Health State Descriptions for Canadians
82-619-MIE
Cancers
Context
Introduction
Summary table
The cancers
At diagnosis
Therapeutic
options
Subsequent
health states
References
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Therapeutic options
When cancer occurs, the common therapeutic options are surgery, radiotherapy,
and chemotherapy. These may be administered alone or in various combinations.
Hormonal therapy is commonly used as a first line therapy for prostate
cancer. The choice of treatment depends on the size and location of the
tumour, the extent of tumour spread, the patient’s age and general
health. Each therapeutic option can have an impact on any or all of the
functional abilities of the individual. The level of dysfunction that
patients experience will depend on the type of therapy they undergo and
their own coping skills.
These descriptions apply to the health state experienced during cancer
therapy (or following therapy in the case of surgery) and the following
considerations should be noted:
- only the short-term impact of the therapy is included, for example,
the description for “after surgery” includes only the three
to five weeks following the surgical procedure; the descriptions for
radiotherapy and chemotherapy apply to the time during which the therapy
is being administered;
- many cancer patients receive more than one therapeutic modality.
To understand their true emotional and physical state, the cumulative
effects of the diagnosis of cancer, as well as administration of the
various therapies, would have to be considered.
Surgery
Surgery is the most frequently used cancer therapy and cures more patients
than any other single treatment modality. Surgery is necessary to determine
whether a growth is benign or malignant and to obtain tissue that can
determine the type of cancer and extent of spread at the time of diagnosis.
For small, localized, easily accessible tumours, a complete resection
(removal) of the tumour and surrounding margins (tissue around the tumour
and perhaps nearby lymph nodes) can be performed with curative intent.
For more advanced disease, total removal of the cancerous organ might
be necessary.
Following in-patient surgery
| Description |
The majority of surgical procedures for cancer are
performed in-hospital. For the nine cancers studied (other than
leukemia), the common procedures performed are complete or partial
resection of the organ (resection is indicated by the suffix “ectomy”).
They are mastectomy or lumpectomy for breast cancer, prostatectomy
for prostate cancer, cystectomy for bladder cancer, colostomy or
resection of rectum for colorectal cancer, nephrectomy for kidney
cancer, gastrectomy for stomach cancer, lobectomy or pneumonectomy
for lung cancer, and pancreaticoduodenectomy for pancreatic cancer.
This description includes the post-operative effects of any surgery
that requires an overnight stay in hospital, even if just for one
night and typically lasts between 3-5 weeks. For many patients,
the surgical procedure confirms the diagnosis of cancer, resulting
in uncertainty and fear about the future, not only in terms of survival,
but also about additional therapies that might have to be undergone.
Side effects following surgery can range from mild to severe. Some
patients experience minor discomfort for a few days, whereas those
treated with more radical procedures may endure long-term discomfort
and dysfunctionality. Common experiences are arm morbidity following
mastectomy for breast cancer; incontinence and/or impotence after
prostate cancer surgery; difficulty breathing after removal of a
lung; or the psychological impact of a colostomy after colorectal
cancer. In addition, many breast, prostate, bladder and colorectal
cancer patients experience problems with sexuality and self-esteem
following surgical treatment. Post-operative fatigue is generally
quite significant and of long duration. |
| Classification |
Core |
Supplementary |
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Following out-patient surgery
| Description |
The only surgery consistently performed on an out-patient
(ambulatory) basis is lumpectomy or breast conserving surgery for
early stage breast cancer. Patients may experience pain and discomfort
(due to the insertion of drains) and some arm morbidity following
the surgery. They may also be quite anxious and uncertain about future
recurrences and potential adjuvant therapies. |
| Classification |
Core |
Supplementary |
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Radiotherapy (radiation
therapy)
Radiotherapy uses high-energy radiation from a linear accelerator or
other radiotherapy machine to damage or kill cancer cells. The treatment
objective is to target a specific cancerous area, while minimizing damage
to surrounding healthy tissue. Radiotherapy may be administered pre-operatively
to shrink the tumour to facilitate surgery (e.g., for rectal cancer),
or may be given as adjuvant therapy post-operatively to reduce the probability
of local recurrence (e.g., of breast cancer, following breast conserving
surgery). It is sometimes combined with chemotherapy (chemoirradiation)
(e.g., for locally advanced lung cancer).
Radiotherapy may be used to “cure” some cancers (radical
radiotherapy), but it can also effectively palliate symptoms and improve
quality of life when “cure” is not possible. While radiotherapy
is most often administered on an out-patient basis, hospitalization may
be required if the patient has co-morbid conditions, or if radioactive
sources are being implanted directly into the area of the tumour.
While receiving curative
radiotherapy
| Description |
Local radical or curative radiotherapy may be used as
the sole therapeutic agent for a number of potentially curable cancers.
It is generally provided at a hospital or clinic five days a week
for five or more weeks. Side effects of radiotherapy depend on the
treatment dose and the part of the body being treated. Patients experience
mild discomfort and moderate levels of anxiety while undergoing radiotherapy.
Fatigue appears to be the most common side effect and one which has
the most profound impact on quality of life. Local skin changes (itching,
tenderness, swelling or soreness), nausea and vomiting, diarrhea and
ulceration of the radiated area may also occur. |
| Classification |
Core |
Supplementary |
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While receiving palliative radiotherapy
| Description |
Palliative radiotherapy is used to provide pain relief
and improve quality of life when curative therapy has failed or
is not an option. It is usually administered in low doses and with
a short duration (less than four weeks) and is sometimes given only
once.
Patients may experience mild discomfort while undergoing palliative
radiotherapy and most experience fatigue. As patients recognize
that the treatment is non curative, they are often very anxious
and uncertain about their future and may withdraw from social relationships
at this time. |
| Classification |
Core |
Supplementary |
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Chemotherapy
Chemotherapy is the term used to describe a variety of drugs that kill
or inhibit the growth of cancerous cells. Unlike surgery or radiotherapy,
chemotherapy is systemic, meaning that the drugs are usually injected
into a vein and flow through the bloodstream to almost every part of the
body. The drugs damage newly forming cells. Patients usually receive their
treatments at intervals of every three to four weeks in an out-patient
environment, such as a clinic or at home, often over a period of six months.
However, because of the toxicity associated with some chemotherapy combinations,
a short hospital stay may be necessary.
Chemotherapy may be used to cure, control or palliate cancer. Pre-operative
or neoadjuvant chemotherapy may be used to reduce the size and extent
of the primary tumour, to facilitate complete surgical excision. Chemotherapy
is commonly used as adjuvant therapy after local treatment with surgery
or radiotherapy to eradicate or suppress minimal residual disease, decrease
the rate of relapse or improve survival. In cases where a cure is not
possible, chemotherapy is often administered to relieve symptoms, prolong
life and enhance quality of life.
Depending on the specific drugs used, chemotherapy can produce mild,
moderate or severe side effects. The most common reactions, nausea and
vomiting, are now being treated more successfully with anti-emetics (stemetil,
ondansetron or related medications), which can prevent or relieve these
symptoms. The type of cancer and stage at diagnosis will determine which
health state applies during chemotherapy.
While receiving chemotherapy (mild toxicity)
| Description |
This description is based on the regimens of chemotherapeutic
agents used to treat loco-regional colon cancer (5-fluorouracil
[5FU] with folinic acid) and metastatic pancreatic cancer (gemcitabine
[Gemzar]).
When individuals receive chemotherapeutic agents that have mildly
toxic side effects, they generally experience mild nausea (anti-emetics
are usually administered), some diarrhea and a relatively low risk
of hospitalization for
fever or dehydration. Fatigue is a commonly reported side effect.
Duration of treatment is estimated to be six months. |
| Classification |
Core |
Supplementary |
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While receiving chemotherapy (moderate
toxicity)
| Description |
This description is based on the regimens of chemotherapeutic
agents used to treat loco-regional and metastatic breast cancer
(anthracycline based regimens), lung cancer (cisplatin with other
agents), metastatic bladder cancer (gemcitabine with cisplatin),
loco-regional non-Hodgkin’s lymphoma (CHOP—cyclophosphamide,
doxorubicin [Adriamycin], vincristine [Oncovin] and prednisone,
with or without rituximab [Rituxan]), and metastatic stomach cancer
(doxorubicin [Adriamycin] plus cisplatin).
Individuals receiving chemotherapeutic agents that have moderately
toxic side effects generally experience moderate to severe nausea
and vomiting (the effects of which are lessened with anti-emetics),
weakness, hair loss, neuropathy (nerve damage), risk of infection
and a moderate risk of being hospitalized for fever or neuropathy.
Patients describe their side effects as including discomfort, fatigue
and anxiety. Social relationships can be disrupted due to decreased
sexual desire and mood swings and some patients experience parasthesia
(an abnormal touch sensation, such as burning or prickling in their
fingers or toes) which can create difficulty buttoning clothes or
tying shoes.
Duration of treatment is estimated to be six months. |
| Classification |
Core |
Supplementary |
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While receiving chemotherapy (severe toxicity)
| Description |
This description is based on the regimen of chemotherapeutic
agents used to treat metastatic colon cancer (irinotecan with 5-fluorouracil
and folinic acid), which may require the administration of anti-emetics,
as well as anti-diarrheal medicines.
Patients generally experience severe nausea and vomiting (the
effects of which are lessened with anti-emetics) and very severe
diarrhea, with a high risk of hospitalization for neutropenic fever
and dehydration. They may also complain of sensitive skin, cough,
sore muscles, severe mouth sores, moderate epigastric distress,
shortness of breath (dyspnea), weakness and dizziness. Some patients
experience paresthesia in their hands and feet. Patients’
capacities to sustain social relationships can be compromised during
the administration of chemotherapeutic agents which have severely
toxic side effects, due to fatigue, anxiety, depression and irritability.
Duration of treatment is estimated to be six months. |
| Classification |
Core |
Supplementary |
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Hormonal therapy
Some types of cancer, including most breast and prostate cancers, depend
on hormones to grow. Hormonal levels can be reduced by surgically removing
the organs that produce them (testes or ovaries) or by administering drugs
that stop hormone production or block their effects. This health state
is based on hormonal therapy, which is routinely used as a first-line
therapy for prostate cancer.
While receiving hormonal therapy
| Description |
Generally, hormonal ablation therapy (chemical castration)
is used as the standard treatment for the management of symptomatic
metastatic prostate cancer, which usually presents with bone pain.
While the pain decreases in the majority of cases, important side
effects are impotence or loss of sexual desire, which can be temporary,
long lasting or permanent. Many men also experience hot flashes,
breast tenderness, loss of muscle mass, increased fatigue and weight
gain, which compromises their self-esteem and masculinity.
While the duration of treatment depends on the stage of disease
at diagnosis, the average duration of hormonal therapy is three
months for local or regional diagnosis and eighteen months for metastatic
disease. |
| Classification |
Core |
Supplementary |
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Bone marrow transplantation
Bone marrow transplantation is a treatment for leukemia during which
malignant cells are eliminated through the use of high-dose chemotherapy
and/or radiation. This is followed by bone marrow or peripheral blood
stem cell rescue in order to restore hematological and immunological function.
The objective of bone marrow transplantation is to provide a healthy stem
cell population that will differentiate into blood cells to replace deficient
or pathologic cells of the host. Autologous bone marrow transplantation
involves using an individual’s own bone marrow which has been purged
of cancer through chemotherapy and/or radiotherapy. In allogeneic bone
marrow transplantation, healthy bone marrow from a compatible donor is
used.
Following bone marrow transplantation
| Description |
This description is for the immediate post-surgery
recovery period, which lasts four to six weeks. The first two to
three weeks after bone marrow transplantation has been performed
are critical, as the establishment of the new graft takes 10 days
to three weeks. During this time, patients are without marrow function,
making them susceptible to infection and vulnerable to bleeding.
In addition, they may experience shortness of breath, wheezing,
flank or back pain, fever, mouth ulcers and diarrhea. Patients must
undergo long periods of hospitalization, isolation from friends
and family and high levels of stress. |
| Classification |
Core |
Supplementary |
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