NHS Oncology Program (Important Phone Numbers)

Cancer: The Disease

Cancer is a disease that starts in our cells. Our bodies are made up of millions of cells, grouped together to form tissues and organs such as muscles and bones, the lungs and the liver. Genes inside each cell order it to grow, work, reproduce and die. Normally, our cells obey these orders and we remain healthy. Sometimes the instructions get mixed up, causing the cells to form lumps or tumours, or spread through the bloodstream and lymphatic system to other parts of the body.

Cancer starts from cells within our body.

You cannot catch cancer from another person or pass it on to anyone else.

Cancer that starts in the bladder but spreads to the lungs is still called bladder cancer with lung metastasis.

Tumours can be either benign or malignant. Benign tumour cells stay in one place in the body and are not usually life-threatening.

Malignant tumour cells are able to invade nearby tissues and spread to other parts of the body. Cancer cells that spread to other parts of the body are called metastases.

Cancers are named after the part of the body where they start. For example, cancer that starts in the bladder but spreads to the lung is called bladder cancer with lung metastases.

Information adapted from www.cancer.ca

It is still not possible to tell exactly what causes an individual’s cancer.

Staging

The stage of a cancer is determined by:

• the size of the tumor
• whether the cancer is invasive or non invasive
• whether lymph nodes are involved
• whether the cancer has spread beyond its original site

The purpose of the staging system is to help organize the different factors and some of the personality features of the cancer into categories. Staging is only one piece of information used by your oncologist to plan your treatment. For further information about your stage of cancer, speak to your oncologist.

Common tests ordered for staging, screening and follow up purposes may include:

Chest X-Ray
Used to see if there are deposits of cancer cells within the lungs. An X-ray may show if fluid is present between the lung and the chest wall.

Blood tests
Will vary depending on the type of cancer. Blood tests help to assess the effects of a tumour or treatment on the rest of your body.

Ultrasound
A test that uses high frequency sound waves to form a picture of the internal organs.

Computed Axial Tomography (CAT or CT scan)
A test that combines special x-ray equipment with specialized computers to produce multiple images or pictures of the inside of the body and is able to detect deposits of cancer cells.

Bone Scan
A specialized radiology procedure used to examine the bones of the body to detect areas where cancer cells may have spread.

Magnetic Resonance Imaging (MRI)
A procedure that creates images of the body using powerful magnets and radio waves. Provides detailed images of the body to detect deposits of cancer cells.

Mammogram
An easy Xray of the breast to aid in the detection of cancer cells in the breast

Multi Gated Acquisition Scan (MUGA SCAN)
A non-invasive test that produces a moving image of the heart to evaluate how well your heart is working. It allows the heart’s major pumping chamber (the left ventricle) to be assessed.

Colonoscopy
An exam of the large colon and part of the small bowel with a camera on a flexible tube passed through the anus allowing for visualization or biopsy of a growth.

“It is more important to have the right tests done rather than deciding about treatment using inadequate information.”

Cancer Treatment

“Just as each person is different, each individual’s cancer experience and treatment is different.”

The type of treatment offered to you will depend on:

• the type of cancer
• the size of the tumour
• if the cancer has spread to other parts of your body.

You and your doctor will decide on what treatments will work best for you. Some common treatments for cancer are:

• Surgery
• Systemic Therapy
• Radiation Therapy

Surgery

There are different methods of surgery for the various types of cancer. Each type of cancer has its own way of growing or spreading which determines which surgical approach is used.

To effectively remove a cancer, a surgeon must remove not only the original tumour but also any cancer cells which may have travelled outside the primary tumour area. This may include nearby lymph nodes.

Cancer cells are very small, about 100 million of them can sit on the head of a pin. Even the most accurate test may not detect these cells.

When a surgeon tells a patient “I got it all,” they generally mean they have removed all the cancer that they could see.

Sometimes, cancer cells are left. This is because they are so small they cannot be seen.

There is always a chance or risk that these cells may grow again.

The degree of risk depends on:

• the type of cancer
• the stage of cancer
• the amount of tissue removed at surgery.

Systemic Therapy

Chemotherapy

Chemotherapy is treatment with anticancer drugs. Anticancer drugs are powerful agents that work by destroying cancer cells or by preventing them from multiplying, growing or spreading to other parts of your body.

When you are given a single dose chemotherapy, the agent will only kill some of the cancer cells. That is why most people are given a number of chemotherapy cycles.

Chemotherapy agents may affect the whole body, so healthy cells can also be damaged. This damage to healthy cells causes side effects. These side effects are temporary because the healthy cells will repair themselves.

Goals of Chemotherapy

The choice of treatment to be used will depend on the kind of cancer you have, its stage and what the goal of the treatment is. Chemotherapy is usually given in addition to other cancer treatments, such as surgery, radiation, or other systemic therapies. Your interprofessional team will explain why chemotherapy is a treatment option for you. The goals of your treatment may be to:

• Cure the cancer
  Chemotherapy, by itself or with another treatment, is given to destroy cancer cells in the body. Many types of cancer can be treated with a combination of chemotherapy agents.
• Shrink a tumour before other treatments (neoadjuvant chemotherapy)
  Sometimes chemotherapy is given to shrink a tumour before surgery or radiation
• Destroy cancer cells after other treatments (adjuvant chemotherapy)
  Chemotherapy is often given in addition to surgery or radiation treatments to destroy cancer cells that may have been missed by the surgery or radiation
• Prepare for a bone marrow or stem cell transplant (ablative chemotherapy)
  Chemotherapy is used to destroy the bone marrow before it is replaced by the stem cells or bone marrow from a donor
• Relieve symptoms caused by cancer (palliative chemotherapy)
  Chemotherapy may be given to reduce pain and other symptoms of cancer.

Targeted Therapy

• cancer cells need certain small compounds in the body to grow
• Targeted Therapy is a treatment that interferes with these compounds so that the cancer cells can not use them to grow
• because Targeted Therapies are made to work only on the cancer cells, they do not cause the same types of side effects as chemotherapy
• some of these medicines are taken orally (a tablet or a capsule), and some are given in the clinic intravenously

Biologic Therapy

• your immune system is your body’s defence against disease
• Biologic Therapies are medicines that work with your immune system to help fight your cancer (also called Immunotherapy)
• these drugs are made from natural sources, but they do have side effects, including allergic-type reactions and flu-like symptoms
• may be given intravenously or by injection

Hormonal Therapy

• hormones are natural substances or chemicals in your body
• some types of cancer use these hormones to help them grow
• Hormonal Therapies are drugs that stop certain hormones from being made, or from being active in the body
• stopping the hormones can stop the cancer cells from growing
• may be given orally or by injection

How is Systemic Therapy Given?

The most common ways of giving chemotherapy medications are by mouth (orally), or by intravenous infusion (IV) into a vein or a combination of the two. Your interprofessional team will help you decide on the method that is best for you.

By mouth (orally)
Some systemic therapy drugs can be taken in a pill or capsule form. If you are taking systemic therapy drugs by mouth it is very important to take them as directed. If you change the amount you are taking or the time between pills your treatment may not work as well or it may cause side effects.

• Always take the prescribed dose at the right time. Follow the instructions about taking the drug before or after meals, or with liquids
• Always wash your hands after taking your dose, especially after you touch the medication.
• If you forget to take a dose, follow the instructions from your interprofessional team

By intravenous infusion (IV)
Some systemic therapy drugs need to be infused directly into your bloodstream and are delivered into a vein in your lower arm or through a central venous access device. These drugs can be infused intermittently in the oncology clinic or continuously. When the chemotherapy is ordered over an extended period of time, the chemotherapy is started in the oncology clinic and infused via a pump over 24 hours for a preset number of days at home.

By injection (often referred to as “shot”)
Some systemic therapy drugs are given through a needle under the skin into the tissue or a muscle. (Information adapted from Canadian Cancer Society’s “Chemotherapy” – A Guide For People With Cancer)

Systemic Therapy Side Effects

Everyone responds differently to each systemic therapy drug. Your interprofessional team cannot say for sure how you will tolerate the chemotherapy but will provide you with a list of potential side effects. Many of the side effects can be managed or lessened so it is important to have good communication with your interprofessional team so they can help you to minimize the side effects and allow you to carry on your normal activities as much as possible. Side effects will gradually disappear when treatment is over, depending on the types of drugs you were taking and your general physical health. Some side effects may be permanent. You will be asked to attend a one hour systemic therapy education class about the clinic and systemic therapy treatment.

Central Venous Access Devices

A central venous access device (CVAD) is a catheter used to deliver intravenous fluids, chemotherapy, medications or blood components. The tip of the catheter sits in the large blood vessel right above the heart called the superior vena cava (SVC). Different types of catheters exit the body at different places. Your interprofessional team will discuss with you if a central line is appropriate for you.

Implanted Vascular Access Device (IVAD-Port)

The implanted vascular access device is inserted by a surgeon or radiologist using a local freezing and is considered a long-term access device. It is a chamber placed under the skin in your chest that connects to a catheter that leads to the SVC. It is completely under the skin and has no parts outside of your body. The IVAD is accessed each time with a special needle through the skin. When not in use the IVAD needs to be flushed monthly. A dressing is only required when the IVAD is accessed.

Peripherally Inserted Central Catheter (PICC)

The Peripherally Inserted Central Catheter is a catheter inserted at the bedside by a specially trained registered nurse using ultrasound and a cream to numb the skin or in special procedures by a radiologist using a local freezing. The PICC is inserted in a large vein in your upper arm and advanced to the SVC. The external portion of the catheter is secured on the arm with a dressing that needs to be changed once a week. It is easily removed by a RN when treatment is over.

Tunnelled CVC (HICKMAN)

A tunnelled catheter is inserted by a surgeon using a local freezing. It is inserted into a vein near the neck and advanced to the SVC. The external portion of the catheter is tunnelled 3 - 5 cm through subcutaneous tissue to an exit site on the chest. It is secured with absorbable sutures and a dressing that needs to be changed once a week.

Radiation Therapy

What Is Radiation Therapy?

Radiation therapy is the use of a certain type of energy (radiation) to destroy cancer cells. Other names for this common method of treating cancer are radiotherapy, x-ray therapy or irradiation.

Radiation in high doses destroys cells in the area being treated by damaging the DNA in their genes, making it impossible for them to grow and divide. During radiation therapy, both cancer cells (which are growing in an uncontrolled way) and healthy cells are affected, but most healthy cells can repair themselves afterwards.

The NHS Oncology Program does not presently offer radiation treatment. If the chosen treatment is radiation or a combination of radiation and chemotherapy, you will be referred to a Radiation Oncologist from the Juravinski Cancer Centre. The initial consultation often occurs at the oncology clinic in St. Catharines. At that appointment, the treatment will be discussed and appointments for the actual treatment in Hamilton will be arranged. Consent forms are signed and information about radiation side effects is given and explained. Directions to the Juravinski Cancer Centre are provided, as well as information about the Canadian Cancer society volunteer driver program. Follow-up appointments after radiation may be made at the St. Catharines oncology clinic.

The Types of Radiation Therapy

The different types of radiation therapy are:

External Beam Radiation Therapy	Brachytherapy	Systemic Radiation Therapy
Also called external radiation therapy	Also called internal radiation therapy or implant therapy	Also called unsealed internal radiation therapy

The Goals of Radiation Therapy

Radiation therapy can have many different purposes, and it can be combined with other ways to treat cancer. The goals of your treatment may be to:

• Cure the cancer
  Radiation therapy by itself or with another treatment, is given to destroy cancer cells in the body.
• Shrink a tumour before other treatments
  Sometimes radiation therapy is given to shrink a tumour before surgery or chemotherapy.
• Destroy cancer cells after other treatments
  Radiation therapy is sometimes given after surgery or chemotherapy to destroy cancer cells that may remain.
• Relieve symptoms caused by cancer
  Radiation therapy may be given to reduce pain and other symptoms of cancer.

Radiation Therapy and Side Effects

Many treatments for cancer can have side effects but it’s hard to know if and when they might happen to you. Side effects from radiation therapy vary from person to person, depending on:

• the amount of radiation
• the part of your body being treated
• your treatment schedule
• your general physical health
• other medications you are taking

Some people think that having side effects means that the radiation is working and not having them means that it’s not. Side effects are caused by damage to healthy cells during treatment. They are different from person to person and are not a sign of whether the treatment is working or not.

Your radiation therapy team is there to help you manage any side effects you have. They will explain which side effects to report right away, and which ones can wait until your next appointment. Ask them about ways to reduce your side effects or make them easier to deal with. If you notice any unexpected side effects or symptoms, talk to your radiation therapy team.

Information adapted from Canadian Cancer Society’s “Radiation Therapy”- A guide for people with cancer.

Combination Therapy

You may receive two or more of the treatment types listed above, at the same time, or one after the other. Research has shown that often the combination of treatments can fight the cancer better together than if they were used alone.

About Clinical Trials

The Niagara Health System Oncology Program participates in phase II, III, and IV clinical trials. We are members of the NCIC Clinical Trials Group (NCIC-CTG) and Ontario Clinical Oncology Group (OCOG) and work closely with a number of industry partners. There are several studies actively recruiting patients at any time and many more that continue to collect information on patients previously enrolled in studies.

Clinical trials have led to many new advances in health care research.

Have You Considered a Clinical Trial?

If you or someone you care about has been diagnosed with a disease, understanding your treatment options is an important first step. Many patients and their families don’t realize that a clinical trial may be a treatment option worth considering. Clinical trials offer early access to promising new treatments that are not yet widely available to the public.

Did You Know a Clinical Trial Could Be a Treatment Option for You?

By participating in a clinical trial, you could be among the first to benefit from the newest treatments available. For many patients, clinical trials also provide an opportunity to play a more active role in their health care, reducing feelings of helplessness and being out of control.

Another important reason that patients get involved in clinical trials is to support the advancement of research. Through clinical trials, doctors and scientists have developed less invasive approaches to surgery, more effective treatment options and new drugs with fewer side effects. As a result, many patients are living longer and enjoying a better quality of life.

What You Need to Know About Clinical Trials

A clinical trial is a scientific study to investigate new ways to prevent, diagnose or treat diseases. Clinical trials are federally regulated and closely monitored to ensure the safety and care of participants. If you decide to enroll in a clinical trial, you should know that there is no guarantee that you will receive the newer treatment being tested. At the very least, however, you will receive the best available standard treatment.

Contrary to popular belief, clinical trials are not just for people who have not responded to other therapies. There are clinical trials that test new treatments for various types and stages of diseases. Other clinical trials focus on ways to control the side effects of treatments, while some look at ways to prevent illness. However, a clinical trial isn’t suitable for everyone. There may not be a clinical trial for your type of disease or the eligibility criteria for a trial may not match your situation.

Some patients are surprised to learn that clinical trials usually take place in the same location where they would normally receive care, and that they are followed closely by a team of doctors, nurses and other health professionals. Patients are free to leave the study at any time.

Know the Risks

While there are many benefits to being part of a clinical trial, there are risks to consider too. Not all new treatments being studied will turn out to be better or even as good as the best available standard care. There may also be unknown side effects with the new treatment. And being in a clinical trial may be time-consuming, requiring more trips to the study site, more tests and extra medications.

Make an Informed Decision

Knowing all of your options is an important part of making the best decision for you. You should talk to your doctor about whether a clinical trial might be a suitable treatment option for you. A referral from your doctor is required to participate in any clinical trial. To find out more about clinical trials and what is available to you, speak to your doctor and research your options on the Internet.

For more information about clinical trials visit:

• Canadian Cancer Society at www.canadiancancersociety.ca
• Ontario Institute for Cancer Research www.oicr.on.ca

Adapted with permission from OICR