The remaining 700,000 or so often proceed to chemotherapy either immediately or upon cancer recurrence, spread, or newly recognized metastases. “Cures” after that point are rare.
I’m speaking in generalities, understanding that each cancer and each patient is unique.
Chemotherapy
Chemotherapy alone can cure a small number of cancer types. When added to radiation or surgery, chemotherapy can help to cure a wider range of cancer types. As an add-on, chemotherapy can extend the length and quality of life for many patients with cancer. Since chemotherapy is by definition “toxic,” it can also shorten the duration or harm the quality of life and provide false hope. The Table summarizes what chemotherapy can and cannot achieve in selected cancer types.
Careful, compassionate communication between patient and physician is key. Goals and expectations must be clearly understood.
Organized chemotherapeutic efforts are further categorized as first line, second line, and third line.
First-line treatment. The initial round of recommended chemotherapy for a specific cancer. It is typically considered the most effective treatment for that type and stage of cancer on the basis of current research and clinical trials.
Second-line treatment. This is the treatment used if the first-line chemotherapy doesn’t work as desired. Reasons to switch to second-line chemo include:
- Lack of response (the tumor failed to shrink).
- Progression (the cancer may have grown or spread further).
- Adverse side effects were too severe to continue.
The drugs used in second-line chemo will typically be different from those used in first line, sometimes because cancer cells can develop resistance to chemotherapy drugs over time. Moreover, the goal of second-line chemo may differ from that of first-line therapy. Rather than chiefly aiming for a cure, second-line treatment might focus on slowing cancer growth, managing symptoms, or improving quality of life. Unfortunately, not every type of cancer has a readily available second-line option.
Third-line treatment. Third-line options come into play when both the initial course of chemo (first line) and the subsequent treatment (second line) have failed to achieve remission or control the cancer’s spread. Owing to the progressive nature of advanced cancers, patients might not be eligible or healthy enough for third-line therapy. Depending on cancer type, the patient’s general health, and response to previous treatments, third-line options could include:
- New or different chemotherapy drugs compared with prior lines.
- Surgery to debulk the tumor.
- Radiation for symptom control.
- Targeted therapy: drugs designed to target specific vulnerabilities in cancer cells.
- Immunotherapy: agents that help the body’s immune system fight cancer cells.
- Clinical trials testing new or investigational treatments, which may be applicable at any time, depending on the questions being addressed.