By Richard Frank, MD
It is a fact of life for some cancer patients that they will be off and on some form of cancer treatment for the rest of their lives. They are dealing with a cancer that cannot be fully eradicated. Some situations involve cancers that never seem to go fully away or into remission, whereas others go into remission for a period of time but then come back or “relapse.” In these situations, the need for continuous treatment must be balanced against the side effects and the impact of treatment on quality of life. And then there is the ever important question of just how much treatment is enough?
The answer is different for every patient. For example, I recently surprised one of my long-term patients, whom I will call Jane, by telling her that it was “time for a chemo holiday.” Jane was diagnosed with the bone marrow cancer multiple myeloma back in 2001. She received intravenous chemotherapy for several months before undergoing an autologous (her own cells) stem-cell transplant after receiving high-dose chemotherapy. Her cancer was greatly reduced in amount but was always detectable even at low levels. After a two-year interval without treatment, the cancer needed to be treated. Jane received chemotherapy, then thalidomide for a period of time until it caused limiting nerve damage (called peripheral neuropathy). But then the drug lenalidomide (Revlimid) was approved for use and that kept her cancer in check for several years. When that stopped working, Jane received another newly approved chemotherapy called bortezomib (Velcade). She has received Velcade for approximately three years. She comes for weekly injections of the medicine, which has worsened her neuropathy but controlled the myeloma; she is having difficulty putting on jewelry and sometimes cannot hold a glass for very long. Because of this and the fact that her cancer is remaining stable and is not a threat to her life (not affecting her vital organs) I proposed a break from treatment. Her next therapy would be yet another medicine newly approved to treat myeloma, called carfilzomib (Kyprolis). Clearly, another advantage of surviving an incurable cancer is the prospect of being able to survive longer due to advances in cancer research.
Multiple myeloma is one cancer in which patients may be on treatment for many years. Other blood cancers in this category include low-grade or indolent non-Hodgkin’s lymphomas and chronic myelogenous leukemia (CML). Among the organ-based cancers or “solid tumors,” if the cancer is metastatic (has spread from the site of origin, most commonly to the liver, bones, lung, or brain), then patients are facing the prospect of cancer therapy for the rest of their lives. But the treatment strategy depends on the data; that is, what clinical trials have shown is the best strategy to extend life while minimizing side effects and maximizing the quality of that life. For example, recent studies in lung cancer indicate that continuous or maintenance chemotherapy of lesser intensity after an initial more intensive treatment period of three to four months may help control the cancer and lead to longer survivals. Unfortunately, these gains are measured in weeks to a few months; some may opt for a treatment holiday and reinstitution of chemotherapy when and if the cancer regrows in order to avoid further side effects from treatment. In contrast, patients with metastatic colorectal cancer do better and often live longer if some form of chemotherapy is utilized on an ongoing basis, rather than on a stop-and-go basis.
Patients who are living with cancer and the prospect of long-term chemotherapy need a good dialogue with their oncologist to discuss the risks and benefits of ongoing treatment and should ask from time to time about a chemo holiday.