Common cancers--immunotherapy and multidisciplinary therapy: Parts III and IV

The refractoriness of many solid tumors to cytotoxic chemotherapy has led to the exploration of new therapeutic modalities, including immunotherapy. Immunotherapy does not have a direct cytotoxic effect on the cancer cell but is an attempt to promote rejection of the tumor by the host, chiefly through the cellular arm of the immune system. The clinical success with immunotherapy (primarily adoptive immunotherapy) among patients with unresectable malignant melanoma and cancer of the kidney has not been marked by the large numbers of patients responding but by occasional dramatic effectiveness of therapy for these cancers, which usually are refractory to chemotherapy. Long-lasting responses and even complete disappearance of all known metastases are possible for a small percentage of patients with melanoma or renal cell carcinoma who undergo immunotherapy. A reasonable approach for patients with good performance status (no symptoms or ambulatory with symptoms but not bedridden) is entrance to clinical trials, especially trials examining adoptive or active immunotherapy for melanoma or adoptive immunotherapy for renal cancer. The overall treatment of patients with cancer has changed. Primary-care physicians detect almost all cancers. The days when "taking it out" is the best we could offer a patient are over. As we learn more about the use of adjuvant or neoadjuvant chemotherapy and radiation therapy, it is likely one or both of these modalities will be incorporated into the treatment of additional solid tumors previously managed solely with surgical resection. Increasingly, additional therapy is being given for earlier-stage disease as we define how to maximize the potential for cure with minimal toxicity. Many new therapies are on the horizon, including the use of noncytotoxic treatments as an adjunct to a surgical procedure. Such therapies include the use of angiogenesis inhibitors, tumor vaccines, and immunotherapy. Now and in the future, patients will be best served when treated in an environment that can integrate medical, surgical, and radiation oncology actively.