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Treatment Methods
What should I know about the treatment modalities to help me in choosing the treatment?
  • Surgery
    • Modern day surgery is reasonably safe except in old age or when the disease is very advanced
    • It is good for visible disease. Used alone in very early stage cancers.
    • Modern development has been - Organ preservation surgery. Here surgery is limited to removing the cancer tissue with minimal rind of normal tissue and leaving the organ alone. The organ may have microscopic disease, which is taken care of by radiation therapy, e.g. in cancer of the breast, nowadays, entire breast removal is done only exceptional patients.

  • Chemotherapy
    • Cancer has the potential to spread all over the body. Chemotherapy drugs, which can circulate all over the body, have the ability to eliminate these cells.
    • There is much apprehension about chemotherapy. Present day chemotherapy is much safer than before. The problem arises only when cancer is advanced and concurrently body is weak.
    • Newer drugs targeting only the inside of cancer cells are being developed rapidly. Many times the objective of cancer treatment is just to overcome the present crisis – that is managing cancer as chronic disease.
    • Recently several targeted drugs are made available as tablets. In future cancer may be kept under control like in diabetes and hypertension.

  • Radiation therapy
    • Occasionally used alone.
    • Most of the time used in combination with surgery and or chemotherapy
    • There has been tremendous technological improvement to make the radiation safer and cancer control better. The problem arises only when cancer is advanced and concurrently body is weak.

    The use of surgery, radiation therapy and chemotherapy alone or in combination varies from cancer to cancer based on whether it cancer very limited, confined to the site of origin or has invisibly or visibly spread elsewhere in the body.

What are the types of radiotherapy?
  • Palliative: The intention here is to relieve the symptoms and make the patient feel better. The dose given here is less and tumour may come under control for 3 to 6 months. Possibility of cure is 0 to 5%.
  • Radical: Here the intention is to eliminate the cancer. Patient may be cured or may get just palliative benefit. Possibility of cure may be 5% to 100% depending on the type, stage and location of cancer.

What are the techniques of radiotherapy?
Following are the techniques with increasing complexity and cost of treatment in the order given. Also, the side effects decrease dramatically, but increase in the cancer control may not be proportional to the money spent.

  1. Simple: Usually given,
    • When the intention is control and to relieve the symptoms (palliative treatment).
    • Given in 5 to 10 sittings over 1 to 2 weeks. Occasionally a single session is given.
    • Side effects possibility – least.

  2. Complex
    • Conventional radiation.
    • Effort is made to spare the normal tissues but most of the portion of normal tissue cannot be avoided.
    • Dose to the cancer is kept at a level that can be tolerated by the normal tissue with out severe side effects.
    • 5 to 7 weeks of treatment, 5 sittings per week.

  3. 3DCRT (3 D Conformal Radiotherapy)
    • Multiple beams around the body is directed towards the cancer avoiding the normal tissues
    • Radiation dose is confined in and around the cancer. However, area of radiation is rounded in shape, which includes some amount of normal tissue that can be avoided
    • Side effects are less compared to 2) given above.
    • Some sites of cancer show better control of tumour compared to 2) given above
    • 5 to 7 weeks of treatment, 5 sittings per week

  4. IMRT (Intensity Modulated Radiotherapy)
    • 80 to 120 beams around the body is directed towards the cancer avoiding the normal tissues
    • Cancer spreads like a crab around the normal tissue and is highly irregular in shape. IMRT’s irregular shape can be matched this irregular shape of cancer spread. The visible growth as seen in CT scan and/or MRI and or PET-CT is marked. The possible areas where invisible (microscopic) cancer cells could have spread are also included for treatment. Normal tissues are marked and attempt is made to keep the radiation dose well below the limits of tolerance.
    • Side effects are least compared to 2 & 3 given above
    • Control of cancer is better in certain sites compared to 2 & 3
    • 5 to 7 weeks of treatment, 5 sittings per week. In cancer prostate treatment duration is 7-8 weeks.

  5. IGRT (Image Guided Radiotherapy)
    • In IGRT, type of treatment delivered is usually IMRT mentioned in 4)
    • Location of cancer is checked with imaging (CT scan or treatment beam itself) before giving the IMRT on predetermined days.
    • Treatment delivery is most precise compared to 2), 3) & 4) given above
    • Side effects are least compared to 2), 3). & 4) given above
    • Control of cancer is better in certain sites compared to 2), 3). & 4) given above
    • 5 to 7 weeks of treatment, 5 sittings per week. In cancer prostate treatment duration is 7-8 weeks.

  6. Stereotactic Radiotherapy (SRT)
    • Used in brain tumours
    • May not be applicable in all situations
    • Given over 5 to 6 weeks
    • When possible, better dose of radiation can be given than IMRT or IGRT
    • Side effects – least possible

  7. Stereotactic BodyRadiotherapy (SBRT)
    • Used in other than brain tumours
    • May not be applicable in all situations
    • Given over 5 to 6 weeks
    • When possible, better dose of radiation can be given than IMRT or IGRT
    • Side effects least possible

  8. Stereotactic Radiosurgery (SRS)
    • Used in brain tumours
    • May not be applicable in all situations
    • Given over 3 to 5 sittings – shortest course in radiation
    • When possible, better dose of radiation can be given than IMRT or IGRT
    • Since best possible radiation schedule is given, it can take care of even resistant cancers in the brain
    • Side effects – least possible

  9. Stereotactic body radiosurgery (Body SRS)
    • Used in other than brain tumours
    • May not be applicable in all situations
    • Given over 3 to 5 sittings – shortest course in radiation
    • When possible, better dose of radiation can be given than IMRT or IGRT
    • Since best possible radiation schedule is given, it can take care of even resistant cancers all over the body
    • Side effects – least possible

What Is Cyberknife Robotic Radiosurgery And When It Is Useful?
  • It is the use of radiation focused from 100 – 300 directions with sub-millimeter accuracy, tracking the movement of the cancer lump and automatically adjusting the position of patient during the entire treatment. No machine has all these features put together. The treatment is delivered in surgical precision in 3 to 5 days. The cancers or part of the cancer, which are resistant to conventional treatment, are likely to respond to this.
  • Its uses:
    • It is used in many non-cancerous conditions like AVMs (Arterio Venous Malformations) and benign tumours of brain and spinal cord
    • Alone, where it is used when surgery is not possible in early stage diseases (stage I & II), it gives nearly as good a result as surgery for that stage and condition of the patient. It is also useful in elderly patients (aged > 70 years) with early cancer when surgery cannot be done or when patient does not want surgery.
    • In combination with surgery, chemotherapy and conventional radiotherapy makes a significant contribution in improving the survival or control of cancer in stage III of cancer. Here cure probability may be lesser, but cancer can be controlled for long time in significant percentage of patients.
    • In cancer recurrence: When cancer comes back after surgery or radiation therapy
    • For palliation: When not curable CyberKnife helps in improving quality of life and facilitates living with cancer
  • It is a boon for the patients who have early cancer (stage I & II), yet not suitable for surgery and in whom cancer is spreading slowly in stage III & IV.
  • Repeated treatments with CyberKnife (even at same site) can result in long-term control of cancer.
  • However, CyberKnife being a robot, is the most expensive radiosurgery machine and hence treatment is also expensive.
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