Angiogenesis is a process by which new blood vessels are formed. Some cancerous tumors are very efficient at creating new blood vessels, which increases blood supply to the tumor and allows it to grow.
Cancer cells initiate angiogenesis by sending signals to nearby tissue and activating proteins that foster blood vessel growth. As researchers gained a better understanding of this process, they have developed several drugs that inhibit angiogenesis and short-circuit cancer development.
Blood vessels feed tumors the nutrients and oxygen they require to thrive and spread, so researchers also are investigating whether a tumor’s established blood vessel network can be made to fight the cancer.
A number of angiogenesis inhibitors have been approved by the Food and Drug Administration and are currently being used to treat cancer :
MD Anderson offers dozens of chemotherapy drugs to treat a wide variety of cancers, both as standard treatment and through clinical trials of new, innovative therapies. Researchers are continually working to tailor chemotherapy drugs to attack specific tumors, which provides a highly effective treatment with fewer side effects and less impact on healthy organs and tissues. Here are the types of chemotherapy procedures available at MD Anderson :
Chemotherapy uses powerful drugs to kill cancer cells, control their growth, or relieve pain symptoms. Chemotherapy may involve one drug, or a combination of two or more drugs, depending on the type of cancer and its rate of progression. Chemotherapy can be used in combination with other treatments such as surgeryor radiation, to make sure all cancer cells have been eliminated.
Chemotherapy is administered in three ways :
Side effects vary from patient to patient and with the type of chemotherapy drugs used. The good news is that there are therapies to help you cope with some side effects, and lost hair does grow back, although sometimes in a different color or texture.
The most common side effects of chemotherapy include :
Much of today's cancer research is devoted to finding missing or defective genes that cause cancer or increase an individual's risk for certain types of cancer. Gene research at MD Anderson has resulted in many important discoveries. We identified the mutated multiple advanced cancers gene (MMAC1) involved in some common cancers. We also performed the first successful correction of a defective tumor suppressor gene (p53) in human lung cancer. Current gene therapies are experimental, and many are still tested only on animals. There are some clinical trials involving a very small number of human subjects.
Gene therapy is a complicated area of research, and many questions remain unanswered. Some cancers are caused by more than one gene, and some vectors, if used incorrectly, can actually cause cancer or other diseases. Replacing faulty genes with working copies also brings up ethical issues that must be addressed before these therapies can be accepted for preventing cancer. Talk to your cancer specialist about the implications of gene therapy.
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a cancer treatment that involves filling the abdominal cavity with chemotherapy drugs that have been heated. Also known as “heated chemotherapy,” HIPEC is performed after the surgeon removes tumors or lesions from the abdominal area.
After all visible tumors are removed, cisplatin, a chemotherapy drug, is heated to 103 degrees Fahrenheit (42 degrees Celsius) and pumped through the abdominal cavity. The patient lies on a special cooling blanket to keep their body temperature at safe levels during the procedure. Surgeons physically rock the patient back and forth on the operating table for about 1½ -2 hours to ensure that the drug reaches all areas of the abdomen, killing any cancer cells that remain after surgery and reducing the risk for cancer recurrence. The heat makes the drug more effective in killing cancer cells, and it also increases blood flow to the area.
Hyperthermic intraperitoneal chemotherapy has several benefits as compared to standard chemotherapy :
Hyperthermic intraperitoneal chemotherapy does have some side effects. Patients must be prepared to receive nutrition through a feeding tube or IV for about two weeks, while the digestive system recovers from the intense dose of chemotherapy.
There are treatments that use the body's own natural defenses to fight cancer. Immunotherapy, also known as biotherapy or biological response modifiers, works on white blood cells - the body's first line of defense against disease. White blood cells can be stimulated in various ways to boost the body's immune response to cancer, with little or no effect on healthy tissue. Immunotherapy can also be used to lessen the side effects of other cancer treatments.
Some immunotherapies have received approval from the Food and Drug Administration for certain types of cancer. Others are being tested in clinical trials. Biological response modifiers are developed in a laboratory and then injected into the body.
Side effects of immunotherapies can vary, but most exhibit similar symptoms, including fatigue, a rash or swelling at the injection site, and flu-like symptoms including nausea, diarrhea and fever.
There are five general types of biological response modifiers. They can be used alone or in combination with each other, or they can be used in addition to other cancer treatments.
Cancer clinical trials are cancer research studies that involve people. The main purpose of a clinical trial is to find a better way to prevent, diagnose or treat a disease. Clinical trials are part of a long, careful research process. Patients who participate in a clinical trial receive drugs or procedures that already have been researched in successful laboratory and/or animal studies. Most clinical trials study new drugs or procedures, but some study drugs or procedures that have already received approval by the U.S. Food and Drug Administration.
All patients who participate in clinical trials are volunteers. They can choose to stop their participation in a clinical trial at any time.
The terms complementary and alternative are often used interchangeably, however they are, two different approaches to the treatment of disease. Complementary medicine is used in addition to, or to complement, conventional medicine; alternative medicine replaces conventional treatment. Conventional medicine, also known as mainstream, western, allopathic, or regular, is practiced by medical doctors or doctors of osteopathy. While it is unlikely that a physician who practices conventional medicine would recommend a truly alternative treatment, some conventional doctors do practice complementary or alternative medicine, or may recommend a complementary treatment.
Combining conventional treatments options with complementary therapies may also be referred to as integrative medicine, as the two types of practices are both evaluated and may be utilized in a comprehensive treatment plan.
Treatments such as acupuncture, yoga, herbal medicines and nutritional supplements and homeopathy may not have been proven to work, but some have evidence supporting their use. The list of practices that are considered as complementary and integrative medicine (CIM) changes continually, as practices and therapies that are proven safe and effective become accepted as mainstream healthcare practices.
After a cancer diagnosis, patients and their families have many decisions to make in a short time. Where do I go for treatment? What costs will be covered by insurance? What about travel expenses? As a cancer patient, you are urged to take an active role in your care, and make treatment decisions that are best for you and your loved ones.
Consider the following issues before choosing a cancer treatment.
If you have been diagnosed with cancer by your primary care physician, it is wise to get a second opinion from a cancer specialist. In fact, many health insurance plans require a second opinion before covering some treatment costs. If the specialist agrees with the first diagnosis, they can let you know the available treatment options for your cancer.
A prognosis is a cancer specialist's best estimate of how your disease will respond to treatment, and what your life expectancy may be. Some patients whose cancer is discovered in the early stages may only need minor treatment. Others with advanced cancer may have few treatment options, if any, or may have an aggressive cancer with a low survival rate.
Patients who receive the worst news may proceed with treatment anyway; others may refuse treatment. Whatever decision you make, consider the wishes of loved ones, and talk it over with your cancer care team.
Because cancer treatment involves sophisticated techniques, machinery and medicine, it can be very expensive. Some treatments require a hospital stay of one night or more, which adds on to the overall cost. Health insurance and managed care plans rarely cover all the costs of cancer treatment, so it’s important to find out what is and is not covered by your policy. Uncovered expenses are the patient’s responsibility.
Cancer patients travel from all over the world to be treated at MD Anderson, and many bring family members, sometimes for an extended stay. Travel and lodging costs can add up quickly, and must be considered along with treatment expenses.
It is wise to prepare legal documents that spell out how your cancer treatments and personal affairs should be handled if you become unable to make decisions.Advance directives include documents like living wills, medical power of attorney, and do-not-resuscitate orders. MD Anderson offers easy online forms for medical power of attorney and living wills.
Some newly-diagnosed patients may be eligible to join a clinical trial. These carefully controlled studies test new drugs or treatments that may be as good or better than standard care. Clinical trials have provided new hope for some people whose cancer has not responded to traditional treatments. MD Anderson has hundreds of clinical trials underway at any given time.
If you decide to proceed with cancer treatment, then it's time to choose an oncologist (cancer doctor) and a hospital where the treatment will be carried out.
The World Health Organization defines palliative care as care which focuses on patients with life-threatening diseases. The goal of palliative care is to prevent and relieve the suffering of cancer patients and provide the best possible quality of life, regardless of age, cancer stage and treatment plans.
Many people believe that palliative care is only for patients whose cancer cannot be treated or who are close to the end of life. In fact, palliative care is most useful when it is started along with cancer treatment. This way it can help treat common symptoms caused by treatment and ensure the best quality of life. For this reason, palliative care is often referred to as supportive care or symptom control. If the patient's cancer cannot be treated, then the palliative care focus shifts to end-of-life care, which is often provided by a hospice.
Every person with terminal cancer has different needs and feelings as his or her last days approach. Palliative care can help the patient and family :
Hospice care is a type of palliative care for patients whose cancer cannot be treated. To be eligible for hospice services, the doctor must certify that the patient is expected to live six months or less.
Hospice care can be provided at the patient's home, in the hospital, in assisted-care living or a nursing home. Some hospice organizations have facilities where patients can stay for a short time for treatment of uncontrolled symptoms, or to provide a break for the relatives or friends who have been caring for the patient.
Radiation therapy, sometimes called radiotherapy, effectively treats cancer by using high-energy beams to pinpoint and destroy cancerous cells. Although radiation therapy is similar to an X-ray, the dose of radiation in cancer treatment is much stronger and is given over a longer period of time. Many forms of radiation are available. Your oncologist will choose the best therapy based on the type, stage and location of your cancer.
With careful planning, radiation can be directed to the cancer and away from most normal tissues. This means you may receive treatment on more than one side of your body or from different angles. You may also need more than one type of radiation, which may require the use of more than one machine.
Over 50% of cancer patients will undergo radiation therapy; for some, it will be the only cancer treatment they need. Radiation is often used in combination with other treatments. Used before or during other procedures, radiation shrinks the tumor to make surgery or chemotherapy more effective. Used afterward, it destroys any cancer cells that might remain.
There are two basic types of radiation therapy :
Accelerated partial breast irradiation, or APBI, is a localized form of radiation treatment (brachytherapy) that involves the insertion of a radioactive "seed" to kill breast cancer cells that may remain after lumpectomy surgery. APBI delivers a highly effective dose of radiation while greatly reducing treatment time. This procedure requires close collaboration between the surgeon who removes the breast tumor, and the radiation oncologist who treats the tumor area after surgery.
Accelerated partial breast irradiation is performed about one to four weeks after a lumpectomy. A specialized catheter is inserted into the cavity left behind after removal of the tumor. The device remains in place during the course of APBI treatment, usually about 8-10 days.
There are currently three types of single-entry breast brachytherapy devices. Which one to use for the given patient is chosen by the surgeon and radiation oncologist based on the size and shape of the lumpectomy cavity. Each brachytherapy device is designed to hold the radioactive “seed” in designated positions within the device for defined lengths of time to insure radiation of the targeted breast tissue immediately surrounding the lumpectomy cavity :
During treatment, the iridium seed, about the size of a grain of rice, is inserted into the catheters (lumens). The seed is within the device in various dwell positions for a total of 5-10 minutes. The seed is withdrawn and then re-inserted six hours later, for a total of two treatments a day.
Partial breast irradiation is best for women who :
When compared with standard radiation treatment, APBI offers several benefits :
Since the introduction of accelerated partial breast irradiation in 2002, oncologists have been gathering data on cancer recurrence and survival rates in APBI patients. Although the data is still maturing, the results are encouraging, and accelerated partial breast irradiation is poised to become a standard treatment in the future for certain breast cancer patients.
MD Anderson now offers gamma knife radiosurgery to treat difficult tumors in the head and neck area. Gamma Knife provides accurate tumor targeting with a single dose of radiation, freeing patients from multiple radiation treatments and allowing them to return to a normal routine within a few days of treatment.
The Lexsell Gamma Knife® PERFEXIONTM system, manufactured by Sweden-based Elekta, is a fully automated radiosurgery system. Using high-resolution images from magnetic resonance imaging (MRI) and computed tomography (CT) scans, a computer automatically calculates the exact dose to be administered by 192 individual radiation beams. The resulting treatment plan allows radiosurgeons to focus high-dose radiation along the exact dimensions of the tumor, while sparing delicate structures surrounding the treatment area.
The size of the radiation beams can be adjusted to as small as four millimeters in diameter to reach small tumors. The automation allows both radiation oncologists and neurosurgeons to treat multiple lesions in a single procedure.
The Gamma Knife system is proving to be ideal for areas that cannot be reached by surgery. Patients who cannot tolerate surgery or who have had previous radiation therapy to the brain may also be candidates for Gamma Knife. With further study, Gamma Knife may be offered as frontline therapy for certain patients with cancers to the brain, head and neck.
Gamma knife surgery is best for :
A proton is a positively charged particle found in the nucleus of an atom. The protons used in proton therapy are derived from stripping a hydrogen atom of its electron. When protons interact with electrons in the atoms of cancer cells, they impart energy to the electrons, causing them to leave the atom and undergo a series of interactions (ionizing events) that result in damage to the DNA of the cancer cell.
Damaging the DNA destroys specific cell functions, which include the ability to divide or proliferate. A cancer cell's ability to repair molecular injury is frequently inferior to that of cells in normal tissues. As a result, cancer cells accumulate permanent damage and subsequent cell death occurs. As the cell dies, so does the tumor.
Traditional radiation therapy affects everything in its path, so doctors have to limit the dose delivered to the tumor in order to minimize damage to surrounding healthy tissue. With proton therapy, the beam is accelerated to specific energies that determine how deeply in the body protons will deposit their maximum energy.
Protons enter the body with a low dose of radiation, which increases when the beam slows down within the designated target tumor and then protons stop. Compared to an X-ray beam, a proton beam has a low “entrance dose” (the dose delivered from the surface of the skin to the front of the tumor), a high dose designed to cover the entire tumor and no “exit dose” beyond the tumor.The combined effect is greater precision in targeting the tumor with a more potent dose of radiation. The accuracy of proton therapy for treatment delivery is within approximately one millimeter.
Pencil beam scanning, also known as spot scanning, has the ability to treat the most complex of tumors, while leaving healthy tissue and critical structures untouched. Powerful scanning magnets direct thousands of ultra-fine proton beams from multiple directions toward the tumor, creating a “U” shape around healthy tissue and avoiding sensitive areas entirely during treatment. Intricate treatment planning allows the protons to deposit their potent dose of radiation to the exact dimensions of the tumor. Side effects common after radiation therapy are reduced and healthy organs are preserved because the radiation is confined to the tumor.
Stereotactic body radiation therapy (SBRT), also called stereotactic ablative radiotherapy (SABR), is a type of radiation therapy in which a few very high doses of radiation are delivered to small, well-defined tumors. The goal is to deliver a radiation dose that is high enough to kill the cancer while minimizing exposure to surrounding healthy organs.
SBRT is typically used to treat small, early-stage tumors of the lung, or isolated recurrences or metastases from various types of cancer. SBRT has also been used successfully to treat early-stage non-small cell lung cancer, recurrent lung parenchyma cancer,pancreatic cancer, and metastatic cancers in the :
SBRT is being tested at MD Anderson to treat other types of cancer. In some cases, it can be used instead of surgery.
SBRT begins with one or more sessions of treatment planning, which involves using imaging (computerized tomography, magnetic resonance imaging, positron emission tomography scanning and X-rays) to precisely map the exact position of the tumor to be treated. These images are then used to create customized treatment plans in which sophisticated computerized devices direct several radiation beams of different intensities at different angles, so that the radiation is directed precisely to the tumor.
Treatments are usually given once a day for about a week, although this can vary depending on the type of tumor and the condition of the patient. Other images are also taken during the treatment period to account for shrinkage of the tumor or other changes that might affect its position.
Stereotactic body radiation therapy is not appropriate for everyone. The most important considerations are the type of cancer and where it is located, as well as the physical condition of the patient. Meticulous treatment planning and image-guided treatment delivery are crucial for the success of SBRT and for keeping side effects to the lowest possible level. Your radiation oncologist will discuss whether SBRT is suitable for you and what kinds of side effects may result from your treatment.
Stem cells are immature cells that eventually develop into the various types of mature blood cells :
A stem cell transplant replaces defective or damaged cells in patients whose normal blood cells have been crowded out by cancerous cells. Transplants can also be used to treat hereditary disorders such as sickle cell anemia, or to help patients recover from or better tolerate cancer treatment.
Stem cells for transplant come from the following sources :
Human leukocyte antigen, or HLA, typing is the method by which stem cell transplant patients are matched with eligible donors. HLA are proteins that exist on the surface of most cells in the body. HLA markers help the body distinguish normal cells from foreign cells, such as cancer cells.
The closest possible match between the HLA markers of the donor and the patient reduces the risk of graft versus host disease (GVHD). This condition occurs after transplant when your immune cells attack the donor cells, or when the donor cells attack your cells.
The best match is usually a first degree relative (children, siblings or parents). However, about 75% of patients do not have a suitable donor in their family and require cells from matched unrelated donors (MUD). These donors are found through registries such as the National Marrow Donor Program.
HLA typing is done with a blood sample taken from the patient, which is then compared with samples from a family member or a donor registry.
Surgery is the oldest form of cancer treatment. About 60% of cancer patients will undergo surgery, either by itself or in combination with other therapies.
There are several types of cancer surgery :
Curative surgery simply involves removal of a cancerous tumor. It works best on localized cancers that haven't yet spread to other parts of the body, and is often followed by radiation therapy or chemotherapy to make sure all cancerous cells have been removed.
Curative surgery types include :
Ablative cancer treatments use either heat or cold to destroy, or ablate, cancer tumors without the need for more invasive surgery. Special probes are used to deliver ablative treatments directly to the tumor. The surgeon relies on computer imaging to guide the probes to the correct position and monitor the progress of the treatment.
Advantages of ablative therapies include :
Cryoablation is also known as cryotherapy or cryosurgery. A special probe is inserted into the tumor and then cooled to . A ball of ice forms at the tip of the probe, freezing and destroying prostate tissue. Cryotherapy is not as invasive as surgery, and can sometimes be performed as an outpatient procedure. Cryotherapy is currently being used to treat breast, prostate and kidney cancers.
The biggest disadvantage with using cryotherapy to treat prostate cancer is that most men (about 80%) will lose the ability to have an erection. However, for men who already have erectile dysfunction, cryotherapy is a convenient and effective prostate cancer treatment. MD Anderson is conducting research to focus cryotherapy to treat just the tumor instead of the entire prostate, with the goal of preserving erectile function.
A needle-thin probe delivers radiofrequency waves directly to the tumor, heating the tissue until it is destroyed. Radiofrequency ablation is best for smaller, localized tumors. RFA can be used to treat a variety of cancers :
Also known as HIFU, this procedure is used to treat prostate cancer. A special probe uses high-frequency ultrasound to produce heat that kills cancerous tumors. The probe is inserted into the rectum and guided to the proper position using computer imaging. High intensity focused ultrasound can either treat the entire prostate ("full" HIFU) or just certain portions of the prostate ("focused" HIFU). The entire procedure takes from 1-4 hours.
HIFU has been used in Europe, particularly the United Kingdom, to treat prostate cancer for about 10 years. However, it is not currently approved by the Food & Drug Administration for use in the United States. MD Anderson urologists have been treating patients with HIFU as part of clinical trials to test this treatment method. Because the treatment is relatively new, available data on its effectiveness is still maturing.
Transoral laser microsurgery (TLM) was first proposed in 1972 and is now widely used for tumors of the throat and larynx (voice box).
With TLM, a highly specialized carbon dioxide (CO2) laser beam is used instead of a scalpel to cut through the tissue. Unlike other types of lasers, the CO2 laser beam generates minimal heat energy. This limits damage to normal structures around the tumor, such as important nerves, blood vessels and muscles, which are important for speech and swallowing. The surgery is performed directly through the mouth and does not leave a visible scar. The surgeon inserts a thin endoscope through the mouth, and a specially designed microscope lets the surgeon see the tumor and surrounding tissue during the surgery.
At MD Anderson, your surgeon will help you decide if TLM is right for you. Patients undergoing transoral laser microsurgery for throat or larynx cancer are placed under general anesthesia.
Different CO2 laser systems are available for use with transoral laser microsurgery. If you are diagnosed with early-stage cancer of the larynx, then Digital AcuBlade™ laser surgery may be used. With this method, CO2 laser is delivered through a specialized robotic adapter that creates precise incisions. The system, designed by Lumenis Surgical specifically for larynx and vocal cord surgery, uses a computer with an operating microscope. The surgeon programs the computer by entering information about the specific type of procedure that will be performed, the laser beam pattern, the incision length and the depth that the laser will penetrate. The surgeon positions the laser beam on the larynx or vocal cord and performs the procedure by manipulating a joystick on an operating microscope. The CO2 laser moves in straight, curved, or circular patterns to sculpt the most precise incision with the least effect on surrounding normal tissue.
Another type of laser used with TLM is flexible fiber-optic CO2 laser. In 2004, surgeons at MD Anderson were the first to use fiber-optic CO2 laser to reach areas in the throat that otherwise could not be reached and to perform a 360-degree resection around tumors in ways that were previously not possible.
If your surgery for throat cancer has a high risk of bleeding, surgeons at MD Anderson may use thulium laser instead of CO2 laser. The thulium laser is used instead of a scalpel to cut through tissue. It is very precise and is designed to minimize the risk of blood loss during surgery. The skilled surgeons at MD Anderson will choose between a pulsed laser beam and a continuous laser beam to perform the best surgery for you.
MD Anderson surgeons are constantly refining their techniques to treat cancer effectively while decreasing the physical impact of cancer surgery. Minimally invasive surgery techniques are being used to treat an increasing variety of cancers. Here are some of the minimally invasive procedures available at MD Anderson :
Minimally invasive, or endoscopic, surgery takes advantage of advances in computer imaging and robotics to provide effective surgical cancer treatment with a much smaller impact on the patient.
An endoscope is a long, thin tube with special lighting and a narrow lens through which the surgeon can view organs and tissue inside of the body. The endoscope is inserted through tiny incisions, often less than an inch in length, near the tumor location. A microscope provides an excellent image of the tumor. Small, specialized surgical instruments are also inserted through small incisions so that the surgeon can perform the operation without an external incision.
Advantages of minimally invasive surgery include :
Robotic surgery systems consist of one or more robotic arms, precisely controlled by surgeons seated at a console, which enlarges 3-D views of the surgery site. The arms are tipped with an endoscope for viewing the treatment area, or surgical instruments that can fit into an incision less than an inch long. The instrument handles that control the robotic arms have the added benefit of reducing surgeon fatigue during long or complicated surgeries and eliminating "hand tremor."
MD Anderson uses the Da Vinci® robotic surgery system, which has four robotic arms like the one pictured right. Although the robotic arms are doing the actual surgery, they still require direct input from the surgeon and cannot be merely programmed to operate without human intervention.
Candidates for robotic-assisted surgery include patients undergoing prostatectomy, hysterectomy, thoracic procedures and some general surgeries.
Deciding where to seek cancer treatment is difficult. We know you have many options. Here are some of the reasons why we are your best hope for cancer care.