Introduction

The role, availability and efficacy of systemic therapies in the treatment of cancer is continually evolving. A broad range of systemic treatments are known to be effective in treating gynaecological cancers. These include cytotoxic chemotherapy, biological agents and hormonal therapies. These treatments are used in different clinical settings: neoadjuvant, adjuvant and in the palliative setting.

This chapter outlines how these therapies exert their cytotoxic effects, how they are administered and their associated side effects. It also discusses how to decide which treatments are most appropriate for individual patients and when they should be given in relation to surgery. We also discuss the importance of clinical trials and how the response of novel therapies is compared to current treatments.

Cytotoxic Chemotherapy

Basic Principles

Chemotherapy drugs are designed to target rapidly dividing cells by interfering with normal DNA replication. Cancer cells generally have a rapid cell turnover and therefore constantly need to accurately replicate their DNA prior to each cell division. This renders them more sensitive to chemotherapy agents than the slower dividing cells of the body. However, rapid cellular division also occurs in populations of normal cells within the body such as those of the bone marrow, gut mucosa and hair follicles. These cells are therefore sensitive to DNA damage from chemotherapy drugs and this leads to unwanted side effects.

The majority of chemotherapy agents are administered intravenously on a dedicated cancer chemotherapy day unit. Some chemotherapy agents such as etoposide are active and available as oral formulations, and although normally administered intravenously, bleomycin can be given by intramuscular injection. Specifically trained chemotherapy nurses administer the drugs, and patients can spend as short as a few hours to almost the whole day on the unit. This depends on the requirement of premedication to prevent side effects, the rate of administration of the drug and preand post-administration monitoring. Each treatment is generally referred to as a ‘cycle’ of treatment and most are given every 3 to 4 weeks. This cycle length allows time for the recovery of normal cells, in particular the patient's bone marrow prior to further treatment. Every patient is reviewed prior to each cycle of chemotherapy to assess their response to treatment and to identify any potential side effects they may have developed.