When John was diagnosed and met with his "team" of doctors, they all agreed that since this type of cancer is so aggressive that they wanted to blast him with everything they could from the start. The way they explained it was that the chemo would enhance the radiation. Just wondering after reading these boards for a few months why they don't always do chemo and radiation together after some people are diagnosed. Wouldn't it seem that the chance of a recurrance is much higher if only surgery alone is done?

Wanda

At least in my case, the decision to do chemo & radiation was because the alternative surgery would have such a negative effect on my quality of life. The cancer came back anyway and my medical team was unfortunately 100% correct on surgery damaging my neck, shoulder, and ability to swallow. As my ENT put it: "we tried to spare you the ordeal of surgery"
Your point however about chemo & radiation being deemed essential to deter recurrence seems valid enough to me, since when the pathology report post surgery came back, they said that without even more radiation and different chemo, my cancer would more probably than not come back a third time.

My Dr explained it much the same as Jon's did. In fact he simplified it by saying that the Chemo would criple the cells and then the radiation kills the criples.

Yes, Wanda, the chances of recurrence are higher if surgery alone was done, especially if the oral cancer is in a latter stage like mine. Surgery takes away outright the obviously infected area. Chemo would kill whatever remaining cancer cells may be in other parts of the body (since Chemo is not a treatment targetted at a certain area). Radiation, being a targetted treatment, kills cells that may still possibly remain in the infected area after surgery. At least that's how my doctors explained it to me.

Jojo,

I don't believe that the chemo given us actually kills our cancer, only the radiation will do that but I do believe the chemo weakens the cells so that they can be more effectively killed by the radiation and perhaps our own immune system. At least that's what I have been told.

I'll add my 2 cents.

I had 9 weeks of Induction Chemo (IC) followed by 7 weeks of concurrent chemoradiation treatment (CRT). I'm talking here about the CRT.

In my CRT, they gave me weekly doses of carboplatin and taxotere along with daily doses of IMRT (2 Gy per day, 72 Gy total). They tried to schedule the chemo early in the week, so it would be followed by at least 3 doses of IMRT before the week was out. The theory explained to me is that the chemo differentially sensitizes fast-growing cells to radiation; thus, the fast-growing cells would more easily die from the radiation than the slower-growing cells.

Cancer cells are among the fastest-growing cells, followed by the cells that line your mucous membranes, followed by hair cells, and then a host of slower-growing cells. Consequently, for any given dose/level of radiation, concurrent CRT is more likely to kill your cancer (along with your mucous membranes) than radiation alone. Fortunately, your normal cells (like those in your mucous membrane) will grow back in a few weeks.

Hope that helps, Rob

Davidcpa:

My understanding is as follows. Some cancer cells are more robust than others. Chemo will kill the weaker cancer cells but its not powerful enough to kill the more robust cancer cells. Consequently, chemo alone is not a "definitive" treatment for the disease.

However, chemo alone (in the form of Induction Chemo) is a useful adjunct to more "definitive" treatments (like concurrent chemoradiation). As you point out, chemo is not "targeted" to any one location, so if a few cancer cells have metasticized to some distant part of the body, the chemo will reach (and hopefully kill) these cells. This reduces the chance that the cancer will recur at some location distant from the original/primary site (thereby improving your chances of long-term survival).

Once they've used Induction Chemo to "mop up" the few (undetectable) cancer cells that have escaped to distant locations, they can use concurrent chemoradiation treatment (CRT) to attack the original/primary site in a targeted manner.

One thing about Induction Chemo: after its killed the weaker cells, only the stronger (more robust) variety of cancer cells will remain. Without further treatment, these will start growing again and they won't be competing with the weaker cancer cells for resources. So if you wait too long after Induction Chemo to begin your "definitive" CRT, your cancer will be as big as it was to start with and - even worse - it will be composed entirely of those stronger (more robust) cancer cells. So give yourself a SHORT time (e.g., 2 weeks) to recover from the Induction Chemo and then jump right into the CRT.

Hope that helps, Rob

Thanks for the inputs, David and Rob. Am definitely learning a lot here.

Questions for Rob:
If Induction Chemo is not strong enough to kill robust cancer cells, while concurrent chemoradiation therapy will, why not go straight to concurrent chemoradiation? Or is it that either (a) concurrent chemoradiation can't detect the weaker cancer cells, or (b) concurrent chemoradiation is only a targeted treatment? And assuming that concurrent chemoradiation is for targeted treatment, what if more robust cancer cells have metastacized to other distant parts of the body (which weren't killed by Induction Chemo)?

Excuse me if these questions have already been answered in previous points, you may just point me there.

Appreciate your responses.

Jojo

Hi JoJo,

All questions are welcome. Here's what I think:

Concurrent chemoradiation treatment (CRT) is a targeted treatment; it will only kill cancer cells in the region that's targeted. By doing the Induction Chemo (IC) first, they "mop up" most (hopefully all) of the cancer cells that have already escaped to other parts of the body. Yes, the IC might not kill them all, because some might be "robust", and any not killed by IC may end up causing your death. There are no guarantees here. In my view, if you don't do IC and only do CRT, then you haven't even tried to kill those few cancer cells that have escaped to other parts of the body. I think its worth trying.

But the above is merely a bunch of theorizing. I think it is important for researchers to develop (and then test, with the hope of verifying) theories as to what the mechanisms are, because doing so aids our understanding which can lead to ideas for even better treatments. But, from a purely clinical perspective, nobody cares much how it works. All that really matters is performance. Does the process lead to good outcomes? Its quite common that somebody has a clever idea for a new treatment that they think *should* work well, only to discover that it doesn't work at all - or that it works but has some unanticipated (and unacceptably bad) side effect. Would you want a treatment that cures your cancer but gives you excruciating pain for the rest of your life?

So clinicians rely on trials. Preferably large-scale placebo-controlled double-blind trials. For example, give 200 patients CRT but 100 of them get IC and 100 of them don't get IC. Then watch them awhile and see how long they live. If the patients that got IC live significantly longer than those who didn't get IC, and they don't suffer any unacceptable side effects, then it makes sense to give IC to future patients. To the clinician, it doesn't matter how or why IC gets the better result; it only matters *that* IC gets the better result.

On that basis, I'll refer you to two articles in the 25 Oct 2007 issue of the New England Journal of Medicine:

http://content.nejm.org/cgi/content/abstract/357/17/1695
http://content.nejm.org/cgi/content/short/357/17/1705

I also found this one fun to read:

http://jco.ascopubs.org/cgi/content/full/27/23/e52

But this might be easier to read:

http://www.ncbi.nlm.nih.gov/pubmed/18544437?dopt=Abstract

For the kinds of question you are asking, you need to look to this sort of technical literature to find your answers. The folks on this board are patients and patients usually don't know much about how or why different treatments work (or are chosen by their physicians). Patients can tell you their own experiences. But for the kinds of questions you are asking, all you'll get here is a bunch of well-meaning speculation (including my own). Train yourself to read and understand the technical articles... then go read them... and you'll know as much as anyone.

Hope that helps, Rob

Here's what I recollect:

Initially, I was going to definitely have surgery and radiation.

The lymph node biopsy found that the cancer had broken through the lymph node capsules, hence chemo was added.

Best wishes,

Chris