Chemotherapy is the type of cancer treatment in Germany, which destroys malignant cells with the help of medications. Numerous clinical trials are aimed at the assessment of efficacy of the existing chemotherapeutic agents, elaboration of new molecules and cancer treatment regimens. Treatment in Germany takes the advantage of extensive practical experience, modifications of the conventional chemotherapy protocols and comprehensive approach to cancer treatment. German physicians elaborate effective individual schemes for cancer treatment and pay additional attention to managing side effects. Cost of treatment in Germany is regulated by law and corresponds to the quality of medical services.

Content

1. When chemotherapy is administered
2. Types of chemotherapy
3. How is chemotherapy performed?
4. How do doctors choose a chemotherapeutic protocol?
5. When is it worth looking for chemotherapy abroad?
6. Chemotherapy in German hospitals with Booking Health

When chemotherapy is administered

Chemotherapy is the systemic treatment (local and regional treatments also exist, and we will discuss them later) that affect the primary tumor and metastases. Medications target tumors in the hard-to-reach regions and destroy undetectable metastatic foci, which is why indications to their administration are quite broad.

Offering chemotherapy for cancer, specialists in oncology pursue one of the following goals:

• Curing cancer. Some tumors are extremely sensitive to cytotoxic agents and can be completely destroyed by a few chemotherapy courses. For instance, chemo is the first-line option if a patient was diagnosed with blood cancer.
• Preparing for further therapy or consolidating its results. Chemo helps prepare a patient for surgery or radiation therapy, as it reduces tumor volume and makes it more sensitive to irradiation. After the surgery or radiation therapy course, chemo suppresses remaining cancer cells (e.g. undetectable microscopic metastases) and reduces risks of the relaple development. It has been proven that adjuvant (i.e. "post treatment") chemotherapy is connected with longer relapse-free periods and better survival.
• Controlling cancer. In patients with advanced cancer chemo prevents further disease progression, i.e. tumor growth or metastasizing. Although not leading to cure, chemo makes the clinical course of the disease more favourable.
• Managing cancer symptoms. Chemotherapy may also be administered for alleviating bone pain, relieving pressure of a tumor on airways or intestines, reducing intoxication, etc. Palliative chemo is administered individually, as a physician must carefully assess all the possible risks and benefits.

Due to affecting the basic mechanisms of cancer cells’ metabolism and multipurpose cytotoxic action, chemo is indicated for the treatment of different cancers. These are malignant neoplasms of lungs, breasts, stomach and intestines, bones, brain, soft tissues, etc. It can be used as monotherapy or included in complex therapeutic protocols.

Types of chemotherapy

There are seven possible ways of introducing chemotherapeutic agents in the body, as close to the malignant neoplasm as possible. Some of them are systemic (more conventional and investigated approach), while others are local (more novel and targeted approach):

1. Oral. Chemotherapeutic capsules, pills or solutions can be taken orally, according to a physician’s scheme. Oral chemo is suitable for cancer patients with normal function of the gastro-intestinal system. Some of the drugs require a specific diet.
2. Intravenous. This procedure is performed through the permanent peripheral intravenous cannula, so a nurse does not need to puncture the vein each time. Treatment session may take from several minutes to several hours. This depends on the quantity of medications, their individual tolerance, and type of cancer.
3. Intra-arterial. This method is from the group of the targeted ones. With the help of visualizing techniques doctors find arteries that feed tumors and introduce drugs into them directly. It may be hard to reach arteries of liver, lungs, etc., and this type of chemo requires specific skills from oncology specialists.
4. Intramuscular. This procedure is carried out as an ordinary injection. The chemotherapeutic agent is introduced in the muscle or under the skin.
5. Intraperitoneal. In this case chemotherapy is the part of complex intervention, i.e. HIPEC. Doctors combine surgery with local introduction of the cytotoxic medications. Details of the technique will be described below.
6. Intrathecal. When we talk about tumors of the central nervous system, the best way for targeted drug delivery is their injection into the cerebrospinal fluid (CSF). CSF participates in the exchange of substances and can deliver medication to most parts of the spinal cord and brain. Single or several injections may be enough in this case.
7. Topical (cutaneous). Creams or ointments with high medication dosage are applied to the affected skin regions. This is the most attractive option in terms of cost of treatment, as it does not require hospital admission and is not connected with significant side effects.

Some types of treatment are inpatient (e.g. HIPEC), others require visits to a doctor’s office (e.g. intravenous chemo) or can be taken at home (e.g. oral or topical chemo). This influences overall duration and cost of treatment. Some people prefer undergoing therapy at the hospital, under constant medical supervision. Others would rather stay at home, with their beloved ones. When possible clinically, physicians ask about patients’ preferences and consider them.

How is chemotherapy performed?

Intravenous chemotherapy is usually performed through the peripheral intravenous cannula. This means that a nurse will not need to insert a needle in your vein before each procedure. The intravenous cannula may stay in the blood vessel for about 72 hours. It must be sterile. A nurse washes the intravenous cannula with saline before and after each procedure. The infusion may last for several hours, so you will stay in the ward, in comfortable conditions. Intravenous chemotherapy may be performed as an inpatient or day hospital procedure, in both cases you will receive close medical attention from cancer care providers.

Chemoembolization, or intra-arterial chemotherapy, is the inpatient intervention. It starts from the local anesthesia in the groin region, as a physician most often inserts the endovascular catheter into the femoral artery. The catheter is gradually moved in the direction of the target region (i.e. tumor or its metastases). Once it is in place, a physician injects a solution with a chemotherapeutic agent through it and closes the lumen of the vessel with emboli. Thus, a drug stays near the cancer cells for a long time. It does not enter the systemic circulation and does not cause side effects. Chemoembolization is indicated to patients with advanced cancer, who have distant metastases (e.g. liver ones).

HIPEC, or hyperthermic intraperitoneal chemotherapy, is carried out after the cytoreductive surgery. A surgeon opens the abdominal cavity and removes all the visible tumors and metastatic lesions. After that, a heated solution of a chemotherapeutic agent is pumped inside it through the catheters. The solution is heated to 42-43 degrees Celsius, which facilitates its penetration deep into the tissues and killing microscopic metastases. A drug circulates in the abdominal cavity for 1-1.5 hours. After that, it is washed out, and the surgical wound is sutured. Beyond all doubt, HIPEC is an inpatient procedure that is indicated to patients with advanced cancer stages. The cost of treatment with HIPEC is higher compared to usual intravenous chemotherapy, but the results are impressive.

Intrathecal chemotherapy most often includes injecting the drug directly into the CSF, in the lower part of the spinal column. The injection is performed under the local anesthesia, this is an outpatient procedure. Another, more invasive, option is injecting chemotherapeutic agents into the Ommaya reservoir. The Ommaya reservoir is a plastic device that is inserted under the scalp in order to facilitate CSF aspiration or drug delivery. Both options of intrathecal chemotherapy are aimed at treating tumors in the brain and spinal cord or preventing affection of these organs by cancer of other localizations (e.g. in acute lymphoblastic leukemia or Burkitt’s lymphoma).

How do doctors choose a chemotherapeutic protocol?

In German hospitals, cancer treatment schemes are often elaborated by a tumor board. Tumor board is a group of health care providers that elaborate the best possible care plan in conference. For instance, a tumor board for a patient with lung cancer includes oncologist, thoracic surgeon, radiation oncologist, pulmonologist or general practitioner, etc. Joint work of health care providers makes it possible to exclude repeated examinations, reach the best therapeutic results and reduce the overall cost of therapy.

When planning a chemotherapeutic protocol, members of a tumor board consider the following factors:

• Diagnosis
• Histological and immunohistochemical type of tumor
• Expected sensitivity of a tumor to conventional chemotherapeutic drugs
• Presence of metastases, their number and localization
• Already performed treatment and its efficacy
• Age and life expectancy
• Presence of comorbidities
• Liver and kidney function
• Other patients’ individual factors

To assess these parameters precisely, cancer patients undergo examination. The list of necessary diagnostic tests includes blood tests, US scans, CT / MRI / PET-CT, and biopsy. Depending on the result of the discussion, the tumor board chooses one of the internationally approved protocols, local modification of the international protocol, or gives preference to targeted methods (HIPEC, chemoembolization). The scheme of treatment is adjusted to the changes in a patient’s state.

When is it worth looking for chemotherapy abroad?

After reading the information about chemotherapy, the procedure seems effective and simple. So, why may a cancer patient want to travel abroad instead of simply undergoing it in a local hospital?

First, novel medications may not be available in the native country. Unfortunately, oncologists of many countries still use outdated protocols of cancer treatment, as more progressive and safe ones are not approved or just more expensive. However, with spending less on the drugs for chemotherapy the final cost of therapy may become even higher, as you may need additional surgery, etc.

Second, local physicians may not be skilled enough to perform HIPEC, chemoembolization and other invasive types of chemotherapy. Availability of specific equipment and practical experience of health care providers are the cornerstones of successful implementation of modern interventions. If a surgeon performs only 1-2 such interventions annually, mistakes are possible.

Third, local hospitals may not care about your comfort and privacy. You may not want anyone to know that you have cancer. Travelling abroad is a chance to keep the diagnosis a secret. In addition, German hospitals offer comfortable wards and attentive nurses. If necessary, a psychologist will also work with you during the treatment course.

Chemotherapy in German hospitals with Booking Health

If you decide to undergo chemotherapy in one of the specialized German hospitals, it will be reasonable to explore the peculiarities of providing medical services to foreign patients with cancer. First of all, you will need to contact the hospital’s administration and receive the invitation for treatment. You may wait for the response for a few weeks or few months, as the priority is given to local citizens. Beyond all doubt, waiting is not the best option for a cancer patient. After that, you will need to pay for consultations, medicatios, nursing services, etc. Most hospitals have extra fees for foreigners and require medical insurance, so it is almost impossible to calculate the final cost of treatment in advance.

To receive comprehensive assistance during cancer treatment in Germany, contact Booking Health. Booking Health is the medical tourism provider that facilitates receiving medical services in the leading German hospitals. The company will guide you through all stages of treatment abroad and help with:

• Making choice among oncological departments and hospitals based on the annual qualification profile, as different healthcare institutions may specialize in treating different cancer types
• Preparing the chemotherapy program with an approximate price estimate, without repeating the available laboratory tests and instrumental examinations
• Establishing communication with your future attending physician
• Booking the appointment or the hospitalization date, without postponing start of therapy
• Excluding additional coefficients for foreigners from the cost of therapy (saving up to 50% of the initial price)
• Monitoring the course of medical program by Booking Health experts in oncology
• Help in buying chemotherapeutic medicines for further courses, if necessary
• Communication with the German hospitals after the course completion, scheduling further courses
• Control of prices, returning unspent funds
• Organization of additional medical examinations, consultations, etc.
• Organizational issues: receiving visa, buying tickets and booking accommodation, transfer
• Personal assistance of a medical coordinator and interpreter, information support

Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko