What are the common approaches in cancer treatment?

Common Approaches in Cancer Treatment

Cancer treatment fundamentally relies on three primary modalities—surgery, radiation therapy, and systemic therapy (chemotherapy, immunotherapy, targeted therapy, and hormonal therapy)—delivered through a mandatory multidisciplinary team approach to optimize patient outcomes. 1

Multidisciplinary Team Management

All cancer patients must be managed through a multidisciplinary team (MDT) consisting of medical oncologists, surgeons, radiation oncologists, radiologists, pathologists, and specialized nurses. 1 This approach is not optional but represents the standard of care, as multidisciplinary evaluation changes treatment recommendations in 43% of cases compared to single-provider assessments. 2

• The MDT should convene before initiating definitive treatment to establish an integrated treatment plan addressing all therapeutic modalities. 1, 3
• Multidisciplinary clinics where all specialists evaluate the patient on the same day reduce time to treatment initiation by approximately 50% (12.7 vs 24.4 days to neoadjuvant chemotherapy). 4

Primary Treatment Modalities

Surgery

Surgical resection remains the only potentially curative treatment modality for solid tumors and should be pursued when complete resection is feasible. 1

• For early-stage disease (Stage I-II), complete surgical excision with appropriate lymph node assessment is the standard approach. 1
• The extent of resection must be determined by preoperative staging, with conservative techniques (e.g., breast-conserving surgery, lobectomy) preferred when oncologically appropriate. 1
• Sentinel lymph node biopsy has replaced routine axillary dissection for staging clinically node-negative disease. 5

Radiation Therapy

Radiation therapy contributes to 40% of curative cancer treatments and is utilized in approximately 50% of all cancer patients during their disease course. 6

• For definitive treatment, radiation doses should be delivered using standard fractionation (typically 2 Gy/day) with total doses exceeding 60 Gy to the tumor mass when technically feasible without excessive toxicity risk. 1
• Postoperative radiation is indicated for locally advanced disease but should be avoided in completely resected early-stage tumors (Stage I-II N0-N1). 1
• Modern radiation techniques allow increasingly tailored treatments with improved efficacy and safety profiles. 7, 6

Systemic Therapy

Systemic therapy encompasses chemotherapy, immunotherapy, targeted therapy, and hormonal therapy, with selection based on tumor histology, molecular characteristics, and disease stage. 1

Chemotherapy

• Perioperative chemotherapy (neoadjuvant and adjuvant) improves 5-year survival from 23% to 36% in resectable Stage II-III gastric cancer using platinum-based doublets with fluoropyrimidines. 1
• Platinum-based regimens (cisplatin/carboplatin) combined with etoposide or fluoropyrimidines represent standard chemotherapy backbones for multiple solid tumors. 1
• Response rates to first-line chemotherapy typically range 40-70%, with median response durations of 2-9 months in advanced disease. 1

Immunotherapy

Immune checkpoint inhibitors (ICIs) targeting CTLA-4, PD-1, and PD-L1 have revolutionized cancer treatment and are now FDA-approved for multiple solid tumors and one hematologic malignancy. 1

• Six ICIs are currently approved: ipilimumab (anti-CTLA-4), pembrolizumab and nivolumab (anti-PD-1), and atezolizumab, durvalumab, and avelumab (anti-PD-L1). 1
• Pembrolizumab and nivolumab received landmark tissue-agnostic approvals for mismatch repair deficient (dMMR) and microsatellite instability high (MSI-H) cancers—the first biomarker-driven approvals regardless of tumor origin. 1
• Combination immunotherapy (ipilimumab plus nivolumab) demonstrates enhanced efficacy in advanced melanoma compared to monotherapy. 1

Targeted and Hormonal Therapy

• Molecular biomarker testing (e.g., HER-2 status, BRCA mutations, driver mutations) must be performed to guide targeted therapy selection. 1, 5
• Hormonal therapy represents standard treatment for hormone receptor-positive cancers when appropriate. 5, 8

Treatment Sequencing and Combination Strategies

Neoadjuvant Approach

Neoadjuvant chemotherapy can be administered to patients with Stage IB, II, and IIIA tumors to potentially improve resectability, though survival benefit remains uncertain. 1

• Short-term induction chemotherapy with cisplatin-based regimens plus radiation represents the standard for unresectable Stage IIIA disease. 1
• Neoadjuvant therapy should not be routinely undertaken when complete surgical excision is uncertain; these patients should be enrolled in clinical trials. 1

Adjuvant Approach

• Adjuvant chemotherapy efficacy has not been clearly demonstrated in all tumor types and should ideally be performed within clinical trials when evidence is limited. 1
• Adjuvant endocrine therapy alone suffices for hormone receptor-positive, node-negative disease with favorable features. 8

Management of Advanced/Metastatic Disease

For distant metastatic disease (M1), treatment must be individually tailored through multidisciplinary tumor board consultation, with clinical trial enrollment strongly preferred. 1, 5

• Metastatic disease is generally incurable but treatable, with some patients achieving extended survival (many years in select circumstances). 5
• Treatment options include systemic therapy (preferred), radiation therapy for palliation or oligometastatic disease, and surgery in highly selective circumstances for resection of symptomatic lesions. 1
• Best supportive care should be provided to all patients, with palliative care alone being most appropriate for some patients based on disease extent and performance status. 1

Supportive and Complementary Care

Mind-Body Modalities

Mind-body interventions (cognitive behavioral therapy, relaxation training, hypnosis, yoga) are recommended as part of multidisciplinary care to reduce anxiety, mood disturbance, pain, chemotherapy-induced nausea/vomiting, and improve quality of life. 1

• Hypnosis demonstrates consistent efficacy for pain, fatigue, nausea/vomiting, and mood with effects reported after just one brief session. 1
• Psychosocial interventions do not prolong survival but significantly improve symptom management and quality of life. 1

Communication About Complementary Therapies

Oncology healthcare providers must routinely assess, document, and discuss complementary and alternative medicine (CAM) use as part of standard practice, as up to 87% of cancer patients use at least one CAM therapy. 1

• Nondisclosure of CAM use occurs in up to 77% of patients, primarily because providers do not ask. 1
• Seven practice recommendations include: communicating openly, assessing use, educating patients, providing decision support, documenting use, active monitoring, and adverse event reporting. 1

Management of Treatment-Related Toxicities

Immune-related adverse events (irAEs) from checkpoint inhibitors require early recognition and prompt intervention with immune suppression and/or immunomodulatory strategies, as treatment-related deaths occur in up to 2% of patients. 1

• IrAEs typically have delayed onset and prolonged duration compared to chemotherapy adverse events. 1
• Skin, gastrointestinal, endocrine, pulmonary, and musculoskeletal irAEs are relatively common, while cardiovascular, hematologic, renal, neurologic, and ophthalmologic toxicities occur less frequently. 1
• Standardized toxicity management protocols should be implemented across multidisciplinary teams. 1

Critical Pitfalls to Avoid

• Do not delay multidisciplinary evaluation—treatment recommendations change in nearly half of cases when comprehensive team assessment occurs. 2
• Do not initiate definitive treatment without molecular biomarker testing when targeted therapies may be indicated. 1, 5
• Do not dismiss patient-reported CAM use—actively inquire about all therapies to identify potential drug interactions or contraindications. 1
• Do not overlook immune-related toxicities—maintain high clinical suspicion as these can be life-threatening and require immediate intervention. 1