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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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More information

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.

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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.
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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.
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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.

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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.

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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.

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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.

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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.

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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.

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