoma, affects more than 18,000 people each year in the United States — most often, those over age 60. The aggressive disease involves B lymphocytes, immune cells that produce antibodies to fight germs and infections entering the body. When these cells become cancerous, it wages war on the body’s built-in defense system
But, as with the growing consensus about most cancers, DLCBL is not one disease, according to Dr. Nina Wagner- Johnston, director of lymphoma drug development at Johns Hopkins’ Sidney Kimmel Comprehensive Cancer Center in Baltimore. “It’s multiple diseases, and the better we understand their biology, the better we can target the cancer,” she says.
DLBCL breaks down into five subtypes based on behavior, appearance and defining protein or gene: T-cell/histiocyte-rich B-cell lymphoma, primary DLBCL, primary cutaneous DLBCL, Epstein- Barr virus-positive DLBCL and DLBCL not otherwise specified.
In earlier stages, when the cancer is limited to one or two lymph nodes on the same side of the diaphragm, patients typically receive three to six cycles of R-CHOP at 21-day intervals. At stage 3 or 4, patients receive six or more cycles. People at high risk of recurrence may receive different chemotherapies.
The international prognostic index score helps doctors predict risk of recurrence. This measurement takes into consideration the patient’s age and normal daily activity function, disease stage, whether the lymphoma has reached organs outside the lymphatic system and blood level of lactate dehydrogenase, a lymphoma marker. The higher the score, the higher the risk.
Williams received eight cycles of R-CHOP and felt hardest hit by the side effects of the regimen’s prednisone, a steroid. “I would have mood swings,” she recalls. “One minute I’d be happy or my normal self, and then just one word would set me off. I’d cry or have bouts of anger, and sometimes I’d be awake for 36 hours.” Other common side effects associated with R-CHOP include nausea, hair loss, fatigue, weight loss, risk of infection and loss of appetite.
The regimen might be tough to take but it is highly effective. “With R-CHOP, we are able to cure 60%-80% of patients, depending on which study you look at,” says Dr. Loretta Nastoupil, director of the department of lymphoma and myeloma at The University of Texas MD Anderson Cancer Center in Houston.
SLOW + STEADY = HOSPITAL STAY
Yet studies that examine R-CHOP don’t include enough people with a type of DLBCL known as double-hit lymphoma, who typically don’t respond well to the regimen.
B-cell lymphoma cells tend to have one or more of three possible gene mutations — BCL2, BCL6 and MYC — that occur when parts of genes swap places within the chromo- somes that contain them. Double-hit lymphoma involves two of these rearrangements, one in the MYC gene and the other in either the BCL2 or BCL6 gene.
Rather than using R-CHOP, oncologists will consider a more intensive treatment regimen of dose-adjusted EPOCH-R — etoposide phosphate, prednisone, Oncovin, Cytoxan and Adriamycin plus Rituxan, according to Nastoupil. Doctors might also consider EPOCH-R for people who have a higher international prognostic index score. Unlike other chemotherapy regimens, EPOCH is given slowly over five consecutive days.
This slow approach can reduce the toxic side effects on healthy organs,
such as the heart. The dose gradually increases until the maximum amount the patient’s bone marrow can tolerate is reached. Many patients need to stay in the hospital during the infusion.
“It was a shock to me when they told me I would need to go into the hospital for dose-adjusted EPOCH,” says Mary Chamberlain, 65, a social worker from Herndon, Virginia, who is currently receiving the regimen.
“I thought I would spend one day a week every three weeks getting chemotherapy, not five to seven days living in the hospital.”
Chamberlain gets through the stay with visits from her husband, daughter and friends. “My husband brings me breakfast every day on his way to work, and my friends bring puzzles and games,” she says. She also reads or walks the oncology ward. “Sixteen laps is a mile, so I get up and walk that, and drag the chemo machine with me,” she says. “You have to take it with you everywhere. It’s like having a dance partner.”
EPOCH-R, like R-CHOP, brings high survival rates. A 2018 study found that about 71% of people with double-hit lymphoma who received EPOCH-R remained cancer-free for four years.
A NEW PLAN OF ATTACK
If a patient doesn’t respond to therapy or, like Williams, has a relapse, the next step is typically high-dose chemotherapy followed by stem cell transplant. Now there is a new option: chimeric antigen receptor (CAR)-T cell therapy. “In the last two years, the biggest thing that’s happened in diffuse large B-cell lymphoma has been the development and approval of CAR-T cell therapy,” Nastoupil says.
The therapy involves removing a patient’s T cells, re-engineering them in a lab, and then putting them back into the patient’s body to help fight the lymphoma. The treatment forces T cells to recognize a molecule called CD19 on the surface of cancerous cells and attack.
The Food and Drug Administration has approved two CAR-T cell therapies, Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel), for people who continue to progress after at least two types of treatment. “Prior to CAR-T cell therapy, these patients were looking at a median overall survival of six months,” Nastoupil says. “Now survival is dramatically better. For the 40% of patients who are cured, we think they will have a normal life expectancy.”
Since these treatments were approved, researchers have collected data on patients who have received the therapy. That’s important, because often drugs that impress researchers in clinical trials disappoint when used in more widespread groups of patients. Clinical trial participants are often “the healthiest of sick patients,” Nastoupil says, and might do better than others would on an experimental drug. But CAR-T cell therapy continues to perform as well as it did in
It works so well, in fact, that researchers want to know if CAR-T cell therapy might be more effective than high-dose chemo- therapy followed by stem cell transplant. Current clinical trials are making that comparison. If CAR-T cell therapy beats stem cell therapy, it could be used as
a second-line treatment. If the two competitors perform equally, stem cell therapy might keep its second-line spot because it costs less. Both treatments have associated risks and side effects.
Before a stem cell transplant, doctors wipe out the patient’s immune system with high-dose chemotherapy, which brings the risk of infections and other illness.
Low blood counts, another result of a depleted immune system, can thin the blood or cause anemia. Patients may experience low platelet levels, nausea, vomiting, fatigue and mouth sores. Long-term side effects, such as early menopause, thyroid problems and lung or bone damage, are also a concern.
Two major, sometimes life-threatening side effects of CAR-T cell therapy include consequences of an exuberant immune reaction, such as cytokine release syndrome and neurological toxicity. Cytokine release syndrome can cause flu-like symptoms, such as headache, fever, chills, severe nausea, vomiting, diarrhea and severe muscle or joint pain, as well as shortness of breath, low blood pressure and fast heart rate. Neurological side effects include confusion, difficulty speaking, altered consciousness and seizures. Most of these side effects can be managed with medication or resolve on their own.
“Until treatment options work for 100% of patients, it’s not enough,” Ansell says.
Experimental drugs called bispecific T-cell engagers, or BiTEs, may help close that gap. Like CAR-T cell therapy, these drugs trigger the body’s T cells to fight lymphoma. But, for CAR-T cell therapy, doctors draw blood to modify T cells outside the body and then reinfuse them into the patient. BiTEs do not require removal and modification of T cells — they do all their work inside the body.
“The advantage is that it’s off the shelf,” Wagner-Johnston says. “It doesn’t require any of this laboratory manipulation of CAR-T cells, so you don’t have that delay.”
The bispecific drugs activate T cells by latching on to CD3, a protein on the surface of T cells, which then attach to the CD19 and CD20 proteins on cancer cells.
A recent phase 2 clinical trial included 47 patients with new diagnoses who either did not respond to R-CHOP or relapsed soon after treatment, a patient group that typically has low survival rates. Eighty-nine percent of those who received blinatumomab, a type of BiTE, responded partially or completely to the medication.
Mosunetuzumab is being examined in a phase 1 clinical trial involving 218 patients who relapsed or became resistant after multiple prior treatments, including some who had received CAR-T cell therapy. The findings showed that many patients went into complete remission after receiving the experimental drug. “One of the most encouraging things about this drug is that it even worked in some of the people who had not responded to CAR-T cell therapy,” Wagner- Johnston says.
With new treatments on the horizon and the potential for more second-line options, doctors and patients may be able to make more personalized choices. “We are already making significant strides with these novel treatments,” Wagner-Johnston says. “Now we need to try to understand which groups to target so we can maximize therapy and minimize toxicity. I think there’s lots of reason to be hopeful.”