Additional therapy , also known as additional therapy , adjunctive therapy , and adjuvant treatment , is a therapy given on the side primary or early therapy to maximize its effectiveness. The surgery and the complex treatment regimen used in cancer therapy has led to this term being used primarily to describe the treatment of adjuvant cancer. An example of adjuvant therapy is additional treatment that is usually given after surgery in which all detected diseases have been removed, but where there is still a statistical risk of relapse due to an undetected disease. If the disease is known to be left behind after surgery, then further treatment is not technically adjuvant.
The adjuvant agent modifies the effects of other agents, so adjuvant therapy modifies other therapies.
Video Adjuvant therapy
Histori
The term "adjuvant therapy," is derived from the Latin term adjuv? Re , meaning "help," was first coined by Paul Carbone and his team at the National Cancer Institute in 1963. In 1968, the National Surgical Adjuvant Breast and Bowel Project (NSABP) published the results of the B-01 trials for the first randomized trial to evaluate the effects of adjuvant alkylation agents on breast cancer. The results showed that adjuvant therapy given after the initial radical mastectomy "significantly decreased the recurrence rate in pre-menopausal women with four or more positive axillary lymph nodes."
Beginning theories using additional therapies to supplement the main operations were practiced by Gianni Bonadonna and colleagues from Instituto Tumori in Italy in 1973, where they conducted a randomized trial that showed a more favorable survival outcomes accompanied by the use of Cyclophosphamide Methotrexate Fluorouracil (CMF ) after the initial mastectomy.
In 1976, shortly after the experimental Bonadonna landmark, Bernard Fisher at the University of Pittsburgh initiated a similar randomized trial that compared survival of breast cancer patients treated with radiation after initial mastectomy to those who only received surgery. His results, published in 1985, show an increase in disease-free survival for the earlier group.
Despite initial encouragement from breast cancer surgeons who believe that their radical mastectomy is enough to eliminate all traces of cancer, the successful trials of Bonadonna and Fisher bring adjuvant therapy into the mainstream in oncology. Since then, the field of adjuvant therapy has been greatly expanded to include various adjuvant therapies to include chemotherapy, immunotherapy, hormone therapy, and radiation.
Maps Adjuvant therapy
Neoadjuvant therapy
Neoadjuvant therapy, in contrast to adjuvant therapy, is administered prior to primary treatment. For example, systemic therapy for breast cancer given prior to breast removal is considered neoadjuvant chemotherapy. The most common reason for neoadjuvant therapy for cancer is to reduce the size of the tumor making it easier for more effective surgery.
In the context of breast cancer, neoadjuvant chemotherapy administered before surgery can improve survival in patients. If there are no active cancer cells in the tissue taken from the tumor site after neoadjuvant therapy, doctors classify a case as "complete pathologic response" or "pCR." While response to therapy has proven to be a strong predictor of outcomes, the medical community has still not reached a consensus in terms of the definition of pCR in various subtypes of breast cancer. It remains unclear whether pCR can be used as a replacement endpoint in cases of breast cancer.
Cancer therapy adjuvant
For example, radiotherapy or systemic therapy is usually given as adjuvant treatment after surgery for breast cancer. Systemic therapy consists of chemotherapy, immunotherapy or biological response modifiers or hormone therapy. Oncologists use statistical evidence to assess the risk of recurrence of the disease before deciding on specific adjuvant therapy. The goal of adjuvant treatment is to improve the disease-specific symptoms and overall survival. Since treatment is basically for risk, not for a proven disease, it is accepted that some patients who receive adjuvant therapy have been cured through their primary surgery.
Systemic adjuvant and radiotherapy therapy is often given after surgery for many types of cancers, including colon cancer, lung cancer, pancreatic cancer, breast cancer, prostate cancer, and some gynecological cancers. Some forms of cancer fail to benefit from adjuvant therapy. Such cancers include renal cell carcinoma, and some forms of brain cancer.
Hyperthermia or therapeutic therapy is also a kind of adjuvant therapy given along with radiation or chemotherapy to enhance the effects of this conventional treatment. Tumor heating by Radio Frequency (RF) or Microwave energy increases the oxygen content at the tumor site, which results in increased response during radiation or chemotherapy. For example, Hyperthermia is added twice a week for radiation therapy for all treatments in many cancer centers, and the challenge is to increase its use worldwide.
Controversy
The motive found throughout the history of cancer therapy is the tendency to overtreatment. Since its inception, the use of adjuvant therapy has been given the spotlight for its adverse effect on the quality of life of cancer patients. For example, because side effects of adjuvant chemotherapy can range from nausea to loss of fertility, doctors regularly practice with caution when prescribing chemotherapy.
In the context of melanoma, certain treatments, such as Ipilimumab, produce high-grade side effects, or immune-related side effects, in 10-15% of patients parallel to the effects of metastatic melanoma itself. Similarly, some common adjuvant therapies are noted for having the potential to cause cardiovascular disease. In such cases, physicians should consider the cost of future recurrence of more direct consequences and consider factors, such as age and relative cardiovascular health of the patient, before prescribing certain types of adjuvant therapy.
One of the most prominent side effects of adjuvant therapy is the loss of fertility. For pre-pubescent men, cryopreservation of testicular tissue is an option to maintain fertility in the future. For post-puberty men, these side effects can be relieved through cryopreservation of cement. For pre-menopausal women, the choice to maintain fertility is often much more complicated. For example, breast cancer patients of childbearing age often have to consider the risks and benefits associated with starting an adjuvant therapy regimen after primary treatment. In some low-risk situations, low benefit, continuous adjuvant treatment can be a reasonable decision at all, but in cases where the risk of metastasis is high, the patient may be forced to make difficult decisions. Although options for fertility preservation exist (eg, embryo preservation, cryopreservation oocytes, ovarian suppression, etc.), they are more frequent than time-consuming and costly.
As a result of complications that can result from the use of adjuvant therapy freely, the philosophy surrounding the use of adjuvant therapy in clinical settings has shifted towards the goal of doing little harm to the patient. Standards for the intensity of adjuvant treatment doses and medication durations are regularly updated to optimize the efficiency of the regimen while minimizing the toxic side effects that the patient should bear.
Systemic or concurrent systemic cancer therapy
Systemic or concurrent systemic cancer therapy refers to providing medical care at the same time as other therapies, such as radiation. Hormonal adjuvant therapy is given after prostate removal of prostate cancer, but there are concerns that side effects, especially those that are cardiovascular, may outweigh the risk of recurrence.
In breast cancer, adjuvant therapy may consist of chemotherapy (doxorubicin, herceptin, paclitaxel, docetaxel, cyclophosphamide, fluorouracil, and methotrexate) and radiotherapy, especially after lumpectomy, and hormonal therapy (tamoxifen, femara). Adjuvant therapy in breast cancer is used in stage one and two breast cancers after lumpectomy, and in stage III breast cancer due to lymph node involvement.
In glioblastoma multiforme, adjuvant chemoradiotherapy is very important in the case of completely removed tumors, because without other treatments, the recurrence occurs within 1-3 months.
In the early stages, one small cell lung carcinoma, adjuvant chemotherapy with gemzar, cisplatin, paclitaxel, docetaxel, and other chemotherapy agents, and adjuvant radiotherapy are administered to the lungs, to prevent local recurrence, or brain to prevent metastasis.
In testicular cancer, either radiotherapy or chemotherapy adjuvant may be used following orchidectomy. Previously, especially radiotherapy was used, as a full program of cytotoxic chemotherapy produces far more side effects then of course external radiotherapy (EBRT). However, it has been found that one dose of carboplatin is as effective as EBRT in stage II testicular cancer, with only mild side effects (transient myelosuppressive action vs severe and prolonged myelosuppressive neutropenia disease in normal chemotherapy, and less vomiting, diarrhea, mucositis, and no alopecia in 90% of cases.
Adjuvant therapy is very effective in certain types of cancer, including colorectal carcinoma, lung cancer, and medulloblastoma. In fully resected medulloblastoma, the 5-year survival rate is 85% if adjuvant chemotherapy and/or craniospinal irradiation is performed, and only 10% if no adjuvant chemotherapy or craniospinal irradiation is used. Prophylactic cranial prophylaxis for acute lymphoblastic leukemia (ALL) is technically adjuvant, and most experts agree that cranial irradiation decreases CNS risk of recurrence in ALL and possibly acute myeloid leukemia (AML), but can cause severe side effects, and adjuvant intricecal methotrexate and hydrocortisone may be as effective as cranial irradiation, with no delayed adverse effects, such as developmental disability, dementia, and increased risk for second malignancy.
Dose-Dense Chemotherapy
Chemotherapy doses (DDCs) have recently emerged as an effective method of adjuvant chemotherapy. DDC uses the Gompertz curve to explain tumor cell growth after the initial surgery removes most of the tumor mass. Cancer cells remaining after surgery usually rapidly divide the cells, making them most susceptible to chemotherapy. Standard chemotherapy regimens are usually given every 3 weeks to allow normal cell time to recover. This practice has led scientists to the hypothesis that cancer recurrence after surgery and chemotherapy may be due to rapid cell diving beyond the rate of chemotherapy. DDC tries to avoid this problem by giving chemotherapy every 2 weeks. To reduce the side effects of chemotherapy that can be aggravated with more rigorous chemotherapy treatments, growth factors are usually given in conjunction with DDC to restore white blood cell counts. A recent meta-analysis of DDC clinical analysis in early-stage breast cancer patients showed promising results in premenopausal women, but DDC has not been the standard of care in clinics.
Cancer specific
Malignant melanoma
The role of adjuvant therapy in malignant melanoma is and has been hotly debated by oncologists. In 1995 a multicenter study reported an increase in long-term and disease-free survival in melanoma patients using interferon alfa 2b as adjuvant therapy. So, by the end of the year, the US Food and Drug Administration (FDA) approved interferon alpha 2b for melanoma patients who are currently disease-free, to reduce the risk of recurrence. Since then, however, some doctors have argued that interferon treatment does not prolong survival or reduce relapse rates, but only cause harmful side effects. The claims have not been validated by scientific research.
Adjuvant chemotherapy has been used in malignant melanoma, but there is little strong evidence to use chemotherapy in adjuvant settings. However, melanoma is not a malignancy resistant to chemotherapy. Dacarbazine, temozolomide, and cisplatin all have a 10-20% response rate that can be reproduced in metastatic melanoma; However, these responses are often short-lived and almost never completed. Several studies have shown that adjuvant radiotherapy increases the rate of local recurrence in high-risk melanoma patients. Studies include at least two studies of cancer center M.D. Anderson. However, none of the studies have shown that adjuvant radiotherapy has statistically significant survival benefits.
A number of studies are currently underway to determine whether immunomodulatory agents that have proven effective in metastatic regulation are useful as adjuvant therapy for patients with stage 3 or 4 resected disease.
Colorectal cancer
Adjuvant chemotherapy is effective in preventing the development of micrometastatic disease from colorectal cancer that has been surgically removed. Studies have shown that fluorouracil is an effective adjuvant chemotherapy among patients with microsatellite stability or low frequency microsatellite instability, but not in patients with high frequency microsatellite instability.
Pancreatic cancer
exocrine
Exocrine pancreatic cancer has one of the lowest 5-year survival rates of all types of cancer. Because of adverse outcomes associated with surgery alone, the role of adjuvant therapy has been widely evaluated. A series of studies have determined that 6 months of chemotherapy with gemcitabine or fluorouracil, compared with observation, improves overall survival. New trials incorporating immune checkpoint inhibitors such as inhibitors to program 1 (PD-1) and PD-L1 PD-1 ligands are underway.
Lung Cancer
Non-small cell lung cancer (NSCLC) <In 2015, a comprehensive meta-analysis of 47 trials and 11,107 patients revealed that NSCLC patients benefited from adjuvant therapy in the form of chemotherapy and/or radiotherapy. The results found that patients who were given chemotherapy after early surgery lived 4% longer than those who did not receive chemotherapy. The toxicity resulting from adjuvant chemotherapy is believed to be manageable.
Bladder cancer
Neoadjuvant-based chemotherapy chemotherapy has been shown to improve overall survival in advanced bladder cancer, but there is some controversy in administration. Unpredictable patient response remains a weakness of neoadjuvant therapy. Although it may shrink tumors in some patients, others may not respond to treatment at all. It has been shown that delays in surgery over 12 weeks from the time of diagnosis can decrease overall survival. Thus, the time for neoadjuvants becomes important, because neoadjuvant therapy can delay cystectomy and allow the tumor to grow and subsequently metastasize.
Breast cancer
It has been known for at least 30 years that adjuvant chemotherapy improves recurrence-free survival rates for patients with breast cancer. In 2001 after a national consensus conference, the panel of the US National Institute of Health concluded: "Since the adjuvant polychemotherapy improves survival, it should be recommended for most women with local breast cancer regardless of status of lymph nodes, menopause, or hormones."
Agents used include:
However, ethical concerns have been raised about the magnitude of the benefits of this therapy because it involves further patient care without knowing the possibility of relapse. Dr. Bernard Fisher, among the first to conduct clinical trials to evaluate the efficacy of adjuvant therapy in patients with breast cancer, describes it as a "value judgment" in which potential benefits should be evaluated against toxicity and medical and other costs. potential side effects.
Adjuvant combination chemotherapy for breast cancer
Administering two or more chemotherapy drugs at once may decrease the chances of a cancer recurrence, and improve overall survival in patients with breast cancer. The combination of commonly used chemotherapy regimens is:
- Doxorubicin and cyclophosphamide
- Doxorubicin and cyclophosphamide followed by docetaxel
- Doxorubicin and cyclophosphamide followed by cyclophosphamide, methotrexate, and fluorouracil
- Cyclophosphamide, methotrexate, and fluorouracil.
- Docetaxel and cyclophosphamide.
- Docetaxel, [doxorubicin, and cyclophosphamide
- Cyclophosphamide, epirubicin, and fluorouracil.
Ovarian Cancer
About 15% of ovarian cancers are detected at an early stage, where the 5-year survival rate is 92%. A Norwegian meta-analysis of 22 randomized studies involving early stage ovarian cancer revealed the possibility that 8 of the 10 women treated with cisplatin after initial surgery were overtreated. Patients diagnosed at an early stage treated with cisplatin immediately after surgery fared worse than untreated patients. An additional surgical focus for young women with early-stage cancer is on contralateral ovarian conservation for the preservation of fertility.
Most cases of ovarian cancer are detected at an advanced stage, when survival is greatly reduced.
Cervical Cancer
In early-stage cervical cancer, studies have shown that chemotherapy-based adjuvant platinum after chemo-radiation can improve survival. For advanced cervical cancer, further research is needed to determine efficacy, toxicity and effects on the quality of life of adjuvant chemotherapy.
Endometrial cancer
Because most cases of early-stage endometrial cancer are diagnosed early and are usually highly curable by surgery, adjuvant therapy is only given after surveillance and histologic factors dictate that patients are at high risk for relapse. The adjuvant pelvic radiation therapy has been supervised for its use in women under 60 years, as the study showed a decrease in survival and increased risk of second malignancy after treatment.
In advanced-stage endometrial cancer, adjuvant therapy is usually radiation, chemotherapy, or a combination of both. While advanced cancer accounts for only about 15% of diagnoses, it accounts for 50% of deaths from endometrial cancer. Patients undergoing radiation and/or chemotherapy treatments will sometimes experience simple benefits before relapse.
Testicular cancer
Stage I
For seminomas, three standard options are: active surveillance, adjuvant radiotherapy, or adjuvant chemotherapy. For non-seminomas, options include: active surveillance, adjuvant chemotherapy and retroperitoneal lymph node dissection.
As for all reproductive cancers, caution is taken when deciding to use adjuvant therapy to treat early stage testicular cancer. Although the 5-year survival rate for stage I testicular cancer is about 99%, there is still some controversy over whether to overtreat a first-stage patient to prevent relapse or to wait until the patient has a recurrence. Patients treated with standard chemotherapy regimens may experience "second malignant neoplasms, cardiovascular disease, neurotoxicity, nephrotoxicity, pulmonary toxicity, hypogonadism, decreased fertility, and psychosocial problems." Thus to minimize overtreatment and avoid the potential for long-term toxicity caused by adjuvant therapy, most patients are currently treated with active surveillance.
Side effects of adjuvant cancer therapy
Depending on what form of treatment is used, adjuvant therapy may have side effects, such as all therapies for neoplasms. Chemotherapy often causes vomiting, nausea, alopecia, mucositis, myelosuppression, especially neutropenia, occasionally causing septicemia. Some chemotherapy agents may cause acute myeloid leukemia, especially alkylating agents. Rarely, this risk can exceed the risk of primary tumor recurrence. Depending on the agent used, side effects such as peripheral neuropathy induced by chemotherapy, leukoencephalopathy, bladder damage, constipation or diarrhea, bleeding, or post-chemotherapy cognitive disorder. Radiotherapy causes radiation dermatitis and fatigue, and, depending on the irradiated area, may have other side effects. For example, radiotherapy to the brain can cause memory loss, headaches, alopecia, and radiation necrosis of the brain. If the stomach or spine is irradiated, nausea, vomiting, diarrhea, and dysphagia may occur. If the pelvis is irradiated, prostatitis, proctitis, dysuria, metritis, diarrhea, and abdominal pain may occur. Hormonal adjuvant therapy for prostate cancer can lead to cardiovascular disease, and other side effects that may be severe.
src: gut.bmj.com
See also
- adjuvant Analgesic
src: esmoopen.bmj.com
References
Source of the article : Wikipedia
0 Comments