Treatment modalities

• Cell cycle specific – act on cells during particular phases of cell cycle
• Cell cycle non-specific – act on cells regardless of phase
• Neo-adjuvant – used before any other modality to shrink cancer
• Adjuvant – used after another modality to “mop up” remaining cancer cells

(Devita, Lawrence and Rosenberg, 2021) 

• Pre-administration tests checked prior to start of treatment (baseline) and each cycle 
• Full blood count (FBC) check platelets, haemoglobin and neutrophils are at an appropriate level 
• Glomerular Filtration rate (GFR) and urea & electrolytes (U&E) indicate renal function as some chemotherapy can be renal toxic 
• Liver function tests (LFT) chemotherapy is metabolised in the liver and can lead to damage 
• Echocardiogram (ECHO) some chemotherapy can affect the heart 
• Audiology some chemotherapy can affect hearing 

Any changes from baseline may require dose reductions or omissions, or administration of preventative medications.

• IV Fluids – some chemotherapies can affect organs such as bladder or kidneys and require fluids to flush them out  
• Antiemetics - administered before, during and after administration of chemotherapy  
• Photobiomodulation (PBM) Therapy

If the primary tumour is confined to one area and can be safely removed, surgery may be undertaken with curative intent. The resected specimen is examined to confirm clear margins and ensure complete excision.

Surgery is often coordinated with chemotherapy. For example, in osteosarcoma, patients usually receive chemotherapy prior to surgery, followed by resection and then further chemotherapy.

Neoadjuvant therapy refers to chemotherapy given before surgery to shrink the tumour and improve the chances of complete removal.

Adjuvant therapy refers to chemotherapy and/or radiotherapy given after surgery to reduce the risk of recurrence by treating any remaining microscopic disease.

Reconstructive surgery can be offered of the resection is extensive or disfiguring  

Amputation management

Advances in prosthetic design and function mean that limb-sparing surgery is now an option for many patients. Expandable prostheses can also be used in children, allowing adjustment as they grow.  

Limb sparing surgery

Surgery may also support other treatments. For example, some chemotherapy regimens require insertion of a central venous catheter, which remains in place for the duration of therapy.

Central lines

In advanced disease, tumours may cause pain or obstruct vital structures. In these cases, surgery can be undertaken to reduce tumour bulk and relieve symptoms. 

If a patient has a growth or polyp suspected to be pre-malignant, surgery may be undertaken to remove the lesion along with a margin of surrounding tissue as a preventative measure.

These are artificial antibodies designed to bind to specific antigens on the surface of the cancer cell. Some block growth signals within the cell to slow or prevent tumour growth, some mark cancer cells so the immune system recognises them as targets, and others can deliver toxic agents directly to cancer cells or stimulate the immune system’s ability to attack cancer cells. Examples of MABs include rituximab used for Burkitt or B-cell non-Hodgkin lymphoma, dinutuximab (anti-GD2) used for neuroblastoma, and blinatumomab used for relapsed/refractory B-cell ALL.

Are a type of antibody-based immunotherapy which redirect patients’ own T-cells to recognise and destroy cancer cells.  BiTEs can bind two targets at once: a tumour-associated antigen on the cancer cell, and the CD3 receptor on T-cells.  They can trigger T-cell activation and release cytotoxic molecules by bringing T-cells in close proximity with tumour cells, which results in targeted destruction of tumour cells (Dewaele & Fernandes, 2024).  BiTEs have shown promising effectiveness in haematological cancers and are now being increasingly explored as potential treatments for solid tumours (Dewaele & Fernandes, 2024). 

Are a type of MAB that block inhibitory immune pathways which normally act as ‘brakes’ on the immune system and reactivate T cells to enable them to recognise and destroy cancer cells. Examples of check point inhibitors include nivolumab used in relapsed/refractory Hodgkin lymphoma and durvalumab used in clinical trial for paediatric solid tumours.

These vaccines are designed to stimulate the immune system to recognise tumour cells as harmful. The vaccine introduces tumour antigens and T cells are activated and learn to identify the antigens on tumour cells, which then destroy cancer cells. An example of a cancer vaccine is the human papillomavirus (HPV) vaccine which can prevent numerous cancers including cervical, some head and neck, as well as genital warts. In the UK, it is currently given to children aged 12-13.  Research is currently investigating vaccines for neuroblastoma, brain tumours, Wilms, and sarcomas.

Chimeric Antigen Receptor T-cell therapy is used for relapsed or refractory blood cancers (Yang et al. 2023).  It uses patient’s own T cells that have been extracted and genetically modified to recognise and destroy cancer cells. Chimeric Antigen Receptor is an artificial receptor created specifically for that cancer (Dobosz & Dzieciątkowski, 2019). Once the T-cells have been modified, they are reinfused to the patient.  CAR-T therapy can cause some significant toxicities, including Cytokine release syndrome (CRS), which occurs due to rapid immune activation.  Symptoms of CRS include fever, hypotension, and organ dysfunction which highlight the importance of close monitoring and early intervention (Zhang et al., 2023).  CAR-T therapy can also cause neurotoxicity with symptoms including confusion, tremors, or seizures. An early warning sign of this is a deterioration in handwriting (Karschnia et al., 2019).  Management of toxicities include corticosteroids alongside supportive care. 

Are used to stimulate or strengthen the body’s immune system so it can recognise and destroy cancer cells. Examples of cytokine therapies include interleukin which stimulates the growth of T cells and natural killer cells and used in melanoma and renal cell carcinoma treatments, and interferon which can slow tumour growth and was previously used in melanoma and some blood cancers.

This type of immunotherapy uses viruses to infect and destroy cancer cells and can be naturally occurring or genetically modified. Oncolytic virus therapy (OVT) targets specific receptors on cancer cells, causing them to act as hosts for viral replication, before being destroyed (Marayati, Quinn & Beierle, 2019). The benefits of OVT are that it uses a virus’s natural ability to lyse cancer cells and can stimulate a cytotoxic immune response.  Also, direct intratumoral injection allows for destruction of local malignant cells while minimising systemic side effects (Marayati, Quinn & Beierle, 2019).