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Do no harm: How far the use of chemotherapy can be justified in the

treatment of cancer patients

Introduction
In the UK, cancer is a very common condition, with one in three people expected to
develop it at some point in their lifetime 1. Although surgery is the main treatment option,
most patients will also have chemotherapy either before or after surgery to improve their
chances of recovery.2 However, recent evidence has suggested that chemotherapy isnt as
effective as previously thought, and may even do more harm than good. This essay will
assess how far the use of chemotherapy is therefore justified in cancer patients.
Effectiveness of chemotherapy
Chemotherapy works by attacking cells that arent in the G0 phase (a resting period in
which the cells are not dividing) of the cell cycle, i.e. actively dividing cells. Different types
of chemotherapy drugs work in different ways. For example, ifosfamide, an alkylating
agent, is converted into 4-hydroxy-ifosfamide, which exists in equilibrium with one of its
isomers aldophosphamide. This decomposes into isophosphoramide mustard, which
alkalises the cells DNA by forming interstrand crosslinks (DNA lesions that stop DNA
strands from separating and therefore preventing transcription and replication 3). Another
type of drug, antimetabolites, take the place of purine or pyrimidine during the S-phase,

1 http://www.nhs.uk/conditions/cancer/Pages/Introduction.aspx

2http://www.cancerresearchuk.org/about-cancer/cancers-ingeneral/treatment/chemotherapy/about/when-chemotherapy-is-used

3Deans, Andrew J., and Stephen C. West. "DNA Interstrand Crosslink Repair and Cancer." Nature
Reviews Cancer (2011): n. pag. Print.

thus killing cells that are undergoing DNA synthesis. They can also inhibit the action of
DNA polymerase4.
Theoretically, this means that chemotherapy should be effective at
killing cancer cells. However, there is evidence to suggest that this is not the case. In 2004
a study was published in Australia that looked at the randomised clinical trials suggesting a
percentage increase in 5 year survival benefit due to the use of chemotherapy for 22 major
adult cancers in both Australia and the US. They found that overall chemotherapy only
increased the median survival rate by 2.3% in Australia and 2.1% in the US 5. This means
that out of 100 people that had chemotherapy as part of their treatment, only 2 people
would be able to improve their prognosis whereas the other 98 would still have to
experience the side effects of chemotherapy with no benefit whatsoever. To give an
example from the study, in 1998 10,661 women in Australia were newly diagnosed with
breast cancer. 4,638 went on to have chemotherapy, but only 164 (3.5%) gained any
survival benefit. For the remaining 4474 women, the chemotherapy had no effect on their
cancer, but they still experienced side effects of varying severity which may have even
shortened their prognosis. This is a rather high price to pay for the benefit of just 164
women. The study also found that of the median increase in survival for the patients that
did benefit from chemotherapy was very smallfor lung cancer it was only 2 months
between 1984 and 2004and the quality of life of the patients during this time period is
also debatable given the multitude of side effects. This suggests that for the majority of
cancer patients chemotherapy is not the best option for extending their survival time by a
significant amount. This study utilises all the statistically significant trials carried out in two
4http://www.drugbank.ca/drugs/DB00987

5Morgan, Graeme, Robyn Ward, and Michael Barton. "The Contribution of Cytotoxic
Chemotherapy to 5-year Survival in Adult Malignancies." Clinical Oncology 16.8 (2004): 549-60.
Web.

different countries that had been carried out over the course of more than 10 years, which
means that they were working with a very large sample size. This means that their data is
likely to be representative of the population that had undergone chemotherapy, thus
limiting the influence of outliers and making their conclusions more reliable. The fact that
they used data collected in two developed countries also suggests that similar patterns are
likely to be found in other countries in the western world, again adding to the studys
reliability. However, this study was done more than ten years ago, so it is possible that new
chemotherapy drugs have been developed that improve the survival prognosis by a larger
amount in more people.
In another study, 3239 people with bowel cancer who had had surgery were recruited to
investigate whether chemotherapy had any survival benefit. Half of these people had
chemotherapy and the other half did not. The researchers found that the cancer recurred in
293 in the chemotherapy group and 359 in the control 6. Although there is a difference
between these two groups, the absolute improvement in prognosis is very small, around
3.6%. This number is quite similar to the number found by the Australian researchers,
which not only backs up the previous study but also suggests that this improvement might
have been due to other factors such as the stage of the cancer and not just the
chemotherapy itself. Whats more, the patients in the chemotherapy group also
experienced more side effects, such as nausea and fatigue, than the control group, all for a
less than 5% increase in survival benefit. This, in light of the trials findings, makes for an
even weaker case for the use of chemotherapy. Although the sample size for this trial is
also quite big and their results are backed up by previous studies, this trial was mainly
focused on bowel cancer so it is unclear whether the same can be said of other cancers. In
addition, most of the patients in this trial had Stage 2 bowel cancer, so in this case it is

6Group, Quasar Collaborative. "Adjuvant Chemotherapy versus Observation in Patients with


Colorectal Cancer: A Randomised Study." The Lancet 370.9604 (2007): 2020-029. Web.

hard to comment on the effectiveness of chemotherapy in the other stages as the sample
size might not have been large enough.
Between 1999 and 2004, a third trial was carried out by the European Organisation for
Research and Treatment of Cancer looking at whether patients that had chemotherapy
before surgery for stomach cancer would live longer that patients that just had
chemotherapy. The patients were divided into two groups: one had chemotherapy before
surgery and the other had surgery only. The group who had only surgery showed more
lymph node metastases than the group who had had chemotherapy (76.5% vs 61.4%),
however, 27.1% of patients in the chemotherapy group had post-operative complications
compared to 16.02% in the surgery-only group 7. This may have been because the
chemotherapy weakened the patients immune systems making them more susceptible to
infection. Although this trial failed to demonstrate whether having neoadjuvant
chemotherapy would extend the life expectancy of the patients, their results do suggest
that having chemotherapy before surgery may be slightly beneficial in terms of further
metastases, however, the percentage of people who experienced metastases in both
groups was still high. This trial is fairly inconclusive regarding the effectiveness of
chemotherapy, and only looks at pre-surgery chemotherapy so it is hard to tell based on
this study alone whether the same can be said of post-surgery treatment. Carrying out the
trial for a longer period of time, e.g. 20 years, may also have helped determine which
group of patients lived the longest.
Overall, these studies suggest that there may be no real benefit to having chemotherapy if
the aim is to improve the patients chances of survival. However, these studies were done

7Schuhmacher, C. et al "Neoadjuvant Chemotherapy Compared With Surgery Alone for Locally


Advanced Cancer of the Stomach and Cardia: European Organisation for Research and Treatment
of Cancer Randomized Trial 40954." Journal of Clinical Oncology 28.35 (2010): 5210-218. Web.

more than 10 years ago, so more research is needed as there may have been new drugs
developed that are more effective against chemotherapy.
Side Effects
Regardless of the effectiveness of chemotherapy, the majority of cancer patients will end
up having the treatment anyway, and this brings with it a multitude of side effects. These
side effects occur because chemotherapy kills fast dividing cells. However, these drugs
cant differentiate between tumour cells and healthy, fast-dividing cells, such as the
digestive system, which means that the cells are also attacked and killed 8.
The damage that this causes can lead to fatigue, although it can also be caused by
anaemia due to the fact that chemotherapy also attacks cells being made in the bone
marrow such as red blood cells9. This extreme tiredness is one of the most common side
effects of chemotherapy, with over 75% of cancer patients experiencing it at some point
during treatment but only 1/3 of doctors actually recognising it in their patients 10. Fatigue
can stop patients from carrying out their daily activities, such as cooking, cleaning, or even
just having a bath. They may not even have the strength to go out and do the things that
they would normally do, such as shopping or meeting their friends, which considerably
affects their social life. This greatly reduces their quality of life and increases their reliance
on others, which can have a major psychological impact as it may add to their feelings of
being a burden on their friends and family. Since feelings of fatigue are subjective the
8http://www.macmillan.org.uk/information-and-support/treating/chemotherapy/side-effects-ofchemotherapy/possible-side-effects.html

9http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/sideeffects/fatigue-from-cancer-drugs

10Sak, Katrin. "Chemotherapy and Dietary Phytochemical Agents." Chemotherapy Research and
Practice 2012 (2012): 1-11. Web.

patients relatives and doctors may underestimate the effect this has on the patient. This
causes the patient to feel that they have been left to cope alone with their treatment,
creating feelings of loneliness that add to the mental impact that chemotherapy has on
them. Fatigue lasts for weeks if not months after treatment 11, making it a long term side
effect, and given the questionable effectiveness of chemotherapy it appears that putting
patients through such a long period of fatigue might be doing them more harm than good.
Perhaps the most well known side effect of chemotherapy is nausea and vomiting. This is
caused when certain chemotherapy drugs cause the release of serotonin (5-HT), which
stimulates the chemoreceptor trigger zone in the medulla and initiates the process of
vomiting12. Nausea generally lasts for several hours after having treatment, but sometimes
it can last for several days13. Since this is a relatively short term side effect it could be
argued that this is a small price to pay for the supposed benefits of chemotherapy,
however, most patients have several rounds of chemotherapy, and if a drug makes the
patient sick the first time it is likely to make them sick if they have it again. This means that
patients are likely to be continually sick for the duration of their chemotherapy, which has
an effect on their quality of life and can be distressing for their caregivers to watch. The
distress caused by these symptoms can also escalate over time, which could lead to them
refusing other forms of treatmentindeed failure to control the symptoms of nausea and
vomiting can lead to 25-50% of cancer patients delaying or refusing to have further

11http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/sideeffects/fatigue-from-cancer-drugs

12http://www.texasoncology.com/cancer-treatment/side-effects-of-cancer-treatment/common-sideeffects/nausea-and-vomiting/#anchor2

13http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/sideeffects/sickness-and-cancer-drugs

potentially lifesaving treatment14. Fortunately, sickness can be controlled by anti emetics


(anti-sickness drugs) such as 5-HT3 receptor antagonists, which block serotonin receptors
in the CNS and the gastrointestinal tract (e.g. Anzemet and Sancuso), and cannabinoids,
which act on cannabinoid receptors that inhibit the release of neurotransmitters in the brain
. These anti emetics are relatively easy to take as they are usually injected along with the
chemotherapy drugs, however, these drugs can cause side effects such as fatigue and
loss of perception15. There is also evidence to suggest that anti emetics arent as effective
as previously thought. In 2014 a study found that emesis (vomiting) occurred in 95% of
breast cancer patients that took their anti emetics regularly 24 hours after treatment, and in
85% of those that took their medication irregularly 16. Given the effect that nausea can have
on patients opinions on treatment and the relative ineffectiveness of the medication used
to control it, it is arguably unfair to put them through chemotherapy as it has a considerable
effect on their quality of life and may put them off having further treatment that is actually
effective.
A third side effect that can occur is infertility in both men and women. Some chemotherapy
drugs, such as cisplatin and ifosfamide, are more likely to cause infertility than other drugs,
such as 5-fluoruoracil17. However, the risk of infertility is still relatively small, e.g. for

14Schnell, Frederick M. "Chemotherapy-Induced Nausea and Vomiting: The Importance of Acute


Antiemetic Control." The Oncologist 8 (2002): 187-98. Web.

15https://en.wikipedia.org/wiki/Antiemetic

16Castro et al, Effectiveness of Antiemetics in Control of Antineoplastic Chemotherapy-induced


Emesis at Home." Acta Paul Enferm. Acta Paulista De Enfermagem 27.5 (2014): 412-18. Web.

17http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/sexualsideeffectsi
nwomen/fertilityandwomenwithcancer/fertility-and-women-with-cancer-how-cancer-treatmentsaffect-fertility

cisplatin the risk is between 1-10%18. Whether patients experience temporary or


permanent infertility, if at all, depends on a range of factors: their age, the type(s) of drugs,
and the dose. This means that its near impossible to predict whether a patient will become
infertile after their treatment, which for the patients can be quite hard to deal with
psychologically as they have no idea what to expect after their treatment is over even
thought realistically the chances of them becoming infertile are relatively low. For many
people fertility has a great emotional and cultural significance, and finding out that they are
infertile can be both devastating and frustrating, especially if they were planning on starting
a family. In some cases infertility may make patients feel less masculine/feminine, which
severely affects their mental wellbeing and self esteem and may isolate them even further
from their family and friends. Having a partner that is infertile may also put a strain on
relationships, which is the last thing cancer patients need whilst having or recovering from
treatment. Of course, there are ways of preserving patients fertility, but these are not
always effective or practical. Before having chemotherapy it is possible for men to bank
their sperm for later use, but this is not always covered by the NHS. The cost of sperm
banking therefore varies from area to areain London for example it costs 425 to collect
and freeze the sample, then about 300 a year to store it19. Women have the opportunity
to freeze unfertilised or fertilised eggs for later use, but the fertilisation rate is very low: in
2013 the live birth rate for women using frozen eggs was just 13.9% 20. This means that
although fertility treatments are available, in the majority of cases they are largely

18http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancerdrugs/cisplatin?script=true#common

19http://www.conceptfertility.co.uk/price-list/

20Fertility Treatment 2014 Trends and Figures. Publication. Human Fertilisation and Embryology
Authority, Mar. 2016. Web.Report

ineffective, which seems like a high price to pay for a treatment that may also be largely
ineffective.
Conclusion
To conclude, there is a substantial amount of data that suggests that chemotherapy is not
as effective at treating cancer as previously thought. Indeed a recent study funded by
Public Health England has shown that patients dying within thirty days of beginning
treatment are unlikely to have gained the survival or palliative benefits of the treatment,
and in view of the side-effectsare more likely to have suffered harm21, and it is possible
that some of these patients might not have died had they not decided to undergo
chemotherapy. Even for the patients that dont die during chemotherapy, in light of the
effect that the side effects have physically, socially and mentally it is possible that
chemotherapy, a range of drugs that are supposed to cure or manage a patients cancer,
does more harm than good, which goes against the idea of do no harm that is part of the
Hippocratic Oath. Surely the use of such drugs is unjustifiable given that patients often
suffer from a multitude of side effects for very little, if any benefit. More research needs to
be done to further investigate whether there has been any improvement in the
effectiveness of chemotherapy in recent years, but in the meantime patients should be
given enough information to make a balanced and well-informed decision about their
treatment plan, and not feel obliged to follow the conventional wisdom of surgery coupled
with chemotherapy as the primary treatment option.
Word count: 2487 words

21Wallington, Michael et al "30-day Mortality after Systemic Anticancer Treatment for Breast and
Lung Cancer in England: A Population-based, Observational Study." The Lancet Oncology 17.9
(2016): 1203-216. Web.

Bibliography:
Castro, Marielly Cunha, Suely Amorim De Arajo, Thas Rezende Mendes, Glauciane
Silva Vilarinho, and Maria Anglica Oliveira Mendona. "Effectiveness of Antiemetics in
Control of Antineoplastic Chemotherapy-induced Emesis at Home." Acta Paul Enferm.
Acta Paulista De Enfermagem 27.5 (2014): 412-18. Web.
Deans, Andrew J., and Stephen C. West. "DNA Interstrand Crosslink Repair and Cancer."
Nature Reviews Cancer (2011): n. pag. Print.
Fertility Treatment 2014 Trends and Figures. Publication. Human Fertilisation and
Embryology Authority, Mar. 2016. Web.
Group, Quasar Collaborative. "Adjuvant Chemotherapy versus Observation in Patients with
Colorectal Cancer: A Randomised Study." The Lancet 370.9604 (2007): 2020-029. Web.
Morgan, Graeme, Robyn Ward, and Michael Barton. "The Contribution of Cytotoxic
Chemotherapy to 5-year Survival in Adult Malignancies." Clinical Oncology 16.8 (2004):
549-60. Web.
Sak, Katrin. "Chemotherapy and Dietary Phytochemical Agents." Chemotherapy Research
and Practice 2012 (2012): 1-11. Web.
Schnell, Frederick M. "Chemotherapy-Induced Nausea and Vomiting: The Importance of
Acute Antiemetic Control." The Oncologist 8 (2002): 187-98. Web.
Schuhmacher, C., S. Gretschel, F. Lordick, P. Reichardt, W. Hohenberger, C. F.
Eisenberger, C. Haag, M. E. Mauer, B. Hasan, J. Welch, K. Ott, A. Hoelscher, P. M.
Schneider, W. Bechstein, H. Wilke, M. P. Lutz, B. Nordlinger, E. V. Cutsem, J. R. Siewert,
and P. M. Schlag. "Neoadjuvant Chemotherapy Compared With Surgery Alone for Locally
Advanced Cancer of the Stomach and Cardia: European Organisation for Research and
Treatment of Cancer Randomized Trial 40954." Journal of Clinical Oncology 28.35 (2010):
5210-218. Web.
Wallington, Michael, Emma B. Saxon, Martine Bomb, Rebecca Smittenaar, Matthew
Wickenden, Sean McPhail, Jem Rashbass, David Chao, John Dewar, Denis Talbot,
Michael Peake, Timothy Perren, Charles Wilson, and David Dodwell. "30-day Mortality
after Systemic Anticancer Treatment for Breast and Lung Cancer in England: A Populationbased, Observational Study." The Lancet Oncology 17.9 (2016): 1203-216. Web.
http://www.nhs.uk/conditions/cancer/Pages/Introduction.aspx

http://www.cancerresearchuk.org/about-cancer/cancers-ingeneral/treatment/chemotherapy/about/when-chemotherapy-is-used
http://www.drugbank.ca/drugs/DB00987
http://www.macmillan.org.uk/information-and-support/treating/chemotherapy/side-effects-ofchemotherapy/possible-side-effects.html
http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/sideeffects/fatigue-from-cancer-drugs
http://www.texasoncology.com/cancer-treatment/side-effects-of-cancer-treatment/common-sideeffects/nausea-and-vomiting/#anchor2
http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/sideeffects/sickness-and-cancer-drugs
https://en.wikipedia.org/wiki/Antiemetic
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/sexualsideeffectsinw
omen/fertilityandwomenwithcancer/fertility-and-women-with-cancer-how-cancer-treatments-affectfertility
http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancerdrugs/cisplatin?script=true#common
http://www.conceptfertility.co.uk/price-list/

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