Chemotherapy - does it kill or save?

The following is one person's experience with chemo therapy and possibly a history of iatropic (doctor caused) illness.  Gregory wrote me:

My wife and I had the medical adage that since most of surgical oncology is curative, we wanted to fight her cancers with surgery. Each and every one gave her more life to live. All of the surgeons that were involved in her cancer fight over the years are our heroes. I've received numerous emails about my wife's cancer story from patients and their loved ones who have fought cancer with surgery alone (so my wife and I arn't alone with this idea). Lung cancer, breast cancer, colon cancer, brain tumors to name a few. I have a few personal friends who too, have gone with surgery alone (they are still here). Their life was extended not because of chemotherapy or radiation therapy but because of great, competent surgical care.

Cancer chemotherapy and radiation therapy almost without exception, will damage some normal tissue and diminish the immune system. Radiation has been known for a long time to both enhance cancer growth and to halt cancer growth. Damaging the immune system in turn is known to foster the growth of some kinds of other cancer.

We do not yet have really outstanding treatments for most cancers. Modern medicine in general and cancer treatment in particular, is very imperfect. In the hopes of curing disease or helping patients, the medical profession uses rather drastic treatments for devastating diseases they know will kill someone in a short time. Many physicians don't make the families aware enough that these treatments are drastic and can have serious side effects.

Thank you so much for listening. If you have the heart to carry my article on your website, I (and my dearly beloved spouse) would greatly appreciate it. She is behind me (on the other side) helping with all the research I've been doing the last two and a half years. She is my hero!

In the following article, Gregory asks a question which has troubled many of us and that is, is chemotherapy and radiation always appropriate in cancer cases?  Is it appropriate most of the time?  Chemotherapy basically poisons our bodies, demolishes our immune system. It is a 'firehose in bathroom' treatment killing many healthy cells as it kills the cancer.  If a person is a young athlete like Lance Armstrong whose blood is riddled with cancer - a young person who is able to take such a treatment, and has very invasive metastastic cancer, then yes, I can see where chemo might be a good idea.  But I recently lost a friend to bladder cancer.  She had a small tumor in her bladder and another 'shadow' in the close by lymph node. They gave her aggressive chemotherapy.  She was 65 years old and the chemo made her feel sick to death.  She stopped the therapy. Unfortunately, the family, meaning so well and trusting the doctors, overrode her desires and continued the therapy. Doctors could not complete the chemo therapy because they saw that another treatment would kill her.  But time had run out. She died a short 4 months after the initial diagnosis of a small tumor in her bladder and another small tumor in the nearby lymph node.  I have another friend who had a small cancer in her colon.  She was given chemo and at the time, was healthy (they removed the cancer with surgery).  Now she is very weak as her organ systems are shutting down - not from the cancer, from the chemo.

This is a long article - best to print out and read at leisure but I feel it IS worth the time spent to read it as it may help you in future decisions about chemotherapy and radiation with your own family and loved ones.

By Gregory D. Pawelski

My wife had been diagnosed with ovarian cancer in 1972, when she presented with a left DVT (deep vein thrombosis) and pulmonary embolism at Grossmont Hospital in San Diego, CA. Workup which was triggered by this presentation revealed that she did have an ovarian carcinoma for which she underwent total abdominal hysterectomy and received Chlorambucil (Leukeren) treatment. This postoperative chemotherapy drug is among the slowest acting and least toxic of the alkylating agents. Depression of the immune system is slow and reversible, allowing it to regenerate and contribute to healing. She went twenty-four years before experiencing any recurrent ovarian cancer.

That recurrent ovarian cancer was surgically excised in 1996, at Fox Chase Cancer Center in Philadelphia, PA. It was a metastatic transdiaphragmatic tumor from the original ovarian cancer (1972), with attachment to the lung and other midline structures of the chest. Parts of those structures were surgically resected. The Thoracic Surgical Oncologist stated that she was 100% successful and felt Ann did not need any treatment with chemotherapy. She left us with the knowledge that the second place that an ovarian metastasis possibly could occur maybe the Central Nervous System (CNS) like the brain and/or the spine. It is very rare for ovarian cancer cells to metastisize to the CNS. In fact, up until 1994 there have been only 67 well documented cases in medical literature. Metastasis of ovarian cancer cells to the Central Nervous System is uncommon and was rarely seen before the use of present day chemotherapy regimens.

In the Spring of 1997, we let a Gynecologic Oncologist at Reading Hospital in Reading, PA corral us into her receiving postoperative chemotherapy (seven months after having that metastatic tumor surgically excised). She did not have any cancer tumor markers indicate any cancer within her system (she did not have any cancer). Some tumors send out microscopic outposts while others do not. However, Medical Oncologists cannot tell which ones do, so they want to give chemotherapy in nearly every case. It was the hit fast, hit hard type Cocktail Chemotherapy of Taxol and Carboplatin. Patients who develop recurrent ovarian cancer more than 6 months after first-line chemotherapy (in my wife's case, 24 years) can experience another remission following treatment with the identical first-line chemotherapy that was previously used (Chlorambucil). Chemo-resistance is a significant obstacle to successful treatment of ovarian cancer. Resistance to standard chemotherapy regimens of Carboplatin with Taxol ultimately develops in nearly all ovarian cancer patients.

Some chemotherapy drugs do permeate (pass through) the blood brain barrier (the system that protects the brain from foreign substances by blocking their passage from the blood). A group of platinum based drugs like Cisplatin and Carboplatin are such drugs and natural substances such as Taxol, also cross the barrier. My wife developed necrotizing leukoencephalopathy (a form of diffuse white matter injury that can follow this chemotherapy), confirmed by an enhanced MRI in July of 1998. The white matter is the covering of the nerves within the brain. Its function is to speed up the passage of impulses along the nerves. Necrosis is simply a cell dying, all of its coordinated activities going wrong and things shut down. If a cell gets too much heat or is poisoned by a toxic substance or exposed to chemicals that damage its proteins and membraines or radiation that breaks its DNA molecules, that cell can just stop functioning. My wife almost didn't make it through. She could only receive five of the six intended treatments. We met a number of other patients that didn't make it (they died of treatment).

Unfortunately, some these chemotherapeutic agents weaken the blood-brain barrier (BBB) transiently and allow CNS seeding. In essence, it breaks down, damages the blood-brain barrier to invite microscopic cancer cells into the Central Nervous System. In recent years the incidence of CNS metastasis has increased. A NCI study in 1995 reported experience in their clinic where recurrent systemic disease occurred in all patients for which they received dose intense Paclitaxel (Taxol) therapy. Brain metastasis was the only site of disease recurrence. The cerebellum was involved in two out of three patients, presenting with headache, dizziness, unsteady gait, nausea and vomiting (all symptoms and results my wife experienced).

In July, 1998 a large (3.5cm) solitary cerebellar brain tumor was found via enchanced Cat Scan (later confirmed by an enhanced MRI). I contacted Fox Chase Cancer Center. Fox Chase said they did not have a neurosurgeon on staff and wouldn't be able to help us. I then contacted Johns Hopkins Cancer Center with the possibility of receiving stereotatic radiosurgery. Their office said that stereotatic radiosurgery was good only for tumors up to 3 cm. Then I contacted Hershey Medical Center, who gave us an appointment the following Thursday, July 16, 1998.

The tumor was excised from her brain the next day, Friday, July 17, 1998 by a Neurosurgeon at Hershey Medical Center, Hershey, PA. Histologic features were consistent with metastatic papillary adenocarcinoma with extensive necrosis from the ovary. Five days later, she was discharged from Hershey Medical Center on July 22, 1998. The Neurosurgeon stated that he was 99% successful and felt that she should go back to Reading Hospital and receive focal radiation to the local tumor bed (which is 2cm beyond the periphery of the excised tumor site). At the same time, she should receive an MRI of the spine because of suspicions of either another tumor, on her spine or a herniated disc, causing her leg problems.

A radiation oncologist at Reading Hospital (without script, instructions or referral), took it upon himself to give Ann 5 fractions (at 2.0gy per) of focal radiation to the local tumor bed, PLUS 20 fractions (at 2.0gy per) of Whole Brain Radiation. The risk of neurotoxicity from Whole Brain Radiation is not insignificant and this approach is not indicated in all patients with a solitary brain metastasis. Observation, with radiation delayed until evidence of progression, or focal radiation is a better choice in solitary metastasis patients. Whole Brain Radiation induces neurological deterioration, dementia or both. Patients develop progressive dementia, ataxia and urinary incontinence after Whole Brain Radiation. In addition, Whole Brain Radiation Therapy has been recognized to cause considerable permanent side effects mainly in patients over 60 years of age (my wife was 66 years of age). The side effects from Whole Brain Radiation Therapy affect up to 90% of patients in this age group. Local radiation to the tumor bed has been applied to patients to avoid these complications. The treatment method recommended for brain metastases of large solitary tumors exceeding 2cm in diameter is surgical resection followed by 5 fractions of local radiation to the tumor bed.

During radiation treatment, my wife received an Unenhanced MRI to the spine that showed a 1cm lesion. Instead of performing an Enhanced MRI to the spine to further evaluate, Reading Hospital performed a Bone Scan that showed normal bone imaging. Enhanced (contrast) agents increase the sensitivity, conspicuity and accuracy of an exam. The agent most commonly used is Gadolinium. The proper medical protocol for all Metastatic Brain and Spinal MRI's for metastatic diseases is Enhanced (contrast). An Enhanced MRI was not performed. The Radiation Oncologist told us the lesion was nothing and not to worry about it. He also ignored my complaints about her having seizures during radiation therapy.

Nine months later, my wife was admitted to the Reading Hospital during the Memorial Day Weekend of 1999, for a week of testing and evaluation for unexplained falls and light-headiness. A medical oncologist who admitted her said that my wife was supposed to be seen by an Internist (for her blood pressure) and a Neurologist (for a spinal tap). At the end of that week, another medical oncologist told me that she did not have cancer and he'll let her go home the next day. They diagnosed her with Leukoencephalopathy, a type of early delayed reaction affecting the white matter (connective tissue) of the brain. It occurs when the white matter is irritated by Radiation, dead tumor cells, and/or Chemotherapy. She went home the next day in time to fall and break her hip in four places.

After being operated on by an Orthropedic Surgeon, when physical therapy was to be performed immediately, my wife did not become coherent, she was lethargic. I found out that the doctors did not perform a spinal tap during the week before, so I forced the hospital to perform one on her, immediately. Afterwards, tests results showed Adenocarcinoma nodules in the spinal fluid (still, no one knew why?). After the Pathologist did not want to sign off on his diagnosis, I yanked my wife out of the Reading Hospital by ambulance and took her to Hershey Medical for proper medical treatment on Saturday, June 19, 1999.

At Hershey Medical Center, we found out by a Medical Onocologist and a Neurologist that my wife had Leptomeningeal Carcinomatous (remember the undiagnose tumor of nine months prior, not further evaluated?). An Enhanced MRI showed now three (3) metastatic tumors on her spine. Spinal metastases can grow into adjacent structures, such as into the meninges from the spine. The largest of these tumors grew into the meninges on the spine into the spinal fluid, hence Leptomeningeal Carcinomatous. Reading Hospital failed to diagnose cancer

The doctors at Hershey showed me the Enhanced Brain MRI from the previous year's cerebellum excision and the one done presently. The scans showed the progressive deteriation of her white matter (white matter disease). Late delayed effects, occuring several months to many years later, are classified into diffuse white-matter injury, radiation-induced arteriopathy & stroke, and late delayed Radiation Necrosis. These reactions are due to changes in the white matter and death of brain tissue caused by radiation-damaged blood vessels. Radiation Necrosis is part of a series of clinical syndromes related to central nervous system complications of radiation. Symptoms include decreased intellect, memory impairment, confusion, personality changes and alteration of the normal function of the area irradiated (all symptoms my wife had over the past year). Radiation Necrosis can be fatal! It causes pathological changes that impair vascular integrity. It causes cerebral infarctions (strokes). My wife suffered a stroke to the left basal ganlia area around the New Year 2000.

With the damage already done to her by Reading Hospital, the doctors at Hershey Medical (in order to save her life or at least give her some time) had to administer Intrathecal Methotrexate along with systemic radiation to the spine. When both therapies are performed at the same time it doubles the theraputic dosages of each therapy (increasing the neuro-toxic effects on the brain). A Medical Oncologist began two treatments of Intrathecal Methotrexate. A radiation oncologist began performing seven fractions (at 2.0gy per) of radiation to the spine. My wife was transferred from Hershey to Reading Hospital's rehabilitation unit after she was reclassified (under medicare) as an Outpatient (July 3, 1999). Not wanting to go back to Reading Hospital, we tried to transfer her to Reading Rehab Hospital, instead. Because my wife needed to have chemo-radiation treatments elsewhere, she was denied admission to this hospital. We had no other place to go!

The radiation oncologist at Reading Hospital, finished the next eight radiation treatments. After he was explicitly told that she needed only a total of 15 fractions (at 2.0gy per) of radiation to the spine, he wanted to give her 5 more fractions, at a higher dose! I asked him,"why?" He said,"we do things a little differently here, we are a lot more aggressive!" This gave me an indication as to why he gave her Whole Brain Radiation in addition to 5 fractions of focal radiation the previous year (he's over-aggressive). I stopped the radiation treatments at 15.

Ever since the second spinal tap at Hershey (when methotrexate was already being administered), all of her spinal taps were negative for 10 consecutive times up until January of 2000. A Whole Body Bone Scan (November 3, 1999) indicated that the skeletal system demonstrated normal uptake and an Enhanced Brain MRI (November 3, 1999) showed no new areas of abnormal enhancement. Leptomeningeal Carcinomatous has a very poor prognosis, however the cancer cells were eradicated completely from her central nervous system by the methotrexate.

Ann EEG performed at Hershey Medical Center in December 1999, MRI's performed in November 1999, January 2000 and May 2000 at Hershey Medical and a Pet Scan performed at University of Pennsylvania in August 2000, all showed even more diffuse white-matter injury (Radiation Necrosis). Her additional twenty fractions of Whole Brain Radiation resulted in diffuse necrotic effects. The EEG showed generalized diffuse slowing that was significant with global encephalopathy. It is most commonly seen in toxic metabolic and degenerative conditions. There appeared to be a real amount of focal right sided slowing which would indicate cortical dysfunction on that side.

The MRI's showed the ventricles overall were prominent and there was widening of the sulci consistent with cerebral atrophy (wasting away of brain cells and tissues). There was diffuse, abnormal signal intensity within the periventricular white matter, consistent with post radiation changes. The signal abnormality within the white matter appeared slightly increased compared to her prior studies. The Pet Scan showed globally decreased radiotracer uptake within the brain, bilaterally, consistent with involutional change and prior radiation therapy. Delayed radiation injuries result in increased tissue pressure from edema, vascular injury leading to infarction, damage to endothelial cells and fibrinoid necrosis of small arteries and arterioles. My wife suffered a stroke to the left basal ganlia area of the brain in January 2000, confirmed by an enhanced MRI.

Because of previous chemo-radiation treatments, a recurrence of the cerebral metastasis was very likely to happen in the future. It did, observed via that Enhanced MRI of May 2000 at Hershey Medical and that Pet Scan of August 2000 at University of Pennsylvania. Four, mm-sized metastatic tumors were found in and around the previously resected cerebeller tumor and because of her weakened condition, Gamma-Knife would be the best medical protocol. She received Gamma-Knife treatment at University of Maryland Medical Center in Baltimore, MD on September 12, 2000. During the whole time of her admission at the hospital, the doctors kept referring to her continued diffuse white-matter injury (brain radiation necrosis), as if she may too far advanced in that injury to survive much longer. My wife died Thursday, September 21, 2000 at the age of 68 from Cardio-Pulmonary Failure. Minutes before she expired, her temperature was normal, her blood pressure was normal but her pulse was 150 (tachycardia). Her heart was racing to keep up with the lack of brain function and finally quit. Believe me, a slow, arduous, neurological death is not preferable to a cancerous one.

Death by "side effects of treatment" is not the same as "complications of cancer". A lot of cancer patients who succumb to their disease get the wrong information on their death certificates. They die with incorrect, incomplete or misleading diagnosis. Often it will say they died of heart failure, kidney failure, liver failure or lung failure. These can be side effects of cancer treatment as well as progression of the cancer. They are lumped together reducing the general understanding of the impact of cancer.

The white matter disease that my wife experienced and caused her death was primarily a result of Whole Brain Radiation and secondarily a result of Cocktail Chemotherapy of Taxol & Carboplatin (Methotrexate was icing on the cake). The Cocktail Chemotherapy of Taxol & Carboplatin caused microscopic ovarian cancer cells to seed inside the CNS to form a tumor on the cerebellum and tumors on the spinal cord, with concomitant necrotizing leukoencephalopathy. The Whole Brain Radiation resulted in the death of tumor cells and associated reaction in surrounding normal brain. Such reactions tend to occur more frequently in larger metastatic lesions. Late delayed Radiation Necrosis (also known as Radiation Encephalopathy) is often irreversible and progressive, leading to severe disability or death (all symptoms my wife experienced).

There is the legal requirement that all doctors must give the patients the information about informed consent. It is the patient's right to determine what the patient wants done to their own body. It is not enough for consent for a patient to merely sign their name or say "yes" to proceed. It needs to be an "informed" consent which means the patient needs to be told things like the nature of the treatment, all of the risks and alternatives, including their risks and non-treatment if that's an option. We were never informed by any doctor at Reading Hospital involved with my wife's chemotherapy treatments or radiation treatments about the possible late-delayed side effects of treatment, nor the alternatives to treatment. My wife and I were corraled into believing this was the only thing to do, no other choice and no mention of the late side effects of treatment.

Summary:

I have only to convey my own experience with my wife's dreaded fight with cancer. It depends on the individual, each maybe different (maybe not). From my wife's experience with Cocktail Chemotherapy (Taxol & Carboplatin) and Whole Brain Radiation Therapy, it was horrible.

My wife and I had the medical adage that since most of surgical oncology is curative, we wanted to fight her cancers with surgery. Each and every one gave her more life to live. All of the surgeons that were involved in her cancer fight over the years are our heroes. I've received numerous emails about my wife's cancer story from patients and their loved ones who have fought cancer with surgery alone (so my wife and I arn't alone with this idea). Lung cancer, breast cancer, colon cancer, brain tumors to name a few. I have a few personal friends who too, have gone with surgery alone (they are still here). Their life was extended not because of chemotherapy or radiation therapy but because of great, competent surgical care.

In an article recently published in the media about a study at the Netherlands Cancer Institute in Amsterdam about a new test that may help tailor breast cancer treatment, 20 to 30 percent of women with early breast cancer will have a recurrence within five years, but because doctors can't identify those most at risk, they want to give chemotherapy in nearly every case.

So, 70 to 80 percent of women are given chemotherapy unnecessarily. And to those 20 to 30 percent who will have a recurrence within five years, it will only reduce the risk of cancer recurrence by 35 percent. Some tumors send out microscopic outposts, while others don't so most or every woman is given chemotherapy JUST IN CASE their tumors are the type that do.

You put all cancer patients at risk dying from the treatment of cancer so some cancer patients who will get recurrence won't risk it not receiving adjunct treatment. And yet, we don't really know because cancer patient's deaths are neatly lumped together as "complications of cancer" and their death certificates say "heart failure", "lung failure" or "liver failure" or to put it the other way, "died of natural causes". Even you mentioned that medicine seldom considers long term side effects, nor makes a connection at the time of death.

I just lost one of my aunts last month to the side effects of breast cancer treatment. Her daughters allowed her to have a lumpectomy with concomitant chemotherapy and whole body radiation. To a seventy-nine year old, it is like hammering nails on her coffin. Her death was from terminal infections that invade the body after the persons immune system is destroyed by chemo/radiation. Breast cancer is a common type of Adenocarcinoma. Adenocarcinoma is a type of cancer which does not respond well to chemo or radiation. The chance of curing it is probably less than 10%, according to a clinical investigator at the National Cancer Institute.

The chemo disrupting the BBB and leading to brain metastasis was something I was steered to by a number of medical professionals. What I found, coincides with what the thoracic surgical oncologist at Fox Chase told us after Ann's surgical resection. Dr. Dresler stated that the next "possible" place that an ovarian metastasis "could" occur "maybe" the brain. I don't know if she knew the specific data on it back then but I found that data. Until 1994, there have been only 67 well documented cases in medical literature. None of the medical professionals have suggested that my wife was simply number 68. It was so rare, it was virtually non-exsistent. However, I found a number of studies (I highlighted the NCI study because it was from NCI), about the increase number of brain mets from breast, lung and ovarian (they all share one of the chemotherapy protocols of Taxol & Carboplatin), during the 90's. New, novel chemotherapeutic agents have weaken the blood-brain barrier transiently and allowing CNS seeding of microscopic cancer cells. Before these new agents, chemo drugs were strictly vascular, they could never permeate the BBB. They way to give chemo agents to the CNS was by intrathecal means. A number of studies have quietly not further mention the continuation of these protocols. Many studies, like the NCI one, have just been ignored. Many leading cancer centers are not utilizing this protocol anymore. However, many of your local home town cancer clinics are still using it (like whole brain radiation).

Literature of the early and mid-80's on morbidity of Whole Brain Radiation, is flooded with papers reporting long-term side effects, such as dementia, memory loss, radiation induced necrosis, leukoencephalopathy, in up to 50% of two year survivors. Whole Brain Radiation Therapy has been recognized to cause considerable permanent side effects in patients over 60 years of age. Scientists at Brookhaven National Laboratory have the notion that the platinum drugs lower the tolerance of the CNS to radiation.

Cancer chemotherapy and radiation therapy almost without exception, will damage some normal tissue and diminish the immune system. Radiation has been known for a long time to both enhance cancer growth and to halt cancer growth. Damaging the immune system in turn is known to foster the growth of some kinds of other cancer.

We do not yet have really outstanding treatments for most cancers. Modern medicine in general and cancer treatment in particular, is very imperfect. In the hopes of curing disease or helping patients, the medical profession uses rather drastic treatments for devastating diseases they know will kill someone in a short time. Many physicians don't make the families aware enough that these treatments are drastic and can have serious side effects.

 

Gregory D. Pawelski

Wish to contact Gregory?  Write to him at: GregP@suewidemark.com