What are the treatment options for cancer?

Treatment Options for Cancer

The treatment of cancer requires a multidisciplinary approach involving surgery, radiation therapy, chemotherapy, and targeted therapies, with selection based on cancer type, stage, and patient factors to optimize survival and quality of life. 1

Core Treatment Modalities

Surgery

• Primary treatment option for many solid tumors, particularly in early stages
• Goals include complete tumor removal (R0 resection) and appropriate lymph node sampling
• Surgical approaches vary by cancer type:
  • For colorectal cancer: Complete excision with wide lymph node dissection 2
  • For non-small cell lung cancer: Surgical excision for resectable tumors, particularly T4N0 tumors 2
  • For gastric cancer: Surgical resection for localized disease; palliative procedures (gastrojejunostomy, stenting) for obstruction in advanced disease 2

Radiation Therapy

• Used in approximately 40% of cancer patients who achieve long-term survival 3

• Can be delivered as:

  • External beam radiation therapy (EBRT) - standard approach
  • Three-dimensional conformal radiation therapy (3D-CRT)
  • Intensity-modulated radiation therapy (IMRT)
  • Volumetric modulated arc therapy (VMAT)

• Dosing strategies:

  • Conventional fractionation: 1.8-2.0 Gy per fraction
  • Short-course radiotherapy: 5 Gy per fraction for 5 days (25 Gy total) 2
  • Hypofractionated: Higher doses per fraction, fewer treatments
  • For locally advanced non-small cell lung cancer: Minimum 60 Gy with classical fractionation 2

Chemotherapy

• Used as:

  • Neoadjuvant therapy (before surgery)
  • Adjuvant therapy (after surgery)
  • Definitive therapy (without surgery)
  • Palliative therapy (for symptom control)

• Common regimens:

  • For colorectal cancer: FOLFOX (5-6 cycles) 2
  • For gastric cancer: Fluoropyrimidine (fluorouracil or capecitabine) with cisplatin or oxaliplatin 2
  • For non-small cell lung cancer: Cisplatin-based combinations 2

Targeted Therapies and Immunotherapy

• HER2-targeted therapy (trastuzumab) for HER2-positive gastric adenocarcinomas 2
• Immunotherapy for specific cancer types, particularly showing promise in combination with other modalities 2

Treatment Approach by Cancer Stage

Early-Stage Cancer

1. Localized tumors: Surgery with or without adjuvant therapy
2. For breast cancer: Lumpectomy with radiation or mastectomy, with consideration of endocrine therapy for hormone receptor-positive disease 4
3. For colorectal cancer: Surgical resection with lymph node dissection; adjuvant chemotherapy for high-risk features 2

Locally Advanced Cancer

1. Non-small cell lung cancer (Stage III):

   • Multidisciplinary evaluation is essential
   • Options include:
     • Induction chemotherapy followed by surgery for selected Stage IIIA patients 2
     • Concurrent chemoradiotherapy for unresectable disease 2
     • Minimum radiation dose of 60 Gy with classical fractionation 2

2. Rectal cancer:

   • Short-course radiotherapy (5×5 Gy) followed by surgery within 1 week for low-risk T3 tumors 2
   • For high-risk features: Short-course radiotherapy followed by consolidation chemotherapy, then surgery 2
   • Selective chemoradiotherapy for mid-upper rectal cancer 2

Metastatic Cancer

1. Goals shift to improving quality of life and prolonging survival

2. For gastric cancer:

   • Two-drug cytotoxic regimens preferred (lower toxicity)
   • Three-drug regimens reserved for medically fit patients 2
   • Palliative procedures for symptom management (stenting for obstruction, radiation for bleeding) 2

3. For esophageal cancer with metastases:

   • If good performance status: Combination chemoradiation therapy, endoscopic treatment for dysphagia, or chemotherapy 2
   • If poor performance status: Endoscopic therapy for palliation of dysphagia 2

Special Considerations for Elderly Patients

• Advanced age alone should not preclude treatment 2
• Assessment should consider biological rather than chronological age
• Older patients with good performance status can tolerate standard treatments with appropriate supportive care 2
• For elderly colorectal cancer patients: Surgical resection remains important for curative intent; adjuvant therapy should be considered based on functional status rather than age 2

Treatment Decision-Making Framework

1. Diagnosis and staging: Complete pathological diagnosis and accurate staging
2. Multidisciplinary team discussion: Input from medical oncology, radiation oncology, and surgical oncology is essential 2
3. Treatment selection based on:
   • Cancer type and stage
   • Patient performance status and comorbidities
   • Molecular and biomarker profile
   • Treatment goals (curative vs. palliative)
4. Ongoing assessment: Regular evaluation of response and toxicity

Common Pitfalls to Avoid

1. Undertreatment of elderly patients based solely on chronological age rather than performance status and comorbidities
2. Failing to involve a multidisciplinary team in treatment planning
3. Not considering quality of life impacts when selecting treatment modalities
4. Overlooking the importance of supportive care alongside cancer-directed therapy
5. Delaying palliative interventions when appropriate for symptom management

Remember that treatment decisions should be made with consideration of both survival outcomes and quality of life, with the ultimate goal of improving mortality, morbidity, and patient well-being.