Chemotherapy

What is it?

A treatment which uses drugs to treat cancer cells. Sometimes more than one drug is used; this is called combination chemotherapy.

Chemotherapy works on cancer cells in three ways:

  1. It kills cancer cells
  2. It alters the cells damaging potential
  3. It ‘tees up’ the cancer cells for treatment with further drugs (also called pro-drug therapy).

Should I have chemotherapy?

Not a simple response. We said it was complex; each case has to be assessed individually. To help you decide, ask about the drug’s main side effects and trust in your healthcare team. Be guided by this.

The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness. If the drugs lower the levels of healthy blood cells, you’re more likely to get infections, bruise or bleed easily, and feel very weak and tired. You will be checked for low levels of blood cells. Some side effects may be relieved with medicine.

Such is the progress in personalised treatments that neuropathologists can now identify which tumours are likely to respond to chemotherapy. Specific tests might provide information that can be used to influence your treatment and diagnosis. Not all hospitals run such tests but you can ask for them. These tests (also called molecular markers) can:

  • Aid the diagnosis of brain tumours which are sometimes hard to diagnose
  • Allow clinicians to work out a prognosis
  • Indicate whether a tumour will respond to a specific type of treatment

The downside of this is that you may discover that your tumour type might not respond to treatment, so if you ask the question, you need to be prepared that you might receive information you’d rather not know.

The MGMT methylation test detects a chemical change in the DNA that shows how the cells are able to fight certain chemotherapy drugs (i.e. repair the damage caused by the drug so that the cancer cells survive and continue to grow). Tumour samples can also be tested for a ‘1p/19q’ genetic change in the chromosomes that may provide information about the likely sensitivity to DNA acting drugs.

The MGMT and 1p/19q tests will only be relevant to some brain tumours. They can also only be done where a biopsy has been performed, and biopsy material can be obtained and analysed (it does not necessarily matter how long ago the biopsy was performed).

The MGMT methylation test is relevant to all anaplastic gliomas (WHO Grades III and IV).

1p /19q test is relevant to certain tumour types.

The tumour types for which these tests can be done are shown by a tick below.

Diagnosis      Grade MGMT 1p/19q
Anaplastic astrocytoma WHO grade III
Oligodendroglioma WHO grade II
Anaplastic Oligodendroglioma  WHO grade III
Oligoastrocytoma WHO grade II
Anaplastic Oligoastrocytoma WHO grade III
Glioblastoma WHO grade IV

How chemotherapy works

Chemotherapy directly attacks brain tumour cells and disrupts their growth. It is not used to treat all brain tumours and sometimes it is used to shrink a tumour or slow its growth; it won’t always get rid of a tumour. It is generally used to treat a malignant tumour. The blood brain barrier causes problems in the delivery of chemotherapy. The blood brain barrier is there to protect the brain from toxic substances so trying to deliver chemotherapy agents to the site is not easy.

How is chemotherapy given?

Usually in cycles. This gives the patient time for the healthy cells to recover in between treatments. The frequency and length of the treatments depends on the factors mentioned previously. Treatment – rest cycles are often repeated over several months.

What are the major, currently used chemotherapeutic agents?

Main agents used are Procarbazine, CCNU and Vincristine (known as PCV), temozolomide, carboplatin, and carmustine. Until recently, PCV was the mainstay of treatment and temozolomide has been a relatively recent addition. Avastin is the new kid on the block but the jury is still out as to whether this is an effective agent. Research (2003) has shown that it can cause increased tissue invasion. This treatment may be advised but only in combination with other therapies.

Agent What it is How administered Side effects
PCV: chemotherapy combination of more than one drug – procarbazine + CCNU (also called lomustine) + vincristine = PCV. Procarbazine and CCNU are oral medications and vincristine is given intravenously Orally and intravenously over a 28 day cycle Fatigue, nerve discomfort, jaw pain and ringing in your ears.
Temozolomide An alkylating agent that crosses the blood brain barrier and has been approved by NICE. It has shown promise for the long-term management of gliomas and may also be useful in medulloblastomas and metastatic tumours One to six capsules a few days a month for a year or more. Treatment-rest cycles can last for several months or years.

 

NB There is little or no difference between PCV and temozolomide apart from the way it is given.

Fatigue, nausea and constipation.
Carmustine A nitrosourea agent which disrupts the DNA of tumour cells to stop them from proliferating. Intravenously or by biodegradable implants (wafers), which are inserted into the cavity left once the brain tumour has been removed. The agent is then released directly into the tumour. The wafers dissolve over the next two to three weeks. If administered intravenously, you will be an outpatient and the cycle usually repeats every 6 weeks.

 

The disadvantage with Carmustine wafers is that the agent does not reach invading cells but remains local.

Wafers may cause seizures, cerebral oedema and problems with wound healing. Side effects include fatigue, nausea and constipation.
Avastin: also called bevacizumab Anti-angiogenic therapy: it inhibits the growth of blood vessels which feed tumour Intravenously. You cannot have Avastin if you are having surgery. This has not been approved by NICE and therefore may not be funded by your commissioning board. Headache, confusion, vision problems, feeling light-headed, fainting, and seizure

New drugs are being developed and researched. These tend to fall into several camps and would, with luck, be in a clinical trial:

  • Agents that stop cell division
  • Anti-angiogenic therapy: these drugs inhibit the growth of blood vessels which feed tumour;
  • Differentiating agents: these drugs act on the cancer cells to make them mature into normal cells. They work in three ways:
    • They slow down malignancy
    • They limit the number of cells dividing
    • They sensitise the cells to existing therapies
  • Immunotherapy: a seek and destroy mission. These drugs offer a unique method of treatment, and are often considered to be separate from chemotherapy. Compared with other forms of cancer treatment such as surgery, radiation therapy, or chemotherapy, immunotherapy is still fairly new. There are different types of immunotherapy. Active immunotherapies stimulate the body’s own immune system to fight the disease. Passive immunotherapies do not rely on the body to attack the disease; instead, they use immune system components (such as antibodies) created outside the body. Immunotherapeutic agents include interferons, natural proteins that are toxic to cancerous cells and specific antibodies. This treatment can improve the immune system’s ability to locate and destroy tumour cells.
  • Gene therapy: the transfer of genetic material to a tumour cell to destroy the cell or to change the nature of malignant cells so that they become more sensitive to therapy (pro-drug treatment).
  • Targeted molecular therapies: these agents block a specific growth pathway which a tumour cell may use (e.g. tk inhibitors).
  • Intratumoural therapies: this involves inserting new biological therapies directly into the tumour.

How are these agents taken?

  • Most commonly by mouth (orally) – some chemotherapy drugs are given in pill or capsule form.
  • Injection into a vein (intravenously) – you shouldn’t need to be admitted into hospital for this.
  • Injection into an artery (intra-arterially) – not common. This method has fallen out of favour as it has been associated with greater toxicity to the brain.

Chemobrain

Common sense would tell you that any drugs delivered to the brain must be harmful. Cancer survivors struggling with the long-term effects from their treatments cannot help but wonder if there is a cure for the cure.

This is a new area of research. After chemotherapy hair grows back, fatigue abates but a spaced out feeling lingers – impaired memory and an inability to concentrate or multitask dogs some patients. It is suggested that that the cause lies deep within the brain, in regions where immature and newborn cells (progenitor cells) are proliferating. These self-renewing cells, part of the complex structures needed for memory and other normal functions, are particularly vulnerable to toxic chemotherapy drugs. On the other hand the very stress of a brain tumour diagnosis or depression may also contribute to memory loss, so it is hard to say whether chemobrain exists or is exaggerated, and if it is, whether it is prolonged and progressive.

(Adapted from The Cloud of Chemotherapy, Ellen Clegg, The Boston Globe, 5 April 2009).

 

For more information about referrals, and to find out more then why not call our 24/7 helpline on 01983 292405 or email hello@brainstrust.org.uk

 

Our resources have been designed to help you feel informed and on top of things, so you can make the right decisions for your care.

Did this information make you feel more resourced, more confident or more in control?

Date published: 17-05-2009
Last edited: 28-02-2018
Due for review: 28-02-2021

sidebar brainbox

Introduction

The Brain Tumour Data Dashboard lets you explore up -to-date, population level data about the brain tumours diagnosed in England between 2013 and 2015. Using the drop down menus on the left you can select different groups of patients to view in the charts below. In these charts the number of patients for every 100 diagnoses is displayed as images of people. Patients have been grouped by date of diagnosis, type of tumour, age, gender, and region in England.

For each group of patients you can explore the different routes to diagnosis, the proportion of those who received chemotherapy or radiotherapy, as well as the survival of the patients within each group. For more information about what these metrics mean please see the glossary.

How to use

  1. Select the year of diagnosis using the drop down menu.
  2. Select your patient group of interest from the four drop down menus in the following order:
    1. Tumour group
    2. Age at diagnosis
    3. Region of England
    4. Gender of patient
  3. To view a second chart to compare different groups of patients, click the ‘compare’ button.The second chart will appear below the first chart.

*Note that the tool is best used on a laptop or tablet rather than a mobile phone*

Unavailable data

Some of the data in these charts is not available.There are two main reasons for this:

  1. How the data has been grouped

If you cannot select a patient group from the drop down menus, the data is unavailable because of how the data has been organised.

Public Health England has grouped the data like a branching tree. The bottom of the tree contains all the patients with brain tumours, and then each branch divides the data by a certain characteristics, like age, or location of tumour. But the data is divided in an order, starting with location of the tumour (endocrine or brain), then by age, region, and gender. Age is at the start because it makes a bigger difference to survival rates and treatment rates than gender or region. Sometimes, after the data has been split by type of tumour and age, there is not enough data to be split again. This is because to protect patient confidentiality groups cannot contain less than 100 patients. Because some groups cannot be split further, you cannot create ‘totals’ for everyone by region or gender. For example, you cannot see results for all ages by region, or all brain tumours by gender. If these totals were calculated and released, it might be possible to identify patients, which is why Public Health England cannot release this data.

  1. Statistical reasons and data availability

If you can select a patient group from the chart menus, but the chart does not display, the data is unavailable for one of several reasons:

  1. Data is not yet available for the selected year from Public Health England.
  2. Data is not available because the data quality is too poor to release this statistic.
  3. Data is not available as the statistic is not appropriate for this group.
  4. Data is not available because the standard error of the estimate was greater than 20% and so the estimate has been supressed.

Up to date brain tumour data

Brain tumour data may influence the decisions you make about your care. Data also helps you understand the bigger picture, or landscape, in which you find yourself.

Brain tumour data and statistics influence the focus, and work of organisations like brainstrust. The information helps us to understand the scale and impact of the problems we are setting out to solve.

This tool helps you understand the landscape in which you find yourself having been diagnosed with a brain tumour. This landscape can be particularly tricky to navigate as there are many different types of brain tumour, all of which have a different impact.

The information you see represents the most up-to-date, official, population level brain tumour data available for England. Over time we will be adding to the brain tumour data available and publishing reports, with recommendations, as a result of what we learn from this data.

The data behind this content has come from Public Health England’s National Cancer Registration and Analysis Service (NCRAS) and is a direct result of the ‘Get Data Out’ project.

This project provides anonymised population level brain tumour data for public use in the form of standard output tables, accessible here: http://cancerdata.nhs.uk/standardoutput

Incidence

The number or rate (per head of population) of new cases of a disease diagnosed in a given population during a specified time period (usually a calendar year). The crude rate is the total number of cases divided by the mid-year population, usually expressed per 100,000 population.

Malignant

Malignant tumours which grow by invasion into surrounding tissues and have the ability to metastasise to distant sites

Mortality

The number or rate (per head of population) of deaths in a given population during a specified time period (usually a calendar year). The crude rate is the total number of deaths divided by the mid-year population, usually expressed per 100,000 population.

Non-malignant

Not cancerousNon-malignant tumours may grow larger but do not spread to other parts of the body.

Survival

The length of time from the date of diagnosis for a disease, such as cancer, that patients diagnosed with the disease are still alive. In a clinical trial, measuring the survival is one way to see how well a new treatment works. Also called ‘overall survival’ or ‘OS’.

Routes to Diagnosis

Under the ‘Routes to Diagnosis’ tab in the Brain Tumour Data Dashboard, you can explore the ways patients have been diagnosed with brain tumours. There are many ways, or routes, for cancers to be diagnosed in the NHS. A ‘route to diagnosis’ is the series of events between a patient and the healthcare system that leads to a diagnosis of cancer. The routes include:

  1. Two Week Wait

Patients are urgently referred by their GP for suspected cancer via the Two Week Wait system and are seen by a specialist within 2 weeks where they are diagnosed.

  1. GP referral

Diagnosis via a GP referral includes routine and urgent referrals where the patient was not referred under the Two Week Wait system.

  1. Emergency Presentation

Cancers can be diagnosed via emergency situations such as via A&E, emergency GP referral, emergency transfer or emergency admission.

  1. Outpatient

Outpatient cancer diagnoses include diagnoses via an elective route which started with an outpatient appointment that is either a self-referral or consultant to consultant referral. (It does not include those under the Two Week Wait referral system).

  1. Inpatient elective

Diagnosis via an inpatient elective route is where diagnosis occurs after the patient has been admitted into secondary care from a waiting list, or where the admission is booked or planned.

  1. Death Certificate Only

Diagnoses made by Death Certificate Only are made where there is no more information about the cancer diagnosis other than the cancer related death notifications. The date of diagnosis is the same as that of the date of death.

  1. Unknown

For some patients with a cancer diagnosis, there is no relevant data available to understand the route to diagnosis.

 

More information

If any of the statistical terms in this section of the brainstrust website are hard to understand, we recommend looking them up here:

Cancer Research UK’s Cancer Statistics Explained

http://www.cancerresearchuk.org/health-professional/cancer-statistics/cancer-stats-explained/statistics-terminology-explained#heading-Seven

If you are looking for help understanding terms relating specifically to brain tumours, and treatment, then the brainstrust glossary is available here:

https://www.brainstrust.org.uk/advice-glossary.php