As described by Dr Paul Ehrlich in 1907 before discovery of Salvarsan for syphilis, after long 116 years -Scientists and physicians are searching for magic bullets to fight cancer even these days. Cancer is such a disease, where the intense toxicity of the treatment, while trying to achieve a sustainable cure, sometime harms the patient a lot, including loss of life in certain scenario. Be it risk associated with mutagenic potential of radiotherapy, chemotherapy causing second cancers or the life-threatening toxicities, requiring even ICU support, and albeit, with huge financial burden.
The desirable form of treatment is always a treatment which causes cure to maximum and harm to the minimum, if not nil. All research and trials look at this principle, to aim at a higher therapeutic ratio. Closer to this ideal state: That’s our magic bullet! maximum cancer cell killing and minimal or nil side effects.
However, reality is a bit different from the utopian world. All forms of cancer treatment come with a pinch of salt- toxicity and cost as we already told.
Common side effects associated with radiotherapy and chemotherapy:
Radiotherapy- usually side effects of radiation restricted to the local site of disease where radiation is delivered. Darkening of skin at the site of radiotherapy is a concern in most cases, though this is rarely encountered these days due to very conformal radiation technology. Usually diarrhea, cramps and nausea are seen in abdominal radiation, while mucosal ulcers, thick saliva, and pain during swallowing in radiation of face and neck. Increased sleepiness, headache or vomiting, sometimes blurry vision is sometimes seen in cranial radiation where inflammatory vasogenic oedema in brain results into these symptoms.
Thanks to the era of technology, using highly conformal, image guided techniques like IG-IMRT, different kind of particle therapy like Proton and Heavy Ions, and practice of brachytherapy (highly specialized technique of putting radioactive sources very close to tumor delivering a high dose, with minimal normal tissue irradiation – owing to physical property of radiation).
We are chasing the dream of magic bullet quite closely here.
But, Alas! Setting up a radiation facility costs crores, hence needs government or corporate assistance/ sponsorship, but once rolling in- it provides a cost-effective cure as radiotherapy is part of treatment in almost 60% of the cancers. Being an outpatient procedure, radiation therapy is cost friendly in that way too, necessitating minimal admissions, if needed at all.
Chemotherapy: Be it curative intent, intensive protocols in haemato-oncology or adjuvant chemotherapy after surgery, chemotherapy takes care of systemic disease very effectively, even in stage IV patients with terminal illness, adding months to their life. While infused in systemic circulation by intravenous route, it reaches all cells of body almost, causing a lot of side effects, starting from Loss of hair, ulcers in mouth, vomiting -going up-to the extent of toxicity to contractile muscles of heart or tubules of kidney in certain extents, as in drugs like doxorubicin or cisplatin.
Nowadays, excellent supportive care, good pre-medications and improvised drug delivery causes lower rate of side effects, still it causes a high chance of toxicity.
Repeated inpatient admissions also increase the financial burden on patient.
Targetted therapy and Immune checkpoint inhibitors are wonder-boys of this room, with novel mechanisms, targeting at cellular receptor level, causing higher tumor cell kill by suppressing downstream cellular pathways, and increasing immune cell infiltration. They also have their own side effects too, but being designed for specific receptor, they can target cancer cells with very much precision, like a bullet. Though costs are too high to be affordable sometimes- not so magical !
At the world today, where even stem cell transplants are done at regular basis, we are quite close to cure cancer like a chronic disease with pleasant outcomes, with wonderful drugs and even in incurable stages, to achieve significant palliation – to give the patient a better quality of life. The survival stats also speak that way. The question comes now is the affordability of care, pertaining to the very high cost of our bullets now, starting very commonly from lacs of rupees- in targeted therapy like TKI or Immunotherapy.
A recent government report in UK also suggests, to serve a large population, the cost effective and definitive therapeutic modalities like radiotherapy will also play a big role in near future- especially the unmet need for inoperable, advanced cancer treatment, palliative radiation plays a key role.
Having the armory full of the effective treatment modalities, to reach the needy is the goal of today’s world and that will be the real magic we will be looking for, in coming era!
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