Treatment goals
It is important that the goal of treatment is clear in order to manage the expectations of the patient, their relatives and the treating team. It is a requirement in the UK that the goal of treatment is recorded in the patient’s medical notes. The goal can be either with curative intent or for palliation, and there are four main indications for therapy.
Palliative chemotherapy is indicated for the majority of patients with widespread metastasis. The goal of treatment is an improvement in symptoms with a focus on improving quality of life; survival increments are secondary. As a result the treatment should be well tolerated and aim to minimise adverse effects.
Adjuvant chemotherapy is given after an initial intervention that is designed to cytoreduce the tumour bulk and remove all macroscopic disease. Chemotherapy is then given with the intention of eradicating the micrometastatic disease that remains. The focus is on achieving an improvement in disease-free and overall survival.
Neoadjuvant chemotherapy or primary medical therapy is where chemotherapy is administered before a planned cytoreductive procedure. This can result in a reduced requirement for surgery, increase the likelihood of successful debulking, reduce the duration of hospitalisation and improve the fitness of the patient prior to interval debulking. This approach has the same goals as adjuvant treatment but creates opportunity for translational research to measure responses to treatment and correlate with subsequent specimens removed at the time of surgery.
Chemoprevention is the use of pharmacological agents to prevent cancer developing in patients identified as being at particular risk. Therefore the agents used are designed to modify risk and as such should not have significant adverse effects.
Treatment approach
The dosing schedule and interval is determined by the choice of drugs and recovery of the cancer and normal tissues. For most common chemotherapy regimens, the treatment is administered every 21 or 28 days, which defines one cycle. A course of treatment often uses up to six cycles of treatment. An increase in effectiveness can be achieved by changing the approach to treatment. In some cases this will increase toxicity too, but it can change the nature of the toxicity and such developments are evaluated in clinical trials.
Low-dose therapy
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