Ewing Sarcoma: Chemotherapy

What is chemotherapy?

Chemotherapy (chemo) uses anticancer medicines to kill cancer cells. The medicines are made to attack and kill cancer cells, which grow quickly. Some normal cells also grow quickly. Because of this, chemo can also harm those cells. This can cause side effects.

When is chemo used for Ewing sarcoma? 

Chemo is often part of the treatment for all Ewing sarcomas. This is because even if it looks like the cancer is still just in the place where it started, cancer cells have often already spread to other parts of the body. Chemo can kill these small areas of cancer cells. Without it, the cancer is much more likely to come back.

Your child's healthcare provider will likely recommend chemo in these cases:

• As the initial treatment for Ewing sarcoma (regardless of how far it’s spread). This can often shrink the main tumor. This might make surgery or radiation easier. It can also often kill any cancer cells that have reached other parts of the body. After chemo, surgery and/or radiation are used to remove or destroy the remaining tumor.

• After surgery or radiation therapy. Chemo is often used here to kill any cancer cells that have been left behind.

How is chemo given for Ewing sarcoma?

Before treatment starts, you’ll meet with a medical or pediatric oncologist. These doctors specialize in treating cancer with medicines such as chemo. The doctor will discuss your child's treatment options with you and explain what you might expect. 

Depending on the specific chemo medicines your child receives, he or she may get them in one of these ways: 

• Intravenous (IV). The medicine is given through a small needle that’s been put into a vein. The medicine may drip in slowly over several hours, or it may be given more quickly over a few minutes. 

• Oral. You swallow these medicines as pills.

Chemo is usually given in an outpatient setting. That means that your child gets it at a hospital, clinic, or healthcare provider's office. Then he or she can go home after the treatment. Less often, your child may need to stay in the hospital during treatment. Your child’s healthcare provider will watch him or her for reactions during your treatments. Since each of your child’s chemo treatments may last for a while, he or she may want to take along something that’s comforting, such as music to listen to.

To reduce the damage to healthy cells and to give them a chance to recover, chemo is given in cycles. Each cycle consists of one or more days of treatment, followed by some time to rest. Cycles normally last two or three weeks. Most people get four to six cycles as part of their initial treatment, which usually lasts for several months. After surgery and/or radiation, chemo is given again. The total length of treatment is close to a year. Your child’s healthcare provider will talk about your schedule with you.

What chemo medicines are used to treat Ewing sarcoma?

These are some common chemo medicines used to treat Ewing sarcoma:

• Actinomycin-D

• Cyclophosphamide

• Doxorubicin

• Etoposide

• Ifosfamide

• Vincristine

Chemo for Ewing sarcoma is given as a combination of several medicines. The most common chemo regimen in the U.S. is vincristine, doxorubicin, and cyclophosphamide, alternating with ifosfamide and etoposide (VDC/IE).

What are common side effects of chemo?

Side effects of chemo are different for everyone. They vary based on the medicines you receive. Below is a list of the some of the most common side effects from chemo. Ask your child’s healthcare provider what side effects to watch for.

• Hair loss. If your child has hair loss, his or her hair will usually grow back after the treatment stops.

• Nausea and vomiting. This side effect can often be controlled with medicines. Ask your child's healthcare provider about it.

• Mouth sores. Chemo can sometimes cause mouth sores. This might make it hard to eat or swallow. It's important to avoid foods and substances that could irritate your child's mouth.

• Diarrhea. If your child has diarrhea, ask his or her healthcare provider about antidiarrheal medicines. You may also need to make changes to your child's diet.

• Loss of appetite or changes in the way things taste. Talk to your child's healthcare provider if you find your child is having trouble eating or is losing weight. There are often ways to help.

• Increased risk of infection. During chemo treatments, your child's white blood cell count may become low. This means his or her immune system won’t work as well as it usually does. It’s a good idea to avoid people who have illnesses that he or she could catch. It’s also a good idea to take extra precautions against cuts and scrapes that could become infected. Your child's healthcare provider will check his or her blood counts regularly during treatment. Be sure to let the healthcare provider know if your child has any signs of infection. Symptoms can include a fever, sore throat, a new cough, or burning during urination.

• Bleeding and bruising more easily. Chemo can also lower blood platelet counts. Platelets are needed to help the blood clot properly. 

• Fatigue. Your child may feel tired while getting chemo. This often goes away once treatment ends. 

Some other side effects can also be seen with certain chemo medicines. For example:

• Cyclophosphamide and ifosfamide can harm the bladder. This might cause problems with urination.

• Vincristine can harm nerves. This may cause tingling and numbness, especially in the hands or feet.

• Doxorubicin might damage muscles in the heart.

• Some chemo medicines might affect your child's ability to have children later in life.

• Some medicines can raise the risk of another cancer (especially leukemia) later in life.

Working with your child's healthcare provider

It's important to know which medicines your child is taking. Write his or her medicines down, and ask the healthcare team how they work and what side effects they might have.

Talk with your child's healthcare providers about what signs to look for and when to call them. For example, chemo can make your child more likely to get infections. Make sure you know what number to call with questions. Is there a different number for evenings and weekends?

It may be helpful to keep a diary of your child's side effects. A written list will make it easier to remember your questions when you go to appointments. It will also make it easier for you to work with your child's healthcare team to make a plan to manage side effects.