Chemotherapy for Gastric Cancer: The Basics
- Chemotherapy is a drug, or combination of drugs, that kill cells that grow quickly, such as cancer cells.
- The therapy is most often given through a needle into a vein (IV chemotherapy), but sometimes it can also be taken as a pill, capsule, liquid, or as an injection.
- The most common drugs for gastric cancer are fluorouracil, leucovorin, oxaliplatin, and docetaxel (or FLOT).
- Common side effects include fatigue, nausea, hair loss, infections, anemia, and loss of appetite. Patients may be worried about severe side effects, but there are many measures doctors can take now to help offset them.
There are different chemotherapy options depending on the burden of disease, which refers to how sick someone is. There are different ways you can receive the medication, though the most common way is through a needle into a vein (intravenous or IV chemotherapy). Sometimes, it can also be taken as a pill, capsule, a liquid by mouth, or as an injection or shot.
Treating Gastric Cancer
Read MoreTreatment for gastric cancer that has spread to other parts of the body usually involves chemotherapy, which is sometimes combined with immunotherapy. Immunotherapy works by helping a patient’s immune system to recognize and attack cancer, but it’s not for everyone.
How Chemotherapy works
Chemotherapy is a medication that travels through the bloodstream and reaches all parts of the body (also known as a systemic therapy). In general, they are powerful chemicals that treat cancer by attacking cells during specific parts of the cell replication (cell cycle). Cancer cells go through this process faster than normal cells, so chemotherapy has more of an effect on these fast-growing cells.
“Chemotherapy is typically a drug that swims through your body, killing off cancer cells wherever they are, whether they are in your esophagus, in your great toe, in your hip, or your liver, or anywhere else. It’s a body-wide flush of cancer therapy,” Dr. Whit Burrows, a thoracic surgeon at University of Maryland Medical System, explained to SurvivorNet in a previous conversation. “So, [it’s] very different from surgery, where we locally remove the cancer, or radiation therapy, when we don’t remove it, but we locally treat it.”
The goals for chemotherapy include:
- Shrink tumor size
- Lower the total number of cancer cells in your body
- Reduce the likelihood of cancer spreading
- Reduce current symptoms
Chemotherapy is administered in cycles, with a period of treatment followed by a period of rest to allow the body to recover from the treatment’s side effects. The length and number of treatments, as well as the specific kind and dosage of medications used, will vary from patient to patient.
In gastric cancers, there are a few different options for the approach to chemotherapy.
“We have some specialized terms. [When] we’re giving chemotherapy before surgery, we call that neoadjuvant and if we’re giving it after surgery, we call it adjuvant, Dr. Nicholas Hornstein, a medical oncologist at Northwell Cancer Institute in Manhattan, tells SurvivorNet.
“For gastric cancer, the term perioperative chemotherapy might also be employed. That means we’re going to give chemotherapy before and after surgery. Depending on who you are and what stage of disease you have, you might be somebody who benefits from chemotherapy before, after, or both,” he adds.
Chemotherapy terms to know:
- Neoadjuvant therapy (or preoperative): Chemotherapy that is intended to shrink the tumor before surgery or radiation.
- Perioperative Chemotherapy: This includes any chemotherapy around the time of surgery, e.g., preoperative, intraoperative, and immediately postoperative chemotherapy.
- Adjuvant therapy (or postoperative): Chemotherapy that attacks cancer cells after surgery or radiation.
- Curative intent: Chemotherapy as the only treatment. It cures the cancer.
- Palliative intent or definitive therapy: Chemotherapy shrinks tumors and lessens symptoms, but does not cure the cancer.
Types of Chemotherapy
There are several kinds of chemotherapy drugs used for patients with gastric cancer. In some instances, a combination of drugs is used. For gastric cancer, you usually have a combination of three or four drugs.
“Chemotherapy [for gastric cancer] is in short called FLOT. It’s comprised of four ingredients: fluorouracil (5-FU), leucovorin, oxaliplatin, and docetaxel. It can be somewhat hard to tolerate, but doses can be reduced based on a patient’s age, frailty and other medical comorbidities,” Dr. Hornstein explains. Treatment can also include 5-FU and Oxaliplatin alone (without docetaxel). It is a perioperative option in addition to FLOT. 5-FU and Cisplatin also has catergoy one evidence although, the most common regimen is FLOT followed by 5-FU and Oxaliplatin.
Preparing for Chemotherapy
It is likely that you will have tests before and during your chemotherapy course. These help your doctor decide whether you are fit enough for treatment and they can also compare the results with future tests to see how your treatment is working. Several tests may be performed, such as:
- A complete physical examination
- Blood tests
- X-rays
- Scans
One of the most important tests is called a complete blood count (CBC): this is done to get the levels of blood cells produced by the bone marrow. Chemotherapy medication can stop your bone marrow producing enough red blood cells, white blood cells and platelets. So, before your treatment starts you need to have a blood test to check your levels of these. Depending on your results, your oncologist may recommend delaying chemotherapy or using specific treatments to improve your values before starting.
“We think about things like frailty, tolerance to therapy and whether or not they’re really going to be able to withstand additional efforts such as chemotherapy. Overall though, the vast majority of patients with gastric cancer will get some type of chemotherapy to help reduce the probability that their cancer recurs,” Dr. Hornstein adds.
Understanding Chemotherapy Side Effects
Chemotherapy affects everyone differently, so there’s no real definite side effects you can count on.
Below are some of the more common side effects that can affect patients during and after treatment. And while it’s important to note that we’ve come a long with the management of these side effects, they can still have a great impact on people during their cancer battle.
Nausea
“One of the things that patients worry most about is nausea with chemotherapy,” Dr. Michael Ulm, gynecologic oncologist at West Cancer Center, said during a previous interview with SurvivorNet. “Everybody remembers what their parents went through or what their aunts and uncles went through probably 15 or 20 years ago.”
Even though people can still anticipate nausea, Dr. Ulm said your nausea shouldn’t be as bad as you’re imagining with today’s arsenal of treatments to combat the side effect with medications you can take at home.
“I tell my patients, with modern medicine and modern antiemetics that you should never have severe nausea and you should never throw up,” Dr. Ulm said.
Even with modern medications, some patients still have significant nausea. You should work with your healthcare team to discuss ways to mitigate these symptoms in future cycles.
Hair Loss or Thinning
Many chemotherapies can cause hair loss or thinning.
Hair loss typically begins about three to four weeks after patients begin chemotherapy and continues throughout treatment. Patients can expect regrowth around four to six weeks after they complete treatment, but some patients may experience some changes to hair color and texture when it begins growing back.
The hair loss associated with chemotherapy is temporary, but this can be an incredibly distressing side effect for some. To help patients cope with hair loss, a doctor or nurse may be able to recommend a local cosmetologist or other resources that can help slow down the process.
Fatigue
Fatigue is another possible symptom that has the potential to worsen as chemotherapy cycles add up. If chemotherapy left you with anemia, you can try treating that to ease exhaustion. But rest breaks, frequent exercise, and getting plenty of sleep at night can also help fight fatigue.
In an earlier interview, Dr. Zachary Reese, a medical oncologist at Intermountain Healthcare, spoke with SurvivorNet about what chemotherapy-related fatigue is like.
“What I typically tell patients is that (chemotherapy) is a bit of a roller coaster ride,” he said. “You’re going to feel tired about a week into treatment, and that’s when you’ll hit bottom. And then you’ll start to come back up again just in time to do it all over. You’ll feel a little more tired the second time around than you did the first, and it will last a day longer.”
Heart Problems
Cardiotoxicity, or problems in the heart and vascular (circulation) system, can be a side effect of chemotherapy.
“From chemotherapy, high doses of anthracyclines, in particular, have been the prototype of cancer therapies that lead to cardiotoxicity,” Dr. Emanuel Finet, a transplant cardiologist at Cleveland Clinic Cancer Center, previously told SurvivorNet.
Cancer patients at a high risk for heart problems can be older, younger with more aggressive chemotherapy, obese, smokers or dealing with pre-existing cardiovascular disease.
Blood-Forming Cell Damage
Chemotherapy drugs can damage all three types of blood-forming cells: red blood cells, platelets and white blood cells. This in turn can lead to various issues like anemia (low red blood cell count), thrombocytopenia (low blood platelet account) or neutropenia (low number of a type of white blood cell called neutrophil).
“One of the things that’s changed in the coronavirus days is that now we’re giving everybody this drug called Neupogen or Neulasta, and it helps boost your white (blood cell) count,” Dr. Ulm recommended as a way to help your body fight infections. It is worth nothing that it is not given for all types of therapy and is reserved only for regimens that carry a high risk of neutropenic fever.
Nerve Damage
Nerve damage, or neuropathy, can leave you with symptoms like “pins-and-needles,” pain, burning, numbness, weakness or trouble detecting heat and cold.
These symptoms might worsen as chemotherapy treatments progress, but there are ways to combat them. Steroids, numbing patches or cream, antidepressant medicine, anti-seizure medication physical therapy, relaxation techniques, acupuncture or dosage adjustments may help with these symptoms.
And while the symptoms of nerve damage might go away once you finish treatment, there can be lasting effects that require ongoing treatments.
Questions to Ask Your Doctor
- How will I receive chemotherapy treatments? Will I need a port?
- How often will I have chemotherapy? For how long?
- What are the risks and benefits of treatment with these drugs?
- Will my health insurance cover my treatment with this drug?
- What are the common side effects of the chemotherapy I will receive?
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