Whereas chemotherapy agents are basically drugs that damage all growing cells (to a greater or lesser extent), biologic agents are drugs (usually complex manufactured proteins) that seek and bind to specific targets on the surface of cancer cells. They are—to use a crude analogy—like ‘smart bombs’ that ‘home in’ on specific characteristics of the cancer cells and, hopefully, avoid doing damage to normal cells, which do not have those targets on their surface. When they work well, biologic agents produce much less ‘collateral damage’.
The earliest drugs that worked by biological means, specifically targeting cancer cells by altering one aspect of the internal environment, were hormone treatments, which are still today a major part of the treatment of some cancers, notably cancer of the prostate and cancer of the breast.
Later I’ll show you how biological and hormone treatments are both evolving. Here, the most important thing to realise is that not all cancers can be treated by hormone or biological treatments. There are hormone agents or biologic agents presently available for a lot of cancers, but not for all. For example, if you have breast cancer and it happens to have oestrogen receptors on it, then hormone treatments (such as tamoxifen or letrozole) can be used. If it doesn’t have oestrogen receptors, then those treatments will not be effective. If the cancer cells happen to have a marker called her2/neu on them (see page 57) then a drug called trastuzumab (Herceptin) can be used in addition to chemotherapy. But if the cancer cells do not have that marker on them, Herceptin will not be of any value.
These are just a couple of examples. Biological therapy is evolving very rapidly indeed, and new biologic agents are becoming available for use in different tumours all the time. So you and your medical team will need to discuss those new agents as they emerge.
Treatment options—when can you choose?
In some cancer situations, there are several approaches to the treatment, and all of them are basically equivalent. When that happens, then you can choose among them.
In other situations, there is only one approach that is known to be effective, or at least more effective than anything else. In those situations, you have to decide whether or not the recommended plan is actually acceptable to you.
Where there are several options, all equivalent, your own preferences are highly relevant. Here’s an example. In certain cases of breast cancer we know that after removing the breast (mastectomy), radiotherapy is usually not required: there is no additional benefit in adding radiotherapy in most cases. On the other hand, there are also many cases in which the surgery is more limited—using lumpectomy or its equivalent, instead of removing the entire breast. In these latter cases, studies show very clearly that radiotherapy given after the operation is required. Without radiotherapy after limited surgery, the incidence of local recurrence, the cancer coming back in the breast or in the scar, is significant. With it, the chance of local recurrence is markedly reduced. It’s not zero, but it’s much lower than it would otherwise have been.
So, for most cases of breast cancer where the tumour is not very large, we could say that limited surgery plus radiotherapy is the same as mastectomy, in terms of local treatment. In other words, they both achieve the same result in minimising the chance of the cancer coming back in the breast area or near the scar.
This is where your preferences are paramount.
You might, let’s say, live a long way from the nearest radiotherapy centre, or it might be very awkward for you to come in to the centre every day. You might also feel that the final cosmetic result is not of major importance. If so, then you might choose (as many people do) to have a ‘once only’ mastectomy, which does not require radiotherapy afterwards.
If, on the other hand, you feel that the final cosmetic result is important and you don’t mind the extra time and inconvenience of getting the radiotherapy, and you can accept the slightly increased chance of local recurrence, then you might choose to have lumpectomy with radiotherapy as the local treatment, instead of mastectomy.
The bottom line is simply this: which treatment or combination of treatment has the highest success rate in treating this particular cancer in this particular situation?
If there are two or more combinations of treatment that have equal success rates, then it is usual to select the combination that has the lowest incidence of side effects and long-term consequences.
STEP FOUR
‘Do I have to have treatment now?’
Taking a breath—and a moment to assess the situation and the future
Another problem with thinking of all the cancers as one single rapidly progressive disease is that it’s very difficult to think calmly about treatment options and make decisions.
If you think of cancer as a single, universally and rapidly fatal disease—which, unfortunately, the majority of people still do—then you may feel a strong urge to start treatment as quickly as possible. Furthermore, if you think of every type of cancer as posing an immediate and serious threat to health and life, you might also tend to play down or even dismiss the severity or consequences of any side effects of treatment because you feel that the ends justify the means. While that is certainly true in some situations, it is not true in others.
This section will help you appreciate the range of treatment options by matching them, as far as possible, to the degree of risk in your own case.
This section is all about taking a breath—and spending a moment or two discussing and thinking about the situation, and about the options for treatment which may improve it.
For most people, the news of the diagnosis is truly shocking. And the shock is made worse, as I’ve pointed out, if you believe that all the cancers are one single disease requiring urgent and immediate treatment.
That’s why I want to make the point in this section that what really matters is balancing the benefits and the risks of the particular treatment options in your particular case.
There is no universal rule that if it’s cancer it’s got to be treated today, no matter how toxic the treatment.
What matters is getting a true and accurate picture of your own situation from your medical team, and matching the treatment with the risk.
As you will see here, there are some situations where treatment can, and should, be delayed. There are many others where it shouldn’t. And there are a few where there needs to be considerable discussion before treatment decisions can be made.
So take a leisurely look at this section. I hope that it will inform you and supply you with a background understanding of the situation, so that when you talk to your medical team, you can focus on the details of your own particular case.
Balancing potential benefits against potential risks
This question bothers almost every person who has a cancer diagnosis: ‘Do I actually need treatment now?’ (Or, more commonly, ‘Do I actually need more treatment now, after the initial surgery or the biopsy?’)
Because there are so many different cancers, and because each of them can be diagnosed at various stages in various people, it’s actually quite difficult to arrange the spectrum of treatment options into a sensible all-embracing scheme. Nevertheless, I am going to try to do that now. I will lay out a seven-category system that groups the various cancer situations together based on the primary objective or aim of treatment.
This approach is actually novel, so it might seem to some that I am putting very different tumours together under the same heading.
In a way, that’s exactly what I am doing. And it may be very useful to you. It may actually help you to understand the whole objective of the treatment of your own particular tumour if you see it compared with the treatment of another tumour. It is often easier to understand a plan of treatment when