A diagnosis of cancer is usually a critical event in a person's life because it carries with it the threat of premature death, pain and disability. Today, however, many cancers can be cured or palliated for extended periods of time if initial treatment involves the appropriate therapy. In order to receive appropriate treatment, patients must understand the type of cancer they have and the treatment options that are available. As the curative potential for cancer treatments has increased over the past several decades, so has the complexity of information needed to make appropriate treatment decisions. Since very few cancers require emergency treatment, it is important for patients, relatives and friends to allow themselves ample time to learn exactly what their diagnosis means.
Two of the most important things a patient can do following a diagnosis of cancer are to become educated about treatment options and to seek a second opinion. Historically, patients often relied upon a single physician recommendation or out-of-date print materials to make their treatment decisions. Now, the Internet has become a unique resource because it provides a vehicle for real-time distribution of information directly to cancer patients and their families. Currently, there are several Internet resources designed to educate patients. CancerConsultants.com, oncolink.com and the National Cancer Institute web site (www.cancer.gov) are all designed to educate patients and provide current, comprehensive, disease-specific information from screening to treatment.
Each individual involved needs to gather information on the nature of the cancer and how it can be treated (surgery, radiation or chemotherapy). This information educates patients and enables them to ask their physicians the right questions about their cancer treatment so that they can understand the options presented by the physician. However, the main source of information about treatment options comes from the physician who will be directing treatment. For a variety of reasons, it is frequently advantageous for patients with cancer to seek more than one opinion about how their cancer can be treated. Second opinions are a common practice in any area of medicine that is complex and that has multiple treatment options available. Getting a second opinion allows patients to become more informed about their cancer and their treatment options and also provides reassurance.
What is a Second Opinion?
Getting a second opinion involves obtaining a review of the cancer diagnosis and the treatment recommendations of the physician who is treating the cancer. Either the patient or the primary physician can initiate the process of getting a second opinion. Usually, patients can obtain a second opinion by getting a referral to a second physician or to a multidisciplinary team of experts in a cancer center. This doctor or team of doctors will review the pathology (how the cancer looks under the microscope), the extent of cancer, the physical condition of the patient and the proposed treatment. The doctor(s) then communicate their opinion regarding treatment to both the patient and the primary physician. The only problem with referral by the treating physician is that there may be a tendency to refer to physicians with the same treatment philosophies, thereby ensuring a concurrent opinion.
A second opinion should be independent and may be best performed by a physician or team of physicians who do not have a close relationship with the treating physician. More and more cancer patients are being evaluated in larger centers where multidisciplinary teams involving surgeons, oncologists, radiation therapists and sub-specialist oncologists have a role in determining treatment recommendations. In this multidisciplinary setting, second opinions are more likely to be comprehensive.
Who Should Get a Second Opinion?
Although no one has precisely defined the specific situations that merit a second opinion, there are clearly situations where a second opinion would be helpful and most patients would benefit. Patients who feel that they may not fully understand the consequences of the diagnosis and the treatment options should consider a second opinion. The basic complexity of the diagnosis and treatment options, as well as failure of the physician to communicate with the patient, can interfere with the understanding of the situation. In some instances, a patient may experience denial, which can be overcome if a second physician or team of physicians offers similar advice.
Patients, relatives and friends need to keep in mind that second opinions are a normal part of cancer management and they should not be concerned about hurting the feelings of the primary physician. If a patient decides to obtain an independent second opinion, it is important to communicate with the primary physician not only to obtain needed information for review, but also to keep the treating physician informed. Most physicians welcome the opportunity to have another consultant review and approve their care decisions, or perhaps suggest another treatment that may be better. There are instances when a patient will have a basic disagreement with their physician and will need to change physicians, but this is not the main purpose of a second opinion. Most of the time, patients simply need to make sure they are getting the best advice.
Specific Situations Where A Second Opinion is Useful
Non-Cancer Specialist Treatment Recommendations: In the United States , doctors other than oncologists often diagnose and treat patients with cancer. Cancers are diagnosed and treated by family doctors, internists, pediatricians, gynecologists, urologists, ear-nose-and-throat doctors and other non-cancer specialists. In most instances, appropriate therapy is administered. However, patients not treated by specialists in cancer treatment should consider seeking a second opinion. In some situations, physicians will not refer patients for a second opinion because they may lose control and revenue from treatment, they may be threatened by having their patient believe some other doctor is more knowledgeable or often they are just too busy to bother with consulting other physicians. The patients of these types of physicians are probably the most in need of a second opinion.
Cancer Sub-specialists: Many types of cancers are treated by several different types of cancer specialists. For example, prostate cancer may be appropriately treated by urologists who are surgeons, radiation oncologists and/or medical oncologists who use drug treatment. Each specialist may think that the treatment they advise and are involved with is the best treatment for the patient. This is dramatically shown in recommendations for the primary treatment of localized prostate cancer. For localized prostate cancer, surgeons almost invariably advise surgery (radical prostatectomy) as the primary treatment and radiation oncologists invariably advise radiation therapy (either external beam or brachytherapy). A patient with early prostate cancer may want to consult an oncologist or multidisciplinary team who would not be treating this stage of prostate cancer as well as a surgeon and a radiation oncologist to obtain a thorough understanding of treatment options. Seeking a second opinion from a different type of specialist can be informative but it can also, unavoidably, create confusion about treatment options that will need to be resolved by having all of the available information and making an informed decision.
Apparent Lack of Treatment Options: A second opinion can be useful in some patients who are told that there is no appropriate treatment for their cancer and that there is no hope of survival or palliation. Such patients have nothing to lose by seeking a second opinion. In this situation, patients should seek out physicians and institutions that specialize in treating their type of cancer and perform clinical trials. Often, this is accomplished by finding out who is performing clinical trials of novel treatments for the type of cancer in question. Here again, information available on the Internet can help locate such physicians and institutions.
Clinical Trials: Progress in cancer treatment has come predominantly from participation in clinical trials. There are many types of clinical trials, some of which may benefit a patient with a specific cancer and some of which may not. Doctors who participate in clinical trials, whether from a single center or as part of a multi-center trial, need to put patients on these trials and often have trouble finding patients to participate. Unconsciously, such doctors may suggest a trial that may not represent the best treatment for a patient with cancer. When participation in a clinical trial is recommended by the treating physician, a second opinion should probably be obtained to make sure this is the appropriate treatment. The patient should also be aware of all the clinical trials that are available for his or her cancer before selecting the one the treating physician recommends. Two sources of ongoing information regarding clinical trials include comprehensive, easy-to-use listing services provided by the National Cancer Institute (cancer.gov) and eCancerTrials.com. eCancerTrials.com also provides personalized clinical trial searches on behalf of patients.
Rare cancers: If a patient has a rare cancer, it is usually best to seek a second opinion unless the diagnosis is made at a center that specializes in the treatment of this cancer. If a local expert is available, treatment should probably be switched to that doctor. If the expert is far away, which is likely, the treating physician can usually coordinate treatment by phone or e-mail communication. Even if your cancer isn't all that rare, there may be benefit from finding someone with a special interest in the specific type of cancer being treated. For instance, kidney cancer is not really rare, but it's not common either. Usually patients with kidney cancer are treated on multi-center protocols carried out in large institutions. This is because the newer treatment protocols require specialized treatment and clinical trial accrual has to be pooled from several institutions to be meaningful.
Surgery as Primary Treatment: If there is any doubt about the operability or inoperability of a cancer, a second opinion is in order. In this situation, patients are urged to seek second opinions in institutions where large numbers of patients are treated. For instance, esophageal cancer may be considered inoperable in a hospital that performs one such procedure a month, but may be considered operable in an institution that performs several per day. Just as important can be the determination that a cancer deemed operable is in fact inoperable and surgery would be harmful.
Small and Rural Hospitals: Patients who live in a rural area and get treatment at a small hospital probably should get a second opinion from a larger medical center before treatment is initiated. Although smaller hospitals typically deliver excellent treatment, it is prudent to ensure that the recommended treatment is appropriate and can be safely administered. Small and rural hospitals may not see a large volume of cancer patients, and while they are usually fully capable of delivering treatment, it is best to seek a second opinion to help determine what the appropriate treatment is. Sometimes, the recommended treatment will determine whether a patient should receive their treatment at their local hospital or travel to a larger medical center. For example, most small hospitals can effectively deliver chemotherapy; whereas patients requiring a complicated procedure, such as a stem cell transplant, may need to travel to a larger institution that treats a higher volume of patients.
Aggressive Treatment: Most of the cancers that can be cured with chemotherapy (acute leukemias, lymphomas, testicular cancers) require intensive treatment. Intensive treatment may consist of high doses of chemotherapy or radiation therapy and requires rigid adherence to prescribed doses of drugs to ensure that optimal treatment is delivered. Intensive treatment also requires careful monitoring for complications and aggressive supportive care. In many instances, intensive treatment can be administered locally, but such patients are usually best treated in centers that use state of the art protocols (clinical trials) and treat large numbers of patients. All too often, oncologists treat patients with curable cancer with lower doses of chemotherapy in order to decrease side effects. This practice can seriously compromise the chance for cure. Patients should determine how many patients are treated per year and what the results of local treatment are at the treating institution. Treating physicians should present patients with their own results and not results from patients treated in other institutions.
Specialized Treatment: In many instances, specialized treatment is required to achieve optimal cure or control rates. One example of this is stem cell transplantation. Allogeneic or autologous bone marrow or blood stem cell transplants can often offer the best result for patients with blood and lymphoid cancers such as leukemia, lymphoma and multiple myeloma and other cancers such as breast, ovarian and testicular. However, not all medical centers offer this type of therapy. If the treating center does not offer stem cell transplant, a second opinion may be in order. Another example of specialized treatment is treatment for liver cancer. Recent clinical trials have suggested that sophisticated treatment techniques such as intra-arterial chemotherapy, chemo-embolization, radiofrequency ablation, radioactive isotopes and conformal radiation therapy can be of major benefit for the treatment of liver cancers. However, not all centers have the capability of delivering this type of treatment. Patients with liver cancer and other cancers that can be treated by specialized methods require second opinions at specialized institutions.
Cost of Second Opinions
One of the problems with second opinions is that insurers may not cover the expense. However, many insurance and health care companies do pay for such opinions and acknowledge the importance of second opinions. In some situations, insurers will even insist on a second opinion. This is often the case when the primary physician advises an expensive treatment.
Health Maintenance Organizations (HMOs) have a vested interest in keeping patients within the system. This may cause a conflict of interest between the patient and the HMO, especially if very expensive treatment is only available outside the HMO system. The more money the HMO spends on second opinions and treatments outside the HMO system, the less money there is available to treat patients within the system and the less the HMO makes in profit. However, most reputable HMOs can deliver state of the art treatment for most cancers. It is a good idea, however, for HMO members with cancer to make sure they are informed about clinical trials or other promising new treatments. HMO members may also be discouraged from trying expensive treatments that have only a small chance of success, even if that chance is real. It is also important for HMO members undergoing cancer surgery to inquire about the number of such procedures performed each year by the HMO and the results. The best protection for an HMO member is to seek a second opinion even if she or he has to pay for it.
In summary, patients should become their own advocates and become as knowledgeable about their treatment options as possible. When there is any doubt about the diagnosis or treatment plan, patients should obtain a second opinion. Second opinions will not offend competent physicians. Second opinions will, however, provide reassurance to patients and family members and ultimately allow patients to receive the most appropriate therapy.
Sunday, November 4, 2007
The Importance of a Second Opinion Following a Diagnosis of Cancer
Understanding Cancer Treatment Options
Introduction
Very few cases of cancer require emergency treatment. Most patients benefit from taking the time to learn about their disease and explore all treatment options. Before choosing a treatment strategy it is important to understand the stage and extent of cancer, the different types of cancer treatment and the goal of treatment. Many patients decide to obtain a second opinion in order to help them make treatment decisions.
Staging
After cancer is diagnosed, a physician will perform several tests to determine the stage and extent of disease. Staging is the process of describing the location of the disease at the time of diagnosis. The American Joint Commission on Cancer is the most widely used cancer staging system. The stage is determined by measuring the size of the primary Tumor, the extent of lymph Node involvement, and the absence or presence of Metastases. This is referred to as the TNM staging system.
Staging provides invaluable information about the location and extent of the disease. After determining the stage of the cancer, physicians and patients can begin to explore treatment options. At this point, it is important for patients to gather as much information as possible about the treatment of their cancer.
Understanding the Different Types of Treatment
There are several different types of cancer treatment. One type of treatment may be best for some cancer patients, while another will be more beneficial for other patients. It is up to the individual to determine which course of action is most appropriate.
Conventional Treatment: In the West, methods of cancer treatment traditionally follow the medical, or allopathic, model. The term allopathy derives from two Greek words: allo meaning opposite and pathos meaning suffering. The basis of this medical system is to focus on disease and employ methods that oppose it. In the medical model, treatments are based on evidence, usually gathered in carefully controlled clinical trials that determine whether a new treatment is effective and safe for patients. In the United States, these conventional treatments are approved by the Food and Drug Administration (FDA) before they can be administered to patients. Conventional treatment can be divided into two categories:
Standard Treatment: Standard treatment refers to treatment that has been proven safe and effective in clinical trials and is approved by the FDA for a specific use. Standard treatment is the “accepted” best treatment for a specific type and stage of cancer.
Experimental Treatment: Experimental treatment refers to a potentially encouraging treatment that is under evaluation, but has not yet been approved by the FDA. Experimental treatment is offered through a clinical trial. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Often, clinical trials offer access to the newest and most promising treatment strategies. It is extremely important to decide whether or not to participate in a clinical trial before receiving any treatment from a physician. Once treatment has been initiated, this almost always excludes patients from participating in a clinical trial designed for patients in their circumstance. Even when there is evidence that a new treatment modality may be better than standard treatment, it takes years to change the existing standard treatment.
Complementary/Alternative Treatment: Complementary and Alternative Medicine (CAM) describes medical therapies practiced outside “mainstream” or conventional Western medicine. CAM contains a variety of healing philosophies and medical practices that are not currently accepted or used by conventional medicine, such as acupuncture, aromatherapy, biofeedback, herbal remedies and more.
Complementary medicine consists of medical therapies that are most often used to supplement conventional medical treatments. Because these treatments are utilized in addition to allopathic therapies, they most often focus on promoting wellness or managing symptoms. Most CAM therapies can be used as a complement to conventional medicine. A benefit of complementary therapies is that the patient can use well-researched conventional treatments against cancer while utilizing complementary medicine to reduce stress, enhance their immune system and/or reduce side effects of conventional cancer treatment. The vast majority of CAM practitioners and cancer patients who utilize CAM therapies use complementary medicine as a means of integrating the best of what both types of medicine have to offer.
In contrast to complementary medicine, alternative medicine is used in place of conventional medicine. Alternative medicine attempts to treat disease specifically, without use of any allopathic therapies. Therapies commonly used as complementary medicine are considered alternative medicine when used in place of conventional treatment. For minor health issues, alternative medicine is generally not dangerous. However, most practitioners of conventional medicine, and many who practice complementary medicine, are uncomfortable with the exclusivity of alternative medicine and its failure to utilize treatments that are known to benefit certain diseases when the illness is serious. In such instances, alternative therapies may delay conventional treatment and result in a more serious illness, complications or death. Many patients who do turn to alternative medicine do so only after conventional medicine has nothing more to offer or because they believe the risks of a mainstream treatment outweigh the risks of the alternative therapy they are investigating. In some instances, a very negative experience with conventional medicine leaves a patient in search of alternative forms of medicine.
Goals of Treatment
In order to explore treatment options, it is important to understand the goal of treatment. The ultimate goal of treatment is cure, which requires eliminating all detectable or measurable disease and any undetectable disease. Micrometastases are undetectable areas of cancer that have spread away from the original site of cancer. Primary treatment is an initial approach to remove detectable disease, but may not remove all micrometastatic disease. In many earliest stage cancers, primary treatment is curative if the cancer is limited to detectable disease.
Since there is a potential for micrometastatic disease even after all of the measurable disease is removed, the primary treatment for many stages of cancer is non-curative. When the potential for micrometastatic disease is significant, additional treatment is often necessary to eradicate any remaining cancer cells. Adjuvant therapy is treatment that is delivered following primary treatment and may include chemotherapy, hormonal therapy and/or biologic therapy. Neoadjuvant therapy refers to treatment that is delivered prior to primary treatment. Sometimes, cancer has grown so large that surgical removal of the entire cancer is difficult. The goal of neoadjuvant treatment is to shrink the cancer, thereby facilitating more complete surgical removal.
Sometimes with advanced cancer, primary and adjuvant treatment may not be beneficial because eliminating measurable disease is not possible. In such cases, patients may elect to receive palliative treatment. The goals of palliative treatment are to alleviate pain and side effects from the disease, prolong life and maintain quality of life.
Treatment Modalities
Cancer treatment may consist of one or more treatment modalities, depending on the type, stage and extent of cancer. Some treatment modalities, such as surgery and radiation, are local treatments used to eradicate visible tumors. Other treatment modalities, such as chemotherapy and biological therapy, are systemic treatments that circulate in the blood to eradicate cancer that has spread away from the original site.
Optimal treatment of cancer often requires more than one therapeutic approach. Often, one or more treatment modalities may be used in order to provide the most complete treatment for the patient. Increasingly, it is common to use several treatment modalities concurrently or in sequence, with the goal of preventing both local and systemic cancer recurrence. This is referred to as multi-modality treatment of the cancer. These modalities may include surgery, radiation therapy, chemotherapy and/or biological therapy. Thus, it is important for patients to be treated at a medical center that can offer multi-modality treatment involving medical oncologists, radiation oncologists and surgeons.
Surgery: Surgery is a local treatment used to remove visible tumors. In addition, surgeons frequently remove the tissue adjacent to the cancer during surgical resection of a tumor. Information gained about the tumor during surgery is useful in predicting the likelihood of tumor recurrence and the need for other treatment modalities.
Radiation Therapy: Radiation therapy, or radiotherapy, uses high-energy rays to damage or kill cancer cells by preventing them from growing and dividing. Similar to surgery, radiation therapy is a local treatment used to eliminate or eradicate visible tumors. Radiation therapy is not typically useful in eradicating cancer cells that have already spread to other parts of the body. Radiation therapy may be externally or internally delivered. External radiation delivers high-energy rays directly to the tumor site from a machine outside the body. Internal radiation, or brachytherapy, involves the implantation of a small amount of radioactive material in or near the cancer.
Chemotherapy: Chemotherapy is the general term for any treatment involving the use of drugs to kill cancer cells. Cancer chemotherapy may consist of single drugs or combinations of drugs. Chemotherapy can be administered through a vein, injected into a body cavity or delivered orally in the form of a pill. Chemotherapy is different from surgical or radiation therapy because it is considered a systemic treatment. The cancer-fighting drugs circulate in the blood to parts of the body where the cancer may have spread and can kill or eliminate cancers cells at sites great distances from the original tumor.
Biological Therapy: Biological therapy is referred to by many terms including immunologic therapy, immunotherapy or biotherapy. Biological therapy is a type of treatment that uses the body’s immune system to facilitate the killing of cancer cells. Types of biological therapy include interferon, interleukin, monoclonal antibodies, colony stimulating factors or cytokines and vaccines.
Hormone Therapy: Hormones are naturally occurring substances in the body that stimulate the growth of hormone sensitive tissues, such as the breast or prostate gland. When cancer arises in breast or prostate tissue, its growth and spread may be caused by the body’s own hormones. Therefore, drugs that block hormone production or change the way hormones work, and/or removal of organs that secrete hormones, such as the ovaries or testicles, are ways of fighting cancer. Hormone therapy, similar to chemotherapy, is a systemic treatment in that it may affect cancer cells throughout the body.
Choosing the Appropriate Treatment
Appropriate cancer treatment choices vary depending on many factors. What is appropriate for one patient may not be appropriate for another. Patients who understand the specific characteristics of their disease and understand the many different facets of cancer treatment will be able to make informed treatment decisions.
Understanding the Relationship Between Anemia and Cancer
Anemia, a common side effect of cancer treatment, is a condition in which there are fewer red blood cells than normal. The function of red blood cells is to transport oxygen to the tissues of the body. Without an adequate number of red blood cells, the body’s need for oxygen cannot be effectively met. Common symptoms of anemia include severe fatigue, shortness of breath, diminished activity level, reduced overall feeling of well-being, and possible mental dysfunction. Anemia may also exacerbate existing medical conditions. For example, the heart has to work harder in an anemic patient, which may aggravate a heart condition. Furthermore, severe anemia may cause a treatment delay or dose reduction, as well as reduce the effectiveness of some chemotherapy agents and radiation, thus jeopardizing the possibility of the best long-term results from treatment. Fortunately, there are treatments available to improve anemia and its symptoms.
Anemia in cancer patients may occur either as a direct result of the cancer or as a side effect of cancer treatment. Chemotherapy, radiation therapy, and blood loss during surgery are all common causes of anemia in cancer patients. Over 60% of patients treated with chemotherapy develop anemia. This is because chemotherapeutic agents kill rapidly dividing cells in the body, including cancer cells, as well as several types of normal cells like red blood cells.
Early detection and prompt treatment of anemia is the best strategy for preventing severe anemia from occurring and ensuring that when anemia does occurs, the duration is limited. Although healthcare providers try to monitor for anemia, patient observations are an important source of information on warning signs and they should notify their doctor or nurse if they are feeling abnormally fatigued.
The treatments available for chemotherapy-induced anemia in cancer patients are Procrit® and Aranesp®. These agents are FDA approved and have been safely used in cancer patients. They contain a synthetic erythropoietin, which stimulates the production and maturation of red blood cells, ultimately increasing red blood cell levels enough to correct anemia. Procrit® is approved to be given 3 times per week, while Aranesp® is approved for administration only once every 2 weeks. Every 2 week administration has the added advantage of reducing the burden of frequent doctor visits for patients and their caregivers.
Although most patients develop anemia as a direct consequence of chemotherapy, diet may also play a role in reducing the severity or duration of anemia in some patients. Iron, folic acid, amino acids, and vitamins B6, B12, and C are all important components to the development and maturation of red blood cells. Green leafy vegetables, eggs, fruit, legumes, grains, and meats should be included in the diet of a person that is diagnosed with cancer, or one that has already developed anemia. Additionally, patients should ask their physicians if supplementation is necessary to manage their anemia.
Although anemia can pose serious consequences, early identification and subsequent intervention with effective treatments such as Procrit® and Aranesp® may help to correct anemia, thereby improving patients’ quality of life and making it possible for them to receive optimal therapy.
Patient Action to Prevent Infection During Treatment for Cancer
Most patients would prefer to prevent infection rather than having to deal with its results. Your first line of defense should always be prevention. Below are some simple but effective steps to avoid infection:
-Always wash your hands with soap and plenty of water. Many infections are transmitted through hands and things that you touch, such as doorknobs. Washing your hands thoroughly is the most important thing you can do to prevent infection.
-Avoid people with colds or the flu.
-Avoid large crowds to reduce the likelihood of coming into contact with sick people.
-Bathe daily and carefully dry your skin.
-Take steps to prevent cuts or scrapes, as these provide entry points for infection.
-Use an electric razor instead of a blade to avoid cuts.
-Use caution with sharp objects.
-Wear gloves when appropriate.
-If you have a cut or scrape, keep it covered with a clean bandage until it heals.
-Prevent cracks in your skin by using lotion.
-Cook your food thoroughly to kill any potential microorganisms that may be on raw food.
If Cancer Runs in Your Family: Understanding Hereditary Risk and Genetic Testing
A genetic risk for cancer means that certain cellular mutations that increase an individual’s risk for developing cancer are passed down through generations, giving each new family member who inherits a cancer susceptibility gene a potentially increased risk for developing certain cancers. These hereditary mutations are responsible for about 5–10 percent of cancer incidence.
Although hope remains that research in the field of gene therapy may someday find a way to repair these gene alterations, for now we are at least able to identify gene mutations through genetic testing—an important step in understanding your genetic susceptibility for cancer and the first step in managing your risk. However, even though you may gain important information from a genetic test, the decision to be tested should be made carefully. Here are some things to consider as you decide whether genetic testing is an appropriate choice for you:
Genetic Counseling
Because the implications of genetic testing and its findings for you personally and within your family are potentially very complicated, you may wish to seek the guidance of a genetic counselor. Testing and its results are complex—for example, if a genetic mutation is revealed, it is not certain that an individual will develop the associated cancer nor is the absence of a mutation a guarantee that an individual will not develop cancer. Furthermore, genetic testing does carry certain risks and limitations, which should be considered before you undergo such a procedure. A genetic counselor can help you understand these issues as well as the following:
Whether genetic testing is the right choice for you
Your results and their particular significance for you
How to share your results with other family members, as these findings may indicate that they are also at risk for the same hereditary mutation
Is Genetic Testing Right for You?
Potential candidates for genetic testing have one or more of the following characteristics:
Diagnosed with early-onset cancer*
Experienced more than one cancer diagnosis
Have a strong family history of cancer or a family history of rare cancers**Consult with your physician to determine if you’ve been diagnosed with early-onset cancer or whether you have a strong family history of cancer and to learn which types of cancer are consider rare cancers.
What You Can Learn from Testing
If you do undergo genetic testing, you may learn the following:
Your high-risk status will either be confirmed or you’ll be able to rule out the presence of a genetic alteration found in other family members.
If you do test positive, you can increase your screening practices, which may detect cancer at an early and most treatable stage.
Some cancers may be prevented entirely with preventive surgeries.
Limitations and Risks of Genetic Testing
In some circumstances genetic tests don’t offer any benefit. For example, if you may be at genetic risk for a type of cancer for which there is no reliable screening method or effective treatment, knowledge of this alteration would be of little or no use. Additionally, because these tests are only predictive and not definitive, there are no absolute answers about the likelihood that you will develop cancer. As well, though these tests are technologically sophisticated, they are still not 100 percent accurate, allowing the possibility that they will fail to identify a cancer-causing mutation or that a gene may be incorrectly identified as mutated. Risks to further look into include the potential for employment or insurance discrimination based on high-risk status for developing cancer and the potential anxiety for the entire family that the knowledge of an inherited mutation may cause.
For more information about genetic testing, go to http://patient.cancerconsultants.com/Testing.aspx?TierId=1085&DocumentId=736.
Six Tips for Choosing a Doctor and Getting High-quality Care
If you’re like most people who have been diagnosed with cancer, you want the best care possible from the best doctor possible. But how do you know which doctor is right for you? The answer is not simple. Different people have different needs and different priorities that play into their choice of a doctor. The following six tips can help guide your search:
1.Understand Your Diagnosis
A great first step is to find out as much specific information as you can about the details of your diagnosis. Knowing exactly what type of cancer you have can help you find the best doctor to treat your specific case.
Understanding the extent to which your cancer has spread is also important. If you have localized cancer, your first encounter should probably be with a cancer surgeon. If you have widespread cancer, you may more appropriately be referred to a medical oncologist.
Once you understand your diagnosis, a next step is to learn about standard treatment options for your type and stage of cancer. If your doctor offers you a treatment plan that is inconsistent with what you’ve learned from your research, you may not be able to assess on your own whether it’s a better or worse approach, but it will allow you to initiate informed discussions with your doctor or to seek a second opinion.
2.Get Input from People You Trust
As you begin your own research into your diagnosis and treatment, you may also want to ask people you trust for a physician referral. For example, your primary care doctor or a local oncologist may be able to refer you to an expert in your type of cancer.
The first doctor you see for your cancer care may also be able to help you plan your subsequent care. If you have lung cancer, for example, you first see a surgeon. The surgeon can then refer patients to the physicians who will provide the post-surgery cancer care.
3.Get the Care That Your Diagnosis Requires
Keep in mind that though many doctors will be able to provide high-quality cancer care, those who focus on your specific type of cancer may have important additional expertise.
Finding a physician who focuses on your particular type of cancer may require some travel and visiting a large cancer center. Once your treatment strategy is developed, however, you may be able to receive the bulk of your care closer to home.
In particular, patients facing stem cell transplants and rare cancers these or similar may benefit from highly specialized care because most oncologists do not handle these situations on a regular basis.
All patients may want to consider choosing a doctor who is board certified in the specialty in which he or she practices.
4.Consider a Second Opinion
Another step that many cancer patients take when selecting a doctor is to get a second opinion. Second opinions are a common practice in any area of medicine that is complex and that has multiple treatment options. Getting a second opinion allows patients to become more informed about their cancer and their treatment options and also provides reassurance.
For tips on when to seek a second opinion, go to When to Seek a Second Opinion.
5.Be Comfortable with Your Choice
In addition to finding a doctor with expertise in your type of cancer and pursuing a second opinion if you choose, keep in mind the value of finding a doctor with whom you feel comfortable. Some patients, for example, believe strongly in the role that complementary and alternative medicine plays in treatment. When choosing a doctor, these patients will need to consider how much it matters to them that their doctor either does or does not endorse those beliefs.
6.Remember: There’s No One Right Answer
There is no simple or one-size-fits-all formula for finding a doctor. Each patient—and each doctor—is unique. Finding a doctor who specializes in your type of cancer is a good starting point, but you may also wish to consider such factors as travel time and how comfortable you are with the doctor. You may be happiest taking the recommendation of a trusted individual, or you may want to research options on your own. Ultimately, you need to do what’s right for you.
Nutrition Tip: Green Tea
The component plentiful in green tea shown to be responsible for chemopreventive and chemotherapeutic actions in laboratory studies is the polyphenol called epigallocatechin gallate (EGCG). This compound has been found to prevent cancer cells by changing the way normal cells react to potential carcinogens entering the body. EGCG also appears to create chemical changes that kill active cancer cells in multiple myeloma, breast, cervical, and colon cancer tumors.3,4,5,6
In addition, recent observations from the Mayo Clinic suggest that green tea may fight chronic lymphocytic leukemia (CLL), and a clinical trial is now underway to test the effect of green tea in CLL patients.7 Clinical studies at the University of Parma in Italy have also produced statistically significant evidence of EGCG’s ability to treat precancerous changes in the prostate.8 As well, recent human studies at the David Geffen School of Medicine at UCLA have shown the effectiveness of green tea extracts in treating skin toxicity associated with radiotherapy for solid head, neck, and pelvic tumors. 9
While we wait for further confirmation from clinical trials that green tea both prevents and fights cancer, we can enjoy it knowing that it has no known side effects other than high doses delivering too much caffeine. By following the proper consumption and brewing instructions below, you can get maximum benefit while minimizing caffeine content.
How Much?
Drink three to six cups each day. Drink the tea throughout the day, as studies have found that continuous administration of the EGCG is more effective than a single dose.
Preparation Tip
The most important tip for steeping green tea is to use water that is just below the boiling point. Steep for under three minutes. This will draw out the maximum benefit from the tea and the least amount of caffeine.
Brewing Green Tea
Use one teaspoon of loose tea leaves for a small pot of tea. Use two teaspoons for a large pot of tea. Boil water, then pour into a porcelain teapot or mug and let cool for one minute. Add tea leaves and let brew for 1 to 3 minutes, depending on the desired strength. Serve or add to juice immediately.
What You Should Know About the Side Effects of Surgery for Cervical Cancer
A radical hysterectomy is most effective if the exploration during surgery shows that the cancer has not spread beyond the cervix. However, some patients will have cancer that has spread outside the cervix into the lymph nodes in the pelvis. Before performing a hysterectomy, the doctor will sometimes perform a pelvic lymph node dissection. Pelvic lymph node dissection involves the removal of lymph nodes to determine the presence or absence of cancerous cells. If the lymph nodes contain cancer, usually the surgeon will not proceed with a radical hysterectomy. Instead, another form of treatment, usually radiation therapy and chemotherapy, is generally recommended.
Despite undergoing surgical removal of cervical cancer, some patients may experience recurrence of their cancer. Cancer recurrence occurs more commonly with bulky stage IB or stage II cervical cancer. It is important to realize that some patients with cervical cancer already have small amounts of cancer that have spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of these micrometastases causes recurrence following the initial treatment. External beam radiation therapy with or without implant radiation and chemotherapy are often recommended to cleanse the body of micrometastases in order to improve the cure rate achieved with surgical removal of the cancer.
Surgery on top of living with a diagnosis of cancer can be both an emotionally and physically draining experience. Understanding associated surgical risks, short-term side effects and long-term side effects, as well as asking your doctor pertinent questions before surgery, will give you the tools to mange and cope after your surgery.
Any form of hysterectomy is major surgery with associated surgical risks. Hemorrhage, blood clots, surgical wound complications or allergic reaction to anesthesia are surgical risks that should be discussed with your doctor. In-hospital death occurs after radical hysterectomy in less than 1% of cases.
Normal and expected temporary effects of surgery for the treatment of cervical cancer may include pain, nausea, fatigue and anxiety. Urinary tract infection after the surgery is also common. Additional temporary side effects may include difficulty urinating or having a bowel movement. Since the bladder may be pushed and pulled due to all of the dissection around it, a temporary catheter (tube in the bladder to drain the urine) is usually required to give the bladder time to heal. With a simple hysterectomy, disturbance to the bladder is minimal making urinary complications rare. However, approximately one-third of women undergoing a radical hysterectomy may experience temporary bladder difficulties which may last a few weeks after surgery. Although most women return to normal bladder functioning, a very small percentage may require more permanent self-catheterization. Depending on the type of hysterectomy, your age and general health, recovery from short-term side effects may take 6 to 8 weeks.
In addition to rare bladder dysfunction, injury to the rectum and lower leg lymphedema are also potential long-term side effects of a hysterectomy. In a few cases, injury to the rectum or tubes that drain the kidneys (ureters) or bladder can occur. This may be in the form of a "fistula" or abnormal connection to the vagina. This is a chronic problem that may require surgery to repair the opening. Lower leg lymphedema (swelling) as a result of lymph node dissection may also occur in some cases. Elastic stockings or support hose as well as preventing infection and injury to the leg, can help minimize lymphedema.
Long-term sexual complications due to the removal of the uppermost part of the vagina are reportedly minor. In a few cases, patients indicate some loss of sensation and lubrication, as well as intercourse difficulty due to vaginal shortening. The emotional impact of the surgery may also affect libido in some patients.
The physical loss of reproductive organs has significant long-term physical and emotional side effects and should be discussed with your doctor before surgery. Some patients may want to investigate having their eggs harvested for possible surrogacy before surgery. Once the uterus is removed, women no longer menstruate and can no longer have children. Furthermore, if the ovaries are removed in a woman of child-bearing age, menopause will be induced. Some of the side effects of early menopause include hot flashes, irritability, vaginal dryness, sweats and nervousness. Hormone replacement therapy may be used to help control some of the side effects associated with menopause. The impact of losing reproductive organs is far reaching, affecting future plans as well as emotional well-being.
Surgery is a common form of therapy in the treatment of early stage cervical cancer. The risks of surgery, while remote, should be discussed with your doctor prior to surgery. The potential short-term side effects may cause varying degrees of discomfort that can usually be managed by you and your doctor. Potential long-term effects such as bladder and bowel problems, early induced menopause, as well as the physical loss of reproductive organs, are reportedly the most difficult for patients to deal with emotionally and physically. Using a surgeon and medical team highly experienced in performing hysterectomies may decrease your surgical risks and provide optimal management of side effects. Support groups, family support or professional support may help patients emotionally cope with side effects. Before undergoing any treatment you should understand your responsibility, your medical team’s role, explore treatment options, ask questions and get a second opinion(s).
Who Should be Screened for Cervical Cancer?
Cervical cancer accounts for 6% of all cancers in women. Approximately 15,000 new cases of cervical cancer are diagnosed each year in the United States and roughly 5,000 women die annually from this disease. Screening for abnormal, precancerous or cancerous cells in the cervix is critical for prevention, early detection and diagnosis of cervical cancer.
The National Cancer Institute recommends that women over the age of 18 or those sexually active before the age of 18 should be screened for cervical cancer annually. Women at an increased risk of developing cervical cancer should be particularly diligent in their annual screening. Risk factors include early age at first intercourse (16 or younger), history of multiple sexual partners, smoking and poor nutrition. In addition, a history of sexually transmitted diseases, such as chlamydia, human immunodeficiency virus (HIV), and especially human papillomavirus (HPV) appear to increase the risk of developing cervical cancer. Thirteen different HPVs (wart-causing viruses) have been linked to almost every case of cervical cancer. However, the converse is not true, as the presence of HPV does not guarantee that cervical cancer will develop.
Annual cervical cancer screening involves a pelvic exam and Pap smear. Patients who have an abnormal Pap smear may undergo a relatively new screening test called a Hybrid Capture II to determine the nature of the abnormal cells.
A pelvic examination screens for any palpable abnormal growths or irregularities. During a pelvic exam, a health-care provider inserts a gloved and lubricated finger into the vagina to feel the vagina, cervix, uterus, ovaries, fallopian tubes, bladder and rectum. The pelvic examination is usually performed in conjunction with the Pap smear.
Routine screening with a Pap smear is used to detect cancerous cells as well as abnormal cells that may or may not be precancerous in the cervix. During a Pap smear, a sample of cells from the cervix is taken with a small wooden spatula or brush and examined under a microscope. The results of a Pap smear are classified into five categories: negative or within normal limits (normal); atypical squamous cells of undetermined significance (ASCUS); low-grade squamous intraepithelial lesions (abnormal); high-grade squamous intraepithelial lesions (abnormal); or carcinoma (cancer).
If the Pap smear results are normal, no further evaluation is necessary. Women who have normal results will simply need to continue undergoing an annual examination and Pap smear.
Abnormal results from a Pap smear do not necessarily indicate cancer. Other conditions such as inflammation and sexually transmitted diseases can cause abnormal changes in cells. Some women will exhibit mild dysplasia (abnormal cells), in which case they may need to schedule frequent Pap smears to monitor for any changes. Women with severe dysplasia may need to undergo a biopsy for closer examination of abnormal tissue. A relatively new test called the Hybrid Capture II is used to determine the presence of 13 HPV viruses specifically linked to cervical cancer. The presence of one of these key HPV viruses may further define the nature of abnormal cells identified by a Pap smear. The presence of abnormal cells and one of the 13 high risk HPV virus may indicate that the abnormal cells are precancerous in nature. Conversely, if a high-risk HPV is not present, then abnormal cells are less likely to be precancerous.
Pap smear screening techniques have facilitated the early detection of cervical cancer and have reduced the incidence of cervical cancer by 75% over the past 50 years. To determine if you are at high risk and require additional follow-up other than yearly screening, please consult your doctor.
Understanding Cervical Cancer
The cervix forms the opening to the uterus from the vagina. It is covered with two main types of cells: squamous cells, which cover the part of the cervix that extends into the vagina, and columnar cells, which line the cervical opening. Most cervical cancers develop close to where these two cell types come together, in an area called the transformation zone. Once cervical cancer develops, it can spread throughout the cervix to neighboring organs or to distant sites in the body.
Cancerous and precancerous changes in cervical cells are often first detected by a Pap test, wherein a sample of cells is removed from the cervix using a small wooden or plastic spatula and a brush. The cells are then examined under a microscope in a laboratory. If Pap test results are abnormal, a physician may perform a colposcopy, using a microscope called a colposcope to better see the cervix. The physician applies a mild vinegar solution to the cervix, which makes abnormal cells appear more white than pink. If abnormal areas are identified, the physician may remove samples of tissue so that the cells can be further evaluated—a procedure called a biopsy.
The results of the biopsy allow the physician to diagnose cancer or precancerous conditions. Precancerous changes to the cervix are called cervical intraepithelial neoplasia (CIN). The severity of CIN is graded on a scale of 1 to 3, with 3 being the most severe. CIN2 and CIN3 are considered “high-grade” CIN and may progress to cancer if not treated.
What Is HPV?
There are more than 100 different types of human papillomavirus (HPV), and different types of HPV cause different conditions. Some types of HPV are linked with common skin warts, others cause genital warts, and still others are linked with cancers of the cervix, vulva, vagina, penis, and anus as well as some cases of head and neck cancer. HPV types 6 and 11 account for a majority of cases of genital warts, and HPV types 16 and 18 cause roughly 70 percent of all cases of cervical cancer. The remaining cases of cervical cancer are linked with other high-risk types of HPV.
The types of HPV that cause genital warts or cervical cancer are transmitted sexually. Sexual transmission of HPV is extremely common and generally occurs soon after an individual becomes sexually active. Most infections resolve on their own, but others persist. Persistent infection with a high-risk type of HPV can lead to precancerous changes to the cervix and, if these changes are not treated, to cervical cancer.
How is HPV linked to Cervical Cancer?
The sexually transmitted types of HPV most commonly linked with cervical cancer are HPV 16 and HPV 18 (transmitted sexually), but several other high-risk types contribute to cancer as well.
Though a link between cervical cancer and a sexually transmitted infection was long suspected, studying HPV was historically a challenge because it could not be grown in cell or tissue cultures like some other organisms. It would take the molecular techniques that were introduced in the 1970s to adequately study and understand the virus. Once these techniques were applied, it became apparent that most cervical cancers contained evidence of HPV.
Infection with a high-risk type of HPV does not necessarily lead to cancer. Many infections disappear on their own, and others may persist without causing cancer. Infection does, however, increase the risk of cancer, and virtually all cases of cervical cancer can be linked to infection with a high-risk type of HPV.
Is There a Test for HPV?
The recognition that specific types of HPV are the cause of cervical cancer led to the development of tests to identify women infected with high-risk types of HPV. Information about HPV status may guide decisions about follow-up care.
HPV testing may also have a role in initial cervical cancer screening, but conclusive evidence about this is still lacking. In the meantime some organizations have supported the combination of HPV testing and Pap testing for screening women over the age of 30. Women who test negative for both tests may need not be rescreened for up to three years. The combination of HPV testing and Pap testing is not recommended for screening younger women because most will have HPV infections that will clear without causing precancerous cervical lesions.
What are HPV Vaccines and How Might They Prevent Cervical Cancer?
HPV vaccines fall into two broad categories: preventive and therapeutic. Preventive vaccines are designed to prevent infection with the virus, whereas therapeutic vaccines would treat the infection, precancerous lesion, or cancer in individuals who are already infected. Although prevention of infection is the ultimate goal, treatment of existing infections and cervical changes would benefit the many women who are currently infected.
The two vaccines that are farthest along in development are preventive vaccines. Gardasil™, developed by Merck, targets HPV types 6 and 11 (which are linked with genital warts) as well as the cancer-associated types 16 and 18. Cervarix™, developed by GlaxoSmithKline, targets HPV types 16 and 18 only. Clinical trials of these vaccines suggest that they are likely safe and highly effective. The duration of effectiveness is still uncertain, but it appears to be at least four to five years. Because HPV types 16 and 18 are thought to account for roughly 70 percent of all cases of cervical cancer, widespread use of these vaccines would have the potential to eliminate most (but not all) cases of cervical cancer and precancerous changes to the cervix.
Because infection with HPV is extremely common and generally occurs soon after an individual becomes sexually active, the vaccines are likely to have the greatest effect when administered before the teen years. In addition to being less likely than older children to be sexually active, younger children versus older adolescent and young adult women appear to develop a stronger immune response after HPV vaccination. This may increase vaccine effectiveness.
It is thought that for these vaccines to have the greatest impact it will ultimately be important to vaccinate both girls and boys. Vaccinating a larger number of individuals will reduce transmission of these viruses in the community and will make it less likely that an unvaccinated individual will become infected. Furthermore, in addition to reducing the risk of cervical cancer, the vaccines are likely to reduce the risk of other HPV-related cancers, such as cancer of the penis, anus, and oropharynx (part of the throat). Protection against genital warts would also benefit both boys and girls.
In June 2006, Gardasil was approved by the U.S. Food and Drug Administration (FDA) for use in girls and women between the ages of nine and 26 years. Approval for use in males may be considered after more data become available. GlaxoSmithKline plans to apply to the FDA for approval of Cervarix by the end of the year.
Cervical cancer survivors prone to other cancers
Women who survive cervical cancer are at increased risk for developing other cancers decades later, according to a report in the Journal of the National Cancer Institute. The increased cancer risk is primarily seen in women who were treated with radiation therapy and involves organs that lie near the cervix.
"Previous studies have indicated that the risk of second cancers is increased among cervical cancer survivors, but overall and (body) site-specific risks among very long-term survivors were unclear," Dr. Anil K. Chaturvedi, from the National Cancer Institute in Bethesda, Maryland, and colleagues note.
The findings are based on an analysis of data for 104,760 cervical cancer survivors drawn from several Scandinavian countries and the U.S. The researchers calculated the rate of second cancers over more than 40 years of follow-up.
On the overall analysis, the survivor group was 30 percent more likely to develop a cancer than were women in the general population. Further analysis showed that the rates of human papillomavirus (HPV)- and smoking-related cancers were elevated in survivors who had radiotherapy and those who did not.
Survivors treated with radiotherapy had an elevated risk for cancers in close proximity to the cervix, including cancers of the colon, rectum, anus, bladder, ovaries and genitals. By contrast, no increased risk for these cancers was seen in survivors who did not receive radiotherapy.
The 40-year cumulative rate of a second cancer was higher for survivors diagnosed with cervical cancer before rather than after they were 50 years old: 22.2 vs. 16.4 percent, respectively.
"The most important finding is that even 40 years after a diagnosis of cervical cancer, survivors remain at increased risk of second cancers. These results are consistent with previous studies that showed increased second cancer risks beyond 30 years of follow-up, but that did not have sufficient data on time periods beyond 30 years," Chaturvedi told Reuters Health.
"The increased second cancer risk among cervical cancer survivors underscores the need for screening or regular medical surveillance," he emphasized.
Breast-feeding isn't such a drag on breasts
"A lot of times, if a woman comes in for a breast lift or a breast augmentation, she'll say 'I want to fix what breast-feeding did to my breasts,'" said University of Kentucky plastic surgeon Brian Rinker. So he decided to study any possible connection.
Rinker and his colleagues interviewed 132 women who came in for breast lifts or augmentation between 1998 and 2006. On average, the women were 39 years old, and 93 percent had experienced at least one pregnancy. Among the mothers, 58 percent had breast-fed at least one of their children. The average duration of breast-feeding was nine months.
The results of the study, presented this week at a conference of the American Society of Plastic Surgeons, showed no difference in the degree of breast ptosis (or sagging) between women who breast-fed and those who didn't.
The main factors that did affect sagging were age, smoking status and the number of pregnancies a woman has had.
Rinker noted that the smoking connection made sense because "smoking breaks down a protein in the skin called elastin, which gives youthful skin its elastic appearance and supports the breast."
Pregnancy also "has a very strong contribution to breast ptosis (sagging)," Rinker said in an email interview. "In fact, our study showed that those negative effects increase with each pregnancy."
"Women may be reluctant to breast-feed because of this unfounded myth that doing so means the end of youthful breasts," Rinker said. "Now, expectant mothers can relax knowing breast-feeding does not sacrifice the appearance of their breasts."
Doctors urge cancer patient mental screening
Doctors treating cancer patients should try harder to help them deal with the emotional toll the disease exacts, an expert panel said on Tuesday.
The panel convened by the Institute of Medicine recommended that cancer care providers systematically screen patients for emotional distress and other mental problems and connect them with people who can help.
The medical establishment has worked hard to develop new and better ways to treat tumors while devoting less effort to patients' emotional needs, the panel said.
Many cancer patients undergo harsh chemotherapy and radiation treatments and sometimes disfiguring surgical operations. They suffer prolonged nausea, fatigue, pain and hair loss and are unable to work or maintain social or family obligations.
Link patients to servicesAnd some often have little time left to live.
"Unmet psychosocial needs are common among cancer patients and their families. There are services available that could help them. But right now, they're not being linked up to these services," Adler said in a telephone interview.
Psychosocial health services are an integral part of cancer care, the panel said. Many such services already exist, often at no cost to patients, but care providers often fail to identify patients' needs and do not help them find and use these resources, the committee said.
Screening patients to find those who might need more support for emotional issues may be as simple in some cases as a short questionnaire that a patient would fill out while sitting in the doctor's office waiting room, Adler said.
The panel said it is important that cancer care providers not only screen patients for emotional issues but periodically re-evaluate them to see if their needs have changed.
Such needs might include more information about medical therapies they are undergoing and their possible side effects, treatment for depression and assistance with normal daily activities they can no longer do on their own, the panel said.
The Institute of Medicine advises U.S. policymakers on medical issues.
Some face long-term cervical cancer risk
Women with pre-cancerous lesions may need follow-up tests for 25 years
Women treated for pre-cancerous lesions are at increased risk of developing cervical or vaginal cancer for at least another 25 years, according to a study suggesting that follow-up tests fall dangerously short.
Using data from Sweden’s national cancer registry, the researchers said on Friday women who have had severe lesions in the cervix are more than twice as likely to develop one of the two cancers than women in the general population.
The findings underscore the need for follow-up tests to continue for at least 25 years after treatment, far longer than the current five or 10 years standard in most European countries, said Bjorn Strander, a gynecologist at Sahlgren’s University Hospital in Sweden, who led the study.
“This is a warning to the healthcare system to keep track of these women,” he said in a telephone interview. “It has not been known these women remain at risk for such a very long time.”
Most cases of cervical cancer are caused by the sexually transmitted human papilloma virus and is the second most common type of cancer in women. Vaginal cancer is far more rare, with about 13,000 women diagnosed each year.
Risk remains steady
Women in many countries have an annual Pap smear to check for early signs of these lesions, which are easily removed if caught before they develop into cancer.
Nonetheless cervical cancer kills 300,000 each year, mostly in developing countries. Merck and Co’s Gardasil and GlaxoSmithKline’s Cervarix vaccines protect people against certain strains of HPV, but not all.
In their study, the researchers mined the National Swedish Cancer Register for information recorded from 1958 to 2002 on more than 132,000 women diagnosed with pre-cancerous lesions.
They found that 881 women had developed cervical cancer and 111 women had vaginal cancer more than one year following their diagnosis — even after they had their lesions removed.
And the risk remained high for a long time, they said.
“We haven’t investigated why but there are indications it could be because a lack of surveillance,” Strander said. "The risk is quite steady. It does not decrease.”
A woman’s risk also rose if she was older at diagnosis, also possibly due to the healthcare system letting down its guard during follow-up care, Strander said.
The Swedish study, published in the British Medical Journal, did not look at whether a Pap smear or DNA test represented the best way to screen these women but said it merits further study, Strander added.
Two Italian researchers writing in a related editorial agreed the findings should spark further study and said they clearly show current testing guidelines are not sufficient.
“One clear indication is that women treated for (severe pre-cancerous lesions) should continue surveillance beyond the age limit of regular screening,” they wrote.
Saturday, November 3, 2007
3 drinks a day raises breast cancer risk
All types of alcohol — wine, beer or liquor — add equally to the risk of developing breast cancer in women, American researchers said Thursday.
"This is a hugely underestimated risk factor," said Dr. Patrick Maisonneuve, head of epidemiology at the European Institute of Oncology in Italy, who was not connected to the study.
"Women drinking wine because they think it is healthier than beer are wrong," he said. "It's about the amount of alcohol consumed, not the type."
The researchers, led by Dr. Arthur Klatsky of the Kaiser Permanente Medical Care Program in Oakland, Calif., revealed their findings at a meeting of the European Cancer Organization in Barcelona.
Researchers analyzed the drinking habits of 70,033 women of various races and asked them questions during health exams between 1978 and 1985. By 2004, 2,829 of these women had been diagnosed with breast cancer.
Researchers found no difference in the risk of developing breast cancer among women who drank wine, beer, or liquor. Compared with light drinkers — those who had less than one drink a day — women who had one or two drinks a day increased their risk of developing breast cancer by 10 percent. Women who had more than three drinks a day raised their risk by 30 percent.
"A 30 percent increased risk is not trivial," Klatsky said. "It provides more evidence for why heavy drinkers should quit or cut down."
Other factors countSome experts said that people might be confused by suggestions that drinking red wine is healthy, since some studies have suggested that it protects against heart disease.
"None of these mechanisms have anything to do with breast cancer," Klatsky said. Though it is not entirely clear how alcohol contributes to breast cancer, some experts think it raises hormone levels in the blood to levels that could potentially cause cancer.
Still, doctors said that other factors, such as genetics, obesity, and age, were more important in raising the breast cancer risk than was alcohol consumption.
More public education may be needed. "Alcohol has had a lot of good publicity. People may not realize the risk they're taking when they have a few drinks," said Tim Key, of the Cancer Research UK Epidemiology Unit at Oxford. Key was not involved in the study.
According to data published in the British Journal of Cancer in 2002, 4 percent of all breast cancers — about 44,000 cases a year — in the United Kingdom are due to alcohol consumption.
Only a small proportion of women are thought to be heavy drinkers. But experts now say there is enough evidence to blame alcohol for breast cancer — and to start educating the public.
"Any alcohol consumption will raise your breast cancer risk," Key said. "Women don't have to abstain from alcohol entirely, but they need to be aware of the risks they're taking when they have a few too many drinks."
Simple tips to combat breast cancer
A. It wasn't long ago that people felt helpless when it came to defending themselves against cancer. Now, we know that awareness, medical advancements and personal action can help us win this fight against cancer.
Breast cancer statistics have proven that women can take measures to protect themselves. In the 1980s, there was a rapid increase in breast cancer cases (probably at least in part due to better screening via mammography). Though the increase in cases continued into 2000, it has slowed.
While it is the most common cancer among American women (excluding skin cancers) and the second leading cause of cancer death, there is some very encouraging news. Death rates from breast cancer have continued to decline since 1990, and the largest decreases are in women under age 50. Most likely, these decreases are a direct result of increased awareness, early detection, and improved treatment.
WINNING AGAINST BREAST CANCER
There are two key tools women have when it comes to winning against breast cancer: prevention and early detection. Here are some ways to put these tools to work:
Prevention:
1) Watch Your Weight: Those extra pounds translate into added risk. Added fat cells produce additional estrogen, which can stimulate growth in our breast cells and increase our risk of developing cancer.
2) Exercise Regularly: Research has given us plenty of motivation to embrace daily exercise. Studies have indicated that exercise can lower estrogen levels over time, as well as strengthen our immune system and lower stress.
3) Reduce Estrogen Exposure: Any extra exposure to estrogen can stimulate breast cell growth, thereby increasing our risk of breast cancer. In addition to extra weight, other sources and triggers of estrogen include: hormone replacement therapy (HRT) or dehydroepiandrosterone (DHEA), significant alcohol consumption, and red meat or other animal fats (including dairy fat).
4) Eat Cancer-Fighting Foods: There is some truth to the old saying, "You are what you eat." Our eating habits directly affect our bodies' functions, from maintaining energy levels to fighting cancer cells. A cancer-fighting diet will include plenty of fruits and vegetables, while limiting fats. Some people are going with organic diets, in hopes of eliminating extra hormones, pesticides and genetically modified organisms from their diets; however, the research is still needed to learn if organic foods carry additional health benefits over other foods.
5) Quit Smoking: If you needed another reason to quit, here it is. Smoking is a key culprit behind many diseases, and breast cancer is one of them. If you have breast cancer, smoking can even interfere with your treatment. Talk with your physician to learn about the many resources available to you to help you stop smoking.
6) Know Your Risk: Most women with breast cancer have no apparent risk factors and having one or more risk factors doesn't necessarily mean you'll get breast cancer; however, women should discuss their risk factors with their physician. This information may affect their recommendations for mammograms. There is a wide range of uncontrollable and controllable risk factors. Some of these include: age, genetics, family history, previous incidence of breast cancer or abnormal biopsy, weight, alcohol use, and tobacco use.
Another key factor is race. Overall, Caucasian women have the highest incidence rate for breast cancer among U.S. racial/ethnic groups, but African American women have the highest death rate from breast cancer. Research has shown that African American tend to seek treatment when their cancer is at a more advanced, less treatable stage, which tells us there continues to be a need for increased awareness and accessibility to health care resources.
EARLY DETECTION
1) Regular Exams: Around age 20, women should self-examine their breasts monthly, about three to five days after their period ends. This allows women to become familiar with their breasts' normal structure and identify any changes or abnormal characteristics. Also, your physician should exam your breasts once every three years starting at age 20, and every year after age 40. If you're not sure if you're doing a self-exam properly, talk to your physician.
2) Report Any Changes: In addition to lumps or masses within the breast tissue, women should look for changes in skin color (reddening or bruised appearance) or texture (ridges or dimpling), nipple changes, nipple discharge, swelling and changes in shape or symmetry. Also, talk to your doctor if you experience any tenderness or burning in your breasts.
3) Get Your Mammogram: Mammograms are an extremely powerful ally in detecting breast cancer in its early stages. At age 35, women should consider getting a baseline mammogram, which provides a reference point for future mammograms. At age 40, women should begin getting a yearly mammogram.
Smoking not linked to aggressive breast cancer
Whether cigarette smoking raises a woman’s chances of ever developing breast cancer has remained a controversial question, with some research indicating a risk and other studies not.
Researchers at Fox Chase Cancer Center in Philadelphia investigated whether female smokers who got breast cancer were more likely to have a more serious form.
Nine percent of the breast cancer patients were smokers when they were first seen.
“For patients who developed breast cancer, there did not appear to be a difference in the cancers that they presented with based on whether or not they had ever smoked,” Dr. Matthew Abramowitz of Fox Chase Cancer Center, one of the researchers, said in a telephone interview.
“In addition, there did not appear to be a difference in the type of treatment they were offered, whether or not they were smokers,” added Abramowitz, whose findings were presented at a meeting of the American Society for Therapeutic Radiology and Oncology in Los Angeles.
Abramowitz said the study did not evaluate whether smokers were more likely than nonsmokers to have complications in treatment for breast cancer or die from the disease.
Abramowitz said the findings do that mean that smoking is any less hazardous than multitudes of studies have shown.
The National Cancer Institute said cigarette smoking causes 87 percent of lung cancer deaths and is responsible for most cancers of the larynx, mouth, esophagus and bladder. It said tobacco use, particularly cigarette smoking, is the most preventable cause of death in the United States.
Quality of life is key to cancer survival
They found patients with a below-average quality of life before getting treatment for lung cancer — those in poor health or with inadequate support networks — had nearly a 70 percent higher death rate than those with a better one.
"It's intuitive that someone who is in better physical shape and has a support system will do better than someone who comes in already debilitated and doesn't really have anyone to help them go through treatment," said Dr. Nicos Nicolaou of Fox Chase Cancer Center in Philadelphia in a telephone interview.
Doctors routinely consider factors such as tumor size, stage of the disease and other measures to predict how long a patient with cancer will survive.
But factors that make up a patient's quality of life — overall health, mobility, emotional stability, social support and financial resources — may make the most difference, Nicolaou and colleagues found.
"If you have someone to help you with your meals, transportation, give you your medications and take care of your daily needs, both physical and emotional, you will be able to get through the treatment better," he said.
Researchers at Fox Chase and Henry Ford Hospital in Detroit studied 239 patients with lung cancer enrolled in a treatment trial involving both radiation and chemotherapy.
The study was designed to evaluate the role of quality of life as a prediction for survival. Questions included things like: "Do you have trouble taking a long walk?" or, "In the past week, did you feel irritable? Did you feel depressed?"
Some 91 percent of patients completed a standardized quality of life survey before treatment. All patients were followed for at least 17 months.
What they found is quality of life emerged as the most significant predictor of overall patient survival.
"We conducted two different statistical analyses including all the usual prognostic factors and either way, quality of life remained the strongest predictor of overall survival," Dr. Benjamin Movsas of Henry Ford Hospital said in a statement.
"What's more, if a patient's quality of life increased over time, we saw a corresponding increase in survival," he said.
People who were single, divorced or widowed had significantly lower quality of life scores, and fared far worse in the study.
For these patients, doctors may need to take a more active role in ensuring that support services are in place before a patient undergoes cancer treatment, Nicolaou said.
"It is incumbent on the treatment team to make sure the patient's needs are met and the patient gets the support he needs to get through the treatment," he said. "It has to be an integral part of decision-making."
