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BRAIN TUMORS:
CANCER MEDICINE AND
TARGETED THERAPY
JASSIN M. JOURIA, MD
DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR,
PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL
AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY
SCHOOL OF MEDICINE AND HAS COMPLETED HIS
CLINICAL
CLERKSHIP
TRAINING
IN
VARIOUS
TEACHING HOSPITALS THROUGHOUT NEW YORK,
INCLUDING KING’S COUNTY HOSPITAL CENTER AND
BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE
MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR
KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY
OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN
THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA
CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING
EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO
DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS
TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE
UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO
DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA
IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY.
Abstract
The field of brain tumor research, diagnosis, and treatment is rapidly
evolving. Over 120 types of brain tumors have been identified to date,
and that number continues to increase. As the brain tumor research
grows, so does the ability to provide improved diagnostic procedures
and targeted therapies. It is essential that health clinicians understand
current medical treatment options in order to educate patients and to
develop a treatment plan that has a positive outcome while respecting
the patient's needs and desires.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 4.5 hours. Nurses may only
claim credit commensurate with the credit awarded for completion of
this course activity. Pharmacy content is 1 hour.
Statement of Learning Need
Health clinicians need to know the treatment options for benign and
malignant brain tumors, as well as the side effects the treatments may
cause. The clinician, with the input of the patient, must be able to
understand the potential benefits of treatment, weighed against the
potential side effects.
Course Purpose
To provide health clinicians with knowledge of the current treatment
options for brain tumors and to assist clinicians to offer optimal health
care for a brain tumor patient.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. Over ________ types of brain tumors have been identified
to date, and that number continues to increase.
a.
b.
c.
d.
30
four
60
120
2. The choice of antiepileptic drugs is challenging for
patients with brain tumor-related epilepsy (BTRE)
because BTRE
a.
b.
c.
d.
is untreatable.
is often drug-resistant.
requires surgery as the first line of treatment.
is caused by the presence of a tumor.
3. In brain tumor patients, the presence of _________ is
considered the most important risk factor for long-term
disability.
a.
b.
c.
d.
a cerebral edema
depression
a comorbidity
epilepsy
4. Among the recently marketed drugs, ___________ has
demonstrated promising results and should be considered
a possible treatment option.
a.
b.
c.
d.
lacosamide
carbamazepine
phenobarbital
phenytoin
5. True or False: In patients with a brain tumor, seizures are
the onset symptom in 20-40% of patients, while a further
20-45% of patients will present seizures during the
course of the disease.
a. True
b. False
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Introduction
A brain tumor is an abnormal growth of tissue in the brain or central
spine that can disrupt proper brain function. Physicians refer to a
tumor based on where the tumor cells originated, and whether they
are cancerous (malignant) or not cancerous (benign). Some are
primary brain tumors, which start in the brain. Others are metastatic,
and they start somewhere else in the body and move to the brain.
Brain and spinal cord tumors are different in every individual. They
form in different areas, develop from different cell types, and may
have different treatment options. As the information available about
brain tumors has grown, so has the screening/diagnostic methods, and
specific targeted therapies to provide patients with optimal health
outcomes. Health clinicians need to understand the medical treatment
options for brain tumor patients in order to communicate options to
patients and their families while respecting the patient's needs and
preferences.
Targeted Therapy And Treatment Options
Since there are over 120 types of brain tumors identified to date, and
those numbers continue to increase, the diagnosis of brain tumors has
developed to include performance of a neurologic exam as well as
diagnostic testing that includes an magnetic resonance imaging (MRI),
computed tomography (CT) scan, and biopsy. Treatment options
include watchful waiting, surgery, radiation therapy, chemotherapy,
and targeted therapy. Targeted therapy uses substances that attack
cancer cells without harming normal cells. Many people typically
receive a combination of treatments. The field of brain tumor research,
diagnosis, and treatment may include any of the following medication
and procedural approaches to slow cancer growth and prevent spread.
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Antiseizure or Antiepileptic Drugs
In patients with a brain tumor (BT), seizures are the onset symptom in
20-40% of patients, while an additional 20-45% of patients will
present them during the course of the disease. These patients present
a complex therapeutic profile and require a unique and
multidisciplinary approach. The choice of antiepileptic drugs is
challenging for this particular patient population because brain tumorrelated epilepsy (BTRE) is often drug-resistant. It also has a major
impact on the quality of a BTRE patient’s life and weighs heavily on
public health expenditures.1
In brain tumor patients, the presence of epilepsy is considered the
most important risk factor for long-term disability. For this reason, the
problem of the proper administration of medications and their potential
side effects is of great importance, because good seizure control can
significantly improve the patient’s psychological and relational sphere.2
In these patients, new generation drugs such as gabapentin (GPN),
lacosamide (LCM), levetiracetam (LEV), oxcarbazepine (OXC),
pregabalin (PGB), topiramate (TPM), and zonisamide (ZNS) are
preferred because they have fewer drug interactions and cause fewer
side effects. Among the recently marketed drugs, lacosamide has
demonstrated promising results and should be considered a possible
treatment option.3
It is necessary to develop a customized treatment plan for each
individual patient with BTRE. This requires a vision of patient
management concerned not only with medical therapies
(pharmacological, surgical, radiological, etc.) but also with emotional
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and psychological support for the individual as well as his or her family
throughout all stages of the illness.4
The potential consequences of using the older generation of
antiepileptic drugs (carbamazepine (CBZ), phenobarbital (PB), and
phenytoin (PHT)) must be seen not only in the context of their
potential to cause serious side effects but must also be seen in terms
of their possible contribution to a reduction in the patient’s life
expectancy, due to their negative impact on systemic therapies. In
addition, systemic treatments can also interfere with the metabolism
of these older drugs, thus reducing their plasma levels and
consequently the drug’s efficacy in BT patients.
The newer antiepileptic drugs, such as lamotrigine, levetiracetam,
oxcarbazepine, topiramate and the older antiepileptic drugs, valproic
acid (VPA), can be considered first choice therapies in monotherapy,
for all of the reasons previously discussed. These same antiepileptic
drugs can be considered as add-on, in addition to lacosamide,
pregabalin, and zonisamide.5,6
The therapeutic plan should take into consideration the following:

Whether or not a specific anticancer therapy is needed.

Whether or not a rapid titration is needed (i.e., in patients with a
low life-expectancy, as is the case with brain metastases).
For some patients, antiepileptic drugs may have a secondary,
“positive” effect; for example, pregabalin or topiramate may have a
sedative effect in patients who are agitated, while oxcarbazepine or
lamotrigine will elevate mood in depressed patients.7
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In addition, the team of healthcare professionals should create a
relationship with brain tumor-related epilepsy patients that focuses on
accompanying them and their family throughout the illness, offering
not only medical support, but also the opportunity for patients to be
heard and to be supported during medical and personal challenges
and/or difficulties. Taking care of the patient with BTRE means
listening and understanding the patent’s choices as well as respecting
his or her priorities. Health clinicians need to appreciate the fact that
“taking care of” these patients does not mean “curing” as much as it
means recognizing and responding to the needs of each unique
individual.1,8
Steroids
Steroids are naturally occurring substances. In brain tumor treatment,
steroids are used to reduce the brain swelling, or cerebral edema,
sometimes caused by the tumor or its treatment. The steroids given to
brain tumor patients are corticosteroids – hormones produced by the
adrenal glands. They are not the same as the anabolic steroids used
by athletes to build muscle.9
Dexamethasone and prednisone are the most commonly used
corticosteroid drugs. These steroids can temporarily improve
neurological symptoms by reducing brain swelling but in most cases do
not directly treat the tumor. Because steroids are hormones, their
long-term use requires close monitoring. Steroids may be prescribed
when a brain mass is seen on an MRI or CT scan of the brain, around
the time of surgery or radiation, or sometimes with chemotherapy.
Steroids are used for short-term symptom control although they may
occasionally be continued for a period of weeks or months. Steroids
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can also be used for other reasons. They can improve appetite,
prevent nausea and vomiting from chemotherapy, reduce pain and
prevent allergic reactions to some chemotherapies.10-12
In the case of most brain tumors, steroids are not prescribed to
eliminate cancer cells. One exception is primary central nervous
system lymphoma (PCNSL), which is a lymphoma involving the brain
or spinal cord. If this type of tumor is suspected, steroids are not
usually used until after the diagnosis is confirmed by biopsy or
removal of the tumor. Please note that even in lymphoma steroids are
not typically a long-term cure for this tumor.13
Steroids are usually administered intravenously (IV) or by mouth
(orally). It may take 24–48 hours before the patient will begin to see
the effects of the medication, but the change is often remarkable. The
dose used is dependent on how much swelling is seen on the MRI or
CT scan of the brain. To protect the stomach, patients should take
their steroids with food or milk. An additional medication may also be
prescribed to further protect the stomach. As with all medication, the
goal is to use the lowest, most effective dose. This may mean the dose
is adjusted up or down to find the best dose for the patient. The goal
for steroid use is to administer the lowest dose to control symptoms or
to obtain desired CT or MRI changes.14
When the patient no longer requires steroids, he or she will be given
instructions to slowly taper and stop the drug. Patients should not
abruptly stop taking their steroids. A gradual reduction of steroid dose
allows the body to begin producing its own steroids again. This gradual
tapering avoids adrenal crisis, which is caused by insufficient levels of
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the hormone cortisol. Lowering steroid levels too quickly can also
cause a rebound increase in brain swelling and return of symptoms
and sometimes joint pain.11
Side Effects
Steroids can cause a wide range of unwanted effects. The most
common side effects include increased appetite, weight gain, increased
blood sugar levels (especially in patients who have diabetes),
gastrointestinal problems (i.e., stomach ulcers), frequent urination,
insomnia and mood changes such as irritability or mania, muscle
weakness, susceptibility to infections like pneumonia, thinning of the
skin, and acne. Steroids can interact with other medications, either
increasing or decreasing the levels in the patient’s blood, which can
alter their effectiveness or increase their side effects. Other more
serious side effects can occur, although they are less common. The
benefits of steroid use almost always outweigh their potential side
effects when they are prescribed.9,10
Radiation Therapy
Radiation is a common treatment method for individuals who are able
to tolerate it. This treatment is delivered using high-energy particles or
waves that disrupt the cancer. These particles create small breaks in
the DNA that is inside the cells, which prevent the cancer cells from
dividing and growing.15 The following are common delivery methods16
for radiation:

X-rays

Gamma rays

Electron beams

Protons
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Radiation is especially favorable for cancer that is located in one region
of the body as it can be delivered as a localized treatment. It does not
expose the entire body to treatment as happens with medication,
delivering treatment instead to one specific region.17 Radiation therapy
can be used independently to treat cancer, or it can be used in
conjunction with another method of treatment. In many instances,
radiation will be combined with surgery or chemotherapy.18
The type of radiation therapy used to treat the patient depends on
many factors, including:15

The type of cancer.

The size of the cancer.

The cancer’s location in the body.

How close the cancer is to normal tissues that are sensitive to
radiation.

How far into the body the radiation needs to travel.

The patient’s general health and medical history.

Whether the patient will have other types of cancer treatment.

Other factors, such as the patient’s age and other medical
conditions.
Types of Radiation
There are three primary types of radiation therapy.19 They are:

External-beam Radiation Therapy

Internal radiation therapy

Systemic radiation therapy
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External-beam Radiation Therapy
External-beam radiation therapy is most often delivered in the form of photon
beams (either x-rays or gamma rays). A photon is the basic unit of light and
other forms of electromagnetic radiation. It can be thought of as a bundle of
energy. The amount of energy in a photon can vary. For example, the photons in
gamma rays have the highest energy, followed by the photons in x-rays.
Patients usually receive external-beam radiation therapy in daily treatment
sessions over the course of several weeks. The number of treatment sessions
depends on many factors, including the total radiation dose that will be given.
Intensitymodulated
radiation therapy
(IMRT)
IMRT uses hundreds of tiny radiation beam-shaping
devices, called collimators, to deliver a single dose of
radiation. The collimators can be stationary or can move
during treatment, allowing the intensity of the radiation
beams to change during treatment sessions. This kind of
dose modulation allows different areas of a tumor or
nearby tissues to receive different doses of radiation.
Unlike other types of radiation therapy, IMRT is planned in
reverse (called inverse treatment planning). In inverse
treatment planning, the radiation oncologist chooses the
radiation doses to different areas of the tumor and
surrounding tissue, and then a high-powered computer
program calculates the required number of beams and
angles of the radiation treatment. In contrast, during
traditional (forward) treatment planning, the radiation
oncologist chooses the number and angles of the radiation
beams in advance and computers calculate how much dose
will be delivered from each of the planned beams.
The goal of IMRT is to increase the radiation dose to the
areas that need it and reduce radiation exposure to
specific sensitive areas of surrounding normal tissue.
Compared with three-dimensional conformal radiotherapy
(3D-CRT), IMRT can reduce the risk of some side effects,
such as damage to the salivary glands (which can cause
dry mouth, or xerostomia), when the head and neck are
treated with radiation therapy. However, with IMRT, a
larger volume of normal tissue overall is exposed to
radiation. Whether IMRT leads to improved control of
tumor growth and better survival compared with 3D-CRT is
not yet known.
Image-guided
radiation therapy
(IGRT)
In IGRT, repeated imaging scans (CT, MRI, or PET) are
performed during treatment. Imaging scans are processed
by computers, identifying changes in a tumor’s size and
location due to treatment and allowing patient positioning
or planned radiation dose adjusting during treatment.
Repeated imaging can increase the accuracy of radiation
treatment and may allow reductions in the planned volume
of tissue to be treated, thereby decreasing the total
radiation dose to normal tissue.
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Tomotherapy
Tomotherapy is a type of image-guided IMRT. A
tomotherapy machine is a hybrid between a CT imaging
scanner and an external-beam radiation therapy machine.
The part of the tomotherapy machine that delivers
radiation for both imaging and treatment can rotate
completely around the patient in the same manner as a
normal CT scanner. Tomotherapy machines can capture CT
images of the patient’s tumor immediately before
treatment sessions, to allow for very precise tumor
targeting and sparing of normal tissue.
Like standard IMRT, tomotherapy may be better than 3DCRT at sparing normal tissue from high radiation doses.
However, clinical trials comparing 3D-CRT with
tomotherapy have not been conducted.
Stereotactic
radiosurgery
Stereotactic radiosurgery (SRS) can deliver one or more
high doses of radiation to a small tumor. SRS uses
extremely accurate image-guided tumor targeting and
patient positioning. Therefore, a high dose of radiation can
be given without excess damage to normal tissue.
SRS can be used to treat only small tumors with welldefined edges. It is most commonly used in the treatment
of brain or spinal tumors and brain metastases from other
cancer types. For the treatment of some brain metastases,
patients may receive radiation therapy to the entire brain
(called whole-brain radiation therapy) in addition to SRS.
SRS requires the use of a head frame or other device to
immobilize the patient during treatment to ensure that the
high dose of radiation is delivered accurately.
Stereotactic body
radiation therapy
Stereotactic body radiation therapy (SBRT) delivers
radiation therapy in fewer sessions, using smaller radiation
fields and higher doses than 3D-CRT in most cases. By
definition, SBRT treats tumors that lie outside the brain
and spinal cord. Because these tumors are more likely to
move with the normal motion of the body, and therefore
cannot be targeted as accurately as tumors within the
brain or spine, SBRT is usually given in more than one
dose. SBRT can be used to treat only small, isolated
tumors, including cancers in the lung and liver.
Proton therapy
Proton beams differ from photon beams mainly in the way
they deposit energy in living tissue. Whereas photons
deposit energy in small packets all along their path
through tissue, protons deposit much of their energy at the
end of their path (called the Bragg peak) and deposit less
energy along the way. In theory, use of protons should
reduce the exposure of normal tissue to radiation, possibly
allowing the delivery of higher doses of radiation to a
tumor. Proton therapy has not yet been compared with
standard external-beam radiation therapy in clinical trials.
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Other charged
particle beams
Electron beams are used to irradiate superficial tumors,
such as skin cancer or tumors near the surface of the
body, but they cannot travel very far through tissue.
Therefore, they cannot treat tumors deep within the body.
Patients can discuss these different methods of radiation
therapy with their physicians to see if any is appropriate
for their type of cancer and if it is available in their
community or through a clinical trial.
Brachytherapy
Other Forms of Radiation
Internal radiation therapy (brachytherapy) is radiation
delivered from radiation sources (radioactive materials)
placed inside or on the body. Several brachytherapy
techniques are used in cancer treatment.
Interstitial brachytherapy uses a radiation source placed
within tumor tissue, such as within a prostate tumor.
Intracavitary brachytherapy uses a source placed within a
surgical cavity or a body cavity, such as the chest cavity,
near a tumor. Episcleral brachytherapy, which is used to
treat melanoma inside the eye, uses a source that is
attached to the eye.
In brachytherapy, radioactive isotopes are sealed in tiny
pellets or “seeds.” These seeds are placed in patients using
delivery devices, such as needles, catheters, or some other
type of carrier. As the isotopes decay naturally, they give
off radiation that damages nearby cancer cells.
If left in place, after a few weeks or months, the isotopes
decay completely and no longer give off radiation. The
seeds will not cause harm if they are left in the body.
Brachytherapy may be able to deliver higher doses of
radiation to some cancers than external-beam radiation
therapy while causing less damage to normal tissue.
Brachytherapy can be given as a low-dose-rate or a highdose-rate treatment:

In low-dose-rate treatment, cancer cells receive
continuous low-dose radiation from the source over
a period of several days.

In high-dose-rate treatment, a robotic machine
attached to delivery tubes placed inside the body
guides one or more radioactive sources into or near
a tumor, and then removes the sources at the end
of each treatment session. High-dose-rate
treatment can be given in one or more treatment
sessions.
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The placement of brachytherapy sources can be temporary
or permanent:
 For permanent brachytherapy, the sources are
surgically sealed within the body and left there,
even after all of the radiation has been given off.
The remaining material (in which the radioactive
isotopes were sealed) does not cause any
discomfort or harm to the patient. Permanent
brachytherapy is a type of low-dose-rate
brachytherapy.

For temporary brachytherapy, tubes (catheters) or
other carriers are used to deliver the radiation
sources, and both the carriers and the radiation
sources are removed after treatment. Temporary
brachytherapy can be either low-dose-rate or highdose-rate treatment.
Physicians can use brachytherapy alone or in addition to
external-beam radiation therapy to provide a “boost” of
radiation to a tumor while sparing surrounding normal
tissue.
Systemic
radiation therapy
In systemic radiation therapy, a patient swallows or
receives an injection of a radioactive substance, such as
radioactive iodine or a radioactive substance bound to a
monoclonal antibody.
Radioactive iodine (131I) is a type of systemic radiation
therapy commonly used to help treat some types of
cancer. In many instances, a monoclonal antibody helps
target the radioactive substance to the right place. The
antibody joined to the radioactive substance travels
through the blood, locating and killing tumor cells.
The Food and Drug Administration (FDA) has approved the
drug ibritumomab tiuxetan for the treatment of certain
types of B-cell non-Hodgkin lymphoma (NHL). The
antibody part of this drug recognizes and binds to a
protein found on the surface of B lymphocytes.
The combination drug regimen of tositumomab and iodine
I 131 tositumomab has been approved for the treatment of
certain types of NHL. In this regimen, nonradioactive
tositumomab antibodies are given to patients first,
followed by treatment with tositumomab antibodies that
have 131I attached. Tositumomab recognizes and binds to
the same protein on B lymphocytes as ibritumomab. The
nonradioactive form of the antibody helps protect normal B
lymphocytes from being damaged by radiation from 131I.
Many other systemic radiation therapy drugs are in clinical
trials for different cancer types.
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Radiation Side Effects
Patients may experience both acute and chronic side effects as a result
of radiation treatment. While acute side effects will occur during the
course of treatment, chronic side effects may not appear for months or
years after treatment has ceased. The prevalence of side effects will
depend on the following factors:20

Area of the body being treated

Dose given per day

Total dose given

Patient’s general medical condition

Other treatments given at the same time
The following is a description of the most common acute and chronic
side effects associated with radiation.15
1) Acute:
Acute radiation side effects are caused by damage to rapidly
dividing normal cells in the area being treated. These effects
include skin irritation or damage at regions exposed to the
radiation beams. Examples include damage to the salivary
glands or hair loss when the head or neck area is treated, or
urinary problems when the lower abdomen is treated. Most acute
effects disappear after treatment ends, though some (like
salivary gland damage) can be permanent. Fatigue is a common
side effect of radiation therapy regardless of which part of the
body is treated. Nausea with or without vomiting is common
when the abdomen is treated and occurs sometimes when the
brain is treated. Medications are available to help prevent or
treat nausea and vomiting during treatment.
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2) Chronic
Late side effects of radiation therapy may or may not occur.
Depending on the area of the body treated, late side effects can
include:

Fibrosis (the replacement of normal tissue with scar tissue,
leading to restricted movement of the affected area)

Damage to the bowels, causing diarrhea and bleeding

Memory loss

Infertility (inability to have a child)

Rarely, a second cancer caused by radiation exposure

Second cancers that develop after radiation therapy
depend on the part of the body that was treated. For
example, girls treated with radiation to the chest for
Hodgkin lymphoma have an increased risk of developing
breast cancer later in life. In general, the lifetime risk of a
second cancer is highest in people treated for cancer as
children or adolescents.
Chemotherapy
Chemotherapy is a common treatment for many cancers. There are
approximately one hundred chemotherapy drugs currently in use.21
These drugs can be used individually or in conjunction with other
methods of treatment. The specific drugs used will depend on a variety
of factors, including the location, severity, and scope of the cancer.22
Chemotherapy drugs vary widely in their chemical composition, how
they are taken, their usefulness in treating specific forms of cancer,
and their side effects. Although these drugs differ in the ways
indicated above, they all work to disrupt the ways in which cancer cells
divide and grow. The drugs damage the cells to prevent reproduction.
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Unfortunately, chemotherapy drugs also have the same effect on noncancer cells.23
There are a number of delivery methods that can be used with
chemotherapy.24 They include:

By injection or a “drip” directly into a vein (intravenous
chemotherapy)

By mouth as tablets or capsules (oral chemotherapy)

By other ways, including: by injection into the fluid around the
spine and brain (intrathecal chemotherapy); directly into a body
cavity, for example the bladder; by injection into muscle or
under the skin; directly to the skin as a cream for some skin
cancers.
Chemotherapy is a useful stand-alone treatment. However, it is often
more effective when combined with other therapies such as surgery,
radiotherapy, hormonal therapy, or anti-cancer drugs (targeted or
biological therapies).25 Chemotherapy can be used in the following
ways:26

As a main treatment for cancers, such as lymphomas and
leukemia

Before surgery or radiotherapy to shrink a cancer (called neoadjuvant chemotherapy)

After surgery or radiotherapy to reduce the risk of cancer coming
back by treating any remaining cells (called adjuvant
chemotherapy)

At the same time as radiotherapy to make it work better (called
chemoradiation)
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
To treat cancer that has spread into surrounding tissues (locally
advanced) or to other parts of the body. This may cure certain
cancers but, more commonly, the aim is to shrink and control a
cancer to try to prolong life, and to relieve symptoms.

Chemotherapy to relieve symptoms is called palliative
chemotherapy.
There are 3 possible goals for chemotherapy treatment, which are
highlighted below.27

Cure:
If possible, chemotherapy is used to cure the cancer, meaning
that the cancer disappears and does not return. However, most
doctors do not use the word “cure” except as a possibility or
intention. When giving treatment that has a chance of curing a
person’s cancer, the doctor may describe it as treatment with
curative intent. But there are no guarantees, and though cure
may be the goal, it does not always work out that way. It often
takes many years to know if a person’s cancer is actually cured.

Control:
If cure is not possible, the goal may be to control the disease —
to shrink any cancerous tumors and/or stop the cancer from
growing and spreading. This can help someone with cancer feel
better and possibly live longer. In many cases, the cancer does
not completely go away but is controlled and managed as a
chronic disease, much like heart disease or diabetes. In other
cases, the cancer may even seem to have gone away for a while,
but it’s expected to come back.
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
Palliation:
When the cancer is at an advanced stage, chemotherapy drugs
may be used to relieve symptoms caused by the cancer. When
the only goal of a certain treatment is to improve the quality of
life but not treat the disease itself, it is called palliative
treatment or palliation.
Sometimes, chemotherapy is the only treatment used. In other cases,
chemotherapy may be given along with other treatments. It may be
used as adjuvant therapy or neoadjuvant therapy.28

Adjuvant chemotherapy:
After surgery to remove the cancer, there may still be some
cancer cells left behind that cannot be seen. When drugs are
used to kill those unseen cancer cells, it is called adjuvant
chemotherapy. Adjuvant treatment can also be given after
radiation.

Neoadjuvant chemotherapy:
Chemotherapy can be given before the main cancer treatment
(such as surgery or radiation). Giving chemotherapy first can
shrink a large cancerous tumor, making it easier to remove with
surgery. Shrinking the tumor may also allow it to be treated
more easily with radiation. Neoadjuvant chemotherapy also can
kill small deposits of cancer cells that cannot be seen on scans or
X-rays.
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Administration Methods
There are a number of different methods of administering
chemotherapy. The specific method used will depend on the type,
severity, and scope of the cancer. It will also depend on the health
status of the patient and his or her ability to tolerate the treatment.
The following table provides a description of each of the primary
methods of chemotherapy administration.26
Systemic
chemotherapy
Systemic chemotherapy involves using drugs to treat the
entire body. Treatment is not localized based on the area
where the cancer occurs. Drugs used for systemic (total
body) chemotherapy can be given in these ways:




Oral (PO) — taken by mouth (usually as pills)
Intravenous (IV) — infused through a vein
Intramuscular (IM) — injected into a muscle
Subcutaneous (SQ) — injected under the skin
Some chemotherapy drugs are never taken by mouth
because the digestive system can’t absorb them or because
they irritate the digestive system. Even when a drug is
available in an oral form (such as a pill or liquid), this
method may not be the best choice. For example, some
people with certain symptoms (like severe nausea,
vomiting, or diarrhea) cannot swallow liquids or pills; other
people may have trouble remembering when or how many
pills to take. Still, chemotherapy drugs are powerful
treatments, regardless of their form and the way they are
administered.
The term parenteral is used to describe drugs given into a
vein (intravenously or IV), muscle (intramuscularly or IM),
or under the skin (subcutaneously or SQ). The IV route is
the most common. IM and SQ injections are less often
used because many drugs can irritate or even damage the
skin and muscle tissue.
The IV route gets the drug quickly throughout the body. IV
therapy may be given through a catheter placed in a vein
in the arm or hand, which is called a “peripheral line.” IV
drugs can also be given through a catheter placed into a
larger vein in the chest, or neck, which is known as a
central venous catheter (CVC) or “central line.”
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Central venous catheters (CVCs) or vascular access devices
(VADs) may be needed. Central venous catheters are also
known as vascular access devices. Some types of catheters
are put into the arm (so they are inserted peripherally),
but are threaded into a larger vein in the chest. They are
used for these reasons:
 To give several drugs at one time
 For long-term therapy (to reduce the number of
needle sticks)
 For frequent treatments (using a CVC will not cause
as much wear and tear to the veins, potential
scarring, and discomfort as numerous IVs that go
into the small veins of the arms or hands)
 For continuous infusion chemotherapy
 To give drugs that can cause serious damage to skin
and muscle tissue if they leak outside of a vein
(these drugs are known as vesicants). Delivering
these through a CVC provides more reliable access
to a vein than a short-term IV, reducing the risk
that the drug will leak outside the vein and damage
tissues.
Regional
chemotherapy
When there is a need to get high doses of chemotherapy to
a specific area of the body, it may be given by a regional
method. Regional chemotherapy directs the anti-cancer
drugs into the part of the body where the cancer is. The
purpose is to get more of the drug to the cancer, while
trying to minimize side effects on the whole body. Side
effects will often still happen because the drugs can be
partly absorbed into the bloodstream and travel throughout
the body.
Intra-arterial
With Intra-arterial chemotherapy, the drug is injected into
an artery that goes to a certain area of the body. An intraarterial infusion allows a chemotherapy drug to be given
directly to the cancerous tumor through a catheter placed
in the artery that supplies blood to the tumor. This method
is used to treat disease in an organ such as the liver
(isolated hepatic perfusion), or to treat an extremity such
as the leg (isolated limb perfusion). The goal is to
concentrate the drug in the area of the tumor and decrease
systemic side effects. The catheter is attached to an
implanted or portable pump. Although this approach
sounds like a good idea for better effectiveness and fewer
side effects, most studies have not found it to be as useful
as expected. This approach is being studied for many types
of cancer in clinical trials. Except for these clinical trials, it
is rarely available outside of specialized cancer centers.
Intracavitary
chemotherapy
Intracavitary is a broad term used to describe
chemotherapy given directly into a body cavity. The chemo
drug is given through a catheter placed into one of these
areas as described below.
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Intravesical
Intravesical chemotherapy is often used for early stage
bladder cancer. The chemotherapy is usually given weekly
for 4 to 12 weeks. For each treatment, a urinary catheter is
placed into the bladder to give the drug. The drug is kept
in the bladder for about 2 hours and then drained. The
urinary catheter is removed after each treatment.
Intrapleural
Intrapleural chemotherapy is not used very often but may
be helpful for some people with mesothelioma (cancer that
develops in the lining of the lung), and those with lung or
breast cancers that have spread to the pleura (the
membrane around the lungs and lining the chest cavity).
Intrapleural chemotherapy is given through chest catheters
that may be connected to an implantable port. These
catheters can be used to give drugs and to drain fluid that
can build up in the pleural space when cancer has spread
to that area.
Intraperitoneal
Intraperitoneal chemotherapy has become one of the
standard treatments for certain stages of ovarian cancer. It
may also be used to treat some recurrent colon cancers, as
well as cancers of the appendix or stomach that have
spread extensively within the abdomen. Intraperitoneal
chemotherapy is given through a Tenckhoff catheter (a
catheter specially designed for removing or adding large
amounts of fluid from or into the abdominal cavity) or
through an implanted port attached to a catheter.
Chemotherapy injected into the port travels through the
catheter into the abdominal cavity where it’s absorbed into
the affected area before entering the bloodstream. This
approach can work very well, but it can also have more
severe side effects than regular IV chemotherapy. The
higher doses that are used, along with more gradual
absorption of the drug into the body, may be part of why
the side effects may be worse.
Intrathecal
chemotherapy
Intrathecal chemotherapy is given directly into the fluid
surrounding the brain and spinal cord (the cerebrospinal
fluid or CSF) to reach cancer cells in the fluid and the
central nervous system (brain and spinal cord). Most
chemotherapy drugs that are put into the bloodstream are
unable to cross the barrier between the bloodstream and
the central nervous system, called the blood-brain barrier.
Intrathecal chemotherapy gets the drug directly to the
central nervous system. Intrathecal chemotherapy is given
in 1 of 2 ways:

The chemotherapy can be given by a lumbar
puncture (spinal tap) done daily or weekly. This is
when a thin needle is placed between the bones of
the lower spine and into the space through which
the CSF flows around the spinal cord.
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
A special device called an Ommaya reservoir can be
used. It’s a small, drum-like port, which is placed
under the skin of the skull. An attached catheter
goes through the skull into a ventricle (a space
inside the brain filled with CSF). A special needle is
put through the skin and into the port to give the
chemotherapy.
Chemotherapy is given this way when it is needed to treat
cancer cells that have entered the central nervous system
(this is called leptomeningeal spread). This is seen most
commonly in leukemia’s, but also may happen with some
lymphomas and advanced solid tumors like breast and lung
cancers. Intrathecal chemotherapy does not help when
tumors have already started growing in the brain or spinal
cord.
Intralesional
chemotherapy
Intralesional chemotherapy refers to the drug being
injected directly into the cancerous tumor. It may be used
for tumors that are in or under the skin, and rarely for
tumors that are on an organ inside the body. It is only
possible when the tumor can be safely reached by a
needle, and is most often used when surgery is not an
option.
Topical
chemotherapy
In this use, chemotherapy is applied to the skin in the form
of a cream or lotion. Most often, it is put onto skin cancers
such as the basal cell or squamous cell types. It is also
used to treat pre-cancerous growths on the skin. The
patient or a family member usually puts on the
chemotherapy cream. It is important to understand the
schedule, know exactly how to use these potent drugs, and
know what kinds of precautions to use.
Alternate
Chemotherapy
Methods
There are other ways you might be given chemotherapy,
depending on the drugs that are being used and the type
of cancer.
Injection into a muscle or skin - Some chemotherapy drugs
are given by injection into a muscle (intramuscular) of the
leg or buttock. This might feel a bit painful or
uncomfortable for a short time. Some drugs are given by
injection under the skin (subcutaneous) using a very fine
needle.
Injection into the spinal fluid (intrathecal): In some
leukemia’s, lymphomas or some brain tumors cancer cells
can pass into the fluid surrounding the brain and spinal
cord (cerebrospinal fluid or CSF). Intrathecal chemotherapy
can be used to destroy these cancer cells or to try and
prevent this from happening. Chemotherapy into a vein or
by mouth cannot reach these cancer cells. The doctor
numbs an area of skin over the spine with local anesthetic.
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After a few minutes they will gently insert a needle
between two of the spinal bones into the CSF (called a
lumbar puncture). The doctor then injects the
chemotherapy through the needle into the CSF. The most
common side effect of a lumbar puncture is a headache. To
help prevent this, the patient will need to lie flat for a few
hours afterwards and drink plenty of fluids.
Into a body space (intracavitary): Chemotherapy drugs can
be given into a space (cavity) in the body, such as the
bladder. This can cause irritation or inflammation in the
area the drugs are given but it does not usually cause side
effects in other parts of the body. A fine tube (catheter) is
usually inserted into the body cavity and chemotherapy is
put in through this tube. It may be drained out again after
a set period of time.
Into the bladder: This may be done to treat early bladder
cancer. Liquid chemotherapy drugs are given directly into
the bladder through a catheter, which is removed when it
is over. Our section on early (superficial) bladder cancer
has more information.
Into the abdominal cavity (intraperitoneal chemotherapy):
This is very occasionally used to treat ovarian cancer and
there is more information in our section on cancer of the
ovary. It may also be used to treat mesothelioma in the
abdomen (peritoneal mesothelioma).
Between the two layers of the pleura (tissue that covers
the outside of the lungs): Chemotherapy is sometimes put
in between the two layers of the pleura to treat cancer cells
that have spread there.
Into a limb (isolated limb perfusion): Chemotherapy is very
occasionally given directly into the blood vessels in a limb.
This is to treat a skin cancer called melanoma that has
come back.
Chemotherapy creams: Chemotherapy creams are used to
treat some types of skin cancer. You put the cream on the
affected skin in a thin layer and cover the area with a
dressing. A specialist nurse or pharmacist will show the
patient how to do this and will explain how often they need
to apply the cream. Although the cream can irritate the
skin in the area or make it sore, it won’t cause side effects
in other parts of the body.
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Types of Chemotherapy Drugs
There are a multitude of chemotherapy drugs that are grouped and
categorized based upon a number of factors, including:28

how they work

their chemical structure

their relationship to another drug
Many drugs will belong to more than one of the groups, as some
chemotherapy drugs act in more than one way. The following is a list
of the different categories of chemotherapy drugs.
Alkylating Agents
Alkylating agents directly damage DNA to prevent the cancer cell from
reproducing. As a class of drugs, these agents are not phase-specific;
in other words, they work in all phases of the cell cycle. Alkylating
agents are used to treat many different cancers, including leukemia,
lymphoma, Hodgkin disease, multiple myeloma, and sarcoma, as well
as cancers of the lung, breast, and ovary. Because these drugs
damage DNA, they can cause long-term damage to the bone marrow.
In rare cases, this can eventually lead to acute leukemia.
The risk of leukemia from alkylating agents is “dose-dependent,”
meaning that the risk is small with lower doses, but increase as the
total amount of the drug used gets higher. The risk of leukemia after
getting alkylating agents is highest about 5 to 10 years after
treatment. There are different classes of alkylating agents, including:
•
Nitrogen mustards, such as mechlorethamine (nitrogen
mustard), chlorambucil, cyclophosphamide, ifosfamide, and
melphalan
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•
Nitrosoureas, which include streptozocin, carmustine (BCNU),
and lomustine
•
Alkyl sulfonates, busulfan
•
Triazines, dacarbazine (DTIC) and temozolomide
•
Ethylenimines, thiotepa and altretamine (hexamethylmelamine)
•
The platinum drugs (cisplatin, carboplatin, and oxalaplatin),
sometimes grouped with alkylating agents because they kill cells
in a similar way. These drugs are less likely than the alkylating
agents to cause leukemia later on.
Antimetabolites
Antimetabolites are a class of drugs that interfere with DNA and RNA
growth by substituting for the normal building blocks of RNA and DNA.
These agents damage cells during the S phase. They are commonly
used to treat leukemia, cancers of the breast, ovary, and the intestinal
tract, as well as other types of cancer. Examples of antimetabolites
include:
•
5-fluorouracil (5-FU)
•
6-mercaptopurine (6-MP)
•
Capecitabine
•
Cladribine
•
Clofarabine
•
Cytarabine
•
Floxuridine
•
Fludarabine
•
Gemcitabine
•
Hydroxyurea
•
Methotrexate
•
Pemetrexed
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•
Pentostatin
•
Thioguanine
Anthracyclines
Anthracyclines are anti-tumor antibiotics that interfere with enzymes
involved in DNA replication. These drugs work in all phases of the cell
cycle. They are widely used for a variety of cancers. A major
consideration when giving these drugs is that they can permanently
damage the heart if given in high doses. For this reason, lifetime dose
limits are often placed on these drugs.
Examples of anthracyclines include:
•
Daunorubicin
•
Doxorubicin
•
Epirubicin
•
Idarubicin
Other Anti-tumor Antibiotics
Anti-tumor antibiotics that are not anthracyclines include the following.
•
Actinomycin-D
•
Bleomycin
•
Mitomycin-C - Mitoxantrone is an anti-tumor antibiotic that is
similar to doxorubicin in many ways, including the potential for
damaging the heart. This drug also acts as a topoisomerase II
inhibitor (see below), and can lead to treatment-related
leukemia. Mitoxantrone is used to treat prostate cancer, breast
cancer, lymphoma, and leukemia.
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Topoisomerase Inhibitors
Topoisomerase inhibitors interfere with enzymes called
topoisomerases, which help separate the strands of DNA so they can
be copied. They are used to treat certain leukemia’s, as well as lung,
ovarian, gastrointestinal, and other cancers. Examples of
topoisomerase I inhibitors include topotecan and irinotecan (CPT-11).
Examples of topoisomerase II inhibitors include etoposide (VP-16) and
teniposide. Mitoxantrone also inhibits topoisomerase II. Treatment
with topoisomerase II inhibitors increases the risk of a second cancer
— acute myelogenous leukemia (AML). With this type of drug, a
secondary leukemia can be seen as early as 2 to 3 years after the drug
is given.
Mitotic Inhibitors
Mitotic inhibitors are often plant alkaloids and other compounds
derived from natural products. They can stop mitosis or inhibit
enzymes from making proteins needed for cell reproduction. These
drugs work during the M phase of the cell cycle but can damage cells
in all phases. They are used to treat many different types of cancer
including breast, lung, myelomas, lymphomas, and leukemia.
These drugs are known for their potential to cause peripheral nerve
damage, which can be a dose-limiting side effect. Examples of mitotic
inhibitors include:
•
Taxanes: paclitaxel and docetaxel
•
Epothilones: ixabepilone
•
Vinca alkaloids: vinblastine, vincristine, and vinorelbine
•
Estramustine
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Corticosteroids
Steroids are natural hormones and hormone-like drugs that are
useful in treating some types of cancer (lymphoma, leukemia, and
multiple myeloma), as well as other illnesses. When these drugs are
used to kill cancer cells or slow their growth, they are considered
chemotherapy drugs.
Corticosteroids are also commonly used as anti-emetics to help
prevent nausea and vomiting caused by chemotherapy. They are
used before chemotherapy to help prevent severe allergic reactions
(hypersensitivity reactions) as well. When a corticosteroid is used to
prevent vomiting or allergic reactions, it is not considered
chemotherapy. Examples include prednisone, methylprednisolone,
and dexamethasone.
Miscellaneous Chemotherapy Drugs
Some chemotherapy drugs act in slightly different ways and do not fit
well into any of the other categories. Examples include drugs like Lasparaginase, which is an enzyme, and the proteosome inhibitor
bortezomib.
Other Types of Cancer Drugs
Other drugs and biological treatments are used to treat cancer, but are
not usually considered chemotherapy. While chemotherapy drugs take
advantage of the fact that cancer cells divide rapidly, these other
drugs target different properties that set cancer cells apart from
normal cells. They often have less serious side effects than those
commonly caused by chemotherapy drugs because they are targeted
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to work mainly on cancer cells, not normal, healthy cells. Many are
used along with chemotherapy.
Targeted Therapies
As researchers have learned more about the inner workings of cancer
cells, they have begun to create new drugs that attack cancer cells
more specifically than traditional chemotherapy drugs. Most attack
cells with mutant versions of certain genes, or cells that express too
many copies of a particular gene. These drugs can be used as part of
the main treatment, or they may be used after treatment to maintain
remission or decrease the chance of recurrence. Examples of targeted
therapies include imatinib, gefitinib, sunitinib and bortezomib.
Targeted therapies are a huge research focus and probably many more
will be developed in the future. A brief discussion is provided here, but
more can be learned about targeted therapies in upcoming literature.
Differentiating Agents
Differentiating agents act on the cancer cells to make them mature
into normal cells. Examples of such drugs include the retinoids,
tretinoin and bexarotene, as well as arsenic trioxide.
Hormone Therapy
Drugs in this category are sex hormones, or hormone-like drugs, that
change the action or production of female or male hormones. They are
used to slow the growth of breast, prostate, and endometrial (uterine)
cancers, which normally grow in response to natural hormones in the
body. These cancer treatment hormones do not work in the same ways
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as standard chemotherapy drugs, but rather by preventing the cancer
cell from using the hormone it needs to grow, or by preventing the
body from making the hormones. Examples include the following:
•
The anti-estrogens: fulvestrant, tamoxifen, and toremifene
•
Aromatase inhibitors: anastrozole, exemestane, and letrozole
•
Progestins: megestrol acetate
•
Estrogens
•
Anti-androgens: bicalutamide, flutamide, and nilutamide
•
Gonadotropin-releasing hormone (GnRH), also known as
luteinizing hormone-releasing hormone (LHRH) agonists or
analogs: leuprolide and goserelin
Immunotherapy
Some drugs are given to people with cancer to stimulate their natural
immune systems to recognize and attack cancer cells. 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.
Types of immunotherapies and some examples include:220
•
Monoclonal antibody therapy (passive immunotherapies), such
as rituximab and alemtuzumab
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•
Non-specific immunotherapies and adjuvants (other substances
or cells that boost the immune response), such as BCG,
interleukin-2 (IL-2), and interferon-alfa
•
Immunomodulating drugs, for instance, thalidomide and
lenalidomide
•
Cancer vaccines (active specific immunotherapies). In 2010, the
FDA approved the first vaccine to treat cancer (the Provenge®
vaccine for advanced prostate cancer); other vaccines for many
different types of cancer are being studied.
List of Chemotherapy Drugs
The following table provides a thorough list of the chemotherapy drugs
by name.23
Individual Drugs
Combination Regimen

Abraxane

ABVD

Amsacrine

AC

Azacitidine

BEAM

Bendamustine

BEP

Bleomycin

Capecitabine & docetaxel

Busulfan

Carbo MV

Cabazitaxel

Carboplatin & etoposide

Capecitabine

CAV

Carboplatin

ChlVPP

Carmustine

CHOP

Chlorambucil

Cisplatin, capecitabine &

Cisplatin

Cladribine

Cisplatin & fluorouracil

Clofarabine

Cisplatin & topotecan

Crisantaspase

CMF

Cyclophosphamide

CTD

Cytarabine

CVP
trastuzumab
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
Dacarbazine

de Gramont

Dactinomycin

DHAP

Daunorubicin

Docetaxel & carboplatin

Docetaxel

Docetaxel & cisplatin

Doxorubicin

Doxorubicin & ifosfamide

Epirubicin

E-CMF

Etoposide

EC

Fludarabine

ECF

Fluorouracil

ECX

Gemcitabine

EOX

Gliadel implants

ESHAP

Hydroxycarbamide

Etoposide & cisplatin

Idarubicin

FCR

Ifosfamide

FEC

Irinotecan

FEC-T

Leucovorin

FOLFIRINOX

Liposomal daunorubicin

GemCap

Liposomal doxorubicin

GemCarbo

Lomustine

Gemcitabine & cisplatin

Melphalan

GemTaxol

Mercaptopurine

Hyper-CVAD

Mesna

ICE

Methotrexate

Irinotecan & cetuximab

Mitomycin

Irinotecan with 5FU & folinic acid

Mitotane

MIC

Mitoxantrone

MM

Oxaliplatin

MMM

Paclitaxel

MPT

Pemetrexed

MVAC

Pentostatin

MVP

Procarbazine

Oxaliplatin with 5FU & folonic acid

Raltitrexed

Oxaliplatin & capecitabine (XELOX

Rasburicase

Streptozocin

Paclitaxel & carboplatin

Tegafur-uracil

Pemetrexed & cisplatin
or CAPOX)
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
Temozolomide

PCV

Thiotepa

PMitCEBO

Tioguanine

POMB/ACE

Topotecan

R-CHOP

Trabectedin

R-CVP

Treosulfan

R-DHAP

Vinblastine

R-ESHAP

Vincristine

R-ICE

Vindesine

TAC

Vinorelbine

TC

TIP

VAD

Vinorelbine & carboplatin

Vinorelbine & cisplatin
Drug Side Effects
Although the specific side effects may differ depending on the type of
chemotherapy used, many patients will experience a range of common
symptoms. Chemotherapy damages normal cells, which causes the
range of side effects experienced, such as nausea, vomiting, lethargy,
headaches, and hair loss.
The normal cells most likely to be damaged are those that divide
rapidly, for instance:29

Bone marrow/blood cells

Cells of hair follicles

Cells lining the digestive tract

Cells lining the reproductive tract
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New and Emerging Treatment Strategies
There is ongoing research in the area of brain and spinal cord tumors.
Medical scientists are looking for causes and ways to prevent them,
and physicians are working to improve treatments.
Understanding Gene Changes in Tumors
Researchers continue to look for the gene changes inside cells that
result in brain and spinal cord tumors. The hope is that learning more
about these gene changes may lead to better ways to treat these
tumors. For example, researchers have found that medulloblastomas
can be divided into 4 main types, based on the different gene changes
in the tumor cells. Some of these tumor types have a better outlook
than others. Physicians are now learning how to use this information to
help decide which individual might need more or less intensive
treatment.30,31
More recently, researchers have identified some of the specific gene
changes found in each type of medulloblastoma that might help the
tumor cells grow. Some of these gene changes can be targeted with
new types of drugs, which are now being tested in clinical trials. In the
future, physicians may be able to develop other drugs that specifically
target these gene changes.32
Imaging and Surgical Treatment
Recent advances in imaging and surgery techniques for brain tumors
have made these procedures much safer and more successful. Often
imaging and surgery may be combined with other medical treatment
of brain tumors. Some of these techniques are highlighted here.
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Functional Magnetic Resonance Imaging
Functional Magnetic Resonance Imaging can identify the site of
important areas of the brain and how close they are to the tumor.
Magnetic Resonance Spectroscopic (MRS) Imaging
Specially processed MRS imaging information is used to make a map
of important chemicals involved in tumor metabolism. This is being
developed to help surgeons direct their biopsies to the most abnormal
areas in the tumor and to help doctors direct radiation and evaluate
the effects of chemotherapy or targeted therapy.
Fluorescence-guided Surgery
In fluorescence-guided surgery, the patient drinks a special dye a few
hours before surgery. The dye is taken up mainly by the tumor, which
then glows when the surgeon looks at it under special lighting from the
operating microscope. This lets the surgeon better separate tumor
from normal brain tissue.
Newer Surgical Approaches
For some types of tumors, a new surgical approach is needed. For
example, in the treatment of some tumors in or near the pituitary
(such as some craniopharyngiomas), an endoscope is used, which is a
thin tube with a tiny video camera lens at the tip. The endoscope is
passed through a hole made in the back of the nose, which allows the
surgeon to operate through the nasal passages and limits the potential
damage to the brain. A similar technique can be used for some tumors
in the ventricles, where a small opening in the skull near the hairline
serves as the point of endoscope insertion. The use of this technique is
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limited by the tumor’s size, shape, position, and by how many blood
vessels it contains.33,34
Radiation Therapy
Several newer types of radiation therapy now let physicians aim
radiation more precisely at the tumor, which helps spare normal brain
tissue from getting too much radiation. The brain is very sensitive to
radiation, which can lead to side effects if normal brain tissue receives
a large dose, especially if the child is very young. Clinical trials have
shown that in some situations, using chemotherapy can let doctors use
lower doses of radiation therapy without lowering the chance that
treatment will be effective. Physicians are now trying to determine if
even lower doses of radiation can be used and still give the same
results.35
Chemotherapy
New approaches may help make chemotherapy (chemo) more useful
against brain and spinal cord tumors.27,28
Adjuvant Chemotherapy
In some individuals with brain tumors, chemo is given right after
surgery to either delay radiation therapy (particularly in infants) or to
decrease the radiation dose needed to treat the tumor. This is known
as adjuvant chemotherapy. Some studies are looking at whether
giving prolonged chemo can help avoid the need for radiation therapy
at all in certain cases.
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High-dose Chemotherapy and Stem Cell Transplant
One of the main factors that limit the doses of chemo that can be
given safely is its effect on the bone marrow where new blood cells are
normally made. A stem cell transplant is a procedure whereby healthy
bone marrow stem cells are transplanted to replace damaged or
destroyed bone marrow. This allows higher doses of chemo to be given
than would normally be possible. First, blood stem cells are removed
from either the individual’s blood or the bone marrow and are stored in
a deep freeze. The patient is then treated with very high doses of
chemo. The blood stem cells are then thawed and infused back into
the body, where they settle in the bone marrow and start making new
blood cells.
Although some individuals with certain brain or spinal cord tumors
(such as medulloblastomas) have responded well to this very intensive
treatment, it can have serious side effects, and it is not yet known if it
is effective enough to become standard. For now, most physicians
consider this treatment experimental for brain and spinal
tumors. Clinical trials are being done to determine how useful it is.
Improving Chemotherapy Drugs
Many chemo drugs are limited in their effectiveness because the
tightly controlled openings in the brain capillaries, sometimes referred
to as the blood-brain barrier, prevents them from getting from the
bloodstream to some parts of the brain tumor. Researchers are now
trying to modify some of these drugs by coating them with tiny layers
of fat (liposomes) or attaching them to molecules that normally cross
the blood-brain barrier, to help them work better. This is an area of
active research.
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Chemotherapy Direct Administration to Tumors
Some newer approaches might help physicians get chemotherapy
(chemo) directly to brain and spinal cord tumors. For example, in one
method called convection enhanced delivery, small tubes are placed
into the tumor in the brain through a small hole in the skull during
surgery. The tubing extends through the scalp and is connected to an
infusion pump, through which chemo drugs can be given. This can be
done for hours or days and might be repeated more than once,
depending on the drug used. This technique can also be used to get
other, newer types of drugs into the tumor. This is still an
investigational method, and studies are continuing.
Imaging and Tumor Monitoring Procedures
Physicians may use a variety of techniques in order to determine what
a brain tumor looks like both before and during surgery. Specialized
images can be generated that shows what functions the brain tissue
near the cancer is responsible for. Generating images both before and
during surgery can increase the likelihood that extensive tumor
removal can be achieved while avoiding these critical areas.33
Before surgery, the location of the brain tumor in relation to other
structures and blood vessels must be determined as precisely as
possible. To achieve this, a variety of tests are performed. These may
include:

Computerized tomography (CT)

Magnetic resonance imaging (MRI)

Positron emission tomography (PET)

Angiography (to map blood vessels)
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Using the information obtained from these tests, the surgeon can plan
and even rehearse the operation in order to obtain optimal results.
Evaluation of outcomes in elderly patients who had undergone surgery
for brain tumors indicated that those who underwent preoperative MRI
experienced better outcomes than those patients who were not
evaluated with MRI before surgery.35
The scans taken before surgery yield a great deal of information, but
they do not always provide the precision needed to avoid critical areas
of the brain during the operation. Sophisticated mapping techniques
can improve the safety and effectiveness of surgery by locating the
exact areas of the brain responsible for speech, comprehension,
sensation, or movement. Brain mapping is also used to help identify
the margin of the tumor and to differentiate between tumor, swelling
(edema), and normal tissue.
Techniques for brain mapping include:36,37

Direct cortical stimulation

Evoked potentials

Functional MRI

Intraoperative ultrasound imaging

Microsurgery
These techniques are described more fully below:33,36,38-42
Direct Cortical Stimulation
In direct cortical stimulation, a probe passes a tiny electrical current
into the brain and delicately stimulates a specific area. The result is a
response from the body, such as a visible movement of the
corresponding body part. This technique may be employed during
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surgery to help identify important functional areas. For example, direct
cortical stimulation has been used during surgery for gliomas to
successfully identify and preserve cortical areas responsible for
language and minimize damage to motor function.
Evoked Potentials
The electrical response of the brain can be measured by stimulating
the brain and measuring the resulting activity, or evoked potentials, on
brain scanning equipment. Evoked potentials may be used to map and
continuously monitor areas of the brain during surgery.
Functional Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a high-speed imaging device that
generates images of the tumor’s use of oxygen. This helps distinguish
between active, normal brain, and non-active tumor or dead tissue
(necrosis). Functional MRI can be an alternative to direct cortical
stimulation. Research indicates that motor and sensory areas identified
with functional MRI are very similar to locations identified with direct
cortical stimulation. This technique is reliable but requires
sophisticated and expensive equipment.
Intraoperative Ultrasound Imaging
The use of ultrasound during surgery can help determine the depth of
the tumor and its diameter. Ultrasound works by sending ultrasonic
wave pulses into the brain, which then reflect back to a device. A
computer measures the amount of time it takes for the “echoes” to
return, and the results are displayed as a TV image. Surgeons can
monitor their movements to verify positioning and results during
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surgery. The waves can also reflect motion such as blood flow.
Ultrasound can make it easier for the surgeon to locate the margins of
the tumor so that more extensive tumor removal can be achieved. It
helps distinguish between tumor, necrosis (dead tumor cells), cysts,
edema, and normal brain. Because ultrasound does not readily
penetrate bone, it cannot be used preoperatively.
Microsurgery
Microsurgery involves the use of a high-powered microscope during
surgery, which allows the surgeon to obtain a magnified view of the
surgical field. Microsurgery is widely used for brain tumor surgery.
Newer Drugs Used In Targeted Therapy
As researchers have learned more about the gene changes in tumor
cells that help them grow, they have developed newer drugs that
target these changes. These targeted drugs work differently from
standard chemo drugs. One example of such a targeted drug is
everolimus, which may shrink or slow the growth of subependymal
giant cell astrocytomas (SEGAs) that can’t be removed with surgery.
Some types of medulloblastomas tend to have mutations (changes) in
genes that are part of a cell signaling route called the hedgehog
pathway. The hedgehog pathway is crucial for the development of the
embryo and fetus, but it can be overactive in some medulloblastoma
cells. Drugs that target proteins in this pathway are now being tested
against medulloblastoma in clinical trials. Many other targeted drugs
are already being used to treat other types of cancer, and some are
being studied to see if they will work for brain tumors as well.
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Angiogenesis Inhibitors
Tumors have to create new blood vessels (a process
called angiogenesis) to keep their cells nourished. New drugs that
attack these blood vessels are used to help treat some cancers,
including some brain tumors in adults. Several drugs that impair blood
vessel growth are now being studied for use against brain tumors in
children.43
Hypoxic Cell Sensitizers
Some drugs increase the oxygen content in the tumor, which makes
tumor cells more likely to be killed by radiation therapy if the drugs
are given before treatment. Studies are now looking to see if this
affects treatment outcomes.44
Immunotherapy
The goal of immunotherapy is to make the body’s own immune system
fight the tumor. Several types of vaccines are being developed against
brain tumor cells. Unlike vaccines against infectious diseases, these
vaccines are meant to help treat the disease instead of prevent it. The
goal of the vaccines is to stimulate the body’s immune system to
attack the brain tumor cells. Early study results of some of these
vaccines have shown promise, but more research is needed to
determine how effective they are. At this time, brain tumor vaccines
are available only through clinical trials. Other types of drugs that
affect the immune system, such as lenalidomide, are also being
studied.45,46
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Therapeutic Viruses
Researchers have done a great deal of lab work with viruses that
reproduce only within brain tumor cells and then cause those cells to
die, while leaving normal cells alone. Research using these viruses in
humans with brain tumors is still in very early stages.47,48
Tumor Treating Fields
Tumor treating fields (TTFields) is an FDA-approved novel therapeutic
option, which studies have shown slows and reverses tumor growth by
inhibiting mitosis (the process by which cells divide and replicate). The
TTFields option was recently approved in the U.S., for glioblastoma
(GBM) in combination with temozolomide for the treatment of newly
diagnosed adult patients. Usually treatment with TTFields follows
surgery and radiation therapy. Tumor treating fields is also approved
in the U.S., for treatment of recurrent GBM as a monotherapy after
surgical and radiation options have been exhausted.49
Adhesive bandages hold insulated ceramic discs (transducer arrays)
that deliver electricity transformed into electromagnetic energy to the
scalp. The battery operated-TTF device generates low intensity,
intermediate frequency, alternating electrical fields to the brain. These
electrical fields exert selective toxicity in proliferating cells thereby
halting cell division and destroying the cancer cells.50 Currently, a
physician must prescribe the TTField device. The prescribing physician
will provide instructions for using the device, replacing transducer
arrays (every 4 to 7 days), and recharging and replacing batteries.
Patients must wear the device for at least 18 hours a day, taking only
short breaks for personal needs, and use the device for at least four
weeks.49
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Other New Treatment Strategies
Researchers are also testing some newer approaches to treatment that
may help physicians target tumors more precisely. The hope is to
develop more effective treatments that cause fewer side effects.
Although these treatment approaches are promising, most are still
experimental at this time and are only available through clinical trials.
Summary
The field of brain tumor research, diagnosis, and treatment is rapidly
evolving. The number and types of brain tumors continues to increase.
Brain tumors are diagnosed by conducting a neurologic exam and tests
that include MRI, CT scan, and biopsy. Treatment options include
watchful waiting, radiation therapy, chemotherapy, and targeted
therapy as well as surgery. Targeted therapy has been highlighted
here and uses substances that attack cancer cells without harming
normal cells. Combination therapy is often done, which may
incorporate diagnostic and surgical approaches. As the research on
brain tumors grows, so does the ability to improve screening, diagnose
and target treatment to provide patients with optimal outcomes. It is
essential that health clinicians understand surgery and treatment
options in order to communicate it to their patients and to develop a
care plan that has a positive outcome while respecting the patient's
needs and desires.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
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1. Over ________ types of brain tumors have been identified
to date, and that number continues to increase.
a.
b.
c.
d.
30
four
60
120
2. The choice of antiepileptic drugs is challenging for
patients with brain tumor-related epilepsy (BTRE)
because BTRE
a.
b.
c.
d.
is untreatable.
is often drug-resistant.
requires surgery as the first line of treatment.
is caused by the presence of a tumor.
3. In brain tumor patients, the presence of _________ is
considered the most important risk factor for long-term
disability.
a.
b.
c.
d.
a cerebral edema
depression
a comorbidity
epilepsy
4. Among the recently marketed drugs, ___________ has
demonstrated promising results and should be considered
a possible treatment option for BTRE.
a.
b.
c.
d.
lacosamide
carbamazepine
phenobarbital
phenytoin
5. True or False: In patients with a brain tumor, seizures are
the onset symptom in 20-40% of patients, while a further
20-45% of patients will present seizures during the
course of the disease.
a. True
b. False
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6. For some patients, antiepileptic drugs may have a
secondary, “positive” effect; for example, ___________
may have a sedative effect in patients who are agitated.
a.
b.
c.
d.
oxcarbazepine
carbamazepine
pregabalin
phenytoin
7. Newer antiepileptic drugs, such as _______________,
can be used as first choice therapies in monotherapy
because they do not have the side effects of some of the
older drugs.
a.
b.
c.
d.
levetiracetam
carbamazepine
phenobarbital
phenytoin
8. The steroids given to brain tumor patients are
a.
b.
c.
d.
the same as the steroids to build muscle.
corticosteroids.
synthetic steroids.
All of the above
9. In brain tumor treatment, steroids are used to
____________________________, which is/are
sometimes caused by the tumor or its treatment.
a.
b.
c.
d.
increase energy to combat lethargy
control bleeding
reduce brain swelling, or cerebral edema
reduce epileptic conditions
10. Which of the older antiepileptic drugs can be considered
a first choice therapy in a monotherapy context?
a.
b.
c.
d.
Lamotrigine
Valproic acid (VPA)
Phenobarbital
Phenytoin
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11. True or False: Healthcare practitioners need to
appreciate the fact that taking care of brain tumorrelated epilepsy patients means finding a cure for the
patient.
a. True
b. False
12. An antiepileptic drug may have a secondary, “positive”
effect such as ______________, which will elevate
mood in depressed patients.
a.
b.
c.
d.
oxcarbazepine
topiramate
pregabalin
phenytoin
13. Dexamethasone and prednisone are the most commonly
used
a.
b.
c.
d.
antiepileptic drugs.
mood stabilizers.
antidepressants.
corticosteroid drugs.
14. Steroids are used for short-term symptom control
although they may occasionally be continued for
a.
b.
c.
d.
a period of weeks.
months.
Answers a., and b., above
None of the above
15. Because corticosteroids are hormones (that are
produced _____________________), their long-term
use requires close monitoring.
a.
b.
c.
d.
by the pituitary gland
synthetically
by the adrenal glands
by the hypothalamus
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16. Steroids may be prescribed for brain tumor patients
a.
b.
c.
d.
when a brain mass is discovered.
around the time of surgery
with radiation or chemotherapy.
All of the above
17. True or False: Corticosteroid can temporarily improve
neurological symptoms by reducing brain swelling and
in most cases treat or reduce the tumor.
a. True
b. False
18. The dose of corticosteroid used in brain tumor patients
is dependent on ________________ seen on the MRI or
CT scan of the brain.
a.
b.
c.
d.
the size of the tumor
the location of the tumor
the type of tumor
how much swelling is
19. When the patient no longer requires steroid treatment,
steroids
a.
b.
c.
d.
may be stopped abruptly.
must be gradually reduced.
must be replaced by synthetic steroids.
produced by the adrenal glands immediately take over.
20. Steroids can cause a wide range of unwanted effects.
The most common side effect(s) caused by steroid
treatment is/are
a.
b.
c.
d.
increased appetite.
weight loss.
decreased blood sugar levels.
All of the above
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21. Steroid treatment can interact with other medications,
which may
a.
b.
c.
d.
increase the steroid levels in the patient’s blood.
decrease the steroid levels in the patient’s blood.
increase the side effects of the steroids.
All of the above
22. Steroids may be prescribed to eliminate cancer cells in
patients diagnosed with
a.
b.
c.
d.
medulloblastomas.
hydrocephaly.
primary central nervous system lymphoma (PCNSL).
cerebral edema.
23. True or False: Steroids can also be used in brain tumor
patients for other reasons: to improve appetite, prevent
nausea and vomiting from chemotherapy, reduce pain
and prevent allergic reactions to some chemotherapies.
a. True
b. False
24. Radiation treatment disrupts the cancer cells: it
prevents them from dividing and growing, by creating
small breaks in the cell’s DNA by
a.
b.
c.
d.
creating hypoxia that starves cancer cells of oxygen.
cutting the blood supply to the cancer cells.
delivering high-energy particles or waves to the cells.
injecting a chemical composition into the cancer cells.
25. Radiation treatment is especially favorable for cancer
that
a.
b.
c.
d.
has metastasized.
is diffused because radiation has a broad exposure.
is located in one region of the body.
is close to or intertwined with healthy tissue.
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26. Which of the following may be an acute side effect
associated with radiation cancer treatment?
a.
b.
c.
d.
Fibrosis
Damage to the salivary glands
Memory loss
Infertility
27. ___________________ is a rare, chronic side effect of
radiation treatment.
a.
b.
c.
d.
Fatigue
Hair loss
Infertility
A second cancer
28. Girls treated with radiation to the chest for Hodgkin
lymphoma have an increased risk of developing
_____________ later in life.
a.
b.
c.
d.
medulloblastomas
primary central nervous system lymphoma
liver cancer
breast cancer
29. True or False: Patients should take steroid treatment on
an empty stomach in order receive the maximum benefit
from the treatment.
a. True
b. False
30. External-beam radiation therapy is most often delivered
in the form of photon beams, which is
a.
b.
c.
d.
made up of protons.
either x-rays or gamma rays.
also known as brachytherapy.
also called inverse treatment therapy.
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31. With intensity-modulated radiation therapy (IMRT) the
radiation oncologist chooses
a.
b.
c.
d.
the number of radiation beams.
the angles of the radiation beams.
the radiation doses.
All of the above
32. ___________________ is a type of image-guided
intensity-modulated radiation therapy (IMRT).
a.
b.
c.
d.
Tomotherapy
Brachytherapy
Forward treatment
Internal radiation therapy
33. A tomotherapy machine is a hybrid between
_______________ and an external-beam radiation
therapy machine.
a.
b.
c.
d.
an X-ray
a particle accelerator
a traditional forward treatment plan
a CT imaging scanner
34. True or False: In general, the lifetime risk of a second
cancer is highest in people treated for cancer with
radiation therapy as children or adolescents.
a. True
b. False
35. Which of the following procedures is most likely to
damage normal tissue from high radiation doses?
a.
b.
c.
d.
Tomotherapy
Image-guided radiation therapy
Intensity-modulated radiation therapy
Three-dimensional conformal radiotherapy
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36. With Image-guided radiation therapy (IGRT), repeated
imaging scans are performed during treatment, which
are processed by computers to identify
a.
b.
c.
d.
post-treatment, normal tissue damage.
the type of tumor.
changes in a tumor’s size and location.
whether the tumor is benign or malignant.
37. ___________________ can be used to treat only small
tumors with well-defined edges.
a.
b.
c.
d.
Tomotherapy
Brachytherapy
Stereotactic radiosurgery (SRS)
Internal radiation therapy
38. Photons and protons differ in
a.
b.
c.
d.
only protons use x-rays or gamma rays.
the way they deposit energy in living tissue.
that photons are used intracavitarily.
All of the above
39. True or False: During traditional (forward) treatment
planning, the radiation oncologist chooses the number
and angles of the radiation beams in advance and
computers calculate how much dose will be delivered
from each of the planned beams.
a. True
b. False
40. Stereotactic body radiation therapy (SBRT) treats
tumors that lie
a.
b.
c.
d.
within the brain stem.
within the cerebrum.
outside the brain and spinal cord.
outside the pituitary gland.
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41. _________________ is a radiation treatment that uses
radioactive materials placed inside or on the body.
a.
b.
c.
d.
Image-guided radiation therapy (IGRT)
External-beam radiation therapy
Stereotactic radiosurgery (SRS)
Brachytherapy
42. In brachytherapy, radioactive isotopes, sealed in tiny
pellets or “seeds,” are placed in patients and they give
off radiation that damages nearby cancer cells because
a.
b.
c.
d.
isotopes have differing numbers of protons.
isotopes have the same number of neutrons.
the isotopes deposit energy.
the isotopes decay naturally.
43. Adjuvant chemotherapy is used in some individuals with
brain tumors, after surgery,
a.
b.
c.
d.
to delay or decrease radiation therapy.
in lieu of radiation treatment.
because chemo does not damage healthy cells.
because radiation is not easily delivered to infants.
44. True or False: Episcleral brachytherapy uses a radiation
source that is attached to the liver.
a. True
b. False
45. Chemotherapy drugs are similar in the following way:
a.
b.
c.
d.
they
they
they
they
are similar in their chemical composition.
are taken in the same way, i.e., intravenously.
damage the cancer cells to prevent reproduction.
have similar side effects.
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46. Adjuvant chemotherapy refers to chemotherapy that is
used _________________ to reduce the risk of cancer
coming back by treating any remaining cells.
a.
b.
c.
d.
after surgery or radiotherapy
with radiotherapy
in lieu of radiotherapy
before surgery or radiotherapy
47. _______________ are a class of chemotherapy drugs
that interfere with DNA and RNA growth by substituting
for the normal building blocks of RNA and DNA.
a.
b.
c.
d.
Antimetabolites
Alkylating agents
Anthracyclines
Anti-tumor antibiotics
48. A major consideration when giving or using
________________ is that they can permanently
damage the heart if given in high doses.
a.
b.
c.
d.
alkylating agents
topoisomerase inhibitors
anthracyclines
immunotherapies
49. True or False: Chemotherapy drugs used to treat cancer
damage cancer cells and non-cancer cells alike.
a. True
b. False
50. Passive immunotherapies
a.
b.
c.
d.
the body’s immune system to attack the disease.
use immune system components created outside the body.
stimulate the body’s immune system.
are integrally part of chemotherapy.
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51. With the use of stem cell transplants, higher doses of
chemo may be given than would normally be possible
because stem cells
a.
b.
c.
d.
substitute the DNA and RNA building blocks.
neutralize chemotherapy drugs.
replace damaged or destroyed bone marrow.
are not affected by the blood-brain barrier.
52. Many chemo drugs are limited in their effectiveness
because the ________________ prevent(s) them from
getting from the bloodstream to some parts of the brain
tumor.
a.
b.
c.
d.
blood-brain barrier
white blood cells
the patient’s immune system
fat cells
53. The MRI is a high-speed imaging device that generates
images of the tumor’s use of
a.
b.
c.
d.
metabolites.
fat cells.
oxygen.
therapeutic viruses.
54. The use of ultrasound during surgery can help determine
the
a.
b.
c.
d.
depth of the tumor and its diameter.
tumor’s use of oxygen.
tumor’s response to radiation therapy.
tumor’s ability to replicate cells.
55. True or False: Individuals with certain brain or spinal
cord tumors (such as medulloblastomas) have
responded well to high doses of chemo followed by stem
cell transplant so this treatment has become standard.
a. True
b. False
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CORRECT ANSWERS:
1. Over ________ types of brain tumors have been identified
to date, and that number continues to increase.
d. 120
p. 5: “Over 120 types of brain tumors have been identified to
date, and that number continues to increase.”
2. The choice of antiepileptic drugs is challenging for
patients with brain tumor-related epilepsy (BTRE)
because BTRE
b. is often drug-resistant.
p. 6: “The choice of antiepileptic drugs is challenging for this
particular patient population because brain tumor-related
epilepsy (BTRE) is often drug-resistant.”
3. In brain tumor patients, the presence of _________ is
considered the most important risk factor for long-term
disability.
d. epilepsy
p. 6: “In brain tumor patients, the presence of epilepsy is
considered the most important risk factor for long-term
disability.”
4. Among the recently marketed drugs, ___________ has
demonstrated promising results and should be considered
a possible treatment option for BTRE.
a. lacosamide
p. 6: “Among the recently marketed drugs, lacosamide has
demonstrated promising results and should be considered a
possible treatment option.”
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5. True or False: In patients with a brain tumor, seizures are
the onset symptom in 20-40% of patients, while a further
20-45% of patients will present seizures during the
course of the disease.
a. True
p. 6: “In patients with a brain tumor (BT), seizures are the
onset symptom in 20-40% of patients, while a further 2045% of patients will present them during the course of the
disease.”
6. For some patients, antiepileptic drugs may have a
secondary, “positive” effect; for example, ___________
may have a sedative effect in patients who are agitated.
c. pregabalin
p. 7: “For some patients, antiepileptic drugs may have a
secondary, “positive” effect; for example, pregabalin or
topiramate may have a sedative effect in patients who are
agitated, while oxcarbazepine or lamotrigine will elevate
mood in depressed patients.”
7. Newer antiepileptic drugs, such as _______________,
can be used as first choice therapies in monotherapy
because they do not have the side effects of some of the
older drugs.
a. levetiracetam
p. 7: “The newer antiepileptic drugs, such as lamotrigine,
levetiracetam, oxcarbazepine, topiramate and the older
antiepileptic drugs, valproic acid (VPA), can be considered
first choice therapies in monotherapy, for all of the reasons
previously discussed.”
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8. The steroids given to brain tumor patients are
b. corticosteroids.
p. 8: “The steroids given to brain tumor patients are
corticosteroids – hormones produced by the adrenal glands.
They are not the same as the anabolic steroids used by
athletes to build muscle.”
9. In brain tumor treatment, steroids are used to
____________________________, which is/are
sometimes caused by the tumor or its treatment.
c. reduce brain swelling, or cerebral edema
p. 8: “Steroids are naturally occurring substances. In brain
tumor treatment, steroids are used to reduce the brain
swelling, or cerebral edema, sometimes caused by the tumor
or its treatment.”
10. Which of the older antiepileptic drugs can be considered
a first choice therapy in a monotherapy context?
b. Valproic acid (VPA)
p. 7: “The newer antiepileptic drugs, such as lamotrigine,
levetiracetam, oxcarbazepine, topiramate and the older
antiepileptic drugs, valproic acid (VPA), can be considered
first choice therapies in monotherapy, for all of the reasons
previously discussed.”
11. True or False: Healthcare practitioners need to
appreciate the fact that taking care of brain tumorrelated epilepsy patients means finding a cure for the
patient.
b. False
p. 8: “Healthcare practitioners need to appreciate the fact
that ‘taking care of’ these patients does not mean ‘curing’ as
much as it means recognizing and responding to the needs of
each unique individual.”
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12. An antiepileptic drug may have a secondary, “positive”
effect such as ______________, which will elevate
mood in depressed patients.
a. oxcarbazepine
pp. 7-8: “For some patients, antiepileptic drugs may have a
secondary, “positive” effect; for example, pregabalin or
topiramate may have a sedative effect in patients who are
agitated, while oxcarbazepine or lamotrigine will elevate
mood in depressed patients.”
13. Dexamethasone and prednisone are the most commonly
used
d. corticosteroid drugs.
p. 8: “Dexamethasone and prednisone are the most
commonly used corticosteroid drugs.”
14. Steroids are used for short-term symptom control
although they may occasionally be continued for
a.
b.
c.
d.
a period of weeks.
months.
Answers a., and b., above
None of the above
p. 9: “Steroids are used for short-term symptom control
although they may occasionally be continued for a period of
weeks or months.”
15. Because corticosteroids are hormones (that are
produced _____________________), their long-term
use requires close monitoring.
c. by the adrenal glands
p. 8: “The steroids given to brain tumor patients are
corticosteroids – hormones produced by the adrenal glands….
Because steroids are hormones, their long-term use requires
close monitoring.”
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16. Steroids may be prescribed for brain tumor patients
a.
b.
c.
d.
when a brain mass is discovered.
around the time of surgery
with radiation or chemotherapy.
All of the above
p. 8: “Steroids may be prescribed when a brain mass is seen
on an MRI or CT scan of the brain, around the time of surgery
or radiation, or sometimes with chemotherapy.”
17. True or False: Corticosteroid can temporarily improve
neurological symptoms by reducing brain swelling and
in most cases treat or reduce the tumor.
b. False
p. 8: “These steroids can temporarily improve neurological
symptoms by reducing brain swelling but in most cases do
not directly treat the tumor.”
p. 9: “Steroids are usually administered intravenously (IV) or
by mouth (orally)…. The dose used is dependent on how
much swelling is seen on the MRI or CT scan of the brain.
18. The dose of corticosteroid used in brain tumor patients
is dependent on ________________ seen on the MRI or
CT scan of the brain.
d. how much swelling is
p. 9: “Steroids are usually administered intravenously (IV) or
by mouth (orally).… The dose used is dependent on how
much swelling is seen on the MRI or CT scan of the brain.”
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19. When the patient no longer requires steroid treatment,
steroids
b. must be gradually reduced.
pp. 9-10: “When the patient no longer requires steroids, he or
she will be given instructions to slowly taper and stop the
drug. Patients should not abruptly stop taking their steroids.
A gradual reduction of steroid dose allows the body to begin
producing its own steroids again. This gradual tapering avoids
adrenal crisis, which is caused by insufficient levels of the
hormone cortisol.”
20. Steroids can cause a wide range of unwanted effects.
The most common side effect(s) caused by steroid
treatment is/are
a. increased appetite.
p. 10: “Steroids can cause a wide range of unwanted effects.
The most common side effects include increased appetite,
weight gain, increased blood sugar levels (especially in
patients who have diabetes), gastrointestinal problems (like
stomach ulcers), frequent urination, insomnia and mood
changes like irritability or mania, muscle weakness,
susceptibility to infections like pneumonia, thinning of the
skin, and acne.”
21. Steroid treatment can interact with other medications,
which may
a.
b.
c.
d.
increase the steroid levels in the patient’s blood.
decrease the steroid levels in the patient’s blood.
increase the side effects of the steroids.
All of the above
p. 10: “Steroids can interact with other medications, either
increasing or decreasing the levels in the patient’s blood,
which can alter their effectiveness or increase their side
effects.”
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22. Steroids may be prescribed to eliminate cancer cells in
patients diagnosed with
c. primary central nervous system lymphoma (PCNSL).
p. 9: “In the case of most brain tumors, steroids are not
prescribed to eliminate cancer cells. One exception is primary
central nervous system lymphoma (PCNSL), which is a
lymphoma involving the brain or spinal cord.”
23. True or False: Steroids can also be used in brain tumor
patients for other reasons: to improve appetite, prevent
nausea and vomiting from chemotherapy, reduce pain
and prevent allergic reactions to some chemotherapies.
a. True
pp. 8-9: “Steroids can also be used for other reasons. They
can improve appetite, prevent nausea and vomiting from
chemotherapy, reduce pain and prevent allergic reactions to
some chemotherapies.”
24. Radiation treatment disrupts the cancer cells: it
prevents them from dividing and growing, by creating
small breaks in the cell’s DNA by
c. delivering high-energy particles or waves to the cells.
p. 10: “Radiation is a common treatment method for
individuals who are able to tolerate it. This treatment is
delivered using high-energy particles or waves that disrupt
the cancer. These particles create small breaks in the DNA
that is inside the cells, which prevent the cancer cells from
dividing and growing.”
25. Radiation treatment is especially favorable for cancer
that
c. is located in one region of the body.
p. 11: “Radiation is especially favorable for cancer that is
located in one region of the body as it can be delivered as a
localized treatment.”
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26. Which of the following may be an acute side effect
associated with radiation cancer treatment?
b. Damage to the salivary glands
p. 16: “The following is a description of the most common
acute and chronic side effects associated with radiation: Acute
- Acute radiation side effects are caused by damage to rapidly
dividing normal cells in the area being treated. These effects
include skin irritation or damage at regions exposed to the
radiation beams. Examples include damage to the salivary
glands or hair loss when the head or neck area is treated, or
urinary problems when the lower abdomen is treated. Most
acute effects disappear after treatment ends, though some
(like salivary gland damage) can be permanent.”
27. ___________________ is a rare, chronic side effect of
radiation treatment.
d. A second cancer
p. 17: “Chronic - Late side effects of radiation therapy may or
may not occur. Depending on the area of the body treated,
late side effects can include: … Rarely, a second cancer
caused by radiation exposure.”
28. Girls treated with radiation to the chest for Hodgkin
lymphoma have an increased risk of developing
_____________ later in life.
d. breast cancer
p. 17: “For example, girls treated with radiation to the chest
for Hodgkin lymphoma have an increased risk of developing
breast cancer later in life.”
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29. True or False: Patients should take steroid treatment on
an empty stomach in order receive the maximum benefit
from the treatment.
b. False
p. 9: “To protect the stomach, patients should take their
steroids with food or milk. An additional medication may also
be prescribed to further protect the stomach.”
30. External-beam radiation therapy is most often delivered
in the form of photon beams, which is
b. either x-rays or gamma rays.
p. 12 “External-beam radiation therapy is most often
delivered in the form of photon beams (either X-rays or
gamma rays).”
31. With intensity-modulated radiation therapy (IMRT) the
radiation oncologist chooses
c. the radiation doses.
p. 12: “Unlike other types of radiation therapy, IMRT is
planned in reverse (called inverse treatment planning). In
inverse treatment planning, the radiation oncologist chooses
the radiation doses to different areas of the tumor and
surrounding tissue, and then a high-powered computer
program calculates the required number of beams and angles
of the radiation treatment.”
32. ___________________ is a type of image-guided
intensity-modulated radiation therapy (IMRT).
a. Tomotherapy
p. 13: “Tomotherapy is a type of image-guided IMRT.”
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33. A tomotherapy machine is a hybrid between
_______________ and an external-beam radiation
therapy machine.
d. a CT imaging scanner
p. 13: “Tomotherapy is a type of image-guided IMRT. A
tomotherapy machine is a hybrid between a CT imaging
scanner and an external-beam radiation therapy machine.”
34. True or False: In general, the lifetime risk of a second
cancer is highest in people treated for cancer with
radiation therapy as children or adolescents.
a. True
p. 17: “Second cancers that develop after radiation therapy
depend on the part of the body that was treated. For
example, girls treated with radiation to the chest for Hodgkin
lymphoma have an increased risk of developing breast cancer
later in life. In general, the lifetime risk of a second cancer is
highest in people treated for cancer as children or
adolescents.”
35. Which of the following procedures is most likely to
damage normal tissue from high radiation doses?
d. Three-dimensional conformal radiotherapy
p. 12: “Compared with three-dimensional conformal
radiotherapy (3D-CRT), IMRT can reduce the risk of some
side effects, such as damage to the salivary glands (which
can cause dry mouth, or xerostomia), when the head and
neck are treated with radiation therapy.”
p. 13: “Like standard IMRT, tomotherapy may be better than
3D-CRT at sparing normal tissue from high radiation doses.”
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36. With Image-guided radiation therapy (IGRT), repeated
imaging scans are performed during treatment, which
are processed by computers to identify
c. changes in a tumor’s size and location.
p. 12: “In IGRT, repeated imaging scans (CT, MRI, or PET)
are performed during treatment. Imaging scans are processed
by computers, identifying changes in a tumor’s size and
location due to treatment and allowing patient positioning or
planned radiation dose adjusting during treatment.”
37. ___________________ can be used to treat only small
tumors with well-defined edges.
c. Stereotactic radiosurgery (SRS)
p. 13: “Stereotactic radiosurgery (SRS) … can be used to
treat only small tumors with well-defined edges.”
38. Photons and protons differ in
b. the way they deposit energy in living tissue.
p. 13: “Proton beams differ from photon beams mainly in the
way they deposit energy in living tissue.”
39. True or False: During traditional (forward) treatment
planning, the radiation oncologist chooses the number
and angles of the radiation beams in advance and
computers calculate how much dose will be delivered
from each of the planned beams.
a. True
p. 12: “In inverse treatment planning, the radiation oncologist
chooses the radiation doses to different areas of the tumor
and surrounding tissue, and then a high-powered computer
program calculates the required number of beams and angles
of the radiation treatment. In contrast, during traditional
(forward) treatment planning, the radiation oncologist
chooses the number and angles of the radiation beams in
advance and computers calculate how much dose will be
delivered from each of the planned beams.”
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40. Stereotactic body radiation therapy (SBRT) treats
tumors that lie
c. outside the brain and spinal cord.
p. 13: “Stereotactic body radiation therapy (SBRT) delivers
radiation therapy in fewer sessions, using smaller radiation
fields and higher doses than 3D-CRT in most cases. By
definition, SBRT treats tumors that lie outside the brain and
spinal cord.”
41. _________________ is a radiation treatment that uses
radioactive materials placed inside or on the body.
d. Brachytherapy
P. 14: “Internal radiation therapy (brachytherapy) is radiation
delivered from radiation sources (radioactive materials)
placed inside or on the body.”
42. In brachytherapy, radioactive isotopes, sealed in tiny
pellets or “seeds,” are placed in patients and they give
off radiation that damages nearby cancer cells because
d. the isotopes decay naturally.
p. 14: “In brachytherapy, radioactive isotopes are sealed in
tiny pellets or ‘seeds.’ These seeds are placed in patients
using delivery devices, such as needles, catheters, or some
other type of carrier. As the isotopes decay naturally, they
give off radiation that damages nearby cancer cells.”
43. Adjuvant chemotherapy is used in some individuals with
brain tumors, after surgery,
a. to delay or decrease radiation therapy.
p. 38: “Adjuvant chemotherapy … In some individuals with
brain tumors, chemo is given right after surgery to either
delay radiation therapy (particularly in infants) or to decrease
the radiation dose needed to treat the tumor. This is known
as adjuvant chemotherapy.”
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44. True or False: Episcleral brachytherapy uses a radiation
source that is attached to the liver.
b. False
p. 14: “Episcleral brachytherapy, which is used to treat
melanoma inside the eye, uses a source that is attached to
the eye.”
45. Chemotherapy drugs are similar in the following way:
c. they damage the cancer cells to prevent reproduction.
p. 17: “Chemotherapy drugs vary widely in their chemical
composition, how they are taken, their usefulness in treating
specific forms of cancer, and their side effects. Although these
drugs differ in the ways indicated above, they all work to
disrupt the ways in which cancer cells divide and grow. The
drugs damage the cells to prevent reproduction.“
46. Adjuvant chemotherapy refers to chemotherapy that is
used _________________ to reduce the risk of cancer
coming back by treating any remaining cells.
a. after surgery or radiotherapy
p. 18: “Chemotherapy…. After surgery or radiotherapy to
reduce the risk of cancer coming back by treating any
remaining cells (called adjuvant chemotherapy).”
47. _______________ are a class of chemotherapy drugs
that interfere with DNA and RNA growth by substituting
for the normal building blocks of RNA and DNA.
a. Antimetabolites
p. 27: “Antimetabolites are a class of drugs that interfere with
DNA and RNA growth by substituting for the normal building
blocks of RNA and DNA.”
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48. A major consideration when giving or using
________________ is that they can permanently
damage the heart if given in high doses.
c. anthracyclines
p. 28: “Anthracyclines are anti-tumor antibiotics that interfere
with enzymes involved in DNA replication. These drugs work
in all phases of the cell cycle. They are widely used for a
variety of cancers. A major consideration when giving these
drugs is that they can permanently damage the heart if given
in high doses.”
49. True or False: Chemotherapy drugs used to treat cancer
damage cancer cells and non-cancer cells alike.
a. True
pp. 17-18: “The drugs damage the cells to prevent
reproduction. Unfortunately, chemotherapy drugs also have
the same effect on non-cancer cells.”
50. Passive immunotherapies
b. use immune system components created outside the body.
p. 32: “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.”
51. With the use of stem cell transplants, higher doses of
chemo may be given than would normally be possible
because stem cells
c. replace damaged or destroyed bone marrow.
p. 39: “A stem cell transplant is a procedure whereby healthy
bone marrow stem cells are transplanted to replace damaged
or destroyed bone marrow.”
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52. Many chemo drugs are limited in their effectiveness
because the ________________ prevent(s) them from
getting from the bloodstream to some parts of the brain
tumor.
a. blood-brain barrier
p. 39: “Many chemo drugs are limited in their effectiveness
because the tightly controlled openings in the brain
capillaries, sometimes referred to as the blood-brain barrier,
prevents them from getting from the bloodstream to some
parts of the brain tumor.”
53. The MRI is a high-speed imaging device that generates
images of the tumor’s use of
c. oxygen.
p. 42: “Magnetic resonance imaging is a high-speed imaging
device that generates images of the tumor’s use of oxygen.”
54. The use of ultrasound during surgery can help determine
the
a. depth of the tumor and its diameter.
p. 42: “Intraoperative ultrasound imaging: The use of
ultrasound during surgery can help determine the depth of
the tumor and its diameter.”
55. True or False: Individuals with certain brain or spinal
cord tumors (such as medulloblastomas) have
responded well to high doses of chemo followed by stem
cell transplant so this treatment has become standard.
b. False
p. 39: “Although some individuals with certain brain or spinal
cord tumors (such as medulloblastomas) have responded well
to this very intensive treatment, it can have serious side
effects, and it is not yet known if it is effective enough to
become standard.”
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