Chemotherapy: Everything You Need to Know as a Patient

It has become the one word most dreaded by cancer victims. Chemo. A word that encompasses equal portions of dread, hope and despair. Many view it as a last ditch deal, a long, lingering chemical experiment which few survive or profit from. This article will examine at length the history of chemotherapy, the treatments and dosing methods, side effects, expectations and outcomes, the financial motivators that ensure the treatment’s survival and the alternate and often very effective treatments overlooked in favor of the use of chemo.

If your only takeaway from this article is the following, the it has served its purpose.

Chemo is not a cure for cancer. It is not a magic bullet that can be used to rid your body of cancer. Do not rely on it for that purpose, Chemo is simply a tool in the fight against cancer, a treatment that is occasionally met with some success.

Worth noting is that this article relates only to chemo in terms of cancer treatment and not antimicrobial chemotherapy.

This article is over 25 minutes long and if there are certain sections that are not of interest, the list below will help you navigate the article.

Article Contents

1. The origins of Chemotherapy

Not unsurprisingly perhaps, this treatment traces it’s routes back to World War I and the German introduction of chemical warfare. Among the chemical agents used, mustard gas was particularly devastating. Although banned by the Geneva Protocol in 1925, the advent of World War II caused concerns over the possible re-introduction of chemical warfare. Such concerns led to the discovery of nitrogen mustard, a chemical warfare agent, as an effective treatment for cancer.

Two pharmacologists from the Yale School of Medicine, Louis S. Goodman and Alfred Gilman, were recruited by the US Department of Defense to investigate the potential therapeutic applications of chemical warfare agents.

(Authors note — there is so much wrong with the sentence above that reading it now raises a smile. It is, however, the official explanation given by the DOD and we’ll leave it there)

Goodman and Gilman observed that mustard gas was too volatile and they subsequently developed a more stable compound called nitrogen mustard. A year into the start of their research, a German air raid in Bari, Italy led to the exposure of more than 1000 people to the SS John Harvey’s* secret cargo of mustard gas bombs.

• read the unlikely story behind the SS John Harvey in the footer

Dr. Stewart Francis Alexander, a lieutenant colonel who was an expert in chemical warfare, was subsequently deployed to investigate the aftermath. Autopsies of the victims suggested that profound lymphoid and myeloid suppression had occurred after exposure. In his report, Dr. Alexander theorized that since mustard gas all but ceased the division of certain types of somatic cells whose nature is to divide rapidly, it could also potentially be put to use in helping to suppress the division of certain types of cancerous cells.

Goodman and Gilman reasoned that this agent could be used to treat lymphoma, a tumor of lymphoid cells. In collaboration with a thoracic surgeon, Gustaf Lindskog, they injected a related agent, mustine (the prototype nitrogen mustard anticancer chemotherapeutic), into a patient with non-Hodgkin’s lymphoma. A dramatic reduction in the patient’s tumor masses were observed but the effect lasted only a few weeks, and the patient had to return for another set of treatment, This was, in effect the first step to the realization that cancer could be treated by pharmacological agents.

Publication of the first clinical trials was reported in 1946 in the New York Times and chemotherapy was born.

2. How does chemo work?

Chemotherapy is considered a systemic therapy as drugs are introduced into the blood stream and are therefore, in principle, able to address cancer at any anatomic location in the body. Systemic therapy is often used in conjunction with other local therapies (i.e. treatments whose efficacy is confined to the anatomic area where they are applied) for cancer such as radiation therapy, surgery or hyperthermia therapy.

Traditional chemotherapeutic agents are cytotoxic — i.e. they are toxic to our cells, effectively a poison, a natural equivalent would be snake venom which can destroy human cells — and this is they reason they are able to destroy cancer cells. However, we remain unable to fashion traditional agents to specifically target and attack only cancerous cells. Chemotherapeutic agents also destroy healthy cells and therein lies the quandary.

Scientifically we would describe chemotherapy as connoting non-specific usage of intracellular poisons to inhibit mitosis (cell division) or induce DNA damage, which is why inhibition of DNA repair can augment chemotherapy

Chemotherapy can, in its simplest form, be thought of as a way to damage or stress cells, which may then lead to cell death if apoptosis is initiated. Many of the side effects of chemotherapy can be traced to the damage of normal cells that divide rapidly and are therefor, as with cancerous cells, sensitive to anti-mitotic drugs: cells in the bone marrow, digestive tract and hair follicles.

This results in the more common side-effects of chemotherapy:

• myelosuppression (decreased production of blood cells, resulting in immunosuppression)
• mucositis (inflammation of the lining of the digestive tract)
• and alopecia (hair loss).

3. Understanding treatment protocols

Chemotherapeutics are used in two settings, curative or palliative. The first is self-explanatory, the second, palliative, relates to treatments designed to extend life expectancy, management rather than cure of the disease in question. It is a last ditch effort to buy a patient that “extra over” at the end of their innings. Sadly, the quality of this extra time is often compromised by the side effects of chemo and the real world implications of opting for late-stage palliative chemotherapy are often not adequately discussed with the recipient or family.

Combinations of drugs are used in treatment as these have proven more effective in combatting cancers. Cancerous cells have proven themselves immensely adaptive and able to deflect, adapt to and overcome the efforts of a single chemotherapeutical to destroy them, so doctors opt for combinations, determined by the type of cancer in question. There is now a growing debate in the medical community over how aggressive treatment protocols may serve to encourage cancers to metastasize.

If you’ve or a family member has been exposed to or will undergo chemo, you will hear the following terms;

• Induction chemotherapy: The first line treatment of cancer with a chemotherapeutic drug. This type of chemotherapy is used for curative intent.
• Combined modality chemotherapy: The use of drugs with other cancer treatments, such as surgery, radiation therapy, or hyperthermia therapy.
• Consolidation chemotherapy: Given after remission in order to prolong the overall disease-free time and improve overall survival. The drug that is administered is the same as the drug that achieved remission.
• Intensification chemotherapy: Identical to consolidation chemotherapy but a different drug than the induction chemotherapy is used.
• Combination chemotherapy: Thisinvolves treating a person with a number of different drugs simultaneously. The drugs differ in their mechanism and side-effects. The biggest advantage is minimizing the chances o;f resistance developing to any one agent. Also, the drugs can often be used at lower doses, reducing toxicity.
• Neoadjuvant chemotherapy: This is given prior to a local treatment such as surgery, and is designed to shrink the primary tumor. It is also given for cancers with a high risk of micrometastatic disease.
• Adjuvant chemotherapy: Given after a local treatment (radiotherapy or surgery). It can be used when there is little evidence of cancer present, but there is risk of recurrence. It is also useful in killing any cancerous cells that have spread to other parts of the body. These micrometastases can be treated with adjuvant chemotherapy and can reduce relapse rates caused by these disseminated cells.
• Maintenance chemotherapy: A repeated low-dose treatment to prolong remission.
• Salvage chemotherapy: Palliative chemotherapy is given without curative intent, but simply to decrease tumor load and increase life expectancy. For these regimens, in general, a better toxicity profile is expected.

4. Types of Chemotherapeutics

This section if included for the more technically mined. Page down to carry on reading issues relating to dosing and the side effects of chemotherapy.

Alkylating agents

Alkylating agents are the oldest group of chemotherapeutics in use today. Originally derived from mustard gas used in World War I, there are now many types of alkylating agents in use. They are so named because of their ability to alkylate many molecules, including proteins, RNA and DNA. This ability to bind covalently to DNA via their alkyl group is the primary cause for their anti-cancer effects. Read more…

Antimetabolites

Anti-metabolites are a group of molecules that impede DNA and RNA synthesis. Many of them have a similar structure to the building blocks of DNA and RNA. These drugs exert their effect by either blocking the enzymes required for DNA synthesis or becoming incorporated into DNA or RNA. By inhibiting the enzymes involved in DNA synthesis, they prevent mitosis because the DNA cannot duplicate itself. Read more…

Anti-microtubule agents

Anti-microtubule agents are plant-derived chemicals that block cell division by preventing microtubule function. Microtubules are an important cellular structure composed of two proteins, α-tubulin and β-tubulin. They are hollow, rod-shaped structures that are required for cell division, among other cellular functions. Read more…

Topoisomerase inhibitors

Topoisomerase inhibitors are drugs that affect the activity of two enzymes: topoisomerase I and topoisomerase II. When the DNA double-strand helix is unwound, during DNA replication or transcription, for example, the adjacent unopened DNA winds tighter (supercoils), like opening the middle of a twisted rope. The stress caused by this effect is in part aided by the topoisomerase enzymes. Read more…

Cytotoxic antibiotics

The cytotoxic antibiotics are a varied group of drugs that have various mechanisms of action. The common theme that they share in their chemotherapy indication is that they interrupt cell division. The most important subgroup is the anthracyclines and the bleomycins; other prominent examples include mitomycin C and actinomycin. Read more…

5. Dosages and outdated systems

Chemotherapeutical dosage strengths are critical to ensure optimal treatment. Too little and the cancer will continue to grow, to much and the treatment can kill the patient.. It’s a delicate balance and strengths of dosage are determined by an archaic system that ignores various factors, considering only the height and weight of the patient. It is called the BSA or body surface area. The BSA is usually calculated with a mathematical formula or a nomogram, using the recipient’s weight and height, rather than by direct measurement of body area.

The BSA formula was originally developed in a 1916 study and attempted to translate medicinal doses established with laboratory animals to equivalent doses for humans and only included nine human subjects. When chemotherapy was introduced in the 1950s, the BSA formula was adopted as the official standard for chemotherapy dosing for lack of a better option.

Drug absorption and clearance are influenced by multiple factors, including age, sex, metabolism, disease state, organ function, drug-to-drug interactions, genetics, and obesity, which have major impacts on the actual concentration of the drug in the person’s bloodstream. There is high variability in the systemic chemotherapy drug concentration in people dosed by BSA, and this variability has been demonstrated to be more than ten-fold for many drugs

To explain this properly, in two individuals of identical body weight given identical dosages using BSA, concentrations of the drug can be up to ten times higher in one individual than the other. Both patients are at risk, one from under dosage and the other from the potential of being fatally poisoned. Clearly, BSA is not fit for purpose.

In a randomized clinical trial, investigators found 85% of metastatic colorectal cancer patients treated with 5-fluorouracil (5-FU) did not receive the optimal therapeutic dose when dosed by the BSA standard — 68% were under dosed and 17% were overdosed. The problem is exacerbated by rising rates of obesity. We need to do far better to ensure optimal treatment.

Several clinical studies have demonstrated that when chemotherapy dosing is individualized to achieve optimal systemic drug exposure, treatment outcomes are improved and toxic side effects are reduced. In the 5-FU clinical study cited above, people whose dose was adjusted to achieve a pre-determined target exposure realized an 84% improvement in treatment response rate and a six-month improvement in overall survival (OS) compared with those dosed by BSA.

6. The Side Effects of Chemo

Chemotherapeutic techniques have a broad range of well documented side-effects. These side-effects depend largely on the type of medications used in treatment. The most common medications affect mainly the fast-dividing cells of the body, such as blood cells and the cells lining the mouth, stomach, and intestines. Toxicities can occur acutely after administration, within hours or days, or chronically, from weeks to years. As discussed above, correct dosage strengths for treatments are perhaps the best tool to prevent or reduce these side effects.

Immunosuppression and myelosuppression

Virtually all chemotherapeutic regimens can cause depression of the immune system, often by paralysing the bone marrow and leading to a decrease of white blood cells, red blood cells, and platelets. Anemia and thrombocytopenia may require blood transfusion.

In very severe myelosuppression, which occurs in some regimens, almost all the bone marrow stem cells (cells that produce white and red blood cells) are destroyed, meaning allogenic or autologous bone marrow cell transplants are necessary. In some instances treatment has to be halted as immune suppression poses serious risk to the patients life.

Although people receiving chemotherapy are encouraged to wash their hands, avoid sick people, and take other infection-reducing steps, about 85% of infections are due to naturally occurring microorganisms in the person’s own gastrointestinal tract (including the mouth) and skin. The risk of illness and death can be reduced by taking common antibiotics such as quinolones or trimethoprim/sulfamethoxazole before any fever or sign of infection appears. Quinolones show effective prophylaxis mainly with hematological cancer.

In Japan, the government has approved the use of some medicinal mushrooms like Trametes versicolor, to counteract depression of the immune system in people undergoing chemotherapy.

Neutropenic enterocolitis

Due to immune system suppression, neutropenic enterocolitis (typhlitis) is a “life-threatening gastrointestinal complication of chemotherapy”. Typhlitis is an intestinal infection which may manifest itself through symptoms including nausea, vomiting, diarrhea, a distended abdomen, fever, chills, or abdominal pain and tenderness. Typhlitis is a medical emergency. It has a very poor prognosis and is often fatal unless promptly recognized and aggressively treated.

Gastrointestinal distress

Nausea, vomiting, anorexia, diarrhoea, abdominal cramps, and constipation are common side-effects of chemotherapeutic medications that kill fast-dividing cells. Malnutrition and dehydration can result when the recipient does not eat or drink enough, or when the person vomits frequently, because of gastrointestinal damage. This can result in rapid weight loss, or occasionally in weight gain, if the person eats too much in an effort to allay nausea or heartburn. Weight gain can also be caused by some steroid medications. These side-effects can frequently be reduced or eliminated with antiemetic drugs.

Anemia

Anemia can be a combined outcome caused by myelosuppressive chemotherapy, and possible cancer-related causes such as bleeding, blood cell destruction (hemolysis), hereditary disease, kidney dysfunction, nutritional deficiencies or anemia of chronic disease. Treatments to mitigate anemia include hormones to boost blood production (erythropoietin), iron supplements, and blood transfusions.

Nausea and vomiting

Nausea and vomiting are two of the most known and feared cancer treatment-related side-effects. In 1983, Coates et al. found that people receiving chemotherapy ranked nausea and vomiting as the first and second most severe side-effects, respectively. Up to 20% of people receiving highly emetogenic agents in this era postponed, or even refused, potentially curative treatments.

Chemotherapy-induced nausea and vomiting (CINV) are common with many treatments and some forms of cancer. Since the 1990s, several novel classes of antiemetics have been developed and commercialized, becoming a nearly universal standard in chemotherapy regimens, and helping to successfully manage these symptoms in many people. Ensuring accurate levels of dosage also greatly reduce these side-effects. Read more…

Hair loss

Hair loss (alopecia) can be caused by chemotherapy that kills rapidly dividing cells; other medications may cause hair to thin. These are most often temporary effects: hair usually starts to regrow a few weeks after the last treatment, but sometimes with a change in color, texture, thickness or style. Sometimes hair has a tendency to curl after regrowth, resulting in “chemo curls.” Severe hair loss occurs most often with drugs such as doxorubicin, daunorubicin, paclitaxel, docetaxel, cyclophosphamide, ifosfamide and etoposide. Permanent thinning or hair loss can result from some standard chemotherapy regimens.

Secondary neoplasm

Development of secondary neoplasia after successful chemotherapy or radiotherapy treatment can occur. The most common secondary neoplasm is secondary acute myeloid leukemia, which develops primarily after treatment with alkylating agents or topoisomerase inhibitors. Survivors of childhood cancer are more than 13 times as likely to get a secondary neoplasm during the 30 years after treatment than the general population, however not all of this increase can be attributed to chemotherapy.

Infertility

Some types of chemotherapy are gonadotoxic and may cause infertility. Chemotherapies with high risk include procarbazine and other alkylating drugs such as cyclophosphamide, ifosfamide, busulfan, melphalan, chlorambucil, and chlormethine. Drugs with medium risk include doxorubicin and platinum analogs such as cisplatin and carboplatin.

Female infertility by chemotherapy appears to be secondary to premature ovarian failure by loss of primordial follicles. This loss is not necessarily a direct effect of the chemotherapeutic agents, but could be due to an increased rate of growth initiation to replace damaged developing follicles. People can choose between several methods of fertility preservation prior to chemo, including cryopreservation of semen, ovarian tissue, oocytes, or embryos.

Teratogenicity

Chemotherapy is teratogenic ( an agent that can disturb the development of the embryo or fetus) during pregnancy, especially during the first trimester, to the extent that abortion usually is recommended if pregnancy in this period is found during chemotherapy. Second- and third-trimester exposure does not usually increase the teratogenic risk and adverse effects on cognitive development, but it may increase the risk of various complications of pregnancy and fetal myelosuppression.

In males previously having undergone chemotherapy or radiotherapy, there appears to be no increase in genetic defects or congenital malformations in their children conceived after therapy. In females previously having undergone chemotherapy, miscarriage and congenital malformations are not increased in subsequent conceptions. However, when in vitro fertilization and embryo cryopreservation is practised between or shortly after treatment, possible genetic risks to the growing oocytes exist, and it is recommended that the babies be screened.

Peripheral neuropathy

Between 30 and 40 percent of people undergoing chemotherapy experience chemotherapy-induced peripheral neuropathy (CIPN), a progressive, enduring, and often irreversible condition, causing pain, tingling, numbness and sensitivity to cold, beginning in the hands and feet and sometimes progressing to the arms and legs. Read more…

Cognitive impairment

Some people receiving chemotherapy report fatigue or non-specific neurocognitive problems, such as an inability to concentrate; this is sometimes called post-chemotherapy cognitive impairment, referred to as “chemo brain” in popular and social media.

Tumor lysis syndrome

Large tumors and cancers with high white cell counts, such as lymphomas, teratomas, and some leukemias, can lead to some people develop tumor lysis syndrome. The rapid breakdown of cancer cells causes the release of chemicals from the inside of the cells. Following this, high levels of uric acid, potassium and phosphate are found in the blood. High levels of phosphate induce secondary hypoparathyroidism, resulting in low levels of calcium in the blood. This causes kidney damage and the high levels of potassium can cause cardiac arrhythmia. Potentially fatal if untreated.

Organ damage

Cardiotoxicity (heart damage) is especially prominent with the use of anthracycline drugs (doxorubicin, epirubicin, idarubicin, and liposomal doxorubicin).

Hepatotoxicity (liver damage) can be caused by many cytotoxic drugs. The susceptibility of an individual to liver damage can be altered by other factors such as the cancer itself, viral hepatitis, immunosuppression and nutritional deficiency. The liver damage can consist of damage to liver cells, hepatic sinusoidal syndrome (obstruction of the veins in the liver), cholestasis (where bile does not flow from the liver to the intestine) and liver fibrosis.

Nephrotoxicity (kidney damage) can be caused by tumor lysis syndrome and also due direct effects of drug clearance by the kidneys. Different drugs will affect different parts of the kidney and the toxicity may be asymptomatic (only seen on blood or urine tests) or may cause acute kidney injury.

Ototoxicity (damage to the inner ear) is a common side effect of platinum based drugs that can produce symptoms such as dizziness and vertigo. Children treated with platinum analogues have been found to be at risk for developing hearing loss.

Other side-effects

Less common side-effects include red skin (erythema), dry skin, damaged fingernails, a dry mouth (xerostomia), water retention, and sexual impotence. Some medications can trigger allergic or pseudoallergic reactions.

Specific chemotherapeutic agents are associated with organ-specific toxicities, including cardiovascular disease (e.g., doxorubicin), interstitial lung disease (e.g., bleomycin) and occasionally secondary neoplasm (e.g., MOPP therapy for Hodgkin’s disease).

Hand-foot syndrome is another side effect to cytotoxic chemotherapy.

7. What do the outcomes look like for chemo patients?

Not brilliant, and this has as much to do with dosing as with the nature of the treatments themselves. Getting the dosage right and hitting that sweet spot of balancing the efficacy of the attack on the cancer against the toxicity experienced by the patient matters hugely. Because of the reduced toxicity, dose-adjusted patients in the 5-FU trial referenced above were able to be treated for longer periods of time. BSA-dosed people were treated for a total of 680 months while people in the dose-adjusted group were treated for a total of 791 months.

Similar results were found in a study involving people with colorectal cancer who were treated with the popular FOLFOX regimen. The incidence of serious diarrhea was reduced from 12% in the BSA-dosed group of patients to 1.7% in the dose-adjusted group, and the incidence of severe mucositis was reduced from 15% to 0.8%.

Chemo is not a cure for cancer, it is a treatment. Expectations for patients receiving chemo present an issue. Chemotherapy does not always work, and even when it is useful, it may not completely destroy the cancer. People frequently fail to understand its limitations. In one study of people who had been newly diagnosed with incurable, stage 4 cancer, more than two-thirds of people with lung cancer and more than four-fifths of people with colorectal cancer still believed that chemotherapy was likely to cure their cancer.

Fault can be laid squarely at the door of the healthcare profession in this instance, with lack of proper educational materials and poor or absent doctor patient interaction. What the medical profession view as success within the narrow scope of chemotherapeutics and what the public perceive are worlds apart. Success can translate to extending life expectancy by two months or remission. It is the duty of the caregiver to ensure that expectations are shared and understood and that both parties are mutually aware of desired outcomes.

If your doctor or healthcare provider does not offer you total transparency in terms of the above along with access to relevant information pertaining to you your treatment, seek alternate advice.

Despite all the side effects, many of which are life threatening, chemo does still have its place in the medical arsenal against cancer and there are success stories of ‘successful’ outcomes for patients, whether that be extension of life or remission. It is however critical that your doctor evaluates your cancer against all the potential treatments available and assess you correctly in terms of chemo as an appropriate treatment.

8. What are the alternatives to chemo?

Chemotherapeutical’s suffer two basic and telling shortcomings that lead to far from ideal outcomes. They are, at the end of the day, a toxin and toxins are not well tolerated. Their biggest issue however is the lack of cell specificity of the drugs. They cannot distinguish between healthy cells and cancerous cells.

Certain cancers will respond to treatment from chemo whilst others simply shrug off the drugs and acquired resistances renders drugs useless. Newer drugs however, work in a far more targeted fashion that hugely reduce many of the serious side effects associated with chemo treatment.

Targeted Therapies

Targeted therapies are a relatively new class of cancer drugs that can overcome many of the issues seen with the use of cytotoxics. They are divided into two groups: small molecule and antibodies. The massive toxicity seen with the use of cytotoxics is due to the lack of cell specificity of the drugs. They will kill any rapidly dividing cell, tumor or normal. Targeted therapies are designed to affect cellular proteins or processes that are utilized by the cancer cells.

This allows a high dose to cancer tissues with a relatively low dose to other tissues. Although the side effects are often less severe than that seen of cytotoxic chemotherapeutics, life-threatening effects can still occur. Initially, targeted therapeutics were designed to be solely selective for one protein.

Now it is clear that there is often a range of protein targets that the drug can bind. An example for targeted therapy is the BCR-ABL1 protein produced from the Philadelphia chromosome, a genetic lesion found commonly in chronic myelogenous leukemia and in some patients with acute lymphoblastic leukemia. This fusion protein has enzyme activity that can be inhibited by imatinib, a small molecule drug.

Steroids

Steroids are drugs that act like your body’s own hormones. They can help treat many types of cancer, and they can keep you from having nausea and vomiting after a round of chemo. They can also prevent allergic reactions to other drugs. They are not however without risk of their own and prolonged use has been linked to an increased risk of developing nonmelanoma-type skin malignancies and non-Hodgkin’s lymphoma.

Typical steroids prescribed for cancer inlude;

• prednisolone
• methylprednisolone
• dexamethasone
• hydrocortisone

Depending on the type of cancer, it is well worth exploring steroids as an alternative form of treatment. You can learn more about the topic by following this link.

Clinical Trials

There a continuous raft of clinical trials for cancer treatments and you can find an exhaustive list of these on the Cancer.org website for American patients. These can often provide an alternative to individuals who are not comfortable with the option of chemo as a treatment and whose cancer may not lend itself to any of the treatments mentioned above.

Follow the link below to keep updated on trials as they become available and discuss this option with your doctor if you feel a trial may offer you a better outcome.Clinical Trials Information for Patients and CaregiversClinical trials are research studies that involve people. Any time you or a loved one need treatment for cancer…www.cancer.gov

9. The financial incentive for chemo treatment

I’ve left the controversy for last and it is a topic most doctors skirt around, but it is an important issue to address as it helps one to understand the dynamics at play and the eagerness to enroll patients for chemo.

Brand-name chemotherapy is often incredibly expensive, in excess of $100,000 per patient.

Healthcare requires funding to keep its doors open. This is true for a small private practice and applies equally to large hospitals and clinics. Pharmaceutical companies incentivize the sale of their chemotherapeutics to ensure their profitability. Incentives are financial in nature and benefit the prescribing individual or organization. As chemo treatments can last over extensive periods of time and the drugs are costly, the returns can generate a solid revenue stream.

Oncologists were placed in the spotlight by the NYT as early as 2003.

Cancer specialists (oncologists) are pocketing hundreds of millions of dollars each year by selling drugs to patients — a practice that almost no other doctors follow.

The practice of purchasing drugs directly from pharmaceutical companies, often at hugely discounted prices to administer to your patients in the setting of your practice is unique to Oncology and creates an environment for ethical abuse, a potential conflict of interest for these doctors, who must help patients decide whether to undergo or continue chemotherapy if it is not proving to be effective, and which drugs to use.

Another study raised this issue. The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations.

Oncologists receive a 6% markup, meaning when they infuse a patient with a branded $10,000 monthly course of chemotherapy, their practice yields an extra $600. This reduces the desire to prescribe cheaper generics and places additional stress on insurers, who are actively trying to restrict the profits of oncologists. Last month, in August, Forbes ran an article on the topic.

Finally, in an aptly entitled piece from 2019, ny StaffNews, The Cancer in Cancer Medicine; pharma money paid to doctors

If anything gives you pause for thought when your are prescribed chemo, this one single aspect should be at the forefront of your mind. It is a sad reflection on the medical profession that at a point in the patients life, when they are most in need of unbiased, caring, patient focused treatment, they need to be watching their backs — and their wallets.

As promised, we’re at the end and the story below is of little relevance, but of historical interest in the development of chemotherapeutics.

The SS John Henry

In August 1943, Roosevelt approved the shipment of chemical munitions containing mustard agent to the Mediterranean theater. On 18 November 1943 the John Harvey, commanded by Captain Elwin F. Knowles, sailed from Oran, Algeria, to Italy, carrying 2,000 M47A1 mustard gas bombs, each of which held 60–70 lb of sulfur mustard, in clear contravention of the Geneva Convention. After stopping for an inspection by an officer of the 7th Chemical Ordnance Company at Augusta, Sicily on 26 November, the John Harvey sailed through the Strait of Otranto to arrive at Bari.

Bari was packed with ships waiting to be unloaded, and the John Harvey had to wait for several days. Captain Knowles wanted to tell the British port commander about his deadly cargo and request it be unloaded as soon as possible, but secrecy prevented him doing so. (Again the official version. Transporting chemical weapons was a punishable offence under the Geneva Convention)

On 2 December 1943 German aircraft attacked Bari, killing over 1,000 people, and sinking 28 ships, including the John Harvey, which was destroyed in a huge explosion, causing liquid sulfur mustard to spill into the water, mixing with oil from the sunken ships, and a cloud of sulfur mustard vapor to blow over the city. Nearly all crewmen of John Harvey perished in the sinking, this prevented the rescuers from knowing the real nature of the danger until a M47A1 bomb fragment was retrieved from the wreckage.

A total of 628 military victims were hospitalized with mustard gas symptoms, and by the end of the month, 83 of them had died. The number of civilian casualties, thought to have been even greater, could not be accurately gauged since most had left the city to seek shelter with relatives.