Palliative Chemotherapy Report: Case Study of Metastatic NSCLC, 2019

This report delves into the complexities of palliative chemotherapy for non-small cell lung cancer (NSCLC), focusing on a case study of a 66-year-old patient, Katerina, diagnosed with metastatic NSCLC. It explores the crucial considerations in choosing between supportive care and palliative chemotherapy, emphasizing patient beliefs, information presentation, clinician attitudes, and treatment risks and benefits. The report outlines the benefits of chemotherapy in NSCLC, including tumor size reduction and increased treatment efficacy, and discusses the advantages and disadvantages of combination chemotherapy regimens. It also details potential side effects, such as pain, mouth sores, nausea, and blood disorders, and provides insights into monitoring treatment response through imaging techniques and tumor marker testing. Furthermore, the report outlines the information a healthcare provider would share with Katerina to guide her initial treatment choices and follow-up decisions regarding continuing chemotherapy, using clear, patient-friendly language. The report also addresses the role of targeted therapy drugs and the significance of molecular characterization and cancer histology in treatment planning.

Running head: PALLIATIVE CHEMOTHERAPY 1
Palliative chemotherapy
Student name
Institution
Date

PALLIATIVE CHEMOTHERAPY 2
Palliative chemotherapy
Supportive care aims at enhancing the health of the individual by providing relief once the
symptoms occur. Palliative chemotherapy is a treatment that is designed for cancer patients. This
treatment option aims to reduce the severity of the symptoms but not cure the illness. Palliative
chemotherapy aims to postpone future symptoms of the disease. In most cases, palliative
chemotherapy is used in patients who have relapsed with an advanced form of cancer after a
prior treatment option (Harrison, Zhang–Salomons, Mates, Booth, King & Mackillop, 2015).
Supportive Care Versus Palliative Chemotherapy
There are four important considerations that are used to determine whether a patient would be
managed using supportive care only as compared to palliative chemotherapy, they include, the
patients beliefs and attitudes, the presentation of information, the clinicians attitudes and the
benefits or risks involved in the various treatment methods/ the patient beliefs and attitudes are
usually based on their friends, family, media, health care workers and previous experience. The
belief and attitudes also vary according to age and other demographic variables. The nature of
presenting the information greatly influences the patient’s choice between supportive care and
palliative chemotherapy. The outcome of the treatment option may be presented according to the
survival rate or death rate. Also, medical uncertainties can be explicitly mentioned or not
mentioned at all. The doctor’s attitudes are mostly influenced by the aim of the therapy and the
need to enhance the quality of life of the patient. Several studies have shown that it is essential to
consider the nature and the risk of the treatment option before administering the treatment. The
chosen option should have fewer risks and offer a significant amount of benefits. The stage of
cancer also determines the preference of the treatment option. The molecular characterization of

PALLIATIVE CHEMOTHERAPY 3
the tumor greatly influences the treatment option administered to the patient. Without forgetting,
the histology of the cancer cell is an essential consideration in supportive care or palliative care.
There is various histology for lung cancer; the tumor may be small cell lung cancer, Non-Small
Cell Lung Cancer, or squamous NSCLC or non-squamous NSCLC (Henselmans, van Laarhoven,
de Haes, Tokat, Engelhardt, van Maarschalkerweerd & Sommeijer, 2019).
Benefits of Chemotherapy
Chemotherapy has a lot of benefits in treating NSCLC. This treatment option for cancer that
involves injecting the drug into the blood or taking them orally. Chemotherapy helps to decrease
the tumor size, making it easy to remove through surgery or radiation. Chemotherapy also helps
to increase the effectiveness of the surgery or radiation by destroying any hidden cancer cells
that may be in other parts of the body (Nowicki, Woźniak & Krajnik, 2015). Chemotherapy is
mostly administered to patients before the surgery because patients can cope with the side effects
of the treatment option more easily. For patients in stage I and II chemotherapy after the surgery
can help to prevent the reoccurrence of cancer. For patients in stage III lung cancer that can not
be removed by surgery, chemotherapy is sometimes used in combination with radiotherapy.
Stage IV patients are often placed under chemotherapy treatment only. For these patients,
radiotherapy is only used in palliation of the symptoms. Chemotherapy studies have proven that
the treatment option has high survival rates. Another benefit of this treatment option is that the
toxicity level is negligible and is often outweighed by the patient experiencing relief form the
tumor symptoms (Roeland & LeBlanc, 2016).
Chemotherapy as Combination

PALLIATIVE CHEMOTHERAPY 4
The majority of chemotherapy regimens in NSCLC are given in combination. In early stages of
Non-Small Cell Lung Cancer, two chemotherapy drugs can be combined, carboplatin or cisplatin
and another drug; gemcitabine with paclitaxel or vinorelbine may be used. For elderly patients or
very young patients with advanced cancer may combine chemotherapy with targeted therapy
drugs such as bevacizumab (Avastin), necitumumab (Portrazza), or ramucirumab (Cyramza).
This combination helps to reduce the tumor size without compromising the immune system of
the patient. Targeted drugs are drugs that are designed to attach to targets on the cancer cells
surface thus preventing growth of the tumor. Individuals are required to meet specific molecular
biomarkers before they are administered targeted drugs (Brule, Al-Baimani, Jonker, Zhang,
Nicholas, Goss & Wheatley-Price, 2016).
Advantages and Disadvantages of Chemotherapy in Combination
Administering chemotherapy drugs as the combination has several potential advantages and
disadvantages. The advantage of administering the medications in combination is that there in
increased efficiency. Each drug has a unique target that it addresses in the body of the patient.
Administering drugs in combination will increase efficiency and improve the quality of the
treatment option. Administering a combination of drugs also helps to destroy any underlying
tumors that may not have been detected. This enhances the quality of care of the patient. The
major disadvantage of using chemotherapy drugs in combination is that the side effects are more
severe. All chemotherapy drugs have side effects and administering two drugs increases the
severity of these side effects. Another disadvantage is that in some rare cases the drugs may
contraindicate and cause more harm instead of rectifying the illness (Stene, Helbostad,
Amundsen, Sørhaug, Hjelde, Kaasa & Grønberg, 2015).

PALLIATIVE CHEMOTHERAPY 5
Side Effects of Chemotherapy
Chemotherapy has various side effects. The side effects of chemotherapy depend on the general
health of the patient, the type of cancer, types of drug used, and the dosage of the medicines
(Heikkilä & Kaasa, 2017). Side effects are a result of chemotherapy damaging healthy cells.
Tumors, which cause cancer, are actively growing cells. The working mechanism of
chemotherapy is to destroy active cells which are overmultiplying. During the process of
destroying active cells, the healthy cells are destroyed. The cells that are mostly affected are in
the digestive system, the mouth, hair follicles, and blood. Most of these side effects can be
treated. Several medications are available for preventing and managing side effects. Also, several
researchers are continually working to develop drug combinations or whole drugs which will
result in fewer side effects (Kenmotsu, Naito, Mori, Ko, Ono, Wakuda & Takahashi, 2015).
In palliative chemotherapy, the most common side effect is pain. Patients reported experiencing
pain in muscle tissues, headache, stomachaches, and pain from nerve damage which involves
burning sensation, numbness and shooting pains in the body extremities. Most of the pain types
usually decrease with treatment, for example giving pain-relieving medication or using nerve
blocks and spinal treatments to block pain signals from reaching the brain. Alternatively, the
chemotherapy dose can be adjusted to reduce the pain. However, nerve damage pain increases
with each dose of chemotherapy. Usually nerve damage takes several years or months to be
resolved in some patients; the pain may remain forever in some patients (Cortés, Urquizu &
Cubero, 2015).
Another side effect of palliative chemotherapy is sores in the mouth and throat. The
chemotherapy drugs often damage the cells found in the throat, mouth and surrounding areas,

PALLIATIVE CHEMOTHERAPY 6
resulting in a condition called mucositis. In most patients, mouth sores begin to appear five to
fourteen days after the treatment has started. Proper care is required to prevent the sores from
getting infection. The most common therapy for this side effect is eating a healthy diet and
practicing proper dental hygiene will keep the teeth and mouth clean. Most mouth sores usually
disappear when chemotherapy treatment stops (Park, Lee, Ahn, Ahn, Park & Sun, 2018).
Nausea and vomiting are common side effects of chemotherapy. The degree of this side effect
varies on the dosage of the chemotherapy drug and the specific drug used. Using proper
medication before and after each intravenous doses of chemotherapy can help reduce the feeling
of sickness in the patient’s stomach(nausea) and throwing up (Fennell, Summers, Cadranel,
Benepal, Christoph, Lal & Ferry, 2016).
In some cases, chemotherapy can cause blood disorders. The drugs usually attack the bone
marrow which is responsible for creating new blood cells. The result is the patient having very
few blood cells. During palliative chemotherapy treatment, the clinician may recommend blood
tests to monitor the number of blood cells. The most common tests are Complete Blood Count
(CBC), which shows the levels of white and red blood cells. Very few red blood cells can result
in anemia, while very few white blood cells increase the risk of getting an infection. Another
blood test conducted is platelet count, which measures the number of platelets. Very few
platelets increase the risk of bleeding more than average. Most blood disorders return to normal
when the chemotherapy treatment is stopped (Sheng, Fang, Yu, Chen, Zhan, Ma & Zhang,
2016).
There are other side effects of the drug depending on the patient’s health status. Diarrhea or
constipation sometimes occurs. It is essential to treat diarrhea early enough before the patient

PALLIATIVE CHEMOTHERAPY 7
becomes dehydrated. On the other hand, the patient may experience constipation. Medication
used to alleviate pain is the causative factor for constipation. This side effect can be treated by
eating balanced meals that contain a lot of fiber, drinking enough fluid and doing exercises.
There are also some minor side effects such as fatigue, mood disorders and sexual disorders
(Valdes, Nicholas, Goss & Wheatley-Price, 2016).
Monitoring Response to Therapy
The response to cancer to the therapy is monitored in various ways. Imaging techniques have
been used in monitoring the treatment option for cancer. Through x rays, computed tomography
scans (CT scans), magnetic resonance imaging (MRI), and ultrasounds the tumor is located, the
stage in development is analyzed, and the treatment progress is monitored. The most common
imaging technique is the positron emission tomography (PET). This technique produces a beam
of light equivalent to the size and location of the cancer tumor in the patient’s body (Antonia,
Villegas, Daniel, Vicente, Murakami, Hui & Cho 2017).
Recent developments in technology have resulted in the development of tumor markers testing.
All cells, cancerous and non-cancerous produce certain tumor substances on their surfaces
(Nowicki, Woźniak & Krajnik, 2015). The tumor substances for cancerous cells are usually
activated and can be distinguished from normal noncancerous cells which the tumor substance
has not been activated. Tumor makers testing allows the clinician to measure the extent of the
tumor and determine if the treatment option is successful or failing. The tumor markers testing
also helps to detect if the cancer is spreading to other body parts. The tumor markers have the
ability to be modified to detect specific antigens or antibodies in the blood for blood tests and

PALLIATIVE CHEMOTHERAPY 8
other serology purposes (Gandhi, Rodríguez-Abreu, Gadgeel, Esteban, Felip, De Angelis &
Cheng, 2018).
Case study
In the case study provided, the patient, Katerina, will be provided with information on what the
disease is, the mechanism of action, the extent of the tumor, the treatment options available, and
the side effects of the treatment option. In lay terms the exact words used are as follows: “cancer
is a condition where the cells of the body begin to multiply and grow out of control and forms a
tumor in the body. A tumor can be felt as a hard lump. Lung cancer is cancer that initially
develops in the lungs. Lungs are sponge-like organs found in the chest; They make up part of the
breathing system. Having lung cancer interferes with the normal breathing system and can result
in chest problems such as coughs, breathing difficulties and chest pain. There are two lungs in
the human body; there are three sections in the right lung, and two sections in the left lung. These
sections are scientifically referred to as lobes. Currently, there is a tumor in the upper right lobe
of your lung. There are two types of lung cancer, Non-Small Cell Lung Cancer and Small Cell
Lung Cancer. The most common type of lung cancer is Non-Small Cell Lung Cancer, which is
what you have. There are different stages of cancer depending on the size and the extent of
spread in the body. The stages range from stage I to stage IV; the lower the number, the less the
size and extent of the cancer spread. Occasionally, lung cancer may spread to the surrounding
bones which increases the risks involved. Currently, your cancer has spread to the bones, and
urgent treatment is required to prevent further damage. Early detection of cancer helps to
improve the success of the treatment option chosen. Currently, there are various treatment
options available for Non-Small Cell Lung Cancer, for example, surgery, radiotherapy,
chemotherapy, targeted therapy, and palliative procedures. Surgery is used to remove the tumor.

PALLIATIVE CHEMOTHERAPY 9
Usually another treatment option is applied to kill the cancer tumor before it is surgically
removed. Radiotherapy involves the use of radiation. The radiative waves ae directed to the
source of the tumor, and the waves kill the cells. The advantage of this method is that it kills all
the tumor cells. The disadvantage of this method is that exposure to high levels of radiation can
have serious health effects and can cause mutation. Also, the radiation waves damage healthy
cells (Reck, Rodríguez-Abreu, Robinson, Hui, Csőszi, Fülöp & O’Brien, 2016). Chemotherapy is
the use of drugs to destroy cancerous cells. The drugs are taken orally or through an injection.
The advantage of this method is that there are a variety of drugs available that are very effective.
The disadvantage of this method is that the side effects involve loss of hair and other minor
complications like pain. Targeted therapy is a treatment option that is like chemotherapy except
the drugs are specific to the cancer cells. There are fewer side effects. The disadvantage of this
method is that there is little variety as most of the medications are under research. The palliative
procedure is treatment option where the treatment option is to reduce the severity of the
symptoms but not cure the illness. Palliative chemotherapy aims to postpone future symptoms of
the disease” (Jänne, Yang, Kim, Planchard, Ohe, Ramalingam & Haggstrom, 2015).
Role of Radiotherapy in NSCLC
Other anti-cancer treatment modalities such as radiotherapy have a role in NSCLC. Depending
on the extent of cancer, these treatment options can help to destroy the tumor and prevent the
reoccurrence of cancer. Some of the anticancer treatment modalities for NSCLC are noninvasive
which provides a better alternative to the patient. However, they have adverse side effects. It is
recommended that the anticancer treatment modalities should be combined with chemotherapy.
A combination of two modalities is very effective and can help improve the health outcomes of
the patients (Garon, Rizvi, Hui, Leighl, Balmanoukian, Eder & Carcereny, 2015)

PALLIATIVE CHEMOTHERAPY 10
Role of Targeted Therapies
Targeted therapies such as EGFR inhibitors have a high potential in the treatment of NSCLC.
Targeted therapies play a significant role in the treatment of NSCLC. They have fewer side
effects as compared to chemotherapy since they do not attack healthy cells in the body. The
therapy works by attacking specific cells in the body. The EGFR inhibitors, for example, act by
preventing the cells from producing EGFR. This prevents the tumor from increasing in size and
helps to contain cancer. Surgery may be required to remove the tumor form the patient. Further
research is being conducted on targeted therapies to help produce a variety of drugs that are more
specific to the cancer type and stage. The research also aims to reduce the side effects caused by
target therapies (Rizvi, Hellmann, Snyder, Kvistborg, Makarov, Havel et& Miller, 2015).

PALLIATIVE CHEMOTHERAPY 11
References
Antonia, S. J., Villegas, A., Daniel, D., Vicente, D., Murakami, S., Hui, R., ... & Cho, B. C.
(2017). Durvalumab after chemoradiotherapy in stage III non–small-cell lung
cancer. New England Journal of Medicine, 377(20), 1919-1929.
Brule, S. Y., Al-Baimani, K., Jonker, H., Zhang, T., Nicholas, G., Goss, G., ... & Wheatley-Price,
P. (2016). Palliative systemic therapy for advanced non-small cell lung cancer:
investigating disparities between patients who are treated versus those who are not. Lung
Cancer, 97, 15-21.
Cortés, Á. A., Urquizu, L. C., & Cubero, J. H. (2015). Adjuvant chemotherapy in non-small cell
lung cancer: state-of-the-art. Translational lung cancer research, 4(2), 191.
Fennell, D. A., Summers, Y., Cadranel, J., Benepal, T., Christoph, D. C., Lal, R., ... & Ferry, D.
(2016). Cisplatin in the modern era: The backbone of first-line chemotherapy for non-
small cell lung cancer. Cancer treatment reviews, 44, 42-50.
Gandhi, L., Rodríguez-Abreu, D., Gadgeel, S., Esteban, E., Felip, E., De Angelis, F., ... &
Cheng, S. Y. S. (2018). Pembrolizumab plus chemotherapy in metastatic non–small-cell
lung cancer. New England journal of medicine, 378(22), 2078-2092
Garon, E. B., Rizvi, N. A., Hui, R., Leighl, N., Balmanoukian, A. S., Eder, J. P., ... & Carcereny,
E. (2015). Pembrolizumab for the treatment of non–small-cell lung cancer. New England
Journal of Medicine, 372(21), 2018-2028.
Harrison, L. D., Zhang–Salomons, J., Mates, M., Booth, C. M., King, W. D., & Mackillop, W. J.
(2015). Comparing effectiveness with efficacy: outcomes of palliative chemotherapy for
non-small-cell lung cancer in routine practice. Current Oncology, 22(3), 184.
Heikkilä, R., & Kaasa, S. (2017). Chemotherapy in end-of-life care.

PALLIATIVE CHEMOTHERAPY 12
Henselmans, I., van Laarhoven, H. W., de Haes, H. C., Tokat, M., Engelhardt, E. G., van
Maarschalkerweerd, P. E., ... & Sommeijer, D. W. (2019). Training for Medical
Oncologists on Shared Decision‐Making About Palliative Chemotherapy: A Randomized
Controlled Trial. The oncologist, 24(2), 259-265.
Jänne, P. A., Yang, J. C. H., Kim, D. W., Planchard, D., Ohe, Y., Ramalingam, S. S., ... &
Haggstrom, D. (2015). AZD9291 in EGFR inhibitor–resistant non–small-cell lung
cancer. New England Journal of Medicine, 372(18), 1689-1699.
Kenmotsu, H., Naito, T., Mori, K., Ko, R., Ono, A., Wakuda, K., ... & Takahashi, T. (2015).
Effect of platinum-based chemotherapy for non-small cell lung cancer patients with
interstitial lung disease. Cancer chemotherapy and pharmacology, 75(3), 521-526.
Nowicki, A., Woźniak, K., & Krajnik, M. (2015). Understanding the purpose of treatment and
expectations in patients with inoperable lung cancer treated with palliative
chemotherapy. Contemporary Oncology, 19(4), 333.
Nowicki, A., Woźniak, K., & Krajnik, M. (2015). Understanding the purpose of treatment and
expectations in patients with inoperable lung cancer treated with palliative
chemotherapy. Contemporary Oncology, 19(4), 333.
Park, S. E., Lee, S. H., Ahn, J. S., Ahn, M. J., Park, K., & Sun, J. M. (2018). Increased response
rates to salvage chemotherapy administered after PD-1/PD-L1 inhibitors in patients with
non–small cell lung cancer. Journal of Thoracic Oncology, 13(1), 106-111.
Reck, M., Rodríguez-Abreu, D., Robinson, A. G., Hui, R., Csőszi, T., Fülöp, A., ... & O’Brien,
M. (2016). Pembrolizumab versus chemotherapy for PD-L1–positive non–small-cell lung
cancer. New England Journal of Medicine, 375(19), 1823-1833.