Chemotherapy

The nature of cancer is what makes it notorious; the immune system is unable to cure the disease on its own because it has a hard time recognizing it from normal cells. Although tumors can be removed through surgery, it is not the most effective method of treatment because it does not always work. In some cases, the surgeon may be able to extract most of the tumor but may not be able to reach a few remaining cancer cells. With cancer, it is not considered treated unless every single cancer cell has been killed. When a few cells are left behind, they will keep dividing and the tumor will eventually grow back. While there are numerous methods used to treat cancer, including surgery, the most commonly used method is chemotherapy. It can also be coupled with another form of therapy called radiotherapy, where radiation is used to damage the DNA of the cancer cells. Even when the therapy is over and the cancer is considered cured, the patient must not let their guard down as there is a possibility that a few cancer cells remain. This is why doctors use what's called a maintenance therapy after the official therapy is done. The purpose of the maintenance therapy is to prevent cancer relapse. When a cancer relapses, it brings with it the same shock it brought when it was first discovered, if not an even greater shock. It strongly affects the psychological state of the patient and their family, and makes it harder for doctors to cure because it may have come back stronger than before by developing resistance towards the previous drugs used. Usually, doctors use a different form of chemo after a relapse.

Chemotherapy uses cytotoxic drugs to kill cancer cells. They contain chemicals that are toxic to cells and prevent their replication and growth. The chemicals interfere with the cells’ cycle or DNA composition and prevents further division. Depending on the patient’s cancer, different drugs may be given to them. A patient can be given one or multiple chemo drugs. In most cases though, at least 2 drugs are used to prevent resistance. Chemotherapy treatments are often referred to as “regimens” or "protocols". The names of the protocols are sometimes acronyms that use the initial of each drug used in the regimen/protocol. For example, one chemotherapy regimen commonly used for lymphoma is called CHOP, which refers to the drugs Cyclophosphamide, Hydroxydaunorubicin, Oncovin, and Prednisolone. Chemotherapy treatments can range from a few weeks to a couple of years, depending on the type of cancer and the patient’s ability to withstand the medication. Because of the potency of the drugs, there must be a short break between the sessions that they receive the drugs in to allow the body cells to recover from the damage. These sessions are known as cycles. Depending on the cancer, some cycles can last as short as one day while others may last as long as three weeks. A series of cycles is called a course, and one course can take anywhere from 6 months to 2 or more years.

One of the main concerns with chemo is its side effects. While it does its work of killing cancer cells, it also damages normal body cells. The immense amount of drugs taken are very strenuous for the body and require strong perseverance. One of the most common side effects associated with chemo and cancer is hair loss. The reason why hair falls is because in addition to killing cancer cells, chemo drugs target rapidly growing cells, such as hair cells. While this is bad news for the patient, it is only temporary. The normal cells are much better at repairing themselves than cancer cells. This means that once the chemotherapy stops, the hair will grow back. The potency of the chemo drugs depends on the stage and type of cancer. In rare cases, patients actually die from the chemo rather than the cancer itself. Aside from hair loss, there are dozens of chemo side effects that include fatigue, nausea and vomiting, sore throat and mouth, loss of appetite (change in taste), weak immunity, low blood cells, numbness, and loss of balance.

When doctors notice that a certain chemo regimen is ineffective, they might add and remove a few drugs instead of switching to an entirely new regimen and begin what's called a "second line of treatment". A third or even fourth line of treatment indicate that the previous lines were not sufficient enough to fight the disease and that multiple changes to the regimen had to be made. The worst and rarest of them all, however, is what's called a salvage treatment. As the name indicates, this treatment is used as a last resort when all else has failed to salvage what little is left, perhaps prolonging a patient's life by a short amount. Before a salvage treatment is given, the family is informed about it and are given a consent form where it is explained that one of the side effects could be death.

In Saudi Arabia, the chemo protocol that Dalal had been given was called NHL-BFM 90. It was given in three different protocols (I, II, and M). Changing from one protocol to another depended on the treatment's effectiveness and the progression of the cancer. NHL-BFM 90 protocol II, for example, is only given when the cancer is either stage III or IV. Protocol I had eight drugs and when the doctors switched to protocol II, three of those eight drugs had been replaced. The tables below show the NHL-BFM 90 protocols that were in Dalal's official treatment plan.