Medical Oncology & Hematology

Cytotoxic chemotherapeutics have been the mainstay of chemotherapy regimens as they directly interrupt the cancer cells ability to divide, grow, and spread. Cytotoxic chemotherapeutic drugs, whether oral or IV, are transported in the bloodstream throughout the body. Cancer cells, even 1 or 2 of them, require nutrition through the bodies blood stream.  Cancers produce chemicals that tell the neighboring arteries to produce branches to support their growth and it is haphazard to say the least. This produces many more blood vessels than the neighboring tissues to support them and leads to a large delivery of blood.  Subsequently increasing greatly, the delivery of all chemotherapy to the cancerous tissue and leading to the cancers demise.

Cytotoxic chemotherapeutics can be used to destroy the known primary tumors, but also to search out and destroy other smaller cancer cell nests not seen on initial staging scans as they are too tiny to see on conventional imaging.  These chemicals are also able, often in smaller doses that are not even causing a patient any side effects, to augment the effects of radiation given in a patients’ care plan.  When given in conjunction with radiation this leads to improved cure rates.

Cytotoxic drugs affect all dividing cells, including those of healthy tissue.  The cells most likely to be injured are the gastrointestinal lining cells and the bone marrow.  However, chemotherapy dosing schedules are derived around the recovery of these tissues entirely prior to the next dosing of the chemotherapy. Because cancer cells often divide markedly faster than normal cells, they are particularly sensitive to chemotherapeutic drugs. This allows us to dose the chemotherapeutic drugs at a certain intense schedule and stop, the subsequent break in dosing allows the body’s cells to recuperate and the cancer cells that have been targeted are still dying with the next cycle of chemotherapy.

Hormonal therapy is also called endocrine therapy.  The reason for this label is that many cancers, including breast,  prostate, and more, are growing due to their cells having receptors for growth that are triggered by the patients’ own hormones. These endocrine glands have no ducts and dump the hormones directly into the bloodstream.  These hormones then flow directly to the tumor and bind to receptors on the outside of the cancer cells and trigger growth.  Without this stimulation the cancer cells will go dormant or even die. Endocrine therapy whether IV, oral, or intramuscular stops the cancer cells from getting this signal.

Cancer types that are growing due to the production of hormones from these endocrine glands are numerous. Subsequently many patients will be offered hormonal therapy.  This can be in the setting where the cancer has spread widely and it is used to kill the cancer directly, as it is associated with a much better quality of life and superior response rates compared to chemotherapeutic agents.  It can also be used to prevent a recurrence of cancer after other curative modalities like chemotherapy, surgery or radiation. In that setting it is often administered either intramuscularly or orally for years.  The patient’s quality of life in these settings is often excellent with no side effects.

Hormonal therapy can be employed prior to other therapies, with other therapies, or after other therapies.  The terms applied to this respectively are neoadjuvant, concurrent, and adjuvant.

Immunotherapy is rapidly becoming the changing face of oncologic care. It has become a mainstay in therapy in the last 5 years.  It is driving the fight against cancer currently, and we recognize that here at Millennium Oncology and are pushing its utilization to the fullest. Immunotherapy is designed to inhibit certain substances that the cancer cells are releasing into the blood stream that effectively paralyze the bodies natural first line in fighting cancer, the immune system.  The cells that are being effectively put to sleep are called natural killer cells. By binding to and blocking these chemicals your body is able to reawaken NK cells and recognize what it has been missing.  It then attacks the foreign proteins on the cancer and kills it.  At Millennium Oncology we use these immunotherapies front line and as much as possible in later lines of therapy when indicated.

There are several types of immunotherapy, including monoclonal antibodies, cancer vaccines, oncolytic virus therapy, T-cell therapy, and non-specific immunotherapies.  The non-specific agents are often a delivery agent coupled with a radiation type or even a very potent chemotherapy drug that will be ingested by the cancer cells and not healthy normal cells, these are called conjugates.  

Immunotherapy is different from traditional chemotherapy and can have lesser but much varied side effects. Because your body is awakening to fight the malignancy it can awaken and be mistaken.  Much along the lines of an autoimmune disease like Lupus or Rheumatoid Arthritis it can wake up and misrecognize you.  Common side effects from these therapies lead to your body attacking itself. Most commonly are diarrhea and hypothyroidism. Other much less common side effects can be against almost any organ or gland in the body.  Most of the time they are minor and treated with a dose of corticosteroids, but uncommonly they can be severe and limit the use of the drug in the future.

Intrathecal Chemotherapy is treatment in which anticancer drugs are injected directly into the fluid-filled space between the thin layers of tissue that cover the brain and spinal cord. These tissues are called the leptomeninges.

The cerebrospinal space is the area surrounding the spine and brain, which contains cerebrospinal fluid. Cerebrospinal fluid (CSF) is a colorless fluid.  It is produced in the main 2 ventricles of the brain, in an area called the choroid plexus.  The fluid acts as a buffer around the brain and spinal cord, to keep them safe from injury from trauma.

Intrathecal (IT) chemotherapy is used to treat cancers that have entered into the CSF, not cancers located inside the brain itself. Chemotherapy given intravenously and/or by mouth are typically not able to cross into the CSF due to a blood brain barrier.  This barrier is due to cells of the brain wrapping the arteries and preventing chemicals from entering the actual brain matter.  This creates a sanctuary site for cancer to grow. Giving chemotherapy directly into the CSF allows the medication to reach the cancer cells in the leptomeninges but not necessarily into the brain itself. Therefore the treatment is used only for disease in these leptomeninges and not for cancer in the actual brain.  This procedure of chemotherapy administration minimizes the potential systemic (overall) side effects that intravenous chemotherapy can cause and allows a large dose of chemotherapy to be introduced directly to the cancer and no other tissues.

IT chemotherapy can be used to treat or to prevent cancer in the CSF. IT chemotherapy may be administered as part of a chemotherapy regimen or on an as-needed basis. Typically used in lymphoma and leukemia therapies exclusively.

Intravesical therapy is exclusively used by Urologists and Oncologists.  Intravesical therapy involves the instillation of either Bacille Calmette-Guerin (BCG) or chemotherapy directly into the bladder through a catheter that is inserted into your urethra. BCG is a type of bacteria that elicits a major immune reaction in the bladder and causes the immune system to flood into the area and destroy superficial bladder cancers.  It is also interestingly used as a TB vaccine. Chemotherapy is injected to directly kill the cancer cells and is typically a second line therapy after BCG. While the intravesical therapy is in the bladder and the foley catheter is clamped off the patient is instructed to roll in various positions for up to 2 hours to allow all of the bladder surface to be exposed.  The catheter is then unclamped and drained and the catheter is removed. This technique is advantageous as it most of the time allows the rest of the body to be free of any ill effects.

Molecular therapy is another groundbreaking advance in cancer chemotherapeutics.  Monoclonal antibodies have been and are being developed that recognize and home in on only certain proteins found on cancer or receptors on the cancer cells surface. By binding only to these specific targets, they minimize toxicity to any normal human cells.  They cause the cells to die via a direct mechanism and by recruiting other normal human proteins (complements) to target the cancerous tissue.  They are given by mouth and intravenously depending on the specific agent. We at Millennium Oncology use them daily and routinely.  They have become a mainstay of cancer therapy both in upfront treatments and also as low toxicity maintenance therapies.

This type of therapy is exclusively delivered by Millennium Oncology Radiation Oncologists. These doctors have spent their lives learning the proper utilization of all the newest techniques available. There are two types of radiation therapy (also called radiotherapy).  External beam (teletherapy) and internal radiation therapy (brachytherapy). Teletherapy is given via a large machine with no tunnel.  It rotates around the body in 360 degree circle and delivers radiation through as many as 300 ports as it travels.  It can be made to deliver the radiation to the tumors with as little as 1 millimeter of overshoot in the desired area in all dimensions (stereotactic body radiotherapy or volume loop therapy). These treatments are delivered Monday through Friday and take about 15 minutes. There can be anywhere from 1 treatment to 40 treatments depending on the tumor type and the desired effect. There is typically no pain associated with these treatments and minor fatigue. 

Radiation can be of various forms; photons and electron are the typical types.  These both work by damaging a cells DNA.  They typically work by hitting open and dividing DNA and stopping the cells ability to divide and populate. They also damage cells that are not diving but to a lesser extent. This effect takes time as not all cells are open and dividing at the same time.  This is why there are subsequent treatments often.  The dose of radiation is calculated based on the surrounding healthy tissues ability to recover from the radiation.  Tissues in the body all have different levels of lifetime doses that are safe.  It is a myth that if a patient gets radiation to one site that they cannot ever get radiation elsewhere. 

Brachytherapy is given in internally.  It is given wither by placing a solid radioactive isotope in a particular area or can be given intravenously.  It works in the same fashion as external beam  radiotherapy.

Once radiation is delivered it takes days to start seeing the effect, but the effect can then continue to kill cancer cells for weeks to months.

Click here to see the different types of radiation services we offer.

Designed to interact with the targeted tumor directly. They block tumor cell proliferation, instead of killing cells like standard chemotherapy.