Treatment

Chemotherapy

Siteman Cancer Center has multidisciplinary teams with subspecialties in all types of cancer and areas of treatment. Medical oncologists treat patients using chemotherapy approaches, but work as a team with other types of practitioners, such as radiation and surgical oncologists, and other specialists and support services, to ensure that you are treated first as a patient and appropriately for your specific cancer type and subtype, even down to the genetic level. The depth and breadth of the expertise at Siteman gives you treatment options not available in other hospitals in the region.

Chemotherapy is a type of medical treatment for cancer that uses drugs to destroy or slow the growth of cancer cells. While the term chemotherapy is associated in most people’s minds with intravenous or systemic cancer treatment (chemo), it refers to any drugs that are given to fight cancer, including biologics/immune therapy, targeted therapy and medications that are given by different routes: orally, topically in the form of creams and ointments, regionally (confined to the area of the tumor) or systemically via an intramuscular injection or intravenously through a vein. Chemotherapy’s effect can be diffuse, targeted to a specific receptor on a cancer cell, or act as a vaccine.

Depending on the type and extent of the cancer, chemotherapy can be curative, killing all the cancer cells; control your cancer, almost like a chronic disease; or ease cancer symptoms by shrinking tumors causing pain or distress.

It can be given alone, several different types together, or in conjunction with surgery or radiation. Chemotherapy can be given before cancer surgery (neoadjuvant therapy) to shrink a tumor and make it easier to remove. Some combinations of chemotherapy and radiation (chemoradiation) can enhance the treatment effects of both. It may also be given in conjunction with stem cell or bone marrow transplants for certain types of cancer.

Because cancer cells grow and divide quickly, they can be targeted with drugs. Other cells in the body that grow quickly, such as hair follicles and cells in the mouth and intestine can also be affected, causing side effects. Some of these effects resolve after therapy is over. Your oncologist’s office has information sheets on the expected side effects of specific chemotherapy drugs.

Some promising medical therapies: chemotherapy, immunotherapy and biologic therapies are available only in clinical trials. Siteman Cancer Center has the largest number of clinical trials in the region, which means you have access to therapies not otherwise available.

Watch video series on the chemotherapy treatment process at Siteman

History of Excellence

Vaccines:

  • A novel vaccine trial under way at Siteman and two other centers is aimed at slowing the progress of metastatic breast cancer. Researchers at these three institutions are looking at MUC-1, a protein that is overexpressed on breast cancer cells and in many other cancers. By producing a double antibody and containing it in a vaccine, they hope to stimulate the patient’s immune system to respond strongly and produce both antibodies and T-cells, which would cause a regression of the cancer. Clinical trials may show the vaccine can also be given in early cancer to prevent relapse.
  • Siteman leads the way in using immunotherapy and vaccines for brain tumors. Immunotherapies stimulate your body’s own natural defenses to fight cancer growth. Besides vaccines, immunotherapy includes immune checkpoint inhibitors, monoclonal antibodies, and biologic therapy.

Subspecialization:

  • Oncologists at Siteman specialize in treating only a specific type of cancer, such as leukemia, lymphoma or multiple myeloma. This ensures that your physician is concentrating on your type of cancer and all the innovations coming along to treat it.
  • Many Siteman oncologists are also researchers, bringing innovative treatments to clinical trials, making new drugs available faster. For instance, prostate cancer specialists have also pioneered studies of effective chemotherapy for patients with advanced prostate cancer. For patients who have failed standard therapy and are looking for experimental approaches, Siteman offers a range of chemotherapy clinical trials.

Washington University Department of Medicine

To learn more about the Department of Medicine, Divisions of Hematology and Oncology at Washington University School of Medicine, please visit their website http://oncology.wustl.edu/.

High Dose Chemotherapy and Stem Cell Transplant

Bone marrow transplantation and stem cell transplantation both refer to a procedure in which healthy hematopoietic (blood producing) stem cells are infused into your body to replace damaged or diseased bone marrow that fails to produce enough healthy blood cells of its own. If the healthy cells are taken from the blood it is called stem cell transplant; if from the bone, it’s a bone marrow transplant. At Siteman, most transplants are stem cell. Cells can either come from the patient (autologous transplant) or from a donor (allogeneic transplant).

At any given time, Siteman offers more than 40 therapeutic clinical trials for patients with leukemia, lymphoma, multiple myeloma and related disorders, including studies that incorporate bone marrow/stem cell transplantation. The bone marrow/stem cell transplant program at Siteman is a Core Center and Steering Committee Member for the BMT Clinical Trials Network, an NIH-funded nation-wide consortium of leading transplant centers.

In recent years, Siteman physicians have conducted clinical studies that led to the approval of novel drugs to mobilize, or harvest, stem cells for transplant in patients with non-Hodgkin lymphoma and multiple myeloma, as well as effective treatments for elderly patients with acute myelogenous leukemia (AML).

They were the first to use a novel suicide gene approach for gene therapy to control graft-versus-host disease, a serious complication of transplantation, and have pioneered novel pharmacologic approaches to reprogram cells of the immune system to prevent graft versus host disease (GVHD). And unlike many top hematologic cancer centers, Siteman’s bone marrow/stem cell transplant program is fully integrated. The same doctors managing the blood disease oversee the transplant process. The need for transplant is customized to the individual patient.

Once the stem cells are harvested, the patient undergoes high-dose chemotherapy treatment to kill any residual cancer cells in the body. Following chemotherapy, the previously collected stem cells are infused (transplanted) through an intravenous catheter. Over the following seven to 14 days, the blood counts fall to low levels because the bad marrow was destroyed by the chemotherapy and it takes time for the newly infused stem cells to start producing blood. During that time, there is a high risk of infection due to low white blood cells, and of bleeding due to low platelets, and frequent need for transfusions. The duration of hospitalization typically averages 3-4 weeks, but varies from patient to patient and is based on the type of transplant.

Siteman’s dedicated stem cell transplant unit has state of the art HEPA filtering systems to prevent germ exposure while bone marrow is regenerating.

Regional Chemotherapy

Regional chemotherapy is intended to concentrate cancer-fighting drugs in a specific region of the body, limiting its effect and side effects systemically. Siteman excels in several types of regional chemotherapy:

  • Regional intraperitoneal (IP) chemotherapy is a new technique sometimes used to treat ovarian or primary peritoneal cancer. It is underutilized because it requires a higher level of expertise and more intensive monitoring. Those patients who are eligible and can tolerate it have a significantly improved survival. In IP chemotherapy, the anticancer drugs are carried directly into the peritoneal cavity through a thin tube. More than one anticancer agent, called combination chemotherapy, may be used. Siteman is a leader in the development of IP chemotherapy, improving the safety profile of this life-prolonging therapy.
  • Bladder regional chemotherapy: Medical oncologists at Siteman currently are investigating a series of new anti-cancer drugs that can be placed in the bladder, either in combination with standard medications or alone. Chemotherapy is delivered through a catheter directly into the bladder for a period of time as an outpatient procedure and usually involves a series of treatments.
  • Intrathecal therapy: For some patients, chemotherapy given by catheter or port into the spinal fluid, intrathecal administration, is a good option.
  • Catheters and ports also may be placed in the chest cavity, bladder, or pelvis, depending on the location of the cancer to be treated.
  • Chemoembolization is a special type of regional chemotherapy that may be used to treat cancer that has spread to the liver. Interventional radiologists, working in conjunction with medical oncologists at Siteman, perform this leading-edge therapy. Artery-blocking particles are injected into the hepatic artery (the main artery that supplies blood to the liver) and anticancer drugs are injected into the artery between the blockage and the liver. That concentrates the drug in the liver. Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive enough blood circulation from the hepatic portal vein.

At Siteman, cancers that are especially amenable to regional chemoembolization include:

  • Primary liver and bile duct cancers
  • Metastasis liver tumors spread to the liver from:
  • colon cancer
  • breast cancer
  • carcinoid tumors and other neuroendocrine tumors
  • islet cell tumors of the pancreas
  • ocular melanoma
  • sarcomas
  • other vascular primary tumors in the body

Depending on the number and type of tumors, chemoembolization may be used as the sole treatment or may be combined with other treatment options such as surgery, chemotherapy, radiation therapy, or radiofrequency ablation.

Isolated Limb Infusion

Although melanoma accounts for only 4 percent of skin cancers, it is responsible for 80 percent of skin cancer deaths. Approximately half of newly diagnosed cases of melanoma are isolated to the extremities, and in about ten percent of these, after surgery, lesions recur within the same extremity.

A new treatment, only offered in this area at Siteman Cancer Center, provides a way of treating advanced, recurrent melanoma of the extremity. Called ILI (Isolated Limb Infusion), it provides high-dose chemotherapy to the affected limb, while sparing the rest of the body from its effects. Only a few centers around the country offer ILI for treatment of melanoma and other skin or soft tissue malignancies of the extremities.

ILI is only appropriate for melanoma tumors confined to the leg or arm. By isolating the blood supply in that extremity, the medical oncologist can treat it with much higher doses of chemotherapy than the entire body could tolerate. It is the best alternative for multiple melanomas confined to one limb that can’t be surgically removed. Having ILI as an option helps avoid amputation of the cancerous limb and offers a reasonable chance of controlling the disease.

Under general anesthesia in the operating room, catheters are inserted into the femoral artery and vein. A pneumatic tourniquet is tightened at the thigh to prevent blood flowing in and out of the leg. Then a powerful chemotherapy is circulated through the vessels for 60 minutes. After that, the chemotherapy is flushed out of the leg and the tourniquet removed.

The patient stays in the hospital for 3 to 5 days until the inflammation in the leg resolves. Three months after the procedure, a PET-CT scan is done to check response to the treatment. Two-thirds of patients will have significant shrinkage or eradication of the tumors, and half of these patients will have a complete response, meaning all tumors disappear completely.

ILI has the advantage of being minimally invasive and repeatable when needed, because in many patients, the tumors will eventually start growing again.

Topical chemotherapy

Topical chemotherapy is given as a cream or ointment applied directly to the cancer. This method is more common in treatment of certain types of skin cancer. Cutaneous lymphoma, for one, can often be maintained in remission with only topical treatment. Topical treatments may include:

  • Topical steroids to decrease inflammation of the skin
  • Photodynamic UVA/UVB light therapy: This treatment uses special drugs, called photosensitizing agents, along with light to kill cancer cells. The drugs only work after they have been activated or “turned on” by certain kinds of light.
  • Mechlorethamine: This topical is used to treat mycosis fungoides in patients who have received previous skin treatment. Part of a group of cancer medicines called alkylating agents, it interferes with the growth of cancer cells.
  • Bexarotene gel: This retinoid cancer medication interferes with the growth and spread of cancer cells in the body to treat cutaneous T-cell lymphoma. It is usually given after other cancer medications have been tried without successful treatment.

Targeted Therapy

This type of treatment uses drugs or other substances to identify and attack specific types of cancer cells with less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins, or other molecules involved in the growth and spread of cancer cells. Targeted treatments are enhanced by the Washington University Genomics and Pathology Service (GPS), which offers genomic testing and next generation sequencing of tumor genes that can identify optimal patient treatment strategies for your specific cancer type and subtype. Several different types of targeted therapies are being used as standard treatments or tested in clinical trials at Siteman Cancer Center:

  • Monoclonal antibody therapy is a type of targeted therapy in which the antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given intravenously alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Bevacizumab is a monoclonal antibody that may be used with chemotherapy to treat ovarian epithelial cancer, fallopian tube cancer, or primary peritoneal cancer that has recurred.
  • PARP inhibitors are targeted therapy drugs that block DNA repair and may cause cancer cells to die. PARP inhibitor therapy is being studied in treating ovarian epithelial cancer that remains after chemotherapy.
  • Oncolytic virus therapy is a type of targeted therapy that is being studied in the treatment of melanoma that uses a virus that infects and breaks down cancer cells but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells.
  • Signal transduction inhibitor therapy blocks signals that are passed from one molecule to another inside a cell to kill cancer cells. Several different types are used to treat some patients with advanced melanoma or tumors that cannot be removed by surgery. If your melanoma has a certain mutation, you may receive a BRAF or MEK inhibitor therapy.
  • Angiogenesis inhibitors are a type of targeted therapy that blocks the growth of new blood vessels. In cancer treatment, they may be given to prevent the growth of new blood vessels that tumors need to grow.

Biologic/Immunotherapy

Although not yet standard of care, immunotherapy that uses your own natural immunity to fight the cancer is showing promise in clinical trials. This approach to treatment focuses on stimulating the patient’s immune system to fight disease. Siteman researchers are now participating in clinical trials to test this form of therapy with a variety of approaches, including immune checkpoint inhibitors and vaccines. These clinical trials are extremely important, especially for cancer patients with aggressive tumors that don’t respond well to standard therapies.

  • Vaccines: Given as a personalized cancer vaccine, this approach boosts your immunity to fight the cancer cells. Creating a personalized vaccine begins with samples of DNA from a patient’s tumor and normal tissue and making a vaccine from the most likely proteins in mutant cancer genes to stimulate the patient’s T-cells to attack the cancer.
  • Checkpoint blockade therapy: Another approach in immunotherapy trials is called a checkpoint blockade. This immune-based cancer treatment, which has been successful against advanced lung and skin cancers in clinical trials, takes advantage of immune T cells that are present in many tumors but have been shut off by cancer cells activating a safety mechanism called the checkpoint system that prevents immune cells from attacking the body’s own tissues.

Checkpoint blockade drugs in testing disable that safety mechanism, allowing our immune T cells to use their destructive capabilities on the tumors. One danger of this approach is that it increases the chances that those same immune cells erroneously will attack healthy tissue, causing serious autoimmune disease. Researchers have found that by identifying mutated tumor proteins that are the specific targets of the reactivated T cells that attack the tumors, they can create vaccines that only unleash the T cells on the tumors, and so far, tests have been very successful.