Submitted by Dr.Kattlove’s Cancer Blog

Many oncologists believe that we can cure more patients’ cancers if we can just give the patients high enough doses of chemotherapy. For years, it has been a maxim in oncology that the more chemotherapy you give, the more cancer you kill. A colleague of mine, who didn’t believe this, compared this theory to the situation of a person in a foreign country trying to make himself understood by shouting instead of speaking the native’s language.

This week’s Journal of the National Cancer Institute carried an article written by European investigators that confirmed my colleague’s skepticism. The researchers treated patients with a type of lung cancer called small cell cancer, with very high doses of chemotherapy and compared them with a group that received standard doses. By the end of 4 years, over 80% of patients in either group were dead. The only thing the high dose patients got out of their treatment was more toxicity.

Small cell lung cancer is a type of lung cancer that is very different from the garden variety that we usually see. It comes from a different cell than the typical lung cancer (adenocarcinoma or squamous cell) and only about 10-15% of lung cancer patients have this type. It is also special in that it almost always spreads from the moment it begins. This means that surgery is generally not helpful, because it will likely come back somewhere outside the lung. Treatment is usually with chemotherapy and radiation therapy. Although the cancer usually comes back in spite of all this, some patients whose cancer is found early are cured.

My colleague’s sense that you need to use chemotherapy that “spoke” to the cancer reminds me of an elderly patient I saw with small cell lung cancer. He certainly would not have been a match for high doses of chemotherapy so I treated him with the gentlest regimen that in good conscience, I could give him. After 2 years, there was no sign of the cancer. The chemotherapy spoke the right language to his cancer.

High dose chemotherapy was once the darling of the field. About 15 years ago many patients with breast cancer were treated with massive doses of drugs. The doses of the drugs were so high that the patients needed to have their bone marrow cells saved and given back after the treatment or they would have died of bone marrow failure. Physicians and patients alike were so passionate about the procedure that insurance companies were sued if they refused to pay for this very costly ($100,000) procedure. Then the clinical trials were completed and showed that high dose chemotherapy was no better than the standard regimens.

Still, hope springs eternal in oncology –after all without hope, many of us would have dropped out of the field. Now, breast cancer patients are given “dose dense” treatment. This means that the patients receive standard doses of chemotherapy, just more often. So far, over 3-4 years, it looks like this treatment has a slight edge over conventional treatment, but at a big expense in both money and toxicity.

Is this the final answer? A little better – or perhaps not better at all?

I suspect my skeptical colleague would say that maybe we’re not speaking louder, just speaking faster and that doesn’t work either.

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