Treatment Modalities for Cancer

There are many types of cancer treatment. The types of treatment that you receive will depend on the type of
cancer you have and how advanced it is.
Some people with cancer will have only one treatment. But most people have a combination of treatments, such as
surgery with chemotherapy and radiation therapy.

Biomarker Testing for Cancer Treatment

Biomarker testing is a way to look for genes, proteins, and other substances (called biomarkers or tumor markers)
that can provide information about cancer. Biomarker testing can help you and your doctor choose a cancer
treatment

Chemotherapy
Chemotherapy is a type of cancer treatment that uses drugs to kill cancer cells. Learn how chemotherapy works
against cancer, why it causes side effects, and how it is used with other cancer treatments.
How chemotherapy works against cancer ?
Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly.
Chemotherapy is used for two reasons:
 Treat cancer: Chemotherapy can be used to cure cancer, lessen the chance it will return, or stop or
slow its growth.
 Ease cancer symptoms: Chemotherapy can be used to shrink tumors that are causing pain and other
problems.

Nursing Management

 Chemotherapy agents should be administered only by adequately prepared registered

professional nurses who are skilled in the administration.

 It is important that the bedside nurse be aware of the potential adverse effects of the
agent being administered.
Classification of Chemotherapeutic Agents
Routes of Administration

1. Intravenous Chemotherapy – extravasation (escaped from the vein) of some chemotherapeutic agents can
result in significant harm to the surrounding tissue. Therefor you must always know before administering a drug
whether it is a vesicant (an agent capable of causing tissue damage).
2. Regional Chemotherapy – via alternative routes allow high concentrations of drugs to be directed to localize
tumors.
Methods are: topical, intra-arterial, intracavitary, intraperitoneal, and intrathecal.
a. Topical – fluorouracil cream can be applied to the skin to treat actinic keratoses (sun keratoses).
b. Intra-Arterial – infusions involve some risk but enable major organs or tumor sites to receive maximal
exposure with limited serum levels of medications. As a result, systemic side effects are lessened.
c. Intracavity – instills the medication directly into an area such as the abdomen, bladder, or pleural space.
d. Intraperitoneal – is an option for cancer involving the intra-abdominal area, such as ovarian cancer.
e. Intrathecal – most medications given systematically are not effective against CNS tumors because they
cannot cross the BBB. Via a lumbar puncture it may instill chemotherapeutic agents into CNS.

Adverse Reaction
 Hypersensitivity reaction and extravasation.
1. Hypersensitivity Reaction – an exaggerated immune response to a foreign substance.
*The antineoplastic agents most commonly implicated in the development of hypersensitivity reactions:
 L-asparaginase (Elspar), carboplatin (Paraplatin), cisplatin (Platinol-AQ), paclitaxel (Taxol), bleomycin
(Blenoxane), and teniposide (Vumon).
*ADMINISTERING a drug with anaphylactic potential (potential to cause a possibly fatal hypersensitivity reaction).
Take the following precautions to ensure client safety:
• Obtain an allergy history from the client.
• Administer a test dose if ordered by the physician.
• Stay with the client the entire time the drug is being administered.
• Have emergency equipment and drugs readily available.
• Obtain baseline vital signs.
• Establish a free-flowing IV line for the administration of fluids and emergency drugs, in case they are needed.

Manifestation:
Dyspnea, chest tightness or pain, pruritus (itching), urticaria (wheals), tachycardia, dizziness, anxiety, agitation,
inability to speak, abdominal pain, nausea, hypotension, cloudy mental status, flushed appearance and cyanosis.
*If anaphylactic reaction is suspected, take the following actions:
• Immediately stop the drug administration
• Maintain IV access with 0.9% saline.
• Maintain the airway.
• Place the client in a supine position with the feet elevated, unless contraindicated.
• Notify the physician
• Monitor the client’s vital signs every 2 minutes until he or she is stable.
• Administer epinephrine, aminophylline, diphenhydramine (Benadryl), and corticosteroids according to the
physician’s order.

2. Extravasation
 before administering a chemotherapeutic drug, note its vesicant potential – and its Extravasatio
 Careful assessment of the IV site is required during and after the infusion of antineoplastic agents because
some agents may cause tissue damage If extravasated (infiltrated).
 Nonvesicant agents have no significant soft tissue toxicities.

Vesicant chemotherapeutic agents can cause or form a blister and cause tissue destructions. Commonly:
• doxorubicin (Adriamycin) and vincristine (Oncovin), Cisplatin (Platinol-AQ) and paclitaxel (Taxol)
 a) Irritant drug can produce venous pain at the site and along the vein, with or without an inflammatory
reaction
• Pain, erythema, swelling, and lack of a blood return indicate extravasation.

Guidelines of the management of extravasation (Oncology Nursing Society’s Cancer Chemotherapy Guidelines)
General recommendations are:
• Stop drug administration
• Leave the needle in place, and attempt to aspirate any residual drug from the tubing, needle, and site.
• Administer an antidote, if appropriate, then remove the needle.
• Do not apply direct manual pressure to the site.
• Apply warm (for vinca alkaloid) or cold compresses as indicated.
• Observe the site regularly for pain, erythema, swelling, induration and necrosis.
• Document the appearance of the site before and after chemotherapy.
Safe preparation, Handling, and Disposal.

Undue exposure to antineoplastic drugs can occur from three major routes:
• Inhalation of aerosols
• Absorption through the skin
• Ingestion of contaminated materials

Guidelines:
1. The wearing of gloves and gowns during preparation and administration.
2. The use of a biologic safety or laminar-flow cabinet for preparation.

Immunotherapy
Immunotherapy is a type of cancer treatment that helps your immune system fight cancer. The immune system
helps your body fight infections and other diseases. It is made up of white blood cells and organs and tissues of the
lymph system.
Immunotherapy is a type of biological therapy. Biological therapy is a type of treatment that uses substances made
from living organisms to treat cancer.

 uses the immune system, the body’s main defense against infection and disease, to fight cancer. Some types
of immunotherapy are called biologic therapy.
 Immunotherapy can (1) boost or manipulate the immune system and create an environment that is not
conducive for cancer cells to grow or (2) attack cancer cells directly.
 Types of immunotherapy include cytokines, vaccines, and monoclonal antibodies.
 Antibodies are proteins made by the immune system that bind to a target antigen on the cell surface.
Monoclonal antibodies (drugs ending in -mab) are the most successful immunotherapy. Because each
antibody is specific to an antigen, that mechanism is used to develop specific drugs to treat cancer. Many of
the monoclonal antibodies are targeted therapies.

Side effects of Immunotherapy

 The administration of one type of immunotherapy usually induces the endogenous release of other
agents. The release and action of these agents result in systemic immune and inflammatory
responses.
 Common side effects include flu-like symptoms, including headache, fever, chills, myalgias, fatigue,
malaise, weakness, photosensitivity, anorexia, and nausea.
How does immunotherapy work against cancer?

As part of its normal function, the immune system detects and destroys abnormal cells and most likely prevents or
curbs the growth of many cancers. For instance, immune cells are sometimes found in and around tumors. These
cells, called tumor-infiltrating lymphocytes or TILs, are a sign that the immune system is responding to the tumor.
People whose tumors contain TILs often do better than people whose tumors don’t contain them.
What are the types of immunotherapy?
Several types of immunotherapy are used to treat cancer. These include:
 Immune checkpoint inhibitors, which are drugs that block immune checkpoints. These checkpoints are a
normal part of the immune system and keep immune responses from being too strong. By blocking them,
these drugs allow immune cells to respond more strongly to cancer.
 T-cell transfer therapy, which is a treatment that boosts the natural ability of your T cells to fight cancer. In
this treatment, immune cells are taken from your tumor. Those that are most active against your cancer are
selected or changed in the lab to better attack your cancer cells, grown in large batches, and put back into
your body through a needle in a vein.
T-cell transfer therapy may also be called adoptive cell therapy, adoptive immunotherapy, or immune cell therapy.
 Monoclonal antibodies, which are immune system proteins created in the lab that are designed to bind to
specific targets on cancer cells. Some monoclonal antibodies mark cancer cells so that they will be better
seen and destroyed by the immune system. Such monoclonal antibodies are a type of immunotherapy.
Monoclonal antibodies may also be called therapeutic antibodies.
 Treatment vaccines, which work against cancer by boosting your immune system’s response to cancer cells.
Treatment vaccines are different from the ones that help prevent disease.
 Immune system modulators, which enhance the body’s immune response against cancer. Some of these
agents affect specific parts of the immune system, whereas others affect the immune system in a more
general way.

Radiation Therapy

Radiation therapy is a type of cancer treatment that uses high doses of radiation to kill cancer cells and shrink
tumors. Learn about the types of radiation, why side effects happen, which side effects you might have, and more.
Radiation therapy (also called radiotherapy)
 XRT may be used as a primary, an adjuvant, or a palliative treatment.
 When used as a primary modality, it is only treatment used and aims to achive local cure of the
cancer (e.g., early-stage Hogkin’s Disease, skin cancer, prostate cancer, carcinoma of the cervix).
 As an adjuvant treatment, XRT is used either preoperatively or postoperatively to aid in the
destruction of cancer cells (e.g., colorectal cancer, early breast cancer).
 Can be used in conjunction with chemotherapy to treat disease in sites not readily accessible to
systemic chemotherapy, such as the brain.
 As a palliative treatment, XRT can be used to reduce pain association with obstruction, pathologic
features, spinal cord compression, and metastasis. When the cancer widespread, XRT is not
appropriate, for too much normal issue would be harmed.
 May be used to destroy tumor in localized area to relive a distressing manifestation. A few
radiation treatments can be quite effective in relieving pain from a metastatic bone lesion.

How radiation therapy works against cancer

At high doses, radiation therapy kills cancer cells or slows their growth by damaging their DNA. Cancer cells whose
DNA is damaged beyond repair stop dividing or die. When the damaged cells die, they are broken down and
removed by the body.
 Radiation therapy does not kill cancer cells right away. It takes days or weeks of treatment before DNA is damaged
enough for cancer cells to die. Then, cancer cells keep dying for weeks or months after radiation therapy ends.

Types of radiation therapy

There are two main types of radiation therapy, external beam and internal.

1. Excisional-Beam Radiation Therapy – or teletherapy is delivery of radiation from a source placed at some
distance from the target site.

 The dose of radiation that reaches the surrounding normal tissues is reduced, leading to much less toxicity.

a. Intensity-modulated radiation therapy (IMRT) - Treatment enhancements in EBRT include the ability to
control different intensity or energy levels of radiation beams at different angles directed at the tumor. Enables
higher doses to be delivered to the tumor while sparing the important healthy structures surrounding the tumor. Be
given as hyperfractionated twice-daily.

b. Image-guided radiation therapy (IGRT) – uses continuous monitoring of the tumor with ultrasound, x-ray,
or CT scans during the treatments to allow for automatic adjustment of the beams as the tumor changes shape or
position in an effort to spare the healthy surrounding tissue and reduce side effects. Additional treatment
enhancements include respiratory gaiting, where the treatment delivery is actually synchronized with the patient’s
respiratory cycle, enabling the beam to be adjusted as the tumor or organ moves.

c. Stereotactic boy radiotherapy (SBRT) – uses higher dose of radiation to penetrate very deeply into the
body to control deep-seated tumors that cannot be treated by other approaches such as surgery. Usually 1 to 5
treatment days per week for 6 to 8 weeks for conventional EBRT.

d. Proton therapy – utilizes higher linear energy (LET) in the form of charged protons generated by a large
magnetic unit called a cyclotton. It is capable of delivering its high-energy dose to a deep-seated tumor, with
decreased doses of radiation to the tissues in front of the tumor while virtually no energy exist through the
patient’s healthy tissue behind the tumor. Deep tumors in close proximity to critical structures, such as heart or
major blood vessels.

2. Internal Radiation Therapy – involves placement of specifically prepared radioisotopes (radioactive

isotopes) directly into or near the tumor itself (brachytherapy) or into the systemic circulation.

• Sealed-Source Radiation Therapy – (radioactive material is enclosed in a sealed container)- is used for both
intracavity and interstitial therapy.

2 Major Types

1. Intracavity therapy- the radioisotope, usually cesium 137 or radium 226, is put in an applicator, which is then
placed in the body cavity for a carefully calculated time, generally 24-72 hrs.

 are used to treat gynecologic cancers, such as the uterus and cervix.
2. Interstitial therapy- the radioisotope of choice (e.g., iridium 192, iodine 125, cesium 137, gold 198, or radon 222)
is placed in needles, beads, seeds, ribbons or catheters, which are then implanted directly into the tumor.

 use to treating such malignancies as prostate, pancreatic, or breast cancer. May be temporary or
permanent, depending on the site and radioisotopes used.

a. Unsealed-Source Radiation Therapy – (radioactive material is administered systematically, such as by

injection or orally.) – are used in systemic therapy.

External beam radiation therapy

External beam radiation therapy comes from a machine that aims radiation at your cancer. The machine is large
and may be noisy. It does not touch you, but can move around you, sending radiation to a part of your body from
many directions.

External beam radiation therapy is a local treatment, which means

it treats a specific part of your body. For example, if you have cancer in your lung, you will have radiation only to
your chest, not to your whole body.

Internal radiation therapy

Internal radiation therapy is a treatment in which a source of radiation is put inside your body. The radiation source
can be solid or liquid.
Internal radiation therapy with a solid source is called brachytherapy. In this type of treatment, seeds, ribbons, or
capsules that contain a radiation source are placed in your body, in or near the tumor. Like external beam radiation
therapy, brachytherapy is a local treatment and treats only a specific part of your body.

With brachytherapy, the radiation source in your body will give off radiation for a while.

Internal radiation therapy with a liquid source is called systemic therapy. Systemic means that the treatment
travels in the blood to tissues throughout your body, seeking out and killing cancer cells. You receive systemic
radiation therapy by swallowing, through a vein via an IV line, or through an injection.

With systemic radiation, your body fluids, such as urine, sweat, and saliva, will give off radiation for a while.
TOXICITY
 acute or early toxicity most often begin within 2 weeks of the initiation of treatment occur when normal
cells within the treatment area are damaged and cellular death exceeds regeneration.
 Body tissues most affected are those that normally proliferate rapidly such as the skin, the epithelial lining of
the gastrointestinal tract, and the bone marrow.
 Altered skin integrity is common and can include alopecia (hair loss) associated with whole brain radiation.
 Other skin reactions, occur along a continuum ranging from erythema and ry desquamation (flaking of skin)
to moist or wet desquamation to potentially ulceration.
 Factors that contribute to severity of radiation dermatitis; the dose and form of radiation, inclusion of skin
folds in the irradiated area, increased age and the presence of medical comorbidities.
Systemic side effects:
 Fatigue, malaise, and anorexia (may be secondary to substances released when tumor cells are destroyed)
 Early effects tend to be temporary and most often subside within 6 months of the cessation of treatment
  Late effects (approximately 6 months to years after treatment) of radiation may occur in body tissues that
were in the field of radiation. These effects are chronic, a result of permanent damage to tissues, loss of
elasticity, and changes secondary to a decreased vascular supply.
 Severe late effects include fibrosis, atrophy, ulceration, and necrosis and may affect the lungs, heart, central
nervous system, and bladder.
RADIATION SAFETY STANDARDS
Three key principles you should follow to protect yourself and others from excessive radiation exposure:
1. Distance – less exposure dose of ionizing rays.
2. Time – minimize the amount of time you are exposed to the radiation source. (Limited to 30 mins of direct
care per 8-hour shift.)
3. Shielding – reduces radiation exposure as the thickness of the lead shiel is increased and maintain maximum
distance as well and limit the duration of exposure.

 The staff members caring for clients with radioactive implants are rotated to limit the amount of exposure of
each employee.
 Staff members must wear their own film badges or dosimeters while in the client’s room.
 Talk the client from the doorway of the room.
 Encourage family to telephone.
 Prepare the client ahead of time for limited employee contact.
 Before the radiation source is inserted, the client should be provided with ways to pass time.

Treatment Consideration for Radiation Therapy

1. Tumor location in relation to surrounding normal tissue affects both treatment effects and side effects.
2. The size of the treatment field affects the dose of XRT. If a small area is treated, the client can tolerate a
higher dose of radiation than if a larger area is treated.
3. The clint’s overall health or performance status affects the ability to tolerate XRT.
4. The therapeutic ratio of the treatment effects on the tumor to the side effects on normal tissue is an
important cost=benefit determination is decision making about XRT.
5. The side effects a client may experience are related to total dose or radiation.
6. In general, only the area in the treatment field is affected by the radiation.
7. Administering the radiation in divided (fractionated) rather than single doses minimizes the side effects by
allowing the normal cells time to recover.

Surgery
When used to treat cancer, surgery is a procedure in which a surgeon removes cancer from your body. Surgery is
used to treat many types of cancer. It works best for solid tumors that are contained in one area.

 Has a major role in the diagnosis, staging treatment of cancer.

 It is also an integral part of the rehabilitation and palliation for clients with cancer.
 Surgery is use less frequently as a method of cancer prevention.
 Preoperatively, evaluate the client’s understanding of the proposed procedure and the physical change that
will occur. Clients with cancer may be nutritionally compromised and may require nutritional therapy.

Diagnostic Surgery
 the biology of the tumor, its size and location, and the proposed method of treatment
determine which surgical method should be used.
  A negative biopsy result does not prove the absence of cancer but rather might indicate
inadequate or misplaced tissue sampling. Negative needle biopsy results generally must be
followed by additional specimen collections to obtain an accurate diagnosis.
1. Cytologic specimens – can be obtained from tumors that tend to shed cells from their surface.
 Examination of fluids aspirated from the effusion or ascitic fluid.
 Specimen may collected using an endoscope to examine a questionable area – direct visualization of GI tract,
bronchoscopy of the lungs, laryngoscopy of the larynx, colposcopy of the cervix an vagina, cystoscopy of the
bladder, or laparoscopy of the pelvic or abdominal cavity.
 During these test, areas of concern can be examined, tissue samples and aspirates taken for biopsy, the
extent of the disease staged, and pathological processes excised.
2. Needle Biopsy – a simple method of obtaining tissue samples.
 In a fine-needle aspiration, tumor cells are withdrawn from the tumor with a needle and syringe. A core-
needle biopsy is essentially the same procedure; however, the needle is larger, and a core or barrel of tissue
is obtained.
 Core needle allows to examine the cells with their spatial relationship intact, whereas fine-needle aspiration
provides individual cells or clumps of cells for review.
3. Excisional Biopsy and Incisional Biopsy – the size of the tumor an the purpose of the biopsy determine if an
excisional or incisional biopsy is performed. If the suspected tumor is small, the entire tumor is excised for
examination.
 If the suspected tumor is small, the entire tumor is excised for examination (called total or excisional type of
biopsy). It is used for small tumors (2 t o3 cm) for which the biopsy also may serve as the treatment if the
tissue margins contain no tumor cells.

 If it tumor cells remain, a wider excision is required. If the tumor is large, only part of the neoplasm is
excised (called subtotal or incisional type of biopsy).

SELECTED TECHNIQUES USED FOR LOCALIZED DESTRUCTION OF TUMOR TISSUE

 Chemosurgery- Use of chemicals applied directly to tissue to cause destruction

 Cryoablation- Use of liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction
 Electrosurgery- Use of an electric current to destroy tumor cells
 Laser surgery- Use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells
 Photodynamic therapy- IV administration of a light sensitizing agent (hematoporphyrin derivative (HPD)
that is taken up by cancer cells, followed by exposure to laser light with-in 24-48 hours; causes cancels death
 Radiofrequency ablation (RFA)- Uses localized application of thermal energy that destroys cancer cells
through heat; temperature exceed 50 °C (122°F)

Surgery as Treatment

 When surgery is performed with curative intent, the type of tumor determines the extent of the excision.
 For slow-growing tumors, such as squamous cell carcinoma and adenocarcinoma of the skin, a wide local
excision may be sufficient. Tumors of the colon and breast that spread to the regional lymph nodes are
removed with an en bloc excision of the tumor and regional lymph nodes.
 Large tumors, such as sarcoma, which tend to spreads locally without metastasis, are removed with radical
excision, such as aputations.
  In all surgical procedures, various operative techniques and wound irrigation with cytotoxic agent, are used
to prevent dissemination of tumor cells into and beyond the operative field.

Surgery for Recurrence and Metastasis

 Cancer that recurs locally can be resected, resulting in occasional cure, remission or both.
 Local recurrences of sarcoma as well as colon, breast, and skin cancers have been successfully excised.

Excision of metastatic lesions is considered if:

• No other evidence of disease exists and;

• The metastatic lesion has appeared after relatively long disease-free

interval.

 Solitary metastatic lesions that appear in the lungs, liver, or brain can sometimes be removed and obtain
surgical cure.

 Metastatic lesion must exhibit some stability and must be refractory (unreponsive) to chemotherapy and
XRT.

 Metastatic renal cell carcinomas, sarcomas, melanomas, and colon carcinomas have been removed in
selected clients, resulting in cures or prolonged survival intervals.

Prophylactic Surgery

 Risk reduction surgery involves removing non-vital tissues or organs that are at increased
risk of developing cancer.

Factors that are considered when discussing possible prophylactic surgery;

 Family history and genetic predisposition

 Presence or absence of signs and symptoms
 Potential risk and benefits
 Ability to detect cancer at an early stage
 Alternative options for managing increased risk
 The patient’s acceptance of the postoperative outcome (colectomy, mastectomy, and oophorectomy)
 Palliative Surgery

 Carefully considered and used only if the risk-benefit ratio is favorable.

 That benefits client with cancer and improves quality of life includes procedure that;

a) Reduce pain by such means as interrupting nerve pathways or implanting pain-control

pumps.
b) Relive airway obstructions
c) Relieve obstruction in GI and urinary tracts.
d) Relive pressure on the brain or spinal cord
e) Prevent hemorrhage
f) Remove infected and ulcerating tumors, and;
g) Drain abscesses.

Reconstructive Surgery

o Offer a different perspective on rehabilitation to the client who has experienced curative surgery.
o Restoration of form and function is possible to varying degrees, depending on the sire and extent of
surgery.
o Major goal is to improve the client’s quality of life by restoring maximal function and appearance.

Preventive Surgery

o The client at unusually high risk for cancer may elect to undergo a preventive (prophylactic) surgical
intervention.
o Certain condition or diseases increase the risk of cancer occurrence so significantly that removal of
the target organ is justified to prevent cancer development.
o Prophylactic mastectomy (breast removal) and oophorectomy (ovary removal) are controversial
preventive therapies.

Nursing Management

To help the client manage outcomes effectively, the nurse must not only provide excellent care during the
hospitalization but also proactively assist the client with continuing care. The value of home nursing care for cancer
patients is well documented.

Types of surgery
 There are many types of surgery. The types differ based on the purpose of the surgery, the part of the body that
requires surgery, the amount of tissue to be removed, and, in some cases, what the patient prefers.

Surgery may be open or minimally invasive.

 In open surgery, the surgeon makes one large cut to remove the tumor, some healthy tissue, and
maybe some nearby lymph nodes.
 In minimally invasive surgery, the surgeon makes a few small cuts instead of one large one. Inserts a
long, thin tube with a tiny camera into one of the small cuts. This tube is called a laparoscope. The
camera projects images from the inside of the body onto a monitor, which allows the surgeon to see
what they are doing. They uses special surgery tools that are inserted through the other small cuts to
remove the tumor and some healthy tissue.

Because minimally invasive surgery requires smaller cuts, it takes less time to recover from than open surgery.
How surgery works against cancer
Depending on your type of cancer and how advanced it is, surgery can be used to:
 Remove the entire tumor
Surgery removes cancer that is contained in one area.
 Debulk a tumor
Surgery removes some, but not all, of a cancer tumor. Debulking is used when removing an entire tumor
might damage an organ or the body. Removing part of a tumor can help other treatments work better.
 Ease cancer symptoms
Surgery is used to remove tumors that are causing pain or pressure.

BIOTHERAPY

 The use of agents to affect a biologic response.

 Immune response remains the core of biotherapy.
 Includes agents that change the relationship between the tumor and the host by altering the host’s response
to the tumor.

Types:

[Link] Growth Factors

Hematopoietic Growth Factors:

 Are glycosylated proteins that mediate hematopoiesis (the formation and development of blood cells.)
 Hematopoietic growth factors are used to support patients through their cancer treatment.
 They stimulate bone marrow recovery after chemotherapy.

Side effects of Growth Factors are:

Mild to moderate flu-like manifestations, rash, a transient increase in liver enzymes, and thrombocytopenia.

Hematopoietic Stem Cell Transplantation

 Are effective, lifesaving procedure for the treatment of several malignant and nonmalignant diseases.
 Both allow for the safe use of very high doses of chemotherapy agents and/or radiation therapy in patients
whose tumors have developed resistance (refractory) or did not respond to standard doses of
chemotherapy and radiation. Although these procedures are lifesaving, patients may have long-term or
delayed complications that can affect their quality of life.
 The approach in HSCT is to eradicate diseased tumor cells and/or clear the bone marrow of its components
to make way for engraftment of the transplanted, healthy stem cells. This is done by giving higher than
usual dosages of chemotherapy with or without radiation therapy. Life-threatening consequences associated
with pancytopenia and other adverse effects can result from this procedure. After chemotherapy and
radiation therapy are over, healthy stem cells are infused. These healthy stem cells “rescue” the damaged
bone marrow through subsequent proliferation and differentiation of the donated stem cells in the
recipient.

TYPES:

HSCTs are categorized as allogeneic, syngeneic, or autologous.

1. Allogeneic – stem cells are acquired from a donor (graft) who, through human leukocyte
antigen (HLA) tissue typing, has been determined to be HLA matched to the recipient (host).
HLA typing involves testing WBCs to identify genetically inherited antigens common to both
donor and recipient that are important in compatibility of transplanted tissue. Common
indications for allogeneic transplant are certain leukemias, multiple myeloma, and
lymphoma.

2. Syngeneic – is a type of allogeneic transplant that involves obtaining stem cells from one
identical twin and infusing them into the other. Identical twins have identical HLA types
and are a perfect match.

3. Autologous – patients receive their own stem cells back after myeloablative (destroying
bone marrow) chemotherapy. The aim of this approach is purely “rescue.” It allows patients
to receive intensive chemotherapy and/or radiation by supporting them with their
previously harvested stem cells until their marrow generates blood cells again on its own.
Restoration usually takes about 4 to 6 weeks.

4. Myeloablative- consists of giving patients high-dose chemotherapy and, occasionally, total

body irradiation.
 5. Non-myeloablative- Also called mini-transplants; does not completely destroy bone marrow
cells

2. Biologic Response Modifiers – immune biologic responses. It modifies the relationship between the host and the
tumor. It may modulate, or restore the immune response and they may cytotoxic effects

 Nonspecific Biologic Response Modifiers- such as bacille Calmette-Guérin (BCG) and Corynebacterium
parvum, when injected into the patient, these agents serve as antigens that stimulate an immune response.

 Monoclonal Antibodies (MoAbs)- through technologic advances, enabling investigators to grow and
produce targeted antibodies for specific malignant cells.
When the MoAb attaches to the cell surface antigen, an important signal transduction pathway for communication
between the malignant cells and the extracellular environment is blocked. The results may include an inability to
initiate apoptosis, reproduce, or invade surrounding tissues

 Cytokines- substances produced primarily by cells of the immune system to enhance or suppress the
production and functioning of components of the immune system, are used to treat cancer or the adverse
effects of some cancer treatments.
a) Interferons (IFN’s)– are cytokines (small proteins) that have cellular activity in 3 areas: antiviral,
immunomodulatory (inhibition or stimulation of the immune system), and
antiproliferative/antitumor
b) Interleukins (IL’s)– are cytokines (proteins) that serve as regulators of immune system. It is
produced by subsets of T-cell lymphocytes, natural killer cells and dendritic cells (cells that present
antigens to immune system).
 Cancer Vaccines – mobilize the body’s immune response to prevent or treat cancer.
 Autologous vaccines are made from the patient’s own cancer cells, which are taken from tumor tissue
obtained during biopsy or surgical intervention. The cancer cells are killed and prepared for injection back
into the patient.
 Allogeneic vaccines are made from cancer cell lines that are immortalized cells that were originally obtained
from other people who had a specific type of cancer. These cancer cells are grown in a laboratory and
eventually killed and prepared for injection.
 Prophylactic vaccines prevent disease. Three vaccines have been approved by the FDA for the prevention of
HPV.
 HPV2 (Cervarix), recommended for use in females only, protects against HPV types 16 and 18 that are
responsible for about 70% of all cervical cancers (ACS, 2015a).
 HPV4 (Gardasil) provides protection against four HPV types (6, 11, 16, and 18) and is recommended for use
in both males and females.
  HPV9 (Gardasil-9), recommended for both males and females, protects against nine HPV types associated
with cervical, anal, vaginal, and vulvar cancers. HPV9 also protects against genital warts.

(All of the HPV vaccines are given as a series of three doses over 6 months.)

Gene Therapy

 Gene therapy includes approaches that correct genetic defects, manipulate genes to induce tumor cell
destruction, or assist the body’s immune defenses in the hope of preventing or combating disease.

 Challenges confronting cancer gene therapy is the multiple somatic mutations involved in the development
of cancer, making it difficult to identify the most effective gene therapy approach

 At this time, there are no FDA-approved gene therapies for cancer.

Three approaches have been used in the development of gene therapies, with adenoviruses showing the most
promise in each:

 Tumor-directed therapy- is the introduction of a therapeutic gene (suicide gene) into tumor cells in an
attempt to destroy them. This approach is challenging because it is difficult to identify the gene that would
cause optimal tumor destruction, and patients with widespread disease would require multiple injections to
treat every site of disease.

 Active immunotherapy -is the administration of genes that will invoke the antitumor responses of the
immune system.

 Adoptive immunotherapy- is the administration of genetically altered lymphocytes that are programmed to
cause tumor destruction.
Bone marrow transplant

 May be considered as a treatment for clients with the following:

a) Aplastic anemia
b) Malignant disorders, specifically myelodysplastic syndromes, leukemia (certain types of acute leukemia,
chronic leukemic, and preleukemic states), lymphoma, multiple myeloma, neuroblastoma, and selected solid
tumors (breast cancer, ovarian cancer, testicular cancer, poor-risk germ cell tumors)
 c) Nonmalignant hematologic disorders, such as Fan coni anemia, thalassemia, and sickle cell anemia
d) Immunodeficiency disorders, such as severe combined immunodeficiency disease and Wiskott Aldrich
syndrome

a. BMT may be used to counter the toxic effects of chemotherapy or XRT in the treatment of breast
cancer, lymphoma, and other cancers.
b. BMT allows the client to receive lethal and potentially more effective doses of chemotherapy and
XRT without regard to hematopoietic toxicity.
c. With BMT, the damaged bone marrow is replaced by healthy marrow.

BONE MARROW HARVESTING

Allogeneic Bone Marrow is obtained from a relative or unrelated donor having a closely matched HLA type. This
was the most common type of marrow transplant, but it carried the highest rate of morbidity and mortality because
of complications of incompatibility such as graft-versus-host disease (GVHD). The rate of allogeneic transplants has
dropped with the drop in the birth rate and the increased use of autologous and peripheral stem cell transplants.

 Use of marrow from matching donor.

Syngeneic Bone Marrow is donated by an identical twin. Al though syngeneic marrow is a perfect HLA match, which
eliminates the risks of marrow rejection, the incidence of leukemic relapse is higher than when an allogeneic donor
is used because GVHD is considered to have an antileukemic effect.

Autologous Bone Marrow is removed from the intended recipient during the remission phase to allow another
course of ablative therapy to be given if a relapse occurs. Although autologous marrow eliminates the risk of
adverse immunologic responses, such as GVHD and graft rejection, relapse after autologous BMT is a frequent
occurrence.

 The client’s own marrow may be harvested prior to treatment.

 I f the client’s own marrow was harvested, the marrow may or may not have been chemically treated to
destroy any cancer cells. It is the stored (frozen) to be reinfused after the chemotherapy or RT to “RESCUE”
the bone marrow from the lethal effects of the treatment.

GRAFT-VERSUS-HOST DISEASE rejection to bone marrow transplantation.