“ People hear about the dangers of smoking. They hear about the dangers of secondhand smoke. But they don't hear much, if anything, about the dangers of thirdhand smoke. What's tricky about thirdhand smoke is that you can't really quantify the risk.” - Rabih Bechara, MD, FCCP - Chief of Interventional Pulmonology, Pulmonary and Critical Care Medicine at our hospital in Atlanta

Thirdhand smoke forms when particles from a cigarette or other tobacco-burning device seep into materials like hair, clothes, furniture, carpet and walls, and are absorbed. The chemicals then undergo an aging process, which changes their chemical structure. Nicotine reacts with indoor air pollutants like nitrous acid to form carcinogens, or compounds that may cause cancer. The gas is then continuously re-emitted back into the air in a process called “off-gassing.”

Efforts to diffuse the smoke, like opening windows or using a fan, don’t prevent thirdhand smoke from forming or keep it from being inhaled, and the residue may give off harmful chemicals for years or even decades. “Thirdhand smoke is not a one-time thing,” Dr. Bechara says. “It’s actually a phenomenon that accumulates over time with increased exposure.” Normal cleaning methods also aren’t effective against the pollutants. Most of the time, replacing carpets or repainting walls are the only options.

Although it’s a relatively new term, thirdhand smoke has been a research topic for decades. It was first discovered in 1953, when a scientist from the Washington University School of Medicine in St. Louis found that tobacco smoke condensate—or liquid from gas condensation—painted on mice caused cancer. In a 1991 study, researchers found nicotine in the dust of smokers’ homes. A later study, conducted in 2004, found that nicotine was still present in homes where smokers tried to limit exposure, such as smoking outdoors. A 2008 study comparing the cars of smokers to non-smokers’ vehicles showed similar results, even finding that the dashboards of cars driven by smokers who banned smoking in their vehicles had tobacco residue.

The term “thirdhand smoke” became widely known when it was used in a 2009 paper published in Pediatrics. In it, the authors theorized that stressing the potential dangers of thirdhand smoke to children’s health could help persuade adults to quit the habit: “Children are especially susceptible to thirdhand smoke exposure because they breathe near, crawl and play on, touch, and mouth contaminated surfaces.” To reduce the risk to children, the American Academy of Pediatricians issued recommendations to limit children’s exposure. “This is something that’s very important for smokers to know about because it could be an incentive for them to quit smoking for the sake of themselves and their loved ones,” Dr. Bechara says. “Awareness of thirdhand smoke can help smokers realize that it’s not just themselves they’re potentially harming.”

Although no research has been conducted yet on the effects of thirdhand smoke on humans, studies have shown that mice exposed to thirdhand smoke have a greater chance of developing lung cancer. “The important thing to know is that there is a risk, and this risk could predispose people to certain health issues, including lung cancer, liver damage and diabetes,” Dr. Bechara says.

But what if doctors could not only find cancer-related DNA mutations, but repair them at a genetic level? That’s the theory behind CRISPR, a breakthrough technology in genetics that has generated scores of news headlines and sparked a buzz among scientists and doctors. CRISPR has been called a “game-changing” gene-editing technique and one of the “biggest science stories of the decade.” But it also has prompted calls for cautious optimism as scientist determine its full potential to treat cancer and other diseases. “There is uncertain potential for CRISPR as a cancer treatment,” says Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America^® (CTCA).

So how can something that sounds like a kitchen appliance be used to edit genes and potentially treat disease? CRISPR works by targeting stretches of faulty DNA, unravelling a piece of the damaged DNA and cutting it using an enzyme called Cas9. The unraveled sequence is matched to a strand of compatible RNA and rewoven into the DNA strand. Scientists theorize they can manipulate Cas9 to cut sequences of faulty DNA and introduce specific RNA spans to finish the repair. Scientists say the repair process using CRISPR is faster and more accurate than other gene-editing methods used before. This allows researchers to study potential therapies more quickly. “The primary advantage of CRISPR is its ability to easily edit the genome in a precise fashion,” says the National Cancer Institute’s Ji Luo, Ph.D.  

Multiple studies have been launched to determine whether CRISPR can be used to repair DNA mutations in cancer cells or manipulate cells to attack tumors:

• Researchers at Harvard Medical School theorize that cancer cells that have strayed from their primary tumors can be re-engineered by CRISPR to return home as attack cancer cells and shrink or destroy the tumor. The researchers have reported positive results in mice with brain and breast cancer.
• Scientists at the University of Pittsburgh’s School of Medicine are using CRISPR to edit so-called “fusion genes” that can cause cancer. Fusion genes are created when features from two different genes join to form a single abnormal gene that can cause or promote cancer. One such fusion gene is known as the Philadelphia chromosome, which forms when pieces of two chromosomes break off and trade places, forming the defective gene. This gene is associated with chronic myeloid leukemia.
• Several studies are exploring ways CRISPR may make immunotherapies more effective. Doctors at Memorial Sloan Kettering, for example, report that T-cells edited by CRISPR into super immune cells using proteins called chimeric antigen receptors (CAR) produced positive outcomes in early trials. These receptors allow T-cells to better identify and attack certain cancer cells. CAR T-cell therapy was first approved to treat blood cancers last year.

A cup of home-brewed joe may have at least 95 mg of caffeine, enough to jumpstart the day for most. For those who may seek a more potent morning jolt, a 20-ounce take-out from a popular coffee house franchise can have upwards of 475 mg of caffeine, according to the Center for Science in the Public Interest.

Coffee and cancer have had a rocky relationship over the years. Coffee was once recklessly touted as a cancer treatment and later declared a carcinogen. Today, new studies indicate it may help prevent certain types of cancer. And recently, a California judge stirred controversy by ruling that a health warning should be attached to coffee sold in that state. So, what are the myths and realities when it comes to coffee and cancer?

Can coffee increase the risk of cancer?

“There is no clear evidence linking coffee consumption and increased risk of cancer,” says Anthony Perre, MD, Chief of the Division of  Outpatient Medicine at Cancer Treatment Centers of America^® and an Internist at our Philadelphia hospital. In fact, the World Health Organization (WHO) removed coffee from its list of carcinogens in 2016. WHO added coffee to its list of risk factors more than 25 years ago, but reversed course after more recent studies found no evidence that coffee increased cancer risk. “A study published in 2017 showed that drinking two cups of coffee a day may lower the risk for several cancer types, including breast cancer, colorectal cancer, liver cancer and head and neck cancers,” Dr. Perre says. “There are probably a number of factors that may contribute to the reduced risk.” The bottom line is there’s no overwhelming evidence that coffee can cause or help prevent cancer.

Why is coffee considered a carcinogen in California?

While there is no evidence coffee itself raises cancer risk, a substance formed when coffee is processed may. “There has been some concern about acrylamide, which is formed when coffee beans are roasted,” Dr. Perre says. In a court decision that stirred much debate, a California judge ruled that coffee sold in the state required a cancer warning because of the presence of acrylamide. The substance is listed among 900 chemicals that require warning labels under the state’s Safe Drinking Water and Toxic Enforcement Act, known as Prop 65. Acrylamide is a chemical used in the production of some paper and plastic products. It also forms in some starchy foods cooked at high temperatures. According to the American Cancer Society (ACS), “most of the studies done so far have not found an increased risk of cancer in humans.” But the ACS suggests more studies are needed. “For now, it is suggested that we may wish to reduce our consumption of other foods high in acrylamide—like French fries, potato chips, crackers, bread, cookies and breakfast cereals,” Dr. Perre says.

Can drinking hot coffee or other beverages increase cancer risk?

In 2016, WHO classified hot beverages as a probable carcinogen after the International Agency for Research on Cancer concluded that very hot beverages can cause cell damage and inflammation that may lead to cancer. Experts recommend not drinking hot beverages above 149 degrees Fahrenheit, or 65 degrees Celsius.

Are coffee enemas a viable treatment for colon cancer?

Information abounds on the alleged cancer-treating benefits of coffee enemas. The theory behind this unusual treatment is that coffee delivered directly into the colon causes rapid caffeine absorption that jumpstarts detoxification. The treatment was part of The Gerson Therapy, named for Max Gerson, MD, who promoted detoxification through enemas, juices and organic fruits and vegetables. In 1947, the National Cancer Institute called Gerson’s practice into question and found that cancer had progressed in all his patients. The U.S. Food and Drug Administration has not approved The Gerson Therapy to treat cancer or other diseases, and there is no evidence coffee enemas can successfully treat cancer. On the other hand, coffee enemas do come with some risks, including internal burns, colitis and infections.

Wissam Jaber, MD, an Interventional Pulmonologist at our Phoenix hospital, suggests patients check with their oncologists or other members of their care team before trying new or unconventional cancer treatments. Also, he said, those treatments should not act as alternative to their normal care regimen. “I tell my patients, if they want to try new things, let us know about it,” he says. “If we think it’s safe, they are perfectly fine to try them as long as they don't use it as a substitute for proven scientific treatments. If you get approval from your doctor to do something new or different, do it. But don't skip your chemotherapy.”

 Learn new ways to make healthy snacks and meals.

“ Branded drugs are either synthetic, meaning they're made from a chemical process, or biological, meaning they're made from living sources. Synthetic branded drugs can be exactly replicated into more affordable generic versions, but because biologics involve large, complex molecules, they cannot. That's where biosimilars come into play.” - Jamie Joy, PharmD, Director of Clinical Pharmacy Programs for Cancer Treatment Centers of America

When drug manufacturers receive U.S. Food and Drug Administration (FDA) approval on a new drug, they obtain a patent ensuring that no other company can create or sell the drug for as long as the patent is in effect, generally 20 years. These exclusive patents allow for a monopoly on the drug, and, generally, an expensive price tag.

The Hatch-Waxman Act, passed in 1984, reduced the cost of synthetic branded drugs by allowing other companies to create generics, or identical but less expensive versions of the original, branded drug, once the patent expires. In 1984, generic drugs accounted for 19 percent of retail prescriptions. In 2016, they accounted for 89 percent, and a March report from the President’s Cancer Panel found that the U.S. generic drug market saved the U.S. health care system an estimated $253 billion overall in 2016, including $10 billion in savings for cancer drugs.

But at the same time as generic drugs have helped offset the high cost of name-brand medications, some newer drugs, such as the immunotherapy and targeted therapy drugs now commonly used to treat cancer, have driven up prescription prices even more. A May report from the IQVIA™ Institute from Human Data Science found that spending on cancer medications in the United States doubled from 2012 to 2017. Many of these newer-to-market drugs are biological drugs, or biologics, which are branded drugs made from living organisms like yeast, bacteria, or animal or plant cells. In 2005, biologics made up 39.1 percent of the $9.5 billion in Medicare drug spending. By 2014, they accounted for 62 percent of the $18.5 billion spent by Medicare on prescription drugs.

Now that the patents on high-priced biologics are beginning to expire, many experts hope that biosimilars, which are comparable but not chemically identical to their name-brand counterparts, may work the same way generics did to help offset drug prices. In 2010, Congress passed the Biologics Price Competition and Innovation Act, which established an abbreviated regulatory process for biosimilars and paved the way for their approval.

For a biosimilar drug to receive FDA approval, it must be highly similar to the original biological drug and contain no clinically meaningful differences, although there may be minor differences in clinically inactive ingredients. According to the National Cancer Institute, the biosimilar also must prove to be “as safe as, work as well as, and work in the same way as” the original drug, and “be used in the same way, at the same dose, and for the same condition.”

Generic drugs are chemically identical to the original branded drug and, as such, cost significantly less because they don’t require much testing. Because biosimilars are made from living organisms, though, and don’t contain identical ingredients to their name-brand counterparts, they still require some testing. So, they cost more than generics, but less than the branded biologic.

In general, generic drugs cost 40 percent to 50 percent less than the brand product, Joy says. Biosimilars, in contrast, are closer to 15 percent to 20 percent cheaper because of the amount the drug manufacturer has to spend on testing. “But because there are potential cost savings to the drug industry as a whole, I think we’ll see a slow-moving shift toward using biosimilars more and more in the future,” she says.

So far, the FDA has approved 12 biosimilars. The first was filgrastim-sndz, approved in 2015 as a derivative of the branded drug filgrastim, which is used to prevent infection during chemotherapy. The drug bevacizumab-awwb, modeled after bevacizumab, was the first biosimilar approved for cancer treatment, in 2017. The next biosimilar coming down the pike, which will be on the market in 2019, is trastuzumab-dkst, a biosimilar developed from trastuzumab. Like trastuzumab, the biosimilar will be used to treat certain people with breast or metastatic stomach cancers that contain an excess amount of the HER2 protein.

“ No one dies of pre-cancer. It’s a very treatable condition, if it even needs treatment at all. A pathology report may indicate carcinoma in situ. When patients, and even some clinicians, see the word carcinoma, they get misled into thinking they have cancer. Pre-cancer means there are cells that have grown abnormally, causing their size, shape or appearance to look different than normal cells.” - Justin Chura, MD - Chief of Surgery & Director of Gynecologic Oncology and Robotic Surgery at our Philadelphia hospital

Whether abnormal cells become cancerous is, in many cases, an uncertainty. Some of the variables are known, others are not. So what exactly does it mean to be told you have a pre-cancerous condition? Does it increase the risk of getting cancer? Are there any prophylactic (preventative) measures that can be taken to reduce the likelihood that a cancer diagnosis is in your future?

According to Elizabeth Min Hui Kim, MD, MPH, FACS, Director of the CTCA Breast Cancer Institute, pre-cancer is becoming an outdated term in breast oncology as well as other specialties,  because the condition is more complex than a blanket term can describe. “We’re understanding these precancerous cells have certain genes, and we’re using technology to understand how they differ from each other and have different risks based on their biology,” she explains. 

Citing the current body of literature—which includes a 1985 study that re-evaluated 10,366 breast biopsies performed on women at three Nashville hospitals, a 2007 Mayo cohort study, a 2012 study that evaluated breast cancer risk based on atypia type, a 2012 study on the management of high-risk breast lesions and a 2016 study on which Dr. Kim was a lead author—Dr. Kim says doctors can classify the condition into one of three categories: non-proliferative disease, proliferative disease without atypia and proliferative disease with atypia.

How to approach a non-proliferative disease diagnosis depends on the person’s cumulative risk of developing breast cancer, which is a risk assessment based on a variety of factors, including but not limited to family history and breast density as well as personal risk factors that may be modifiable, like body mass index (BMI) and tobacco or estrogen use. If the cumulative risk is determined to be greater than 20 percent, Dr. Kim says enhanced screenings (having both a mammogram and a breast MRI, for example) may be recommended.

Diagnoses in the proliferative disease category indicate that abnormal cells are growing faster than normal cells, but not as fast as cancer cells. “There is abnormal growth or size of the cells, or the cells might be larger than normal,” Dr. Kim explains. An example of a proliferative disease would be an intraductal papilloma of the breast, which is like a polyp. Surgical removal of the area may be advised, depending on the patient.

Proliferative disease with atypia indicates high-risk lesions (abnormal cells) that are growing faster than normal. Depending on the cumulative risk, a form of medical treatment called anti-estrogen therapy or surgery may be recommended.

Modern medicine allows many “pre-cancerous conditions” to be found early. A pap test detects cervical dysplasia (abnormal cells in the cervix), sometimes referred to as pre-cancer. Low-grade dysplasia is typically not treated unless it persists for a couple of years, Dr. Chura says, while high-grade dysplasia would require a biopsy. The biopsy results would dictate the next steps. A colonoscopy detects colon polyps, and skin cancer screenings by a dermatologist are credited with identifying for removal many skin cancers that would have metastasized (spread).

“If you’re diagnosed with some type of dysplasia, whether in the esophagus, colon, cervix, etc., it doesn’t mean you will develop cancer. It means you will need some type of surveillance and treatment plan to manage it,” Dr. Chura says.

The takeaway is that a pre-cancerous condition does not mean you have cancer. It simply means you have an increased risk of cancer, which should serve as a reminder to stay current with medical visits and screening tests and communicate concerns or changes to your doctor.

“These are easily solvable problems and can be addressed with treatments that are a lot less invasive and have a lot more options than if the patient had a malignant disease,” says Dr. Kim. “It’s not cancer until proven otherwise. And if it is, they’ve caught it really, really early.”

Myth: Cancer is just one disease

Around 400 B.C., Hippocrates theorized that cancer was a single disease that would not fully go away, in most cases, even after it was surgically removed. That’s why, for centuries after the scholar’s death, cancer often went untreated for fear that interventions would do more harm to the patient than good. Much has changed since then, thanks to advances made in the last century—especially in the area of precision medicine in the last two decades. Yet despite new evidence to the contrary, some people today still believe that cancer is just one disease. What research has shown is that cancer is many diseases, each with its own characteristics, risk factors, causes and treatments.

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Learn more about cancer treatments.

Three dangerous myths about cancer and cancer treatment

A cancer diagnosis often triggers a rollercoaster of ups and downs, dread and optimism, fear and empowerment. Adding to the distress is the difficult task of gathering information to make an evidence-informed decision on a treatment plan. It is natural for a patient to develop erroneous beliefs about cancer and cancer treatment while missing out on important new insights that research shows may improve treatment outcomes. Eugene Ahn, MD, Medical Oncologist at our Chicago hospital, addresses three myths that are not only incorrect, but also may harm a patient’s chances for thriving after a cancer diagnosis.

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Learn how stress triggered by a cancer diagnosis may amount to PTSD.

If radiation causes cancer, how can it be used to treat cancer?

Radiation is everywhere. Ultraviolet light streams down from the sun. Radon may seep from the cracks in our basements. Nuclear energy keeps the lights on in millions of homes across the world. X-rays and MRIs are used to help diagnose injury and disease. The human body is bombarded with low doses of ionizing and non-ionizing radiation throughout the day, from sources of heat and light to waves from cell phones and microwaves. “Our body has the ability to recover from radiation damage,” says Anderson Bauer, MD, DABR, Radiation Oncologist at our Phoenix hospital. “If it didn’t, we wouldn’t have made it as a species this far in time.” In high or sustained doses, however, radiation may be both damaging and devastating. So how can something so potentially lethal be used to treat cancer? “We get that question all the time,” Dr. Bauer says.

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Learn about the differences in radiology and radiation therapy.

Can hyperbaric oxygen treat cancer?

Oxygen is one of life's essential ingredients. "Every cell in our body requires oxygen to survive," says Wissam Jaber, MD, Director of Interventional Pulmonary Medicine at our Phoenix hospital. "We are built to consume oxygen." Cancer cells' relationship with oxygen is a bit more complicated, and that realization has led to decades of research into whether oxygen is good for cancer or bad for it. The answers are still not definitive, but some have used the unknowns to fuel unsupported claims that certain types of oxygen therapies, including hyperbaric oxygen therapy, can cure cancer.

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Learn more about interventional pulmonology.

7 common chemotherapy myths

If you think you know all about chemotherapy, you may be surprised to hear that it no longer automatically causes severe nausea and vomiting. In fact, medical advances over the years have helped lessen chemotherapy’s impact on the body in many ways. “Chemotherapy has a very bad rap,” says Dennis Citrin, MB ChB, PhD, Medical Oncologist at our Chicago hospital. “While the cancer treatment itself has evolved for the better over the past few decades, its public perception hasn’t quite caught up. Educating patients about the facts is such an important piece of what we do every day.” To help further that education, Dr. Citrin dispels a few of the most common chemotherapy myths.

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Learn how integrative care may help manage the side effects of treatment.

Five chiropractic care myths busted

Cancer patients often experience side effects, caused by either the cancer or the treatment used to fight it—sometimes both. Research has shown that, in many cases, supportive care may help patients manage those side effects and reduce the risk of treatment delays. One such therapy involves chiropractic care. This supportive care service is a non-surgical, drug-free option for some patients with pain or stiffness in the neck or back, muscular tension, headaches, peripheral neuropathy, difficulty walking and other disorders of the musculoskeletal and nervous systems. Like some other supportive therapies, misperceptions and misinformation have clouded some people’s understanding of the impact chiropractic care may have in a cancer care setting.

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Learn more about chiropractic care

In high or sustained doses, however, radiation may be both damaging and devastating. Radiation may disassemble atoms and cause DNA damage in cells, leading to potentially serious side effects, including cancer. Ultraviolet light from the sun may damage skin cells and increase the risk of skin cancer or melanoma. Radon, an odorless gas found in indoor areas and drinking water, has been linked to an increased risk of lung cancer. High doses of ionizing radiation may damage organs and cause blood diseases or neurologic disorders. So how can something so potentially lethal be used to treat cancer? “We get that question all the time,” Dr. Bauer says.

What is radiation?

Radiation was first discovered as a potential cancer treatment around the turn of the 20^th century. But when radiologists in those early years began developing leukemia, it was soon discovered that radiation may also cause cancer. In the decades that followed, the ravages of radiation poisoning have been recorded in the survivors of the 1945 nuclear bomb explosions in Japan, those exposed to nuclear weapons testing and victims exposed after the 1986 explosion at the Chernobyl nuclear power plant.

But researchers and doctors have learned to harness the power of radioactivity to damage cells and unleash it on cancer cells. And today’s radiation therapy technologies are better able to focus that energy with exacting precision with tools designed to spare surrounding healthy tissue. The Calypso® 4D Localization System™, for instance, is designed to adjust the radiation beam to a patient’s breathing and other natural movement. TomoTherapy^® is designed to mold the radiation beam to the exact shape of a tumor. Interventional radiologists have techniques designed to deliver radiation therapy directly to liver tumors. “These technologies reduce the risk of damage to healthy tissue and decrease the chance of a secondary malignancy,” Dr. Bauer says. “And at the same time, they reduce the potential side effects a patient may experience while undergoing radiation treatment.”

Side effects patients experience after radiation treatment may depend on the cancer it is being used to treat. Radiation exposure to healthy lung tissue may cause inflammation and coughing. Damage to healthy tissues in the gastrointestinal tract may cause pain, nausea or diarrhea, Dr. Bauer says. And the risk remains that radiation therapy to treat cancers in young people may increase their chance of developing second cancers later in life. “It’s definitely something we think about, more so in younger patients,” Dr. Bauer says. “We don’t like to take unnecessary risks if there are other options. But the benefit of the cancer treatment far outweighs the risk of a secondary malignancy. It doesn’t mean we ignore the risk.”

  Learn more about leukemia. >>

A blanket. Hospitals are known for being chilly, and even though most infusion rooms (where chemotherapy is administered) supply blankets, it may be even more comforting to have your own soft, velvety covering gifted by someone special. Also consider covers made from other comfortable fabrics, like a jersey knit. A breast cancer patient at our Atlanta hospital told us that her blanket was a source of comfort when she was restless or cold, both at home and in the hospital.

Port pillow. To avoid repeated needle sticks during chemotherapy, many patients have a port implanted under their skin, usually on the chest, where the drugs can be intravenously administered. A port pillow protects the port site from becoming irritated by a seatbelt when riding in the car. You can often find one in a hospital gift shop or on the internet, or look for internet sites that teach you how to make one yourself. A small, soft pillow to place under the arm may also help women who have had breast cancer surgery by reducing the pressure of the arm on the breast.

Silk eye mask. This simple and inexpensive gift may help the patient nap during treatment or allow him or her to sleep through the night at home or in the hospital, where noise and light may interfere with the quality and quantity of sleep. Silk masks tend to be more comfortable than those made of satin or other materials that can be hot or uncomfortable when worn for long periods. Consider adding a lavender pillow spray and wrapping the two in a pretty package with a heartfelt note.

Lounge wear. During treatment, many patients do not feel their best. Some may be in the hospital for extended stays or recuperating at home. A comfortable set of lounge wear or pajamas may be a fitting gift for these occasions. When shopping, consider what limitations the patient may face when getting dressed. For example, a breast cancer patient who has had a mastectomy may have difficulty raising her arms to put on a T-shirt, so a button-down pajama top may be a better option.

Back scratcher or zipper puller. When patients are unable to raise their arms, these two items may come in handy, particularly for patients who live alone. The back scratcher may help them scratch hard-to-reach spots on their backs. Many forms of the zipper puller have been created, with each allowing the patient to reach back and zip up a dress or top without assistance. 

Insulated water bottle. Since patients undergoing chemotherapy need to stay hydrated, a quality water bottle that keeps liquids cold or hot for extended periods may be particularly useful. Consider getting the bottle monogrammed or ordering one with your loved one’s favorite sports team, hobby or color.

Gift cards. Gift cards are helpful in most any situation. Some of the most frequently requested gift cards are for restaurants, meal delivery and car services for patients who cannot drive. You can also buy gift cards to purchase apps, such as guided meditation, or to buy favorite soundtracks, movies and audio books or even games for their tablet or smartphone. Avoid gift certificates for a manicure or pedicure, since many oncologists recommend against patients cutting their cuticles or using artificial nails during treatment. Cuts or breaks in the skin may result in an infection, which may be dangerous for cancer patients, whose immune systems are already over-taxed. Acrylic nails are also not advised during chemotherapy because bacteria may become trapped under the nail bed and cause an infection.

Kindle, iPad or other tablet. These convenient mobile devices can help your loved one pass the time during treatment by watching movies, reading books or magazines, catching up on some work or emailing friends.

Headphones. A nice pair of headphones would allow the patient to listen to music or watch a movie without being disturbed or disturbing others. This gift may be especially appreciated by those sharing a hospital room.

Adult coloring books, journals, a bible or religious or inspirational books. These can all be found online or in a hospital gift shop. 

A nice scarf, hat or “chemo beanie.” Many chemotherapy patients look for ways to dress their scalps after losing their hair during treatment. A colorful, stylish head covering may serve to boost their self-image while also keeping their head warm.

Compression socks. These help with arm or leg swelling while sitting for extended periods, particularly while traveling.

A tote bag. Anita O’Dell, manager of the Lori’s Gifts gift shop at our Atlanta hospital, suggests putting together a tote bag or basket of items the patient can use during chemotherapy. O’Dell recommends including ginger chews (to help with nausea), a beanie or scarf to cover the head, coloring books, games, lip balm, hand lotion, magazines, fruit and healthy snacks, such as nuts, popcorn or hard candies. A travel toothbrush, toothpaste and alcohol-free mouthwash are nice additions to help get rid of the metallic taste chemotherapy may cause.

If you are on a budget or would rather find a gift that does not require shopping, there are other ways to show you care without spending money, including:

Offer your help. Walk the dog, sweep the floor, do the dishes. Most cancer treatments leave patients fatigued at one point or another. These simple tasks can be exhausting when you’re not feeling well. Offer specific services, since many patients are too embarrassed to ask someone to do their housework or run their errands. Tell your loved one you’re coming over to do laundry, go grocery shopping or clean the house, so he or she doesn’t have to be the one to make the suggestion.

Organize a sign-up sheet for the patient’s friends, neighbors and co-workers. Categories can include dropping off meals, dog-walking, laundry, housecleaning, driving the patient to treatment and appointments and carpools for the patient’s children.

Send a card or note. This small gesture may go a long way toward comforting your loved one. Patients report that knowing someone is thinking of them and sending positive energy may be especially comforting on days they are feeling low. One patient told us one of her favorite gifts was an inspirational word jar put together by her co-workers. Her colleagues wrote uplifting messages and placed them in a beautifully decorated jar. She began each day by pulling out a message, and she still uses the inspiration jar today, well after her treatment has ended.

In the past, that may have meant limb amputation, surgical castration or the complete removal of the chest muscle. But today, in this era of personalized, precision medicine, that one-size-fits-all approach has largely fallen out of favor. Instead, cancer treatment is often a matter of weighing options and determining what makes sense for each patient. In many cases, in fact, less is now more when it comes to cancer treatment.

“ We used to tell patients, 'You have a liver metastasis, so you need part of your liver removed.' Now, we tell them, 'You have a liver metastasis, so here is your list of options.' We spend more time weighing the different options than just going ahead and treating, and most of those options spare much more normal tissue than treatments did in the past.” - Steven Standiford, MD, FACS - Surgical Oncologist at CTCA Philadelphia

After decades of research, scientists and oncologists have discovered that cancer is not just one disease but many, each with its own unique characteristics and tailored treatment options. One cancer may respond to a “nuclear” approach, for instance, but another may be treated over the course of a patient’s lifetime as a chronic but manageable illness. These learnings have helped lead to dramatic reductions in the severity and number of treatments patients receive.

They’ve also helped pave the way for more precision-focused treatments, such as targeted therapies, which are designed to pinpoint biomarkers unique to cancer cells, and immunotherapy drugs, which help the immune system recognize and attack cancer cells.

By better targeting the cancer, these treatments typically lead to fewer side effects than chemotherapy and other standard approaches because they do not kill healthy cells. “The issue with non-targeted therapies like chemotherapy is that they can hit anything in their wake,” says Marnee Spierer, MD, Chief of Staff and Chief of Radiation Oncology at CTCA Phoenix. “We are learning that we can be more focused in our treatment and more direct and, therefore, potentially treat patients in a shorter period of time, with fewer therapies and with potentially fewer side effects.”

The evolution of cancer treatment: From more to less

In 1882, William Halsted, Professor of Surgery at Johns Hopkins University, performed the first radical mastectomy, which became the standard of care for breast cancer surgery for almost a century. During a radical mastectomy, a surgeon removes the breast tissue along with the nipple, lymph nodes in the armpit, and chest wall muscles underneath the breast. But 100 years later, in the 1980s, clinical trials found that a lumpectomy was an equally viable option that was far less extensive and easier on the patient, since it removed the primary tumor, not the breast itself.  “When I started practicing in the 1980s, mastectomies were still pretty much the standard, and we would talk about who was a potential candidate for a lumpectomy,” Dr. Standiford says. “Now, it’s completely the opposite. We talk about who is not a candidate for a lumpectomy. The entire perspective has changed.”

In June, the breast cancer treatment paradigm shifted again, when a landmark clinical trial found that two-thirds of women who have early-stage breast cancer and are treated with chemotherapy don’t necessarily need it. The results, published in the New England Journal of Medicine, concluded that most early-stage breast cancer patients with an intermediate risk of recurrence—around 85,000 women a year—may safely forego chemotherapy.

Prostate cancer treatment has undergone a similar evolution. For more than a century, the standard treatment called for removing the prostate during surgery. But research has shown that because prostate tumors grow so slowly, most men are more likely to die of something other than their cancer. So today, many men with early-stage prostate cancer may choose active surveillance over surgery, avoiding potential side effects like incontinence and sexual dysfunction.

Similarly, bladder cancer patients often have their bladder removed, forcing them to either wear a permanent bag to collect urine or undergo surgery to have a new bladder created from the intestines. Now, though, a clinical trial is underway, studying whether patients with certain types of bladder cancer may choose active surveillance over surgical removal of the bladder.

Research has also found that, in certain cases, patients with throat cancer caused by the human papillomavirus (HPV) may receive less invasive treatments than those whose cancer was not caused by HPV. And a study published in August in the New England Journal of Medicine found that many patients with advanced kidney cancer may be treated with chemotherapy alone rather than the standard surgery and chemotherapy combination commonly used to treat the disease today. 

The “less is more” trend has also shifted many radiation therapy approaches. Studies are increasingly finding that fewer but stronger doses of radiation are just as effective as a larger number of doses given at lower concentrations in treating many cancer types. According to study results published in The ASCO Post in October 2017, for example, “a higher-dose, shorter form of radiation is safe, effective, and no more damaging to the breast tissue or skin of breast cancer patients under age 50 than it is in older patients.” Some men may also opt for significantly shortened radiation regimens for prostate cancer. “Prostate cancer patients with certain types of tumors who would have received dozens of radiation treatments in the past now may be eligible for as few as five treatments,” Dr. Spierer says. “This has become increasingly standard within the past few years.”

The quality-of-life factor

The emphasis on quality of life has played its own important role in scaling back aggressive treatments. “There was not nearly the emphasis on quality of life when I started practicing medicine as there is today,” Dr. Standiford says. “In the past, if someone was going to be getting four months of chemotherapy after his surgery, we would tell him he wasn’t going to be able to work for four months. Today, we tell him that if he gets his chemotherapy on Friday, he can be back at work on Monday. Patients nowadays want to be empowered to make their own decisions and get back to normal life as quickly as possible.”

The increased focus on patients’ well-being has also influenced doctors to take a broader view of the risks involved in treatment before making a recommendation. “We now weigh all the factors when treating cancer,” Dr. Standiford says. “Not just cancer risks, but health risks, in general.” For example, a woman treated with radiation for cancer in her left breast has a higher risk of heart attack than a woman who received radiation in her right breast—an important consideration for doctors today. Also, many surgical oncologists heavily weigh the impacts on a lung cancer patient before recommending surgery. “If I perform surgery on someone who will probably have to live with cancer for the rest of his life and, after the surgery, he has to receive supplemental oxygen every day, something he’s never had to do before, I may have treated the cancer, but did I really treat the patient?” Dr. Baik says.

In the same way, a non-small cell lung cancer patient may choose a wedge resection, or the surgical removal of cancerous cells in the lung, as an alternative to a lobectomy, in which up to 40 percent of the lung is removed, because it’s less invasive. But that shouldn’t be the only factor considered, Dr. Baik says. “The recurrence rate with a wedge resection can be high, so choosing the less invasive route isn’t always the right choice,” he says. “You have to be careful. Yes, we want less invasive, but we have to scrutinize the decision and make sure we’re not missing anything.”

The patient’s age and health are also important to consider when choosing cancer treatment options. If an early-stage lung cancer patient is 90 years old and unable to tolerate surgery, for example, radiation may be the preferred choice because it involves a more focused treatment with fewer impacts on healthy tissue. In fact, an August study published in the Journal of the American Medical Association found that for elderly women with breast cancer, surgery may not be the recommended option because it diminishes quality of life.

The “Angelina Jolie effect”

Still, the decision about which treatment to choose ultimately lies with the patient. “I tell some patients that radiation therapy will add very little benefit to their treatment,” Dr. Spierer says. “But some will choose to do it anyways. They want everything. But what they don’t understand is that ‘everything’ still doesn’t guarantee that they’ll be cured, and they’re still getting side effects from the treatment.”

Some doctors say young women are the ones who generally want more aggressive treatments, even when they’re not warranted. This tendency is commonly referred to as the “Angelina Jolie effect,” the term coined to describe the impact made when actress Angelina Jolie announced in a 2013 New York Times op-ed piece that she’d undergone a preventative double mastectomy after learning she was a BRCA1 gene mutation carrier.

“Young people are generally the ones who come in with early breast cancer but request a double mastectomy so they never have to worry about it again,” Dr. Standiford says. “It’s actually the older patients who are more likely to proceed with less treatment in cases when they can.” But patients who opt for more aggressive treatment, even when it’s not warranted, are often ignoring the fact that because they carry certain breast cancer gene mutations, they’re also at an increased risk for other cancers, including ovarian, pancreatic and colorectal. “Being more aggressive with one cancer doesn’t free you from cancer forever,” he says. “It’s not one-stop shopping. A cancer diagnosis is life-long.”

Choosing a potentially unnecessary treatment is often an individual decision, one that can vary dramatically from person to person. “I’ve learned that everyone has a different gray area,” Dr. Standiford says. “There are people who say they still want chemotherapy, even when a doctor tells them it would only give them a 2 percent benefit. But there are also people who turn down chemotherapy if it would give them a 20 percent benefit. Twenty percent isn’t a big enough number for those people. Today, it’s not just that we’re able to determine who doesn’t need chemotherapy. It’s letting people make an informed choice whether they want chemotherapy.”

Less doesn’t mean inferior

In the future, doctors hope researchers will continue to discover biomarkers that will help predict how a certain tumor will respond to treatment so more targeted therapies may be developed. “It’s an interesting, exhausting and exhilarating time to be a doctor,” Dr. Standiford says. “I’ve been practicing for 30 years, and when I was in medical school, we were just learning about T cells and B cells. That was all we knew about the immune system. There are so many sophisticated things researchers are learning now that we never could have imagined.”

Much of what scientists are learning today is made possible by the significant advances that technology has made in recent years. “‘Less is more’ is the theme today because we know more,” Dr. Baik says. “We’ve seen so much more data in the past 20 to 30 years. Prior to that, much of what doctors did wasn’t really evidence-based. We were still recording everything on paper. Now there is much more evidence, and more studies and research being done. Now we’re having tens of thousands of patients studied and looking at the outcome. We’re more aware of what the outcomes are going to be for certain types and stages of cancer.”

Yet the most important takeaway may be that less treatment doesn’t mean inferior treatment. “‘Less’ means using scientific evidence to show that we don’t have to do certain things,” Dr. Baik says. “We may be able to treat you with less and still achieve the same results.”

  Learn more about precision cancer treatment>>

Myth: I am having side effects from treatment that are very personal, but I shouldn’t bother my doctor with vanity complaints.

It is critical to tell the members of your medical team what you are going through, so they can identify resources that may help you manage side effects. Each cancer hospital or organization has different approaches to treating various side effects and problems, but if your cancer center offers supportive care, that would be a great place to start if you don’t feel comfortable talking to your oncologist.

But you really have nothing to lose by discussing it with your physician. For example, a lot of patients deal with decreased libido and increased vaginal dryness while on hormone treatments for breast cancer, and yet few see a sex counselor or are aware that the U.S. Food and Drug Administration has approved a device that may help reduce vaginal dryness. If this side effect is bothering you, it is important and worth your physician’s time. However, not all oncologists are aware of treatment options available to address quality-of-life concerns. So, look for a second opinion or referral to a knowledgeable health care provider, if necessary.

Myth: All I need to get the best treatment outcome is to find the best oncologist and complete the recommended treatment.

There is overwhelmingly evidence that getting the “best” cancer treatment is not just about receiving proven treatment protocols. Your ability to endure the side effects and complete your treatment is dependent on your support system, the support and treatment you receive for side effects as they arise, and your understanding and confidence in the treatment.

A good question to ask your oncologist is “what happens if I have an urgent problem at midnight on Saturday?” Make sure to identify the support systems the cancer center has in place for you. Caring for patient needs only when the patient expresses a need is not enough. Ongoing surveillance and doctor inquiries in between visits are critical to improving quality of life and treatment outcomes.

Myth: I shouldn’t burden my family or loved ones by telling them about my disease.

When it comes to a cancer diagnosis, you will need as much help as you can get to avoid feeling overwhelmed. We tend to think of cancer as a heavy burden that family members must endure, and, yes, caregiver stress is real. But in speaking with families of loved ones surviving cancer, some express gratitude that their loved one didn’t die suddenly from traumatic injury or a heart attack, and that they had an opportunity to show their love and support through words and action for their loved one. Sometimes when we are in the abyss of depression and hopelessness, it takes a village of those who care to help us wake up to greater possibilities. Love and healing do not become grander by excluding others from your experience.

I have treated patients who requested that family members not be informed, but then had to face their relatives’ disappointment that they lost an opportunity to help or spend more time with their loved one, by being kept in the dark. Ask yourself if you would want to know about a loved one’s cancer diagnosis if you were the caregiver. The answer, for many, is, “Yes.” That said, there is nothing wrong with excluding people who irritate you or display insensitivity to your situation. 

  Find out whether hyperbaric oxygen can treat cancer. >>

“ The goal is to alter the prognosis. Additional studies are needed to determine if increasing muscle mass in patients could improve outcomes.” - Cynthia Lynch, MD - Medical Director of the Breast Cancer Center and Medical Oncologist at our hospital in Phoenix

The most recent study, published in the April issue of JAMA Oncology, followed 3,241 stage II and stage III breast cancer patients, concluding that patients with low muscle mass at the time of diagnosis had a lower chance of survival than patients without sarcopenia. In the study, none of the patients’ cancers had yet spread beyond the breast at the time of diagnosis. The study’s authors concluded that even though sarcopenia occurs in more than one-third of newly diagnosed non-metastatic breast cancer patients, the condition has been under-recognized among that population.

The authors also said the findings may be applied to many other non-metastatic cancers, since the association between high muscle mass and improved survival for patients with metastatic disease has been observed in patients with a variety of solid tumors. A similar trial led by the study’s lead investigator, for example, linked low muscle mass in patients with non-metastatic colorectal cancer to a poor prognosis.

Sarcopenia combined with high body fat worsens patients’ outlooks even further. In the JAMA study, breast cancer patients who had both sarcopenia and high body fat were 89 percent more likely to die from the disease. The American Society of Clinical Oncology has also found that sarcopenia combined with inflammation nearly doubles patients’ risk of death from cancer.

Based on the findings, researchers are advising doctors to recommend strength training to patients with non-metastatic disease, in addition to weight loss and dietary changes. “I recommend exercise, as well as a healthy diet, as there are studies demonstrating the benefits of a healthy lifestyle in reducing the risk of breast cancer recurrence,” Dr. Lynch says. “I look forward to seeing studies performed that will evaluate the effects of improving muscle mass on breast cancer outcomes.”

The so-called father of medicine, Greek physician Hippocrates (460-370BC), is credited with coining the word cancer to describe tumors, while another Greek physician, Galen (130-200 AD), is believed to have expounded on the definition to include the term oncos (Greek for swelling), according to the American Cancer Society. The invention of the microscope, followed by widespread availability of anesthesia, resulted in rapid progress in the field of oncology by the mid-19^th century. Since the 1990s, a multitude of oncology specialties have evolved along with innovative therapies, resulting in a declining mortality rate, according to the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.

The branch of medicine dedicated to diagnosing, treating and researching cancer is known as oncology, while a physician who works in the field is called an oncologist. Some oncologists focus solely on particular cancer types or treatments. Depending on the type, stage and location of a cancer, multiple oncology specialists may be involved in a patient’s care. The field of oncology has three main specialties—medical, surgical and radiation—and numerous sub-specialties.

A medical oncologist is a licensed physician (typically in internal medicine) trained in diagnosing, staging and treating cancer. This specialist also leads the development of the cancer patient’s treatment plan, which may include surgery, chemotherapy, immunotherapy, targeted therapy or hormone therapy, while also coordinating with other oncology specialists and clinicians who may have a role in the patient’s care. A medical oncologist is also the doctor a cancer patient will continue to see after treatment, for checkups over the long-term.

A surgical oncologist is a surgeon who specializes in performing biopsies and removing cancerous tumors and surrounding tissue, as well as other cancer-related operations.

A radiation oncologist specializes in treating cancer with radiation therapy to shrink or destroy cancer cells or to ease cancer-related symptoms.

Many cancer types are treated by an oncology sub-specialty. Gynecologic oncologists, for example, are trained to treat cancers of the female reproductive system such as those affecting the uterus, cervix, or ovaries, while hematologic oncologists specialize in diagnosing and treating blood cancers (leukemia, lymphoma and multiple myeloma). A neuro-oncologist treats cancers of the brain, spine and peripheral nerves.

When searching for an oncologist, it’s a good idea to ask prospective physicians if they are board certified in an oncology specialty, says Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America^® (CTCA). Board certification means that, in addition to having completed a residency program, the doctor has also completed an oncology fellowship, which provides training in diagnosing and treating cancer, and he or she has successfully passed a rigorous testing and peer evaluation process in an area of expertise.

“It’s aspirational for an oncologist to be board certified, where such certification exists,” says Dr. Markman, who is board certified in three specialties: internal medicine, medical oncology and hematology. He notes that board certification is not offered for every cancer type, but in those cases, patients may ask doctors about their experience and training in their specialty.

“Ask about the hospital’s experience with your type of cancer,” he says, suggesting that patients or caregivers do their homework and seek a reputable cancer center or hospital. “Ask if the nurses are certified by the Oncology Nurses Society. One of the advantages of a cancer program is that cancer is what doctors in that program are focused on and trained in, and the more patients you take care of, the more experience you have, especially with rare cancers.”

Read more about hospitalists, an emerging specialty. >>

On their own, cancer and autoimmunity often create difficult and challenging circumstances for doctors and patients. In patients diagnosed with either disease, these two opposing forces may collide, further complicating treatments and side-effect management efforts. “There is a definite connection between many autoimmune diseases and cancer,” says Anthony Perre, MD, Internist at our Philadelphia hospital and Chief of the Division of Outpatient Medicine for Cancer Treatment Centers of America^® (CTCA). “For example, many autoimmune diseases may lead to inflammation, which has been implicated as a factor in the development of cancer.”

Autoimmune disease and immunotherapy

Autoimmune disease and cancer both seek to control the body’s immune system, pushing and pulling immune cells in different directions. For patients diagnosed with both diseases, a medical oncologist acts as a referee to see that neither side of this cellular war has an overwhelming advantage, especially if the cancer treatment involves immunotherapy drugs called checkpoint inhibitors. Patients with autoimmune disease, who already have overactive immune systems, may have difficulty tolerating these immunotherapy drugs, which stimulate immune cells to better recognize and attack cancer. “You need to have that conversation upfront, because immunotherapy may not be an option, unfortunately,” says Ashish Sangal, MD, Medical Oncologist and Medical Director of the CTCA^® Lung Cancer Center at our Phoenix hospital. “If you have an active autoimmune disease, immunotherapy can cause your immune system to flare up, so you have a worsening of your autoimmune disease.”

In the seven years since the U.S. Food and Drug Administration approved the first checkpoint inhibitor drug ipilimumab (Yervoy^®), these immunotherapies have changed the course of cancer treatment for many patients. So far, six checkpoint inhibitors have been approved to treat a variety of cancers. “We all have an immune system that needs to step on the gas pedal to fight infections quickly when a foreign invader comes in,” says Alan Tan, MD, Clinical Research Medical Director and Medical Oncologist and Hematologist at our Phoenix hospital. “Immunotherapy fights cancer by releasing the brakes of the immune system and unleashes the power of the immune system to fight cancer cells.” Immunotherapy may be a safe cancer treatment option for some patients with autoimmune disease, by balancing immune suppressive drugs with immune-stimulating checkpoint inhibitors, Dr. Tan says. “The autoimmune condition can often be managed,” he says. “And many times, autoimmune adverse events are a good indicator that the immunotherapy is also working to fight the cancer as well. As always, weigh the risks and benefits and have a well-informed conversation with your physician.”

Risks from disease and treatment

Autoimmune disorders generally attack a single organ or part of the body, often causing inflammation in the affected area. In some cases, that inflammation may increase cancer risk. Autoimmune diseases that affect the gastrointestinal tract—inflammatory bowel disease, Crohn’s disease and colitis, for instance—cause chronic inflammation in the digestive system that increases the risk of colorectal cancer. Chronic inflammation may damage cell DNA, which may lead to uncontrolled cell growth, one of the hallmarks of cancer.

“Chronic inflammation may also suppress our immune system and affect our ability to repair the damage to our DNA,” Dr. Perre says. To battle inflammation and limit autoimmune flare-ups, doctors often prescribe drugs called TNF inhibitors, which help reduce inflammation, or an immunosuppressant such as cyclosporin. These drugs are suspected of increasing the risk of multiple cancers. “Treatments that suppress our immune system are commonly used to treat autoimmune disorders, but they may impair our ability to kill cancer cells,” Dr, Perre says. “Some drugs used to treat arthritis and psoriasis may increase a patient’s risk of developing lymphoma.”

Challenging side effects

Autoimmune diseases cause a variety of side effects, depending on which organ or body part is affected. Many of the symptoms of these side effects, such as diarrhea, skin rashes, fatigue and bone and joint pain, mirror those that some cancer patients experience due to the disease itself or certain treatments. A patient who has irritable bowel syndrome or Crohn’s disease may already have issues with diarrhea and gastrointestinal distress. Or a patient with lupus or psoriasis may struggle with rashes, itchy skin or bone pain. Chemotherapy or immunotherapy may worsen these symptoms in some patients. “A medical oncologist must balance effectiveness of a treatment against side effects and quality of life,” Dr. Perre says. “There are times when the side effects of treatment may limit the ability to give treatment.”

Doctors and researchers know more than ever about the connection between autoimmune disease and cancer, how to balance treatments and manage side effects. Doctors are also learning more about how to balance the benefits of immunotherapy drugs, which were once off limits to cancer patients with autoimmune disease. “When checkpoint inhibitors were first being studied, they excluded patients with autoimmune disease, especially if it was active or required suppressive drugs,” Dr. Tan says. “With more experience, we are more comfortable with trying immunotherapy on patients with active autoimmune disease, as long as it is, in general, under control. Patients should talk to their doctor and consider the benefits and risks of doing so.” 

  Learn more about precision cancer treatment.

Most of us are aware of common, high-risk lifestyle choices that increase your risk of certain cancers, like using tobacco, eating a poor diet or not being physical active. While avoiding these risk factors is important, it’s equally critical to pay attention to indicators from your body that may convey potential health issues. As nonthreatening as they may seem on the surface, you should know that some symptoms, when prolonged, may be a signal of a serious health problem. Knowing your body, monitoring your health and taking action when known symptoms last longer than two weeks can make a big difference in spotting cancer in its early stages.

In my experience, 10 key symptoms of cancer people often overlook include:

• Unexplained weight loss
• Fever of unknown origin
• Night sweats
• New or unexplained pain
• Persistent heartburn
• Mouth or tongue sores that don’t heal
• Bloating
• Irregular bowel patterns
• Unexplained lumps
• Trouble swallowing

These symptoms are often misidentified because they are not specific to just cancer, and therefore can be attributable to other health issues. For example, someone who suffers from irritable bowel syndrome and regularly experiences an irregular bowel pattern does not necessarily assume his or her symptoms could be a sign of colorectal cancer. In addition, common symptoms of ovarian cancer are bloating and feeling full after a few bites of food, but many women may attribute fluid buildup or bloating to normal weight gain. For these reasons, it’s important to know what symptoms can signal more than one health issue.

Here’s the key takeaway: If you experience any of these symptoms for more than two weeks, you should make an appointment with your primary care physician to discuss what you’re experiencing. This way, your doctor is better able to help make sense of what your symptoms mean, perhaps properly diagnose your symptoms and continue to monitor for issues, or refer you to a specialist. When it comes to cancer prevention, you are your own best advocate.

Unfortunately, the feeling typically doesn’t go away, even after a full night’s sleep. Factors including the type and stage of cancer, treatment history, current medications, nutritional status, sleep or rest patterns, emotional distress and certain conditions (such as anemia, breathing problems, decreased muscle strength, pain, etc.) are important considerations in determining how to approach fatigue management.

A number of supportive care services may help alleviate fatigue by addressing some of its underlying causes and may help prevent interruptions in treatment. These services include:

Chiropractic care: Pain may contribute to fatigue and can lead to poor sleep, which compounds fatigue. Chiropractic care providers can help reduce musculoskeletal stress, which may help alleviate pain and improve quality of sleep.

Mind-body medicine: This team offers a variety of techniques to enhance the mind’s impact on physical function, symptoms and health. Talk therapy, relaxation and breathing techniques as well as yoga are examples.

Nutrition therapy: Trained dietitians can evaluate and manage nutritional deficiencies that may contribute to fatigue. Education and recommendations may help correct deficits, including strategies for:

• Adequate hydration maintenance
• Calorie and protein intake, including nutrient-dense foods and liquids as well as quick and easy meal and snack ideas
• Vitamin and mineral deficiencies using food and/or supplements

Oncology rehabilitation: Physical and occupational therapists evaluate and recommend appropriate activities. Hands-on techniques like massage have also been shown to help with fatigue.

Acupuncture: Small studies have shown that acupuncture may be helpful as part of an interdisciplinary approach to managing fatigue.

“ The human mind tends to seek easy-to-understand answers. But cancer is just a name for cells that are rapidly dividing without regard to the body. Each cancer behaves differently based on many factors, and even cancers from the same site of origin, like breast cancer, can be radically different depending on their unique molecular profiles.” - Eugene Ahn, MD - Medical Director of Research and Hematologist/Oncologist at our hospital in Chicago

The word “cancer” actually refers to a collection of more than 100 different diseases, with wide-ranging and varied characteristics that may call for wide-ranging and varied treatments. For example, many prostate and breast cancers respond to hormone therapies that prevent cancer cells from getting the hormones they need to grow. But lung cancer does not generally respond to hormone manipulation treatment, and is instead more often treated with surgery, chemotherapy, radiation therapy, immunotherapy or targeted therapy, either alone or in combination. On the other hand, some drugs are used to treat several kinds of cancer. “Sometimes, drugs overlap and can work for different cancer types, but that’s something that has to be proven through clinical research, because it’s certainly not safe or reasonable to assume that one drug is going to work for every cancer type just because it works for one,” Dr. Ahn says.

Evidence that the drug or therapy works is important, Dr. Ahn says. Still, many cancer patients and their caregivers are tempted to try relatively unproven techniques, such as a radical dietary change, because they seem like quick, easy fixes, despite the lack of evidence that they consistently work. “Cancer is a complicated topic,” Dr. Ahn says. “We’re still learning a lot about each cancer type each year, and it can get very complicated for anyone who gets diagnosed and is looking for solutions. So it can be easy to be drawn into simple narratives or quick-fix solutions that claim to provide magic bullets. A common mistake we see is when a study comes out showing that a dietary change works for a certain cancer type in animals, and people believe that it must therefore work for that cancer type in humans. But one thing most oncologists and scientists know to be true is that it is far easier to cure cancer in animals like mice, in cases when the disease is artificially induced, than it is to cure cancer in humans, in cases when the disease occurs naturally.”

Although there’s something attractive about the simplicity of alternative medicine approaches, cancer patients should use healthy skepticism and be their own advocate when it comes to curative claims that aren’t based on science, Dr. Ahn says. “Be very cautious and use your judgment when you read an article that claims to have found the one cure for cancer,” he says. “There tends to be an assumption that if it’s in the media or on the internet, it must be important, but that’s not always true. And if the sources talk about cancer as only one disease, odds are they don’t fully understand cancer.”

Just as every patient’s cancer is unique, so are the physical and psychological side effects of dealing with the disease. But certain feelings and challenges are universal, particularly for caregivers. 

“ Cancer is a traumatic event for the entire family, not just the patient. It’s not like the flu, where you see an end point. The most common feelings we see among caregivers are feelings of helplessness, anger, frustration, grief, guilt, anxiety, worry and loneliness.” - Alexandria Callahan, LCPC, BC-DMT, GLCMA, Mind-Body Therapist at our Chicago hospital

Caregivers very often become so focused on the patient’s needs that they neglect their own. Experts say this is the most common, and most concerning, mistake caregivers can make. “Caregivers need to make sure they’re eating, getting enough sleep and keeping up with their own medical appointments, because they can’t help anyone if they’re not well,” Callahan says. “It’s the same as an emergency on an airplane—when the oxygen mask comes down, you’re supposed to put your mask on first. As caregivers, we jump at every single thing the patient needs and forget about ourselves. It’s easier to focus externally than internally. It’s cliché, but I tell people all the time to take a deep breath. It engages the diaphragm and forces you to focus on your breath and relaxes your body. You can take 30 seconds out of this crazy day and breathe while you’re waiting for water to boil or you’re at a red light or in the bathroom.” 

She advises all caregivers to find a coping mechanism that works for them. If you find yourself harboring feelings of anger, for example, recognize it and learn how to process it, she suggests. Also realize that many patients take their frustrations out on their caregivers. If this happens to you, try not take it personally. “In that moment, ask the patient if there’s anything they need, and then just give them some space,” she says. “When the caregiver feels overwhelmed, it’s OK to take a break.” 

When Kathleen Fincham’s husband, Mike, was diagnosed with stage IV colorectal cancer in 2013 at age 35, neither of them had any idea what to expect. The Finchams had five young children, including an infant, and Mike Fincham supported the family, working long hours on their dairy farm in northeast Kansas. Over the course of about two years, he underwent two surgeries, six months of chemotherapy and spent more than three months in the hospital. Kathleen Fincham found herself scrambling to take care of her husband while juggling motherhood and helping on the dairy farm. While the Finchams were fortunate to have lots of help from relatives and friends, Kathleen Fincham still experienced moments of feeling overwhelmed and fearful of an uncertain future with her husband. In her case, a strong faith bolstered her during dark times. 

“I relied on my strong belief in the sovereignty of God and knowing that if this is the end of his life here on Earth, we’re not going to be able to control the circumstances and that’s not our job,” she recalls. “We told ourselves that we’re here for as long as God wants us here, and we had an eternal perspective. We were really at peace with that. Obviously, we hoped for more than that, and thankfully, it’s the way it turned out for us.”  

She also found it helpful to carve out some time each day to recharge herself, by going for a run or reading her Bible. She was mindful not to be too hard on herself. “During Mike’s illness, I told myself it was OK if I wasn’t keeping up with everything like I did before,” she says. “I didn’t do quite as much home-schooling that year, and the kids are fine.” 

Robert Bloom, MD, Psychiatrist in our Chicago hospital, echoes Kathleen Fincham’s sentiments, adding that it’s also constructive to forgive friends and relatives who may be oblivious to the physical and emotional toll caregiving takes. He and his wife, Judy, know firsthand the challenges of caring for an ailing loved one. The Blooms’ daughter, Rachel, who was born with spina bifida, lived with her parents until her death in 2016, a few months shy of her 36th birthday.

“The main thing I learned is that most people who aren’t in your shoes don’t understand how difficult it is,” says Dr. Bloom. “Caregiving is a 24/7 responsibility and can be very draining. Early on, I advise everyone of three rules: Don’t feel sorry for yourself, don’t put yourself down, and don’t compare yourself to others. Rather than judge, try to explain.” 

For Judy Bloom, talking with other parents of children with disabilities helped her cope with her own situation. She found a support group when Rachel was a toddler, and decades later, those people remain some of her closest friends. “For me to get together with a group of friends with healthy 3-year-olds didn’t help me,” she says. “Find a group of likeminded people, either online or in person. I met so many people online who I never met in person, and we commiserated together and shared tips. Nobody understands this unless they’re in your shoes.” 

 Judy Bloom also saw a therapist to manage feelings of anger, depression, guilt and resentment, all common emotions for caregivers. And she learned how to ask for, and accept, help. “At first, it was easier to get mad at someone because they didn’t offer to help than to ask them to do something, like go to the grocery store or prepare a meal,” she says. “Most people would love to help someone if asked.” 

Here are some other tips caregivers can follow to help ease the stress: 

• Develop a support network, either online or in person. It’s valuable to talk with others who are similarly situated. If you cannot find a support group, ask a medical professional for recommendations. 
• Be the patient’s advocate. Accompany your loved one to doctor appointments. Do research and ask questions the patient may not think of or is too afraid to ask. Be sure to take notes.
• Stay on top of your own physical and psychological health. Be mindful of your diet, and make time to exercise. You will feel better and have more energy if you’re healthy. If the patient is able, take a walk together or push him or her in a wheelchair. Chronic stress can affect physical health. 
• Do things that aren’t part of your caregiving responsibilities—have lunch with a friend, see a movie or continue a hobby you enjoy, like painting or reading.
• Forgive yourself. You’re human and will have days when you’re short-tempered, grumpy, resentful or worn out. Let it go.
• Ask for help and accept help when offered. Most of us are uncomfortable with leaning on others, but your friends and loved ones likely want to do something—they just may not know what you need. Keep a mental list of necessities, such as meals, rides or someone to do the grocery shopping, sit with the patient while you take a break or watch your children for a few hours.
• Foster open communication with the patient that allows both of you to express anxieties and fears. Experts say patients and caregivers often get caught up in thinking they have to remain positive for the other person, but they find it’s cathartic for both parties to talk about their feelings.
• Engage in activities with the patient that are unrelated to cancer. Play cards or a board game or make popcorn and watch a favorite TV show.
• Turn to national resources for caregivers that may help along your journey. These include:
• American Cancer Society, National Cancer Information Center, 800-227-2345
• Caregiver Action Network, 202-454-3970
• Cancer Support Community, 888-793-9355

  Learn more about managing the challenges of a caregiver. >>

Cancer develops when the DNA inside cells changes or mutates, preventing cells from working properly. In many cases, these mutations may allow defective cells to multiply and grow, forming a tumors. Scientists believe the more mutations a tumor has, or the higher its TMB, the more likely one or more of those mutations will respond to immunotherapy. 

“ The more mutations, the better the response may be. So, the higher the number of mutations, the better the chances of having a benefit from using immunotherapy.” - Ashish Sangal, MD, Medical Oncologist

Immunotherapy drugs are designed to disrupt the signals that allow cancer cells to hide from the immune system. Cancer cells send deceptive signals to protein receptors, located on the immune cells’ surface, as they pass the so-called immune checkpoints. If not for these checkpoints, the immune system may attack healthy cells. Two primary benchmarks are used to determine if a checkpoint inhibitor may work on a given cancer:

• PD L1 is a receptor often found on cancer cells that binds with the PD-1 receptor on immune cells. When the two receptors touch, the cancer cell may send a signal that tells the immune cell it is not a threat, prompting the immune cell to let it go and move on to look for other threats. Checkpoint inhibitors disrupt that signal, allowing the immune cells to better recognize and attack the cancer cells.
• Microsatellite instability (MSI) is a gene mutation that makes it difficult for the DNA in a cell to repair itself, which may lead to the type of unchecked cell growth that causes many tumors to form and grow. Research has shown that tumors with high MSI may respond better to checkpoint inhibitors. The FDA last year took the breakthrough step of approving the cancer drug pembrolizumab (Keytruda^®) to treat cancers with high MSI. It was the first approval of a cancer therapy based not on the tumor's primary location in the body but on a specific genetic feature found in the cancer’s DNA.

So, if doctors already have two ways to measure checkpoint inhibitors’ potential, why do they need another? Researchers theorize that some cancers that are not currently being treated with checkpoint inhibitors may have high TMB. Also, activated immune cells don’t always know what to attack. An immune response is triggered when immune cells detect molecules called antigens. Researchers suspect that cancer cells in tumors with high TMB may have more neoantigens—receptors found on cancer cells that may attract immune cells.

Researchers are conducting multiple clinical trials to determine how TMB may be used to forecast the effectiveness of checkpoint inhibitors and other cancer treatments. Scientists are also working to develop reliable ways of testing the number of mutations found in a cancer and what qualifies as high TMB vs. low TMB. “Moving forward,” Dr. Sangal says, “we are definitely coming to a point where these three things—PD-L1, MSI and tumor mutation burden—will be used to help determine how to use immunotherapies and which cancers may respond or not respond.”

“ Pseudoprogression is a not-uncommon side effect of immunotherapy that's still being studied to be better understood. In the past, the popular belief was that the tumor was getting bigger and treatment should be stopped. Now we know that it's actually a sign that the immunotherapy may be working.” - Pamela Crilley, DO - Department of Medical Oncology Chair at Cancer Treatment Centers of America^® (CTCA)

Most of the time, oncologists discover evidence of pseudoprogression during follow-up tests used to determine the cancer’s response to treatment. “Immunotherapy drugs cause the tumor to flare up initially and get bigger, but that’s only temporary,” says Ashish Sangal, MD, Medical Director of the Lung Cancer Center and Medical Oncologist at our hospital in Phoenix. “So anything that looks bigger in the first three to six months after treatment doesn’t mean it’s a progression.”

For that reason, multiple follow-up tests may be required for patients undergoing immunotherapy treatment. “Immunotherapy may take a longer time to determine results than other therapies,” Dr. Crilley says. That’s why it’s important to be patient when evaluating immunotherapy’s effect. “Patients and physicians are coming to understand that, sometimes, you have to do more than one or two evaluations to really be sure of what’s happening,” she says.

Since 2000, oncologists have largely relied on a system called Response Evaluation Criteria in Standard Tumors (RECIST) to measure cancer’s response to a certain therapy and guide treatment decisions. But a newer rubric, called the immune-related Response Criteria (irRC), accounts for the pseudoprogression phenomenon and is being used in many clinical trials for immunotherapy drugs. “It’s important to know that this is still in evolution, but that we’re working to more properly understand the patterns of response,” Dr. Crilley says.

Some studies have found that pseudoprogression indicates a better outcome, though more studies are needed. While researchers work to learn more about what causes pseudoprogression and what it may mean for patients who experience it, communication between doctors and patients is critical. “Because immunotherapy is still so new, more information is coming out all the time,” Dr. Crilley says. “Oncologists need to educate their patients on what is known at the time and, when new information comes out, communicate that to them in as timely a manner as possible.”

While patients are typically more familiar with radiology procedures because they have encountered them at other times in their lives, some find radiation therapy both foreign and intimidating. The idea of radiation—something they are told to otherwise avoid—being pumped into their bodies is counter-intuitive to some people, and the dark rooms, giant machines, buttons and lights may be unnerving. Radiation also differs distinctly from other cancer treatments in that it is invisible to the naked eye. Surgery, on the other hand, involves removing all or part of a tumor. Chemotherapy, immunotherapy and other medications are delivered in pill or liquid form. "Radiation is very intangible to people," says Anderson Bauer, MD, Radiation Oncologist at our hospital in Phoenix. "You can't feel it. You can't see it or taste it. Every now and then, someone says they can smell it, but this is actually due to some patients detecting the scent of ozone created by radiation interacting with the air.” That’s why many patients benefit from an explanation of how radiation therapy works. 

“ I explain how the radiation comes out of the machine very much like light will come out of a hole By explaining things in a way that people are familiar with, it allows them to better understand what we do.”  - Anderson Bauer, MD, Radiation Oncologist

Other doctors and other clinicians on a cancer patient’s care team may also have similar titles starting with “rad.” "Our primary focus is in using ionizing radiation energy to treat cancer, whereas the diagnostic radiologists are using ionizing radiation to evaluate patients with imaging. And sometimes that’s confusing to people," Dr. Bauer says. Each performs specific duties that differentiate him or her from others on the team. For example:

 Radiation therapists set up the equipment and deliver radiation treatments prescribed by a radiation oncologist. Radiation therapists are not doctors, but are highly trained to operate a variety of sophisticated radiation therapy equipment used in cancer treatment.

 Radiographers set up and perform X-rays, CT-scans, MRIs and other diagnostic imaging tests and pass the results on to a radiologist for interpretation.

 Radiologists are doctors trained to read and interpret imaging scans to help diagnose injuries and disease. Diagnostic radiologists may have specialized training in specific fields, such as mammography or imaging of the gastrointestinal tract.

 Radiation oncologists are doctors who specialize in using radiation to treat cancer. Radiation oncologists may also be part of a larger care team, working with medical oncologists, surgeons or supportive care experts to develop treatment plans and help patients manage side effects.

 Interventional radiologists are doctors who diagnose and treat a variety of diseases, including cancer, using minimally invasive procedures, typically as an alternative to open surgery. For example, they may use image-guided technology to place stents and catheters. For cancer patients, they may use chemoembolization to cut off the blood supply to a tumor or radiofrequency ablation to damage cancerous tissue.

Dr. Bauer says patients should feel empowered to ask questions about their treatment plans and about the men and women delivering their care, to help cut through the confusion they may encounter during cancer treatment. "By having a very comfortable atmosphere for patients, most people can get to where they understand the treatment strategy," he says. "And when people know what the strategy is, they can feel more comfortable and confident in their treatment.”

  Learn how to read a pathology report.

Elderly patients, 65 and older, with weakened immune systems may not have the robust response to immunotherapy some younger patients experience. And because elderly patients are less likely to participate in clinical trials, less clinical data is available on why they may or may not respond to these treatments. “Immunotherapy certainly helps a lot of patients, and we're seeing very exciting responses in certain populations,” Dr. Parikh says. “What we do know is that patients’ immune systems change and evolve over time. And as someone gets older, their immune system also changes. And is someone the age of 65 going to respond the same to immunotherapy as someone who is under 40? That question hasn't been answered yet, and unfortunately, a lot of clinical trials don't have an elderly population. So we don't get those answers very often.”

Cancer risk increases with age for many reasons.

• Cell replication errors occur more often in older people, increasing the chances of producing a DNA mutation that may lead to cancer. A 2017 study by researchers at Johns Hopkins University School of Medicine concluded that errors made when cells continuously divide may be responsible for more than 60 percent of all cancers.
• Years of habits such as drinking, smoking and a poor diet take their toll. A 2016 Harvard study of about 130,000 Americans found that cancer risk may be reduced by up to 40 percent by adopting a healthy lifestyle.
• Exposures to carcinogens and environmental risk factors,  such as asbestos, second-hand smoke, pesticides and ultraviolet light from the sun also increase the risk.

When we’re younger, our cells have repair mechanisms that often fix DNA mutations caused by exposure or replication errors. And when they don’t repair them, the immune system is more likely to kick in to attack the defective cells and kill them. But as we age, our repair mechanisms begin to break down and our immune systems weaken, which may allow defective cells to grow out of control and form a tumor. “I think one challenge with elderly patients is that their immune system may not be as competent, or it may undergo something called immune senescence. Senescent cells, which are not dead but are no longer growing or dividing, sometimes have precancerous characteristics. Other senescent cells, including immune cells, may exist in a zombie-like state—alive, but not functioning properly. Checkpoint inhibitors, designed to allow immune cells to better recognize and attack cancer cells, may not always provide the kickstart required to battle cancer in elderly patients with senescent immune cells. “The jury's still out on the role of immunotherapy or, specifically, checkpoint inhibitors in elderly patients,” Dr. Parikh says.

Research on immunotherapy’s impact on older patients continues, Dr. Parikh says, but clinical data may be limited since older patients are less likely to volunteer for clinical trials. Also, elderly patients may have conditions such as chronic obstructive pulmonary disease (COPD) or heart failure that would make them ineligible for clinical trials. “So we miss out on that very important patient population,” Dr. Parikh says. Still, doctors will continue to turn to immunotherapy when appropriate as a treatment option in patients of all ages, he says. “When it works well for a type of cancer, I don't discriminate based on how old somebody is,” Dr. Parikh says. “We still give them the benefit of the doubt and try it when appropriate.”

Learn about dangerous drug interactions.

The concept of inflammation is sometimes tricky to grasp because it may seem contradictory. On one hand, inflammation is a healthy process, essential to the body’s ability to heal itself. When you have an infection or injury, the immune system releases white blood cells and chemicals to fight off the infection or repair damaged tissue. But when inflammation persists, or when the immune system triggers an inflammatory response when you don’t have an infection or injury—like that caused by arthritis and other autoimmune diseases—it may damage healthy tissues.

“ Chronic inflammation is sometimes called 'smoldering inflammation' because it's inflammation that never really resolves. It's the opposite of 'good' inflammation, which your body uses to get rid of bacteria and viruses, and then, once it achieves its goal, resolves.” - Eugene Ahn, MD - Medical Director of Clinical Research and Hematologist/Oncologist at our hospital near Chicago

Today, researchers have a fairly broad understanding of inflammation’s split personality. They’ve learned that sometimes, chronic inflammation is caused by factors outside of our control, such as inherited gene mutations that raise the risk of chronic inflammation. But it also may result from lifestyle choices you may be able to change. That’s important because so-called lifestyle-dependent inflammation is on the rise. “The connection between inflammation and cancer has been apparent for a long time, but it may be that it’s now coming into sharper focus because of the increase in lifestyle-dependent inflammation we’re seeing,” Dr. Ahn says.

The causes

Chronic inflammation’s role in cancer development isn’t a small one. As many as one in five cancers are believed to be caused or influenced by inflammation. One reason is that chronic inflammation may damage DNA, says Cynthia Lynch, MD, Medical Director of the Breast Center and Medical Oncologist at our hospital near Phoenix. Other times, the inflammatory process produces molecules called cytokines, which stimulate the growth of blood vessels that bring oxygen and nutrients to the tumor. The process also may generate molecules called free radicals that further damage the DNA. These inflammation side effects may help sustain and fuel cancer growth.

The reason inflammation becomes chronic isn’t always apparent. It may be caused by infections that don’t go away, abnormal immune reactions to normal tissues, or certain conditions like obesity. Over time, chronic inflammation may damage DNA, leading to conditions like heart disease, type 2 diabetes, stroke and cancer. “Anything that causes inflammation will cause the DNA of a cell to replicate faster,” says Brad Mons, DO, Head and Neck Surgeon at our hospital in Tulsa. “The more your cells replicate, the higher chance you have of cancers developing.”

Sometimes, cancer-causing chronic inflammation stems from a disease characterized by inflammation. The inflammatory diseases colitis, pancreatitis and hepatitis, for example, are linked to a greater risk of colon, pancreatic and liver cancers, respectively. In these diseases, immune cells create highly reactive molecules containing oxygen and nitrogen that can damage DNA. Inflammation also may cause cells to divide.

Chronic inflammation also may result from a chronic infection, like H. pylori, which is linked to stomach cancer, and hepatitis B and hepatitis C, which are linked to liver cancer. HIV increases the risk of other viruses and very rare cancers, including Kaposi sarcoma, non-Hodgkin lymphoma and invasive cervical cancer.

In other cases, environmental factors are the culprits. Asbestos exposure, for example, increases the risk for mesothelioma. Many environmental carcinogens and risk factors, in fact, are associated with some form of chronic inflammation. According to the National Institutes of Health, up to 20 percent of cancers are linked to chronic infections, 30 percent are linked to tobacco smoking and inhaled pollutants, such as asbestos, and 35 percent are linked to dietary factors, including obesity. “Whether it’s an autoimmune disease like lupus or rheumatoid arthritis, or irritations from a chemical you may be exposed to, such as asbestos, if we can reduce the amount of inflammatory processes in our environment, we can reduce our risk of cancer,” Dr. Mons says.

Reducing the risk

Today, researchers are exploring whether oxygen sensors in the body can be manipulated to reduce chronic inflammation. One study found that tricking immune cells into believing they’re lacking oxygen makes them retreat from the site of inflammation to conserve energy. Researchers are now studying whether medications could be developed to turn on certain proteins that, when activated, inhibit the body’s inflammatory response.

Evidence is also building that aspirin may help prevent chronic inflammation. The non-steroidal anti-inflammatory drug works by reducing the production of prostaglandins, which are chemicals that promote inflammation, pain and fever. In a 2016 report published in the Journal of the American Medical Association, researchers who studied aspirin use in 135,000 patients concluded “long-term aspirin use was associated with a modest but significantly reduced risk for overall cancer, especially gastrointestinal tract tumors. Regular aspirin use may prevent a substantial proportion of colorectal cancers.” Already in the United States, tens of millions of adults take aspirin to reduce the risk of heart attack or stroke. “We take aspirin to prevent heart attacks, so taking it to prevent certain types of cancer isn’t unreasonable,” Dr. Ahn says.

The U.S. Preventive Services Task Force now recommends certain adults ages 50 to 59 years old take low-dose aspirin to help prevent colorectal cancer and suggests older adults also consider an aspirin regimen. “Aspirin is being looked at to treat other cancer types, as well, but there isn’t much data on anything other than colorectal cancer right now,” Dr. Lynch says.

Lifestyle changes

With 35 percent of cancers linked to dietary factors like obesity, stress and lack of exercise, the association between lifestyle habits and inflammation remains a concern. These factors trigger an immune response, even without an infection to fight off or an injured tissue to heal. “The reason inflammation gets so much attention in the press right now is because a lot of it is dependent on our lifestyle,” Dr. Ahn says. “The more sedentary you are and the worse your diet is, the more inflammation you’re generating.”

In fact, a 2016 report from the American Institute for Cancer Research found that maintaining a healthy weight may be as important as avoiding tobacco and overexposure from the sun. And the American Cancer Society found that those who follow a healthy lifestyle, by eating a nutritious diet, limiting alcohol consumption and taking other important steps, are 10 to 20 percent less likely to be diagnosed with cancer.

Diet and exercise top the healthy lifestyle list, Dr. Lynch says. And even small changes can make a difference, like adding more plant-based foods that contain anti-inflammatory phytonutrients to your plate, and eating more fermented foods, such as yogurt and miso, which contain natural probiotics that reduce inflammation. Also, try to avoid carcinogens like asbestos, silica and tobacco, and, if you have an underlying condition like hepatitis B or hepatitis C, seek treatment.

Experts also recommend limiting processed foods, which may increase the risk of throat cancer. “It’s not significant, but the risk is more than it is for someone who eats fresh produce, because those preservatives are acting as irritants,” Dr. Mons says. Alcohol can act as an irritant, too, especially in the head and neck—the first area food or drink touches when swallowed. Another concern: Alcohol and its byproducts may damage the liver and lead to inflammation in the organ.

The bottom line: Focus on what you can change. “I always tell patients that there are certain things they have control over in their lives, and there are certain things they don’t, and they should only worry about the things they have control over,” Dr. Ahn says. “That’s where lifestyle comes into play.”

Women considering HRT should carefully consider the pros and cons unique to their personal health history, experts say.

“ It’s a trade-off of risks versus benefits. In addition to cancer, there are other issues, such as blood clots, that can occur. But there are circumstances when HRT may help control menopausal symptoms and improve a woman’s quality of life. In addition to reducing symptoms of menopause, HRT has other health benefits, such as a decreased risk of colon cancer and osteoporosis.” - Justin Chura, MD, - Chief of Surgery & Director of Gynecologic Oncology and Robotic Surgery at our Philadelphia hospital. 

But for women who have had estrogen-positive breast cancer, HRT is not advised, he says. And for those with a history of ovarian or endometrial cancer, Dr. Chura says he would only consider prescribing HRT for “very short-term use by young women with very bad menopausal symptoms.” That advice is consistent with recommendations issued by the U.S. Food and Drug Administration (FDA), which advises women who “have or have had certain cancers such as breast cancer or uterine cancer” not to use HRT and cautions those who opt for the therapy to take the lowest dose necessary to relieve symptoms for the shortest period of time needed.

HRT typically involves estrogen-only or combination therapy, which contains both estrogen and progestin. Though the treatment has been around for decades, its popularity has waxed and waned as new information has surfaced. Between 1960 and 1975, HRT soared in popularity, until two 1975 studies found an increased risk of endometrial cancer, the New England Journal of Medicine reported in 2007. More concern followed in 2002, with the results of a large, long-term Women’s Health Initiative (WHI) clinical trial that studied 27,347 U.S. women ages 50-79 between 1993 and 1998 and found an increased risk of breast cancer. In 2013, an update to the Women’s Health Initiative Hormone Trials was published, this time with 13 years of data for researchers to study, and the investigators concluded that HRT “may remain a reasonable option for the short-term management of menopausal symptoms for younger women.”

Breast cancer organization Susan G. Komen credits the WHI study for showing that “taking estrogen plus progestin for more than 5 years did more harm than good,” noting that combination HRT raises the risk of both breast cancer and breast cancer death.

“When women take these hormones, their risk of having an abnormal mammogram increases within the first year of use,” the Komen website states. “And, their risk of breast cancer increases within the first 5 years of use. The risk of breast cancer goes up slightly with each year a woman takes estrogen plus progestin. Small yearly increases in risk can add up over time. Some large studies have found women who use estrogen plus progestin for 5 or more years (and are still taking it) about double their breast cancer risk.”

Komen points to multiple studies that suggest a 30 percent increase in breast cancer risk for women using estrogen-only HRT. A 2011 National Cancer Institute summary of the WHI study found that, in addition to an increased risk of endometrial cancer in women with an intact uterus who take estrogen-only HRT, women on combination HRT “were more likely to be diagnosed with breast cancer,” and “the breast cancers in these women were larger and more likely to have spread to the lymph nodes by the time they were diagnosed.”

Other evidence-based risks associated with HRT, according to the National Cancer Institute summary of the WHI results, include urinary incontinence, dementia, blood clots, stroke and heart attacks. The studies also found mammography exams to be less effective in detecting breast cancer early in women who used either combination or estrogen-only therapies.

No matter her situation or eventual decision, each woman should talk to her doctor about whether it’s safe and appropriate for her to consider using HRT, Dr. Chura says. Even if she does opt to take it, HRT remains a short-term solution. “It’s probably not a good idea to take it for more than three to five years,” Dr. Chura says, noting other options are available for women to consider cycling through before resorting to HRT, such as vaginal moisturizers, lubricants and certain antidepressants and anti-seizure medications that may help with hot flashes and mood swings. He encourages women to speak to their doctor about hormone therapies with lower rates of absorption (patches, sprays and vaginal rings, for example) that may be safer than systemic, oral therapy. 

“It comes down to why a woman is taking HRT medication,” says Dr. Chura. “For women whose symptoms are making her quality of life miserable, short-duration hormone therapy may be very appropriate. For others, it may not be an option. Talk to your doctor.”

  Learn more about breast cancer risk factors.

A recent survey by the testicular cancer advocacy group CACTI (Center for Advocacy for Cancer of the Testes International) found that about 45 percent of men never or rarely examine themselves for testicular cancer. And nearly half of all men didn't know the importance of a self-examination or didn't take the notion of one seriously. The data is especially troubling given how critical a simple, regular examination of the testicles may be in discovering a lump or other suspicious changes—and, possibly, in helping to improve treatment outcomes by catching the disease early. "It's detectable if someone is doing a self-exam," says Farshid Sadeghi, MD,  Urologic Oncologist at our Phoenix hospital. "But it may be difficult to detect, or it may be detected late if young men never check themselves."

Testicular cancer, also called testis cancer, is typically treated with surgery, chemotherapy and sometimes radiation therapy. In most cases, the affected teste is removed and a biopsy is performed to determine the specific type of cancer. Affected lymph nodes are also removed, but unlike many of those connected to other organs, the lymph nodes connected to the testicles are not nearby in the groin or pelvis, but in the chest around the aorta and vena cava, two of the largest blood vessels that lead to the heart. "It's a little bit of a challenging operation because you are operating on big blood vessels," Dr. Sadeghi says. "But it’s a rewarding operation because, once you clean out those areas, the patient often has very positive outcomes."

The disease accounts for 400 cancer deaths a year, one-tenth the number of breast cancer deaths and far fewer than other common cancers, such as lung cancer (150,000) and colorectal cancer (50,000). Still, testicular cancer may spread quickly and metastasize if it's not caught early. That’s why, Dr. Sadeghi says, it’s important for young men to check themselves regularly to better feel differences in their testes over time. "The key is you have to have examined yourself to know what your testicles feel like so you can better detect any changes," he says. "If you feel a hard nodule or an irregularity in the shape or if one feels differently than the other, then you should go checked out." CACTI offers a self-examination guide on its website.

 Learn more about diagnostic evaluations for testicular cancer

“ Vaping is increasing in popularity because, so far, there isn't any concrete research that definitively shuts it down. Even if certain e-cigarettes are promoted as containing 'natural' chemicals, you're still inhaling them at a high concentration, and any foreign materials you breathe in are damaging to the airway and could increase your risk of cancer.” - Brad Mons, DO, Head and Neck Surgeon at our hospital in Tulsa

E-cigarettes are battery-powered and deliver heated nicotine in aerosol form. They’ve only been available in the United States for a little more than a decade, since 2007. But despite experts’ cautionary warnings, business is booming, with industry analysts forecasting the market to be worth almost $50 billion worldwide by 2023. E-cigarettes also surpassed every other kind of tobacco product in 2014 to become the most commonly used form of tobacco among young people in the United States, with use among high school students jumping 900 percent between 2011 and 2015.

To help protect children from confusing vaping products sold in packages that may look more like juice boxes and candy than liquid nicotine, federal authorities are working to crack down on certain companies. In May, the U.S. Food and Drug Administration (FDA) and the Federal Trade Commission issued 13 warning letters to retailers that target children. According to FDA Commissioner Scott Gottlieb, the effort is part of a long-term campaign to reduce the use of vaping products by minors so a new generation of young people doesn’t become addicted, since those who use e-cigarettes are about four times as likely to smoke a cigarette.

The operation is also aimed at curbing young people’s use of Juul devices, which resemble flash drives or other small electronic devices, taste like fruit or mint, and have infiltrated schools across the country in recent years. “Schools lament that teenagers equate safer with safe,” reported one New York Times article on the vaping phenomenon.

Among U.S. adults, a May study published in The Journal of the American Medical Association found that one in seven, or 33 million, have tried vaping. It may be that, because e-cigarettes are designed to resemble traditional cigarettes and simulate the cigarette-smoking experience, they’ve gained a greater following than other smoking cessation aids, such as nicotine-flavored gum and patches. Still, a 2017 study from the Centers for Disease Control and Prevention (CDC) found that although many adults use e-cigarettes to help them quit smoking, most don’t stop and, instead, continue using both products. The FDA has not approved e-cigarettes as a way to help people quit tobacco.

Today, scientists are studying e-cigarettes to understand how using them affects people’s health. According to the CDC, e-cigarettes have fewer than the 7,000 chemicals found in the smoke of regular cigarettes. But they may still contain substances like lead and other heavy metals, small particles that can be inhaled into the lungs, additives like propylene glycol and glycerol that may become carcinogenic when heated, and flavorings linked to lung disease, such as the buttery-flavored chemical diacetyl. Diacetyl has been linked to bronchiolitis obliterans, also known as popcorn lung, a serious lung disease that once commonly affected workers in microwave popcorn factories who developed symptoms after breathing in the chemical on a regular basis.

Although the results of ongoing studies on the long-term effects of vaping aren’t in yet, people looking to e-cigarettes as a way to wean off traditional cigarettes should find a better alternative, Dr. Mons says. “It will be interesting to see what the studies find, when they are completed, on the effects of vaping,” he says. “But right now, we just don’t have a full picture of the risks. We do know that there is no evidence to suggest that e-cigarettes are safer or more effective than existing, government-approved smoking cessation methods. Ask your doctor about those. Anything we can do to avoid irritants in the lungs and airway will, I believe, reduce our risk of developing cancer or recurrent cancer in the future.”

But in a growing number of cases, the era of precision medicine has flipped the perceptions about rare and common cancers upside down. Research has shown that some cancers long considered common are just a collection of rare subtypes that happen to share the same origin. Advances in immunotherapy have also led to new treatments for some rare cancers that once were difficult to treat. And advanced genomic testing has revealed molecular features in some rare cancers that may be treated with drugs previously developed for more common forms of the disease. “The definition of rare cancers has changed over time, both because of the role of genomic testing and evidence that different subtypes provide clinically meaningful information that impacts treatment and outcomes,” says Maurie Markman, MD, President of Medicine and Science for Cancer Treatment Centers of America^® (CTCA).

From adamantinoma (a rare form of bone cancer) to Waldenström's macroglobulinemia (a type of non-Hodgkin lymphoma), more than 500 forms of rare cancer have been documented, according to the National Cancer Institute (NCI). Rare cancers are not just those with unpronounceable names found in specific cells or obscure body parts. They also include cancer of the stomach, esophagus, bone, vagina, penis and gallbladder.

Because these cancers are so unusual, information on how to identify, stage or treat them is often difficult to find. “In settings where there is limited experience treating cancers, management of rare cancers is a particular challenge,” Dr. Markman says. “A physician may only see such a case every few years, or even less frequently. And the absence of clinical trials for rare cancers only makes the situation more difficult.”

While deepening their understanding of a specific cancer’s blueprint, scientists and oncologists have discovered that some so-called common cancers may not be that common at all. “Common cancers are being subclassified into clinically relevant, molecularly defined subgroups, and might lose their common cancer designation as a result,” the author of a 2016 article on rare cancers wrote in The Lancet Oncology, adding that “rare is the new common in the post-genomics era.” For instance, melanoma, is the fifth most common cancer diagnosed in the United States, with more than 90,000 new cases a year. But scientists have broken down melanoma into multiple subtypes, each with unique DNA mutations. Melanoma “is a collection of rare cancers, each with a unique biology with distinct implications for therapy—an increasingly common pattern in oncology,” the researchers wrote. Each of these subtypes would be considered rare cancers under NCI guidelines.

Genomic analyses of a rare cancer may also unveil common mutations found in a variety of cancers, which may lead to new treatments. “We may be seeing treatments for rare cancers based on genomic analysis initially conducted on many common cancers or where the mutations are more commonly observed,” Dr. Markman says. “For example, a HER-2 mutation is highly relevant in breast cancer, but the presence of this abnormality may help to define an effective treatment approach in a cancer where anti-HER-2 therapy is not normally considered standard-of-care.” Researchers are studying the targeted therapy drug trastuzumab (Herceptin^®), which is often prescribed to treat HER2-positive breast cancer, as a potential treatment for salivary duct cancer and uterine serous carcinomas, rare and aggressive cancers that may have HER2- positive mutations.

These new discoveries ushered in by the era of precision medicine have helped lead to new treatments and potential treatments for rare cancers. In 2017, immunotherapy drugs known as checkpoint inhibitors were approved to treat Merkel cell carcinoma, an extremely rare form of skin cancer, and Hodgkin lymphoma, a rare blood cancer. Immunotherapy is also being researched as a potential treatment for other rare cancers, such as thymic cancer and mesothelioma.

Still, cancers considered rare continue to present challenges to doctors and patients. According to a 2017 study by the American Cancer Society:

• 59 percent of rare cancers are diagnosed at advanced stages, compared with 45 percent of common cancers.
• The five-year survival rate for men with rare cancers is 55 percent, compared with 75 percent for common cancers.
• The five-year survival rate for women with rare cancers is 60 percent, compared with 74 percent for common cancers.

“The most significant finding was seeing that collectively rare cancers are still likely to be diagnosed at later stages and overall survival is poor,” study author Carol DeSantis, MPH, told CURE magazine. Facing such overwhelming percentages can be devastating to patients. But Stephen Lynch, MD, Intake and Primary Care Physician at our Phoenix hospital, encourages patients to take control of their diagnoses and learn as much as they can about their cancer. “Many times, whether it is a common cancer or a real oddity, a lot of patients really don’t understand it,” Dr. Lynch says. “They’ve been told they have breast cancer. Well, breast cancer is many different diseases. They’ve been told they have lung cancer. That’s many different diseases. So, first and foremost is helping the patient understand the foundation of their disease.”

As scientists and researchers delve deeper into the genomics of each cancer, they are finding that every cancer, like every patient, has unique characteristics that often require individualized treatments. Dr. Lynch says it’s important to educate patients on what makes their specific cancer tick, despite its classification as common or rare. “Digging into that diagnosis and helping patients learn about the unique molecular aspects of their tumor will help them better understand what they are dealing with and what questions to ask,” he says.

  Learn more about the TAPUR study.

“ Vitamins, in general, are natural compounds that aid several body functions, including metabolism, nerve function and skin health. Vitamin D, in particular, helps provide immune support, bone strength and blood-calcium regulation. The nutrient also plays a well-known role in cancer prevention, specifically in breast and colon cancers, and it's a benefit to many patients who have already been diagnosed with cancer.” - Issam Alawin, MD - Medical Oncologist at our hospital in Tulsa

Cancer patients who get the recommended dose of vitamin D during treatment lower their risk of osteoporosis and bone fractures, especially if their treatment regimen includes certain therapies, like steroids or hormone blocks, Dr. Alawin says. Some studies have also found that vitamin D may slow or prevent the development of cancer, and others have investigated whether people with higher levels of vitamin D have lower risks of certain kinds of cancer.

And yet it isn’t always easy to get an adequate amount. Naturally occurring vitamin D sources are limited. Some people assume they can get the vitamin from the foods they eat, but the truth is very few foods have enough of it to qualify as a sufficient source. Dairy products usually contain more vitamin D than other foods, but even cow’s milk, which has 400 international units of vitamin D per quart, doesn’t have enough when you consider the daily recommended intake for most people is 600 international units, says Matt Rinehart, MS, RD, CSO, LD, who leads the Clinical Oncology Dietitian team at our hospital in Tulsa. The sun is our main natural vitamin D source, but it comes with the risk of skin damage. “Unless you’re an avid milk drinker and get a fair amount of sunlight every day, you’re probably coming up short on your vitamin D needs,” Rinehart says.

Vitamin D deficiency is even harder to combat for cancer patients who experience fatigue and other challenging side effects of cancer treatment. “Because of their side effects, many cancer patients would prefer to be at home,” Dr. Alawin says. “They may be too tired to be active outside, or they may feel cold because of anemia and want to stay covered up indoors.”

Many oncologists also recommend that patients stay out of the sun to avoid skin reactions that may result from treatment. Photosensitivity, for example, is often caused by certain treatments, such as radiation therapy, photodynamic therapy and chemotherapy medications like methotrexate (Folex^®, Mexate^®), a drug commonly used to treat leukemia and lymphoma, and fluorouracil (Efudex^®, Adrucil^®), a drug commonly used to treat colon cancer. The effects of photosensitivity may range from mild redness or small pigmented spots to blistering or painful skin peeling. “In all of these cases, vitamin D dietary supplements are recommended,” Dr. Alawin says.

It’s a good idea for cancer patients to have their vitamin D levels tested as soon as they receive a cancer diagnosis, during treatment and on a regular basis after treatment ends, Rinehart says. If patients’ levels are below the daily recommended value, their doctor or dietitian may recommend a supplement. But it’s important to understand which supplements are safe and appropriate—and to know that these vitamins should be taken with food.

Vitamin D is a fat-soluble vitamin, meaning it dissolves in fats and oils digested with food and won’t dissolve as well if taken alone. “We see a lot of patients who come in on a vitamin D supplement already, but because no one’s educated them on the fact that the nutrient is fat soluble, they’re not fully benefiting from it because they’re not taking it with a meal,” Rinehart says. But being fat soluble also means vitamin D may build up in the blood if you take too much, which means that taking a dose higher than what your doctor or dietitian recommends may cause toxicity. “That’s why frequent testing and monitoring are so important,” Rinehart says.

“ Give age-appropriate information, and tell children where the cancer has been found in your body. Also, use the word, “cancer,” and tell them it’s not contagious. They may believe they caused it, so clarify that’s not true. Encourage them to express their feelings, and share your feelings. Tell them your health has changed, but your love for them hasn’t. Warn them about what to expect, like hair loss. Be honest about your feelings, but don’t burden them.” - Lynn Bornfriend, MD, - Psychiatrist at our Philadelphia hospital

Liv Arnold knows firsthand how intimidating, and how important, these conversations can be. In 2016, two days before her daughter’s 6th birthday, Arnold learned she had stage II breast cancer. Arnold’s son was 3 at the time. She and her husband talked to the children about the cancer “in bits and pieces,” and kept it factual. “I said, ‘I have cancer here in my right breast,’” Arnold recalled. “I showed them the bump. I said, ‘Can you feel this? This is what the doctor is helping me with.’ I told them about the mastectomy and that my body would change.”

The children weren’t too interested, she said, and they didn’t ask many questions until the side effects began kicking in. “My son freaked out when my hair was gone,” she said. “He hid and was nervous. And if we were at a school event and my daughter was having fun playing and I’d say we have to go home because I was tired, she’d cry and say she hated cancer. I’d say, ‘I hate it too, but this means the medicine is working.’”

Dr. Bornfriend encourages patients to be transparent with their children, saying it helps quell fears of the unknown. “I think it’s important to let them come to treatment, seeing what it is, what it isn’t, and that people know your parent and are taking good care of them,” she says. “Otherwise, you disappear somewhere, and they don’t know where you’re going and what that means.”

After her surgery, Arnold showed her kids the ports, drains and the burns caused by radiation. She wanted to help them understand why she didn’t feel well. But she always made sure to convey that everything she was doing was to become healthy again.

Transparency should extend to even the most difficult questions, says Dr. Bornfriend. “If they ask you if you’re going to die, reassure them that you and your doctors are doing everything possible to make sure that doesn’t happen,” she says. “Remind them that you have good doctors. If they ask what will happen to them if you die, who will take care of them, review what your plan is for them. Let the kids guide the conversation. If they have questions, it’s important to be honest. Children can sense when you’re not being truthful, and they need to be able to trust what you’re saying.”

Connecting them with adults they know and trust—a teacher, aunt, scout master or church leader, for example—may be helpful, providing the opportunity for a child to confide their fears and feelings in someone other than the patient. “Kids might want to talk about something that’s not appropriate to discuss in front of the patient, like if they’re scared the parent might die, or want to ask something they worry might sound selfish,” says Dr. Bornfriend.

Even when kids ask questions, don’t be surprised if they’re not be all that interested in the answers. “In the middle of an answer, they may walk away or change the subject, and that’s fine,” Dr. Bornfriend says. “They can take little bites of information, and then they’re done.”

Here is an at-a-glance summary of Dr. Bornfriend’s tips that may be helpful for talking to your children about your cancer:

• Be honest and use the word, “cancer.”
• Use age-appropriate language to explain where the cancer is and what the children can expect during treatment (“Mommy may need extra rest,” or “Mommy’s hair may fall out,” for example).
• Explain that cancer is not contagious, and it’s no one’s fault.
• Let them know their energy and playfulness encourage you to get well.
• Encourage them to share their feelings with you or other important people in their life.
• Give them opportunities to help you.
• Hug them daily and let them know that, while your health has changed, your love for them has not.

“ A lot of people have used myths in a bad way to promise hope to cancer patients who are seeking hope and have not been given any hope in order to take their money in exchange for a therapy that doesn't always work. Hyperbaric oxygen is one of them.” - Wissam Jaber, MD - Interventional Pulmonologist

When you breathe, oxygen passes into the lungs and is carried into the blood to feed cells throughout the body. Cancer cells also need oxygen to survive, which is one reason why tumors make new vessels that tap into the body's blood supply, a process called angiogenesis. As tumors quickly develop, they outgrow their oxygen supply, but surprisingly, that does not always inhibit their growth. Studies show that some cancers may thrive and resist treatment when they become starved of oxygen, a condition called hypoxia.

So, if tumors thrive and resist treatment when starved of oxygen, wouldn’t flooding them with oxygen have the opposite effect? That's the theory behind hyperbaric oxygen therapy, which has been touted as a viable cancer treatment. The research doesn’t support such a definitive conclusion. Hyperbaric oxygen therapy, which uses high pressure to force concentrated oxygen into the bloodstream, has been used for decades to treat decompression sickness. Also known as "the bends," this condition occurs when air pressure changes from a rapid ascent in altitude or depth, forming nitrogen bubbles in the bloodstream. These bubbles collect in the joints, usually the shoulders, knees, elbows and ankles, causing pain. One of the most common causes of the bends occurs when deep-sea divers ascend to the surface too quickly. Hyperbaric oxygen therapy is also used to treat carbon monoxide poisoning and deep infections or to help wounds heal.

Lots of research has been conducted on hyperbaric oxygen’s use as a cancer treatment, often with mixed or inconclusive results. In 2015, scientists in Boston made headlines with a study that concluded flooding tumors with oxygen may help some therapies work better. “Since the root of all problems is the lack of oxygen in tumors, a simple solution is to give tumors more oxygen,” Northeastern University researcher Michail Sitkovsky told NBC News. But the same article quoted the American Cancer Society as saying, “Available scientific evidence does not support claims that putting oxygen-releasing chemicals into a person's body is effective in treating cancer.” A 2012 review by researchers in Norway showed that hyperbaric oxygen slowed the growth of some cancers but not others. The writers called for further research. "Differences in response to oxygen between different cancer types should not lead to an exclusion of HBO as a form of cancer treatment or as a cancer treatment adjuvant for selected types of cancers," the review said.

Clinical trials continue to study oxygen therapy’s ability to treat cancer and some of the side effects of cancer surgery and other treatments. But for now, Dr. Jaber says: "There is no therapeutic role for oxygen in cancer. Presenting higher than normal concentrations of oxygen to treat cancer has not been proven scientifically to kill the disease."

“ Cancer patients are whole people with whole histories, and sometimes it's hard to know what is causing certain symptoms.” - Katherine Anderson, ND, FABNO - Chief of the Division of Naturopathic Medicine at Cancer Treatment Centers of America^® (CTCA)

Back pain

Back pain may be a symptom of conditions unrelated to cancer, such as a ruptured disc. But cancer patients who experience these aches and pains during rest or even after medication or physical therapy may want to talk to their doctor about whether the pain is cancer-related.

For some cancer patients, for example, back pain is a sign that the cancer has traveled beyond its origin—namely, to the bones and spine. That especially happens with some breast and prostate cancers, which typically spread first to the bones, but it also happens with other metastatic cancers, such as those of the colon, rectum, ovaries and lung. In fact, about 25 percent of lung cancer patients experience back pain. Because the disease typically isn’t suspected until it has progressed to advanced stages, back pain also may be one of the first symptoms that people with undiagnosed lung cancer notice.

To help relieve back pain that’s not related to cancer, Anderson says she typically suggests that patients use acupuncture as an alternative to opioids. She also prefers options like chiropractic care, generalized stretching, deep breathing techniques and natural anti-inflammatories, such as fish oil and curcumin, a plant-produced chemical.

Itchy skin

In general, itching is not a symptom of cancer, although it may be a sign of advanced cases of pancreatic and liver cancer, when the cancer has progressed enough to cause jaundice—a yellowing of the skin or eyes that occurs when the organs aren’t functioning properly. Most of the time, itching is a sign of much more benign conditions like allergies or dryness, although it may be caused by certain cancer treatments, such as chemotherapy, radiation or targeted therapy.

To help soothe itchiness, patients may try a number of remedies, which typically involve moisturizing and hydrating the skin. Anderson suggests that patients:

• Use skin creams that don’t contain alcohols or fragrances
• Use warm water instead of hot water while bathing
• Use a mild, unscented soap
• Use baking soda instead of deodorant
• Drink plenty of water and get plenty of rest

Night sweats

Menopause and fever are the most common causes of night sweats, but other, external factors may be at play, like exercising or eating spicy foods too close to bedtime. Night sweats may also be caused by cancer treatments like chemotherapy and hormone therapy, or they may develop as a symptom of cancer itself.

The most common types of cancer associated with night sweats are lymphoma, leukemia, bone cancer, liver cancer and mesothelioma. “It’s unclear why some types of cancer cause night sweats, but they may occur because your body is trying to fight the cancer,” Anderson says. “If your night sweats are caused by cancer, you’ll likely experience other symptoms, too, like unexplained weight loss and fevers without infection. Also, they’ll typically stop once your cancer is treated.”

Some tips for managing night sweats include:

• Placing a damp cloth or cold compress on your forehead
• Wearing loose-fitting clothes made of cotton
• Taking a cool shower before bed
• Practicing relaxation and stress-reducing techniques like yoga and meditation before bed
• Using a fan at night

A number of lifestyle changes may also help ease back pain, itchy skin or night sweats. For instance, obesity is a risk factor for back pain in both men and women, and Anderson says she notices night sweats more often in breast cancer patients who are overweight. “Changes in diet and movement are going to help you manage your weight, build muscle mass and improve immune function, and those benefits are going to have a cascade effect to other areas of your life,” she says.

Dangerous interactions may occur when combining oral chemotherapies with a number of things, including certain medications, natural supplements or foods. One study found that interactions occurred in 13 percent of patients on oral chemotherapy drugs, with more than 20 percent of those interactions classified as major.

“ Patients may take oral anti-cancer therapies for years, and the fear is they get lulled into complacency and overlook mentioning to their doctor that they’ve started taking certain medications. I tell patients to have all hands on deck. You want everybody to know everything you’re taking. Rely on the collective expertise of the folks prescribing the meds.” - Stephen Lynch, MD, - Primary Care and Intake Physician at our Phoenix hospital 

Because so many factors are involved in prescribing medications that can trigger an interaction, there’s lots of room for error, says Dr. Perre. For starters, not every hospital and doctor’s office has electronic medical records, which serve as electronic medical charts that are accessible to other health care facilities and contain patients’ comprehensive medical history, including medications they are taking or have taken. Even though multiple electronic databases have been developed that educate medical professionals on prescriptions and their safety information, interactions and black-box warnings, not every health care facility uses the same database. With multiple databases come opposing viewpoints about the severity of the interactions, meaning clinicians are getting mixed messages.

The potential for drug interactions can also go unnoticed at multiple points along the patient’s treatment journey, Dr. Perre says: “What if an oncologist gives a patient a drug that interacts with another drug, and the patient goes to his primary care doctor, and the interaction with the drug prescribed by the oncologist is not in the database used by the primary care physician? Or what if the primary doctor doesn’t have an electronic database? The patient then has to rely on the primary care doctor and/or the pharmacist to recognize the interaction.”

Medications that cause interactions

Antidepressants are among the drugs that have caused a number of troubling interactions for chemotherapy patients, especially those with breast cancer. One in eight Americans takes an antidepressant, which also happens to be the same percentage of women  in the United States who will develop invasive breast cancer over the course of her lifetime, according to the U.S. Centers for Disease Control and Prevention. That’s why it’s important for both patients and practitioners to be aware that multiple studies have shown that women on the popular breast cancer chemotherapy drug Tamoxifen^® who also take certain antidepressants have a much higher risk of death—91 percent, according to one study—than Tamoxifen patients not taking a high-risk antidepressants. Tamoxifen is designed to work when a specific enzyme (cytochrome P-450 2D6, or CYP2D6) is metabolized in the liver. Some of the most popular antidepressants block CYP2D6, preventing Tamoxifen from activating. Dr. Lynch says.

“When you look at the commonality of breast cancer, the duration of time women stay on Tamoxifen (the current recommendation is 10 years) and the possibility that, somewhere along the line, another practitioner might prescribe an antidepressant, it’s a huge potential problem,” says Dr. Lynch.

Other drugs that may cause dangerous interactions when taken with oral chemotherapies include (but are not limited to):

• Warfarin: When this blood thinner is taken with medications like chemotherapy drugs, the combination may increase the likelihood of bleeding or of an unwanted blood clot.
• Anti-nausea drugs: Known as anti-emetics, these medications are often used to treat chemotherapy side effects. Studies have found that taking them with certain oral chemotherapies may cause increased vomiting.
• Antacids: When taken with targeted therapies known as tyrosine kinase inhibitors (TKI), the combination may affect the body’s ability to absorb the cancer-fighting drug. Dr. Lynch says this side effect is particularly concerning because—unlike typically obvious complications like toxicity, which often causes vomiting or other clear symptoms—the body’s failure to absorb the chemotherapy drug may not be apparent until it’s too late and the patient has missed a critical window in the treatment regimen. “Just because a patient doesn’t have an overwhelming, obvious side effect, we as doctors could still be doing a great disservice by reducing the effectiveness of the cancer therapy,” says Dr. Lynch.
• The popular antibiotic combination of trimethoprim and sulfamethozoxazole:  Used to treat urinary tract infections, middle ear infections and bronchitis, this antibiotic should not be taken with methotrexate, a chemotherapy drug widely used to treat breast, skin, head and neck and lung cancers as well as some leukemias and lymphomas.
• Non-steroidal anti-inflammatory drugs (Motrin, Aleve, Advil): Combining these with methotrexate may interfere with the body’s ability to expel the chemotherapy drug as waste, causing potentially lethal toxicity.
• Certain antibiotics, antifungals, antivirals and anti-nausea medications, the potent narcotic methadone and some antihistamines: Combining these with the targeted chemotherapy drugs dasatinib and nilotinib, commonly used to treat chronic myeloid leukemia, may cause sudden death from cardiac arrest.

Supplements to avoid  

Certain supplements also have been shown to interfere with chemotherapy drugs, leading to conditions that poison the body or reduce the chemotherapy’s effects, says Daniel Kellman, ND, FABNO, Director of Naturopathic Medicine and Rehabilitation Services at our Atlanta hospital. “At the same time, supplements have a great potential to improve the quality of life for cancer patients undergoing treatment,” Dr. Kellman says. “That’s where clinical practice experience and understanding biochemistry and pharmacology of these substances becomes really important.”

St. John’s wort, a plant-based supplement used to treat depression, as well as ginseng, ginko biloba and milk thistle, should not be used with many chemotherapy drugs, according to Dr. Kellman. Like certain antidepressants, these over-the-counter supplements interfere with how the body metabolizes the CYP2D6 enzyme, diminishing the chemotherapy drug’s effectiveness by causing it to break down too quickly, or poisoning the body by blocking the drug from breaking down at all. Because licorice extract and grapefruit juice are also metabolized in the liver, Dr. Kellman says patients on certain chemotherapy drugs shouldn’t take them.

His takeaway on taking supplements while undergoing chemotherapy: “Don’t self-prescribe. Try to get professional advice on what’s beneficial before just buying things on the internet or going to a health food store. It’s good to meet with an integrated-minded MD or a naturopathic physician. It’s also important to be very forthright and honest with your oncologist about what you’re taking, because often patients don’t tell their oncologist because they’re worried about getting scolded or told something doesn’t work. But it’s a safety issue.” Still, Dr. Kellman says, a host of natural substances can be safely taken to help patients “dramatically improve their experience during cancer treatment by preventing stomach upset, helping with energy levels, helping reduce neuropathy and helping improve blood counts.”

Dr. Perre advises patients to keep a running list of everything they’re taking, including supplements and over-the-counter medications. “Carry it in your pocketbook or wallet at all times and keep it updated,” he says. “Make sure every practitioner knows what you’re taking at all times. And don’t take any supplements, vitamins or herbs without getting the OK from a health care professional.” Communication is the root of the problem, says Dr. Lynch. “Patients are only asking for trouble if they’re not being honest with their doctor,” he says. “It’s incumbent on the physician to be respectful of patients’ decision. Our job is to educate them, but at the end of the day, we have to know what they’re taking.”

Learn more about what common medicines may interfere with chemotherapy drugs.

Concerned by data showing that colorectal cancer rates among younger Americans are growing sharply, the ACS is recommending that all adults at average or low risk get screened for the disease at the age of 45, instead of 50, as it previously recommended. Adults in good health at average risk and a life expectancy of more than 10 years should continue screening through the age of 75, the ACS recommends. Those older than 76 should consult their doctor about a screening schedule. Men and women at high risk, such as patients with a family history of colorectal cancer, may require a more aggressive screening program.

Two-thirds of all colorectal cancer cases are diagnosed in adults 55 to 84 years old, according to National Cancer Institute statistics from 2011-15. But a 2017 study published in the Journal of the National Cancer Institute found that colorectal cancer diagnoses have risen sharply in young adults over the last 20 years. In fact, "age-specific colorectal cancer risk has escalated back to the level of those born circa 1890 … underscoring the need for increased awareness among clinicians and the general public," the study’s authors note.  

The ACS also is recommending that doctors give patients a wider range of tests to choose from, in hopes that more choices will result in more screenings. "Ascribing to the adage that the best screening test is the one that gets done, and done well, the ACS recommends that patients … be offered a choice of tests based on availability of high‐quality options," the organization said in updating its guidelines. “It is our hope that widespread adoption of this guideline will have a major impact on the incidence, suffering, and mortality caused by colorectal cancer." The ACS advises patients to follow up with a colonoscopy if they receive positive results from tests other than a colonoscopy.

By reducing the recommended age of colorectal screenings and expanding the number of screening options, the ACS hopes to reduce incidence rates and catch the disease early enough to improve outcomes for more patients. "We have known, in recent years, that colorectal cancer rates in people over 50, who have screening available, have decreased significantly, while colon cancer rates in patients under the age of 50 have risen quite significantly," says Jeffrey Weber, MD, Gastroenterologist in our Phoenix hospital. "We have, for a long time, advocated screening for African Americans starting at age 45, because they are at higher risk for the disease, and I feel that starting to screen the rest of the population at 45 will save many lives."

Seven questions you should ask your doctor before getting a colonoscopy.

“ Oncolytic virus therapy, as it's often referred to in the medical community, is now recognized as a kind of immunotherapy, and the excitement around this form of treatment stems largely from its perceived ability to turn on the immune system to fight the cancer.” - Alan Tan, MD - Clinical Research Medical Director & Medical Oncologist and Hematologist at our hospital near Phoenix

When certain viruses, such as human papillomavirus (HPV), chickenpox or smallpox, are genetically modified and injected into a tumor cell, they make copies of themselves, eventually causing the cell to burst. Not only does that reaction kill the cancer cell itself, the dying cell also releases substances, such as tumor antigens, that allow the immune system to recognize that type of cell as foreign, prompting an attack. “These tumors are sort of hiding from the immune system,” Dr. Tan says. “But certain genetically modified viruses may cause the release of tumor-associated antigens and a chemical messenger that, together, trigger an immune response.”

Although the initial findings are promising, using viruses to fight cancer is still very much in its infancy. “By itself, this type of therapy has not been shown to increase overall survival rates,” Dr. Tan says. “Also, in a clinical trial, the majority of patients didn’t seem to benefit.” But researchers believe patient responses may be improved by combining virus injections with checkpoint inhibitor drugs, such as nivolumab (Opdivo^®), ipilimumab (Yervoy^®) and pembrolizumab (Keytruda^®).

Dr. Tan, who has used the therapy to treat patients, is optimistic about its future. “We’ve already seen benefits to patients when combining a virus injection with ipilimumab, for instance, and some studies suggest that this treatment, combined with other therapies, may lead to increased survival rates in patients,” he says. In fact, a National Cancer Institute-sponsored clinical trial is now studying whether patients with advanced melanoma tumors that haven’t responded to immunotherapy will benefit from the therapy. Researchers believe that injecting these patients with a specific genetically modified virus before delivering a checkpoint inhibitor drug may enhance the drug’s effect, by improving the immune system’s ability to recognize the cancer cells.

Right now, talimogene laherparepvec (Imlygic^®), also called T-VEC, is the only oncolytic virus therapy approved by the U.S. Food and Drug Administration, and it’s only approved to treat certain patients with metastatic melanoma that cannot be surgically removed. But research is underway to test how other oncolytic viruses may be used to treat patients with brain tumors and sarcomas, as well as breast, lung, liver and bladder cancers. “We are in the era of precision medicine and immuno-oncology,” Dr. Tan says. “We are getting away from the mentality of a one-size-fits-all treatment strategy. There is unlikely to be a ‘magic bullet’ that cures all cancer because there are just too many differences between types, and even within the same kind of cancer. I think modern-day medicine is on the right track, though, and combining therapies is a major piece of that.”

“ You are multiplying your risk not only twofold, but many-fold when you do the two together.".” - Wissam Jaber, MD, Interventional Pulmonologist

Every cigarette damages the body, and in many ways. "Just one cigarette can increase your risk of cardiovascular disease," Dr. Jaber says. "It increases your blood pressure, and adds cumulatively to the risk of cancer over time." Each time a smoker inhales a lit cigarette, a chemical chain reaction erupts that creates dozens of carcinogenic compounds. These compounds in the cigarette smoke are sucked through the lips, past the tongue and mouth, down the throat and into the lungs, causing inflammation in all those body parts and exposing them to cancer-causing chemicals. Once in the lungs, compounds from the smoke are absorbed into the bloodstream and spread carcinogens to the rest of the body.

Tobacco smoking "can cause cancer almost anywhere in your body" and is linked to 90 percent of all lung cancers, according to the U.S Centers for Diseases Control and Prevention. Cigarette smoking is the leading cause of preventable disease and death in the United States, contributing to more than 480,000 deaths every year. Tobacco smoke damages not just DNA, but also the proteins in cells that repair DNA damage. Smoking also interferes with a process called metabolic detoxification, in which cells neutralize some toxins and flush the harmless byproducts out of the body. "Tobacco is the no-brainer," Dr. Lynch says. "Everyone understands that now. But alcohol, because it does have some benefits with respect to cardiovascular risk reduction, people say it’s good for you."

Unlike cigarettes, not every drink is harmful. Moderate amounts of alcohol may help reduce the risk of stroke and cardiovascular disease. "But it's a fine line," Dr. Jaber says. "When you go beyond moderate use, it increases the risk of breast cancer, colon cancer, aero-digestive cancers and many other cancers." Moderate use is defined by the National Institutes of Health (NIH) and the American Heart Association as no more than two drinks a  day for men and one drink a day for women. Alcohol may increase cancer risk in several ways. It can cause inflammation in the liver and pancreas, raising the risk of cancer in those organs. When metabolized, alcohol produces a substance called acetaldehyde, which may stop cells from repairing DNA damage. "Alcohol is a carcinogen," Dr. Lynch says. "There really is no debate about that anymore. It is a cancer-causing agent, and the more you consume, the higher your risk."

Alcohol enhances the effects of tobacco in several ways—for example, by increasing the production of certain enzymes that convert tobacco tar into carcinogens. Excessive drinking may also suppress the immune system, and smoking and alcohol combined may compound the inflammation caused by each. "It's not one plus one equals two," Dr. Lynch says. "There's a much more exponential synergy when you combine alcohol and smoking." People who drink and smoke are 15 times more likely to develop cancer in the mouth and throat than nondrinkers and nonsmokers, according to the NIH.

Some cancer patients may assume that they might as well continue bad habits like smoking and drinking, because the damage has already been done. Dr. Jaber says that’s a mistake. "We try to make an intervention on both aspects to reduce future risk and improve the outcome during cancer treatment by reducing inflammation caused by drinking and smoking," he says. Various studies have produced mixed results on the success of treating tobacco and alcohol addictions at the same time, but the NIH recommends that approach. "Treating co-occurring disorders remains a challenge," the NIH says. "However, evidence suggests that combining treatments might be the most effective way to address concurrent addictions."

Learn how cancer may determine your diet.

“ Your surgeon should go over everything with you beforehand. But patients are often stressed and taking a lot in at that time. Plus, many of the recommendations vary from patient to patient and from surgeon to surgeon, and they also largely depend on what type of procedure the patient had.” - Aaron Pelletier, MD - Plastic and Reconstructive Surgeon at our hospital in Chicago

To help patients prepare for life after breast reconstruction, Dr. Pelletier and Daniel Liu, MD, Plastic and Reconstructive Surgeon at our hospital in Chicago, answer common questions about what to expect and what to do after surgery:

Q. Will I be able to wear a normal bra afterward?

A. Whether you wear a surgical bra after your procedure will likely depend on your surgeon’s preference and the type of surgery you had performed. Some patients will benefit from wearing a compression bra around the clock for the first four to six weeks, but many will be advised not to, Dr. Liu says. Underwire bras and bras that don’t provide much support generally aren’t recommended in the first six weeks after surgery.

Q. Can I shower after surgery? What about exercise?

A. Patients are typically encouraged to begin showering 48 hours after surgery, and to use warm, soapy water. You shouldn’t worry if water comes in contact with your incisions or drains. As for exercising, ask your surgeon when you may begin working out again, because advice may vary based on the type of surgery you had performed.

Q. Is massage recommended?

A. Massaging may help improve the appearance of scars or break up deeper scars in the soft tissues and chest wall that cause pain or issues with range of motion. But in other cases, such as when shaped implants and expanders are used, massaging is not recommended right after surgery. “Patients need to talk to their surgeon about this and follow his or her advice,” Dr. Pelletier says.

Q. Are there ways to help scars fade?

A. It may take a year or two for tissues to fully heal and for scars to fade, but, typically, scars never go away completely. Although many products, such as vitamin E oil and topical silicone gel sheets, are often touted as tools to help scars fade or disappear, none has been scientifically proven to do so.

Q. How long will drains remain in place?

A. Drains are small tubes placed in the incision that, over time, help to remove extra fluid during the healing process. Drains are commonly used in all types of reconstruction procedures, but many factors go into determining how many drains are used, and when they are removed. Most often, your surgeon will share these details with you before your procedure.

Q. How long does it take for swelling to go down and for the new breast to reach its final size and shape?

A. Each person is different, and much of the recovery process depends on the type of procedure performed. That said, it usually takes about three to six months for swelling to subside and for your breast to achieve a final shape, but it may take longer, particularly for patients who received radiation therapy for breast cancer treatment. Radiation permanently damages tissue at the microscopic level, which makes it harder for tissue to heal.

Also, keep in mind that final breast shape is often affected by gravity and tissue elasticity.

Q. How long do implants last?

A. Newer-generation gel implants will likely last the patient’s lifetime. “I usually tell my patients that in 10 to 15 years, they may need another operation to revise or exchange their implants,” Dr. Liu says. But no surgeon should provide a guarantee as to how long the implants may last. Patients may choose to have their implants exchanged later in life for a number of reasons, and most have nothing to do with problems with the implant itself.

But if a problem does arise, it is most often what’s called capsular contracture, which occurs when a scar forms around an implant and squeezes it, making the breast feel hard. This condition is often treated with surgery to remove the scar and possibly replace the implant.

Q. Will I have to have another procedure?

A. Breast reconstruction often involves more than one procedure, because it usually takes two or more surgeries to complete the reconstruction process while allowing time to heal in between. Sometimes, the process involves a revision procedure. Other times, a follow-up surgery may be necessary to achieve symmetry, while other procedures may be performed to reconstruct the areola or apply a nipple tattoo. “Everyone is different in terms of what she needs and wants, and this is something every patient should discuss with her surgeon,” Dr. Liu says.

Q. Will I still have to have mammograms and perform self-breast exams?

A. Experts say women who have breast reconstruction after a mastectomy don’t need routine mammograms. But if a physical exam finds something concerning, a diagnostic mammogram, ultrasound or MRI may be performed. Every breast reconstruction patient should perform weekly self-breast exams and have annual exams performed by her surgeon, Dr. Liu says.

For women with silicone gel-filled implants, the U.S. Food and Drug Administration recommends that women receive a breast MRI three years after they receive their implants, and every two years after that, to look for signs of ruptures.

Q. When will the numbness go away and feeling return to my breast?

A. Some feeling may return after a number of years, but patients shouldn’t expect a reconstructed breast to recover full feeling. Some numbness is likely to persist even years later.

Breast reconstruction surgery often causes many changes—both physical and emotional. It may take time for you to accept your new breast as your own, especially if it looks nothing like your old breast. Talking with other women who have undergone the same experience may help. Talking with your doctor about what to expect may also offer a sense of control over the road ahead. And make sure to call your doctor if you notice troubling symptoms after your surgery.

“Although it may be a stressful time, listen to your doctor before leaving the hospital,” Dr. Pelletier says. “Before you’re discharged, you should understand how to take care of your surgical sites and how you should care for your breast based on the surgery you had.”

“ We call them hematologic malignancies. Hematologic meaning blood, malignancies being cancer. They are malignancies that occupy the space related to the bone marrow and the blood supply.” - David Topolsky, MD, Hematologist-Oncologist & Medical Oncologist

The three main types of blood cancers are:

Multiple myeloma: This cancer develops in the bone marrow and affects plasma cells, which produce antibodies that attack infections and diseases. When plasma cells become cancerous, they may accumulate in the marrow and damage or weaken bone and cause pain. Cancerous plasma cells also produce faulty antibodies, which make it hard for the body to fight infections. The disease may be treated with targeted therapy, radiation therapy, chemotherapy and/or a stem cell transplant.
Learn more about multiple myeloma

Leukemia: This cancer of the blood cells usually starts in bone marrow and travels through the bloodstream. In leukemia, the bone marrow produces mutated cells and spreads them into the blood, where they grow and crowd out healthy blood cells. Leukemia comes in many forms, but the key diagnosis is determined by whether the disease is acute or chronic. Acute leukemias are fast-growing and may require aggressive treatments.
Learn more about leukemia

Lymphomas: These diseases affect the cells in the lymphatic system. In lymphomas, immune cells called lymphocytes grow out of control and collect in lymph nodes, the spleen, in other lymph tissues or in neighboring organs. There are dozens of types of lymphoma, but the disease is largely categorized as Hodgkin or non-Hodgkin. Immunotherapy may be used to treat some cases of Hodgkin lymphoma. Other lymphoma treatments include chemotherapy and surgery to remove affected lymph nodes.
Learn more about Hodgkin lymphoma and non-Hodgkin lymphoma

Patients with blood cancers often have symptoms common to all three forms of the disease: weakness and fatigue, bone pain, infections, fevers and weight loss. And some leukemias and lymphomas are so similar, they may be considered the same disease, but are named depending on whether they are found in the blood or in the lymph system. For instance, chronic lymphocytic leukemia and small lymphocytic lymphoma affect the same kind of cells—small lymphocytes—and are often considered different versions of the same disease. A definitive diagnosis may require a bone marrow biopsy or a procedure called flow cytometry, in which cancerous cells are analyzed with a laser.

Dr. Topolsky says its critical to accurately diagnose not only the type of blood cancer, but which of the many sub-types the patient may have. "The most important thing for a patient to grasp is exactly what he or she has," Dr. Topolsky says. "There are so many different types of lymphomas and many different types of leukemias. So the most important thing is to have a clear understanding of your specific disease. Good communication and good education from your oncologist or from your doctor is critical in helping you understand what you’re dealing with, and the therapeutic choices available to you."

  Learn more about CAR T-cell therapy for liquid cancers.

It may seem like a simple case of cause and effect when people who live in the same area, work at the same job site, or play on the same sports team develop cancer, especially if it’s the same type of cancer. Some may assume pollution is to blame. Others may suspect toxins in the ground or walls. But proving the connection is often difficult, if not impossible. In fact, very few of the more than 1,000 suspected cancer clusters reported to state and federal health officials each year are confirmed to be cancer clusters, defined by the U.S. Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI) as a “greater-than-expected number of cancer cases that occurs within a group of people in a defined geographic area over a period of time.” Most of the time, the evidence needed to establish a connection doesn’t materialize, either because of outside variables, the limitations of science, eternal mysteries of the world we live in, or because there just isn’t one to find.

IDENTIFYING CLUSTERS: IT'S COMPLICATED

One example demonstrates the confusion around the enduring questions that arise when seemingly obvious links can’t be confirmed. Last summer, World Series champion Darren Daulton became the fourth Philadelphia Phillies player to die of glioblastoma, an aggressive form of brain cancer. Many people, especially fellow former baseball players, wonder about what seems to be an obvious link between brain cancer and baseball—or, at least, between brain cancer and older versions of synthetic turf used in stadiums like Veterans Stadium, which the Phillies called home from 1971 to 2003. But researchers suspect the cluster is probably a coincidence, saying their investigation did not uncover enough evidence to support the belief that the cancers were caused by a single, shared source. The deaths, they added, fit cancer patterns that occur in the general population: Glioblastoma is more common among men than women, and those at highest risk are between the ages of 45 and 70.

While frustrating, the investigation’s results are not unusual in the world of cancer clusters. In some cases, groups of cancer occurrences are natural because the disease is so common—perhaps more common than many realize. In the United States, nearly one in three people will develop cancer during his or her lifetime. Think of a pool cue breaking up a group of balls in a game of billiards. Some may land in the far corners of the table, while others cluster together. Like cancer afflicting neighbors or co-workers, some experts say, it’s completely random.

And cancer is a complex disease, categorized into more than 100 different types, each with its own risk factors, symptoms and causes. The disease often takes years or even decades to develop. Another factor complicating the quest to prove clusters: People don’t always stay in the same place. 

“ The reasons cancer clusters are so difficult to prove are numerous, and include the possibility of random chance, duration of exposure, and the possibility that different people are moving in and out of an area or having different amounts of exposure.” - Pamela Crilley, DO, Chair of the Department of Medical Oncology at Cancer Treatment Centers of America^® (CTCA)

That’s why many cancer clusters that investigators are able to confirm are found in the workplace, rather than in residential communities—because they are often easier to prove, says Asha Karippot, MD, Medical Oncologist and Hematologist at our hospital in Tulsa. When co-workers who have breathed the same fumes, or drank from the same tap, or handled the same material, over time develop the same type of cancer, the source is confined to a smaller space, and more readily verifiable. The “over time” aspect is another key, both to how cancer forms and confirming a cluster link. Environmentally linked cancers occur most often when people—in the case of cancer clusters, the same group of people—are exposed to high, repeated doses of carcinogens. For example, researchers studying cancer clusters in the 1960s discovered a link between malignant mesothelioma and asbestos, a fibrous mineral then common in manufacturing, industrial and consumer products. Then, in the early 1970s, when workers in the same chemical plant were diagnosed with angiosarcoma of the liver, investigators determined that the rare cancer was caused by the workers’ exposure to vinyl chloride, now known to be a major risk factor for their disease.

UNRELATED FACTORS CLOUD THE PICTURE

Other factors, such as smoking, obesity and age, may make cancer clusters even more difficult to prove. “Variables like smoking or obesity can contribute to the appearance of a cancer cluster when one actually doesn’t exist,” Dr. Crilley says. Not everyone who is exposed to a carcinogen will develop cancer—some people are more or less susceptible depending on their genes—while others will develop the same cancer, even if they were not exposed to high-risk toxins. Even when cancer-causing agents are found in a single neighborhood, some residents may be exposed to the substance while others aren’t.

For example, not all the former Phillies players who died of brain cancer played together at Veterans Stadium or stayed with the team for the same length of time. The Philadelphia Eagles also played and practiced at the stadium, but the National Football League hasn’t reported an unusual occurrence of brain cancer among its players. “It’s often difficult to scientifically prove the presence of a cancer cluster,” says Anthony Perre, MD, Chief of the Division of Outpatient Medicine at CTCA^®. “It’s very possible that the cancer cluster does exist. It just can’t be proven.”

In order for a true cancer cluster to be confirmed, certain criteria must be met:

• A greater-than-expected number of cancer cases must occur in a specific population.
• The cancer cases must involve the same type of cancer or different types of cancer that have the same cause.
• The cancers must all be primary cancers, meaning the disease originated in the same area of the body, not in organs where it may have spread.

According to a set of defined steps health officials take in investigating a cancer cluster, they gather information, including:

• The geographic region where the cases occurred
• The number of cases involved
• The type of cancer involved
• Demographic information about the people impacted, such as their age, gender, race and occupation

Sometimes, officials determine further investigation isn’t needed, such as when the cancers:

• Are among blood-related family members, especially if the cancers are known to have a strong genetic link
• Are different types that are not caused by the same factors
• Are the same type but only occur in a few people, especially among those at high risk for that cancer type
• Occur among people who didn’t live in the same place at the time the exposure would have occurred

If more investigation is needed, officials compare the gathered information with similar census and cancer registry data—such as a group with the same age and gender. The picture is even fuzzier when you factor in the subjective decisions officials make when defining the key elements of a cluster, such as its geographic borders and who it may have impacted. That means that, in some cases, two health departments could arrive at two different conclusions about whether the cancer cluster is real or coincidental.

In 2015, when a suspected cluster of brain cancer was reported in the small town of Belews Creek,  the North Carolina Central Cancer Registry investigated cancer cases in counties with coal ash storage facilities. Most of the town’s population relies on wells for its drinking water, and many blamed a storage pond used by Duke Energy to collect waste from its nearby coal-fired power plant. The investigation, however, couldn’t confirm that the incidence of Belews Creek cancers was any higher than in other, comparable areas of the state. But critics say the study unfairly used county-wide numbers, which may not accurately reflect, for comparison purposes, the number of cancer patients living near the coal ash pond. In December 2017, environmental and civil rights groups filed a lawsuit against Duke, alleging it polluted the community’s water supply. The case is still in court.

SCIENCE IS LIMITED, BUT IMPROVING

Those who are frustrated by the lack of conclusions on cancer clusters should also consider the limitations of science, experts say. Often, researchers lack the smoking gun needed to establish a connection. For instance, if many believe asbestos is to blame but all traces of the mineral have disappeared over time, researchers have no evidence to draw from. Or, if some suspect their well water is contaminated by a cancer-causing substance, researchers may not be able to pin down exactly who drinks the water and who doesn’t. It doesn’t help that most cluster investigations involve a small number of cases, which may make it harder for researchers to draw statistically significant conclusions. “Many reported cancer clusters just don’t include enough cases to allow investigators to prove that there is a statistical difference from the expected number of cases,” Dr. Perre says.

But experts say technology is helping to clear up at least some of the picture. In the past few years, scientists have developed more sensitive tools to measure exposure, and the CDC and the NCI are now using software designed to analyze geographical cancer data to determine if clusters are statistically significant. National cancer registries, which help establish a baseline of cancer incidence and spot anomalies more easily, are becoming another important resource for researchers in investigating clusters. “There remain many challenges to proving a cancer cluster, but science continues to advance and epidemiologic studies continue to improve,” Dr. Crilley says.

“The majority of the publicity assigned to breast cancer is a lump, and the majority of patients might feel a mass in the breast, but there are definitely other symptoms besides a lump,” says Ricardo H. Alvarez, MD, MSc, who leads the Breast Cancer Center Institute at Cancer Treatment Centers of America^® (CTCA). Visual changes may be especially key in helping detect breast cancer early.

“ You can see a lot of things just by looking at your breasts in the mirror. When your arms are by your side, you don't always see everything. Put your hands on your hips or raise them up. Having arms in two different positions while looking is also helpful.” - Cynthia Lynch, MD, Medical Oncologist at our hospital near Phoenix

These other warning signs of breast cancer include:

Changes to the nipple and the surrounding area: “Changes in the nipple area can be a genetic malformation or alteration, but when there is nipple retraction—when the nipple becomes inverted—in many cases, that is a sign of cancer,” Dr. Alvarez says. If the nipple wasn’t inverted before and becomes inverted, consult with your doctor.

Bloody nipple discharge: Bleeding from the nipple may be limited and difficult to see, but if you notice blood stains on your bra, pay attention. Dr. Alvarez cautions women not to panic if they notice clear or milky secretions, since these may result from normal physiologic changes during pre-pubertal stages. But if the secretions are unusual, bloody or continuous, he recommends speaking to your health care provider.

Change in color and/or thickening of skin on the breast: Known in the medical community as peau d'orange (a French term meaning skin of an orange), any dimpling or thickening of breast skin that resembles an orange rind is a red flag. These symptoms are often associated with inflammatory breast cancer (IBC), a rare but aggressive disease that usually does not involve a lump and may not be detected by a mammogram. IBC symptoms are caused by cancer cells blocking lymph vessels in the skin. If the breast skin changes color, typically to a pink or reddish hue that covers more than half the breast, that may also be cause for concern.

“Sometimes these changes in coloration can be difficult to find in African Americans and in obese patients with very large breasts,” Dr. Alvarez says. “IBC is very aggressive, and it has common characteristics: rash, thickening of the skin and shooting pain. This type of cancer grows very fast, and patients often experience pain. Sometimes a patient may experience only one or two skin changes and sometimes all four. Sometimes changes are localized in the breast, upper abdomen and posterior (rear) part of the chest.”

Though IBC represents 1-3 percent of all breast cancers, Dr. Alvarez says it accounts for 10 to 15 percent of all breast cancer deaths. “It’s rare, but highly lethal,” he says. “You can see these changes from one day to the next. The majority of time, these skin changes occur in less than six months. Most of our patients woke up one morning and found the changes. It’s often confused with mastitis (inflammation of the breast), but mastitis is extremely rare if you’re not breastfeeding. A vast majority of IBC patients have first been treated first with antibiotics, thinking it’s inflammation, infection or something else.”

Other possible signs of IBC include:

• Increased warmth in the breast
• One breast appearing larger and feeling warmer and/or heavier than the other
• Pain, itching or tenderness in the breast

A non-healing sore anywhere on the breast, including the nipple: A red, scaly, flaky nipple, and any persistent skin change, including blood or fluid from the nipple, may be a sign of Paget’s disease of the breast, another rare form of breast cancer. This disease originates in the nipple. It’s not usually invasive and is most commonly diagnosed in patients in their 70s and 80s, Dr. Alvarez says.

Swelling of axillary lymph nodes (lymph nodes in the armpit): “Many patients who end up diagnosed with breast cancer that has spread to the lymph nodes have no symptoms in the breast, no changes in the structure of the breast, but they come in for a consult because they feel something under their arm,” Dr. Alvarez says. “This may mean that cancer from the breast has traveled to the lymph nodes, and now there is lymph node invasion. These affected nodes may also be in the lower part of the neck if the cancer is a little more advanced. Cancer cells are very smart and use the lymphatic system to invade distant organs.”

It’s important to also remember that not all breast lumps are signs of cancer, a fact that underscores why it’s important to be familiar with the look and feel of your breasts. “Have an awareness of your breasts,” Dr. Lynch says. “You need to touch them to be aware. Breast self-awareness is the terminology now used instead of a self-breast exam.”

“ Everyone, whether you have cancer or not, should avoid or limit processed meats that have been smoked, cured or salted—cold cuts, ham, sausage, bacon and hot dogs. Laboratory studies have shown that nitrates and nitrites, which are commonly added as a preservative to processed meats, may form compounds that are associated with cancer.” - Carolyn Lammersfeld, MBA, MS, RD, CSO, LD, Vice President of Integrative Medicine at Cancer Treatment Centers of America^® (CTCA). 

Cancer patients, regardless of the type of malignancy they have, should also avoid alcohol. “Alcohol contains ethanol, which is a carcinogen that may lead to DNA damage,” Lammersfeld says. “Even one drink per day for women may increase the risk of breast cancer. The reason isn’t completely clear, other than alcohol contains ethanol, which may raise circulating levels of estrogen and interactions between alcohol, nutrients and genes.” For cancer patients who are not in active treatment, Lammersfeld says men should limit alcohol consumption to no more than two drinks per day, while women should have no more than one per day. A drink is defined as a 12-ounce beer, a five-ounce glass of wine or 1.5 ounces of hard liquor.

Depending on your cancer type, consider the dietary recommendations below to help reduce potential treatment-related side effects while also helping to improve your quality of life chances of better outcomes.

Breast cancer

A strong link has been established between breast cancer and excess body fat, which may increase the production of estrogen and insulin, causing chronic, low-level inflammation, which may damage DNA and allow cancer cells to develop.

Eat less of this:

• Saturated fats, including high-fat meat, poultry with skin, butter, coconut, coconut oil, palm kernel oil, lard and full-fat dairy products such as milk, cheese and ice cream
• Alcohol, which is associated with an increased risk of cancer and recurrence
• Sugary drinks

Eat more of this:

• Fiber, including bran, whole grains, vegetables, fruits and beans (at least 21 grams a day or four to six servings daily of beans and/or legumes, nine servings of veggies and fruits daily with a variety of colors) to help you feel full; reduce exposure to harmful substances through elimination and potentially help with weight management.
• Cruciferous vegetables, such as broccoli, cauliflower, Brussels sprouts, cabbage and kale, because they contain sulforaphanes, which may help with detoxification of carcinogens and prevent tumor growth.
• Omega-3 fatty acids, in food (three to four ounces or ¾ cup flaked fish twice a week of fish, such as salmon, halibut, tuna, mackerel, anchovies herring or sardines).  Those with heart disease or high triglycerides, may want to talk with their physician about taking a daily supplement.

Endometrial/uterine cancers

Women with these cancers should eat a plant-based diet, try to maintain a healthy weight and get in at least two-and-a-half hours of physical activity a week.

Eat less of this:

• Saturated fats, found in such foods as full-fat dairy, lard, butter, cream, cheese, lamb, pork, poultry with skin and fatty beef
• High-fat dairy, because it is high in saturated fats and higher in calories than lower fat options
• Foods high in glycemic load like sugary drinks and processed foods, since diets with a high glycemic load have been associated with risk of endometrial cancer

Eat more of this:

• Non-starchy vegetables like leafy greens, peppers and carrots
• Whole grains like brown rice, quinoa and oats
• Legumes, such as beans, peas and peanuts, as a meat substitute and a good source of fiber and phytochemicals
• A variety of fruits for natural sweetness to help with reducing sugary beverages and processed foods
• Whole fruit rather than juice

Colorectal cancer

Patients with this cancer should maintain a healthy body weight and remain active, because excess body weight is the biggest risk factor for this disease.

Eat less of this:

• Red and processed meats
• Alcohol
• Sugary beverages and processed foods, which may make it more difficult to achieve and maintain a healthy body weight.  

Eat more of this:

• Whole-grains foods with fiber (21-38 grams a day) to help with regular bowel movements and to help eliminate harmful substances
• Calcium (1,000 mg to 1,200 mg a day), either by eating a calcium-rich diet (one cup of low-fat milk has 300 mg of calcium), or by using supplements, or with a combination of food and supplements.
• Vitamin D, which may help with cell growth and immune function (600 IU a day for adults younger than 70 and 800 IU a day for adults older than 70; food sources include fatty fish like salmon, tuna and sardines; low-fat milk and yogurt and eggs, though many people need supplemental vitamin D in addition to food)

Esophageal cancer

Patients with this cancer should maintain a healthy diet, since excess body weight has been associated with a higher risk of esophageal cancer. Regular exercise may also help lower the risk.

Avoid this:

• Alcohol, because it has been associated with an increased risk of this cancer
• Processed meats

Eat more of this:

• Fruits and vegetables (five to nine servings a day), mixing up the diet with carotenoids (carrots, sweet potato, cantaloupe, apricots and spinach), citrus (oranges, grapefruit and other fruits high in vitamin C), allium vegetables (garlic, scallions, Chinese chives, onions) and leafy greens (spinach collards, kale, swiss chard, turnip and mustard greens)

 Learn how to revamp your diet.

Telomeres have been compared to aglets, the plastic or metal tips at the end of shoelaces that prevent them from fraying. When an aglet is damaged or worn out, the lace begins to unravel. Telomeres shrink with each cell division or replication. As we age, telomeres become too small to protect the chromosome, no longer preventing cell damage from occurring—and that may create a breeding ground for cancer cells. "Cancer is the end result of an evolutionary process called aging," says Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America^®(CTCA). "It's the end result of all the cell divisions, reproductions and mutations that occur over many, many years."

So, if telomeres shrink with age and age is a leading risk factor for cancer, do longer telomeres reduce the risk of getting cancer? Researchers at Dana Farber Cancer Institute in Boston suspect the answer may be yes, theorizing that telomere length "can affect the pace of aging and onset of age-associated diseases." Meanwhile, scientists at MD Anderson Cancer Center in Houston have concluded that shortened telomeres appear more frequently in cancer patients. Researchers there studied telomere length in dozens of patients diagnosed with a variety of cancers. Their conclusion: "Short telomeres appear to be associated with increased risks for human bladder, head and neck, lung, and renal cell cancers." These studies suggest that shortened telomeres that are no longer able to protect DNA lead to cell death, cell mutations and/or senescence, a zombie-like state that cells reach when they have stopped functioning.

Just as shorter telomeres have been linked to aging, disease and deteriorating health, longer telomeres have been associated with a healthy lifestyle, which may lower cancer risk. "Studies show that people who run a significant number of miles tend to have longer telomeres," Dr. Lynch says. "We know that exercise is good, and it keeps you healthy. Well, maybe one reason is that telomeres may help you maintain the integrity of your DNA." A University of California San Francisco (UCSF) study concludes that changes in lifestyle, including increased exercise and an improved diet, can lengthen telomeres. "These findings indicate that telomeres may lengthen to the degree that people change how they live," author Dean Ornish, MD, UCSF clinical professor of medicine, says in a UCSF article on the study. "Research indicates that longer telomeres are associated with fewer illnesses and longer life."

Predictably, this science has led to theories that telomeres can be manipulated to reverse aging. In a 2010 article published in The Harvard Gazette, scientists said they used telomerase, the enzyme that feeds telomeres , to reverse aging in mice. The mice became significantly healthier when they were given the enzyme, according to the researchers. Organs regenerated, brain cells became more active, and the males regained their fertility. "What really caught us by surprise was the dramatic reversal of the effects we saw in these animals," says Ronald DePinho, then a Harvard researcher and former president of MD Anderson.

In addition to feeding telomeres, telomerase is a powerful enzyme that may be found in many cells, including embryonic cells, active immune cells. But the enzyme is also found in cancer cells, raising concerns that rather than preventing age-related cancer, it may stimulate tumors. Despite research supporting telomeres' role in healthy living, and despite multiple clinical trials exploring their role in cancer and other illnesses, no evidence has been found to suggest that telomere research will lead to immortality or miracle cures. So for now, the Fountain of Youth remains elusive. "We are not designed to last forever," Dr. Lynch says. "Father Time remains undefeated."

 Learn about environmental risk factors for cancer and how to avoid them.

A 2012 Pew Research Center study found that 72 percent of U.S. internet users had searched the web for health-related information, with the vast majority beginning their quest by typing key words into general search engines like Google, rather than dedicated health websites like WebMD. The figure was higher—82 percent—for millennials (aged 18 to 36) compared to Generation X (aged 37 to 52) and baby boomers (aged 53 to 71). By 2017, 89 percent of those diagnosed with cancer, of all ages, went online in search of answers about their disease, according to a recent Healthline survey of 1,500 cancer patients, survivors and caregivers.

In the span of a single generation, patients have pivoted from having difficulty finding medical information and connecting with other patients to information overload, according to Healthline. But while the internet can be a valuable tool in finding answers to medical questions, it also comes with the risk of incomplete, misleading or even false information.

“ Going online to get cancer information for background and to learn about innovative treatments, such as clinical trials, is great. The internet allows you to get more information at a faster pace. But like online reviews for movies or restaurants, you have to be discerning.
The internet is not such a good thing if that's your only source of information.” - Dr. Arturo Loaiza-Bonilla, Chief of Medical Oncology and Medical Director of Research at Cancer Treatment Centers of America^® in Philadelphia. 

Dr. Bonilla recognizes that generational differences are key in how people respond to a cancer diagnosis. “Baby boomers are typically very trusting of their physician and will allow us to give recommendations and, if given options for treatment, often want the doctor to decide,” he says. “Millennials tend to come in more informed. They look online and are more numbers-driven. I tell them that numbers are medians and don’t 100 percent relate to you as a person, but I will put it into context. They’re always looking for new things and have more of a mixed approach, but they want the power to make the decisions. If you tell them about new therapies, they want to jump on those things. There are different mindsets for each generation.”

It’s not surprising that millennials, many of whom have never known a world without the internet, are three times more likely than baby boomers, and twice as likely as Gen Xers, to join an online cancer community after diagnosis, according to the Healthline survey They also “place a higher degree of trust in online resources than older generations.”

That pattern continues when it comes to staying engaged in an online support group, with 59 percent of millennials remaining plugged in, compared to 51 percent of Gen Xers, and just 37 percent of boomers. Survivors of all generations, however, credited online support groups with helping them cope with the fear of recurrence and staying informed of long-term side effects. The internet also helped 61 percent of millennials to seek a second opinion, more than any other generation, the Healthline survey showed.

Dr. Bonilla, who at age 36 straddles the generational line between millennials and Generation X, says he encourages patients to talk to him about the information they are seeking—clinical trials, supplements or prognosis, for example—so he can help direct them to credible online resources.

It’s critical, Dr. Bonilla says, that physicians, particularly oncologists, recognize that in today’s world, online resources are a key part of a cancer patient’s journey.

“We tend not to like to put too much online because we don’t like to give medical advice without seeing a patient, but the internet is a resource for patients and caregivers to get more information about new things happening and to provide some emotional support,” he says.  “Technology and the internet are here to stay, so the quality of the content needs to be more refined, and as that happens, hopefully there will be ways to determine what’s real and what’s fake news and improve the veracity. These are matters of life and death, not just opinion.”

  Learn more about finding online support during your cancer journey.

“The blood-brain barrier has been recognized to be a major issue when using systemic therapy for known or suspected cancer in the brain or spinal cord.” - Maurie Markman, MD, President of Medicine & Science at Cancer Treatment Centers of America^®  (CTCA)

The blood-brain barrier is made up mostly of endothelial cells, which line glands, organs and blood vessels throughout the body. In most cases, endothelial cells have gaps in their membranes that allow essential substances, like medicines, to flow in and out of the bloodstream. In the brain, however, those gaps are sealed with proteins that limit what can pass through. The barrier also contains astrocytes, star-shaped cells that act as the barrier's gatekeepers, determining what gets in and what's kept out. Allowed: essentials such as oxygen and glucose that allow the brain to function. Barred at the barrier: toxins and bacteria that can harm the brain or cause infection.

But the barrier also keeps out many substances that are meant to help the brain, including drugs designed to treat brain cancer. For instance, chemotherapy drugs, designed to kill fast-growing cells like cancer cells, may also kill fast-growing cells elsewhere in the body. The cells of the blood-brain barrier may consider these drugs too toxic to be allowed access to the brain, preventing them from reaching the cancer. Cells in the barrier also have large amounts of a protein called P-glycoprotein (P-gp), which helps flush toxins out of cells. So even if a chemotherapy drug were to penetrate a brain cell, P-gp may promptly remove it. "No matter what drugs you use systemically, there is a blood-brain barrier," says Shayma Master Kazmi, MD, RPh, Hematologist-Oncologist and Medical Oncologist at our hospital in Philadelphia. "So a lot of chemotherapy drugs or immunotherapy drugs don’t get close to 100 percent penetration into the central nervous system. If the drug isn’t getting to where it needs to go, that's problem No 1."

PENETRATING THE BARRIER

Researchers and scientists have searched for more direct ways to penetrate the barrier and reach the brain, including:

   Direct injection: Doctors have injected viruses directly into brain tumors to help stimulate an immune response. The treatment, called oncolytic virus therapy, was featured in a CBS 60 Minutes report detailing a Duke University clinical trial on a treatment for glioblastoma, the most aggressive form of brain cancer. The U.S. Food and Drug Administration (FDA) in 2017 called the treatment a "breakthrough therapy," allowing for an accelerated process to develop new treatments based on the therapy. Still, the FDA has not approved the treatment, and concerns have been raised about the therapy’s potential drawbacks and limitations. It can’t reach some tumors, for example, and it often causes some serious side effects. "It is uncertain how well these therapies are distributed throughout the tumor in the absence of delivery by blood flow," Dr. Markman says. "And the ability to directly penetrate into some tumor masses is highly questionable."

  Radio waves: Researchers in Switzerland claim to have extended the life of some glioblastoma patients, by using electromagnetic-wave treatment in combination with chemotherapy. Electromagnetic waves are believed to disrupt cancer cells and prevent them from growing. Patients were required to wear a cap dotted with electrodes for at least 18 hours a day. "It’s not the easiest thing in the world to do," Dr. Kazmi said. "That's a tough sell."

Clinical trials are underway in search of ways to penetrate the blood-brain barrier to treat not just cancer, but other diseases of the brain, such as Alzheimer's and multiple sclerosis, as well as traumatic brain injuries. What researchers continue to find is that the barrier, like the brain, is complex and not easily penetrated. "It's a protective barrier created by the brain, because the human body is brilliant," Dr. Kazmi says. "The most important part of the body is the brain. The brain will always protect itself so most harmful chemicals don't penetrate it."

  Learn more about treatments for brain cancer.

“Hospitalists help advocate for patients and their families, working with other doctors and clinicians in coordinating the patient's care and determining whether the decisions made are working for the patient as intended.” - Kevin Tulipana, DO, FHM - Director of Hospital Medicine at our hospital in Tulsa

The term “hospitalist” was first coined by the New England Journal of Medicine in 1996, during a time when the number of patients admitted to U.S. hospitals was growing. At the same time, internal medicine and family medicine physicians were seeing more patients in their offices, limiting the time they had left to visit patients in the hospital. To compensate for these trends, health care leaders began hiring or redirecting existing staff physicians to focus their time on treating patients in the hospital.

Although most hospitalists are trained in internal medicine, some—like Dr. Tulipana—have a family medicine background. “I realized when I was practicing as a family medicine doctor in Springfield, Missouri, that it was hard for me to provide continuity of care and quality care to my patients in the hospital because of the number of patients I saw outside of the hospital,” he says. “This was at a time when hospital medicine was in its infancy. I took a leadership role in hospital medicine at a local hospital and realized I was able to really follow these patients and help them navigate the whole process, from diagnosis and treatment to their transitionto the back outside world.”

In 2015, Dr. Tulipana joined Cancer Treatment Centers of America^® (CTCA) as Director of Hospital Medicine because he wanted to use his hospitalist expertise to help patients with complex conditions. “Caring for cancer patients is more than just managing the illness,” he says. Hospitalists at cancer hospitals also coordinate with supportive care clinicians to help meet the patient’s diverse set of needs, from physical side effects and relationship challenges to nutritional deficiencies and faith-based concerns. These doctors are also in a unique position to closely monitor patients and adjust medications as necessary. “We can watch trends in a patient’s sugar and blood pressure levels and take in a tremendous amount of data,” Dr. Tulipana says. “We’re truly able to see the whole picture with a different set of eyes under a much closer microscope.”

“By absorbing and breaking down the drugs, the fat cells may be removing the drugs from the immediate environment around tumor cells in bone marrow or other areas of the body where fat cells are plentiful,” according to the study. “This finding may help explain why obesity is linked to poorer outcomes in several types of cancer.” The study’s lead investigator noted that the research appears to be the first to offer evidence that fat cells may “metabolize and inactivate any therapeutic drug.”

Doctors had previously observed that obese children with acute lymphoblastic leukemia were 50 percent more likely to have a recurrence than their non-obese counterparts. Obese patients with breast, colon, ovarian and prostate cancers have also seen poorer outcomes than those who are not obese. Damien Hansra, MD, Medical Oncologist at  our hospital in Metro Atlanta, explains that chemotherapy drugs work by impairing cancer cells’ ability to divide so that tumors cannot grow and spread. But researchers are finding that obesity complicates the drugs’ impact by altering the tumor microenvironment, or the cells, molecules and blood vessels that surround and feed a tumor cell. This process creates a biological environment in obese patients that may cause tumors to grow.

Obesity leads to increased inflammation, which has been linked to a variety of cancers. A University of Miami study published in 2017 found that “obesity is associated both with a higher risk of developing breast cancer, particularly in postmenopausal women, and with worse disease outcome for women of all ages.”

Overweight and obese people are more likely to have medical conditions that cause chronic inflammation, increasing their risk of certain cancers. In the leukemia study, investigators found that fat cells, which produce high levels of certain enzymes, may break down a class of chemotherapy drugs known as anthracyclines. Some of these enzymes were found in the fat cells of bone marrow in children being treated for acute lymphoblastic leukemia. Absorbing or breaking down the concentration of certain cancer drugs may contribute to “the emergence of drug-resistant tumor cells,” according to the study.

Over the years, under-dosing obese cancer patients, because of concern about cardiotoxicity (damage to the heart caused by the chemotherapy drugs), has stirred controversy, Dr. Hansra says. But in 2012, the American Society of Clinical Oncology, after studying the issue, recommended that “full weight-based cytotoxic chemotherapy doses be used to treat obese patients with cancer, particularly when the goal of treatment is cure. There is no evidence that short or long-term toxicity is increased among obese patients receiving full weight-based doses.”

Dr. Hansra is passionate about educating his patients about the serious health risks obesity poses.

“ Obesity is a systemic, preventable, multi-system inflammatory disease.” - Damien Hansra, MD, Medical Oncologist

“It’s a definite marker of inferior health,” he says. “Key obesity-related syndromes are cardiovascular disease, cerebrovascular diseases (affecting the brain and its blood vessels and arteries), diabetes, high cholesterol, hypertension, kidney disorders and musculoskeletal disorders, all of which require people to take more medications. Add in chemotherapy, hormone therapy and/or radiation therapy for a patient who’s already sick, and it’s a storm of illness, and you’re going to see more and more adverse drug interactions.”

“ People who learn they have an inherited risk for cancer may have a variety of emotional responses that run the gamut, from fear and anxiety to guilt and anger. Learning of an inherited risk for cancer can also provide relief in the form of answers as to why the cancers have happened in the family, as well as a sense of hope and empowerment, affording patients the opportunity to be screened more closely to find cancers at earlier, more manageable stages or, in some circumstances, to take steps such as surgeries to prevent cancer altogether.” - Eric Fowler, Licensed Certified Genetics Counselor

Put simply, a hereditary cancer syndrome is a cancer risk that runs in the family. The risk stems from a defective or mutated gene that is passed from generation to generation. Hereditary cancer syndromes are associated with up to 10 percent of all cancer diagnoses. The cancer type that develops from a syndrome depends on the mutated or defective gene. For instance, hereditary breast and ovarian cancer syndrome stems from mutations in the BRCA1and/or BRCA2 genes. This syndrome significantly increases a person's chance of developing breast, ovarian, prostate and other types of cancer. People with Li-Fraumeni syndrome, characterized by a mutation in the TP53 gene, have a high risk of developing cancer by the age of 30 and are almost certain to get cancer by age 60. People with cancer syndromes have a higher risk for multiple cancers and/or rare cancers, and are more likely to develop cancer at a younger than average age, says Melanie Corbman, a Licensed Certified Genetics Counselor and Manager, Clinical Genetics, Eastern Region at CTCA^®.

Common syndromes and the cancers associated with them:

Patients diagnosed with most cancer syndromes will not necessarily develop cancer. But knowing their syndrome status may empower them to take critical steps—to help detect cancer in its early stages, to help prevent cancer from occurring and to help their loved ones make decisions on whether to seek their own interventions. Some patients, for example, may choose aggressive screening programs. Patients with syndromes that increase breast cancer risks may decide to alternate between mammograms and breast MRIs every six months. For other patients, more aggressive prophylactic surgeries may be the preferred option.

"If someone is not ready to choose surgery, I say start with the screening and see how that goes for you," says Corbman, who leads the High-Risk Program at our hospital in Philadelphia. "The risks increase with age, so someone who is 25 has a lower risk and may be able to put off some decisions if they choose.” Actress Angelina Jolie went the more aggressive route. She was 37 when she had a prophylactic double mastectomy in 2013, after learning she had a BRCA1 mutation. "Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much I could," Jolie wrote in The New York Times. Jolie, whose mother died of ovarian cancer at the age of 56, later had her ovaries and fallopian tubes removed.

A key decision for many patients who are suspected of having a cancer syndrome is whether to get a genetic test to confirm the diagnosis. "You can make a clinical diagnosis of a syndrome without doing any genetic testing. But in most cases, a genetic test is the only way to definitively diagnose some syndromes. Genetic test results may help unlock mysteries of the origins for ancestral cancers. They may alert siblings and offspring to an increased cancer risk. And, for other patients, they may help shape decisions for treatment. For a breast cancer patient, for instance, the confirmation that she has a family syndrome may mean the difference between getting a lumpectomy or a double mastectomy. The diagnosis may also help determine her risk for ovarian cancer.

Corbman and Fowler recommend patients consult with a genetic counselor, along with their oncologists, before making any treatment decisions. "I had a patient recently who was newly diagnosed with breast cancer. So we talked about how information from a genetic test could be helpful in making some surgical decisions," Corbman says. "Many patients say they want that information. But this patient wasn’t ready yet. She said a cancer diagnosis was enough for her to deal with at that time. She was going to have surgery, have her treatment and, when all that was complete, have the genetic testing. And that was a very honest answer."

  Learn the difference between genetics and genomics.

“ Our goal is to treat patients' cancer while protecting them from serious side effects. We never want to cause life-threatening cardiovascular disease later in life.” - Anthony Perre, MD - Chief of the Division of Outpatient Medicine at Cancer Treatment Centers of America

Cardio-oncology involves three main areas of focus: identify high-risk cancer patients, prevent damage to the heart and monitor patient progress. Before cancer treatment begins, oncologists consult with a cancer patient’s primary care physician and/or cardiologist to identify chronic conditions, such as hypertension and diabetes, that increase the patient’s risk for cardiovascular issues. The information is then used to guide the patient’s treatment plan and dictate which therapies are prescribed, Dr. Perre says. Doctors also work together to recommend prevention-based lifestyle changes, such as diet or exercise regimens designed for weight loss or cessation programs to help patients quit smoking, to help lower their risk for heart disease. Once cancer treatment begins, the cardio-oncology team monitors how certain therapies may be affecting the patient’s heart, making adjustments as necessary.

In the past, doctors used an echocardiogram to measure changes in the heart’s ability to pump blood, since lower rates may be a sign of treatment-related heart damage. Today, though, doctors may use a technology called strain imaging to determine whether a treatment is likely to cause complications before signs of heart damage even develop. Such technological advances are helping to expand the options available to reduce patients’ risk of cardiac issues, even though the challenge remains difficult, Dr. Perre says. “Unfortunately, we’re seeing more heart risk from cancer treatments than ever before,” he says. “But we can’t stop the treatments because they’re working well to fight the cancer.”

One reason behind the increase in heart risk: the recent wave of targeted therapy drug approvals by the U.S. Food and Drug Administration. “These drugs are helping us make strides in the fight against cancer,” Dr. Perre says. “But many of them, like trastuzumab (Herceptin^®)—commonly used to treat breast cancer—may affect the heart by reducing its pumping ability, which could lead to congestive heart failure.” Another factor is the rising number of people living with cancer well beyond treatment. In 2016, the number of cancer survivors living in the United States reached nearly 15.5 million, and that record is expected to hit 19 million by 2024. While they’ve survived cancer, these patients may have cardiovascular issues later in life because of damage caused by their cancer treatments.

As a cancer survivor, Dr. Perre knows his cardiovascular risk is higher than the average person’s. To treat his Hodgkin lymphoma, Dr. Perre was given a combination of radiation therapy and doxorubicin (Adriamycin^®), a drug that damages cancer DNA but also carries the potential for heart disease later in life. “I know I’m at a greater danger for heart problems,” he says. “That’s why I have to make sure I take the precautions I can and undergo the proper monitoring.  Prevention and vigilance are such important components of cardio-oncology.”

“ If you don't have a correct diagnosis, you cannot treat the patient correctly,” - Fernando U. Garcia, MD, Pathologist at our hospital in Philadelphia

Many standardized procedures are performed before a diagnosis can be rendered. After the patient’s tissue sample is collected during either a biopsy or excision (the surgical removal of tissue), the pathologist conducts what’s known as a gross examination, performed with the naked eye, rather than under a microscope. Observations noted in the gross examination include the sample’s appearance and characteristics, such as size (typically documented in centimeters), texture (whether it is hard or soft, smooth or lumpy) and color. Gross examinations help determine accurate diagnoses because certain tumors have specific characteristics. The distance between the tumor sample’s edges and remaining healthy tissue—called resection margins—is measured and documented. Leaving behind what’s considered healthy margins during the excision is important because it helps the surgeon determine whether all the cancer was removed and whether the patient may benefit from additional treatment.

The sample is then processed in a machine that dehydrates the tissue and replaces it with paraffin wax, which allows the tissue to be cut so thin that light can pass through it. The pieces are placed on slides, which are stained with dyes that change the tissue’s color so they are clearly visible under a microscope. The pathologist then begins a microscopic evaluation. “You must have a baseline for normal tissue,” says Bradford Tan, MD, Chair of the Department of Pathology and Laboratory Medicine at Cancer Treatment Centers of America^® (CTCA).  “Pathologists understand what normal looks like. We know what to look for and take note of. We look for the presence of a tumor and differentiate what we see compared to what normal tissue looks like.”

The sectioned samples are preserved for future testing, which may be necessary if medical advancements lead to the discovery of a new tumor marker or a new treatment, for example, or if a duplicate slide is needed for the patient to use in seeking a second opinion.

The pathologist needs to identify the type of tumor, which is roughly classified into “five buckets,” according to Dr. Tan. “A tumor that lines a surface, such as the skin or the GI tract, is carcinoma,” he explains. “If the tumor originates from soft tissue like muscle, it’s sarcoma. If it comes from the neural crest (a group of specialized cells found throughout the body), it’s melanoma, and if it’s from blood cells or bone marrow, it’s in the leukemia and lymphoma bucket. The fifth bucket could be a mixture of tumor types or of unknown origin.”

Identifying tumor type is key because tumors behave differently. “A treatment for lymphoma won’t work on a carcinoma,” says Dr. Tan. “Sarcoma usually doesn’t metastasize to lymph nodes, but carcinoma often does, and that’s important. One type of cancer requires a lymph node dissection, and another doesn’t.” And some tumor types, such as breast and lung cancers, require additional analysis because they may benefit from targeted therapies. Hormonal markers in breast tumors help identify which drugs may have the greatest impact, for example. “A breast cancer patient with an estrogen receptor-positive tumor typically gets tamoxifen, but a patient whose cancer is HER2-positive would get trastuzumab (Herceptin^®), and if none of the slides show hormonal markers, the patient will typically get chemotherapy,” says Dr. Tan.  

While all grading systems represent the degree of malignancy, in ascending order, Dr. Tan cautions that grading systems differ by cancer type. “The grading system in one cancer is not equivalent to the grading system in another cancer,” he says. For example, the Gleason grading system, widely used in prostate cancer, is different than the Nottingham grading system used for breast cancer.

Once the pathologist has examined all the tissue samples macroscopically (with the naked eye) and microscopically, and has graded them, he or she stages the cancer, assigning it a number from 0 (zero) to IV, with stage 0 indicating the cancer has not spread from its original location and stage IV indicating advanced disease.

When reading a pathology report, Dr. Tan suggests paying close attention to the tumor type, grade and stage, and he recommends getting a second opinion if you’ve been diagnosed with cancer. “It’s always better to have a second pathologist review the diagnosis,” he says. “You have to make sure that the diagnosis is reviewed and confirmed before you start any treatment. We all trust our physicians. Trust, but verify. Ninety-eight percent of the time, the diagnosis will be correct, but a difference in grading or tumor type could ultimately impact treatment.”

  Learn about the pathologist’s role in cancer care.

So intrigued are scientists that they gave the result a nickname: the abscopal effect, derived from a combination (aptly enough) of two words—ab, which is Latin for “away,” and skopos, which is Greek for “target.” The effect, first reported about 50 years ago, is rare, seen in a small number of patients who undergo radiation therapy for metastatic disease, or cancer that has spread. In these unique cases, when radiation damages cancer cells, the tumor releases proteins called antigens that are recognized as harmful or foreign and attacked by immune system T-cells. This also helps the T-cells recognize and attack cancer cells elsewhere in the body. The abscopal effect is rare because radiation also tends to increase the production of regulatory T-cells, which stop killer T-cells from overdoing their job as part of a self-regulating process that shuts down the immune response before it causes too much harm to the body.

“ Think of the timer on a hot tub. If you set it for 15 minutes, you're turning it on but also imposing a limit because, if you didn't, you'd end up wasting a lot of energy and also risk it getting too hot.” - Christian Hyde, MD - Radiation Oncologist

Researchers have found that radiation delivered in medium to high doses over the course of three to five treatments strikes the kind of biological chord that turns on the immune system. “That seems to be what it takes to wake up the immune system and cause the tumor to become inflamed so that it’s a more fertile ground for immune activity,” Dr. Hyde says. “Radiation makes cancer cells look and act more like virus-infected cells.” When the patient takes an immunotherapy drug like ipilimumab (Yervoy^®) before and during radiation, it may help reduce the number of regulatory T-cells, potentially broadening the immune response to affect other parts of the body, Dr. Hyde says. However, blocking one pathway, similar to blocking one lane of traffic on a highway, is not enough. “Right now, the single-drug combinations with radiation are leading to a greater immune response. But it’s probably not until we get multi-drug combinations combined with radiation in a sequence we know works—which, like vaccines, may need to be repeated—that we’re going to get that specific and memorable response the body needs to get rid of cancer, not only now but five years down the road if it recurs.”

Creating this sequence of treatments to help T-cells identify and fight cancer cells anywhere in the body is, in fact, very similar to the way vaccines work. “The magic of the immune system is not that it’s powerful, but that it’s specific and has memory,” Dr. Hyde says. “If you think about it, you were vaccinated against polio when you were a kid and received four shots, to help your body remember the virus. That’s important because if you get polio now, your body is going to remember that virus. Even if you only have one memory cell left from that vaccine exposure, that one cell is going to become millions of cells, and it’s going to recreate that immune response all over again. That’s what we’re working toward with radiation and immunotherapy combinations, too.”

Researchers are now focused on recreating the abscopal effect with a specific combination of radiation and immunotherapy drugs designed to prompt an immune attack on cancer throughout the body in a more targeted way. Clinical trials on therapies delivered in different combinations may help scientists determine how to help more patients, Dr. Hyde says.

“This is one of the biggest advances we've had in metastatic breast cancer in a long time.” - Sramila Aithal, MD, Hematologist-Oncologist, Medical Oncologist

These new drugs belong to a common class of targeted therapy cancer drugs called kinase inhibitors. A kinase is a protein on a cell that acts like a dispatcher, receiving signals from other cells and then passing on the instructions into its cell's nucleus. Once the signal is delivered, a cell may perform any number of functions, including growing or dividing or even shutting itself off. These specific drugs for breast cancer target two kinase proteins—CDK 4 and CDK 6—that help regulate cell growth and division. Blocking these proteins may help slow cancer cell growth. Some patients with HR-positive and HER-negative metastatic breast cancer have experienced positive outcomes by combining a CDK 4/6 inhibitor with hormone therapy. "Women used to get hormone treatment alone for their cancer and were able to be free from cancer or have a response for up to a year, maybe 16 months in some cases," says Sramila Aithal, MD, Hematologist-Oncologist, Medical Oncologist and head of the Breast Cancer Center at our hospital in Philadelphia. "But by adding this other therapy that targets the CDK 4/6, they have had better responses for more than two years. More important, many people would have chemotherapy for metastatic cancer, especially if it invaded an organ, like the liver or lung. But by using this treatment combination, they’ve been able to postpone chemotherapy for up to 27 or 28 months. That's made a big difference."

Palbociclib  and ribociclib are usually given with the anti-estrogen drug fulvestrant (Faslodex^®), which regulates hormones. Abemaciclib is the first CDK 4/6 inhibitor approved as a stand-alone therapy. CDK 4/6 inhibitors are approved only for HR-positive and HER-negative breast cancer, but clinical trials are underway to determine whether they may be used to treat other cancers, including lung, prostate and other types of breast cancer. Common side effects of these inhibitors include diarrhea, nausea, and fatigue. "These are oral medications, they are easy to administer, and they are very tolerable," Dr. Aithal says. "It’s a huge shift in the paradigm of the way we treat breast cancer."

Gastroenterologists are trained to treat diseases of the GI system, which includes the esophagus, stomach, small intestines, colon, rectum gallbladder, bile ducts and liver—all the organs involved in digesting food and processing waste. But in cancer treatment, these doctors do a lot more. Gastroenterologists may help medical oncologists diagnose and stage tumors or search for metastatic disease. Using a colonoscopy or endoscopy, they may help surgical oncologists locate tumors during surgery. They also may help cancer patients cope with myriad disease and treatment side effects, many of which are GI-related, such as vomiting, diarrhea, constipation and weight loss. "Symptoms related to the gastrointestinal tract represent a major part of the symptoms that cancer patients experience," says Toufic Kachaamy, MD, Medical Director of Interventional Gastroenterology, Endoscopy and Innovation at our hospital near Phoenix.

“A gastroenterologist experienced in taking care of cancer patients works with the oncology team to manage symptoms and improve quality of life and nutrition. All these help patients tolerate cancer treatment better.” - Toufic Kachaamy, MD,  Gastroenterologist & Advanced Endoscopist

For example, say a patient’s lung cancer has spread and the tumor is blocking the bile duct, causing jaundice, or a yellowing of the skin caused by a buildup of waste material in the blood. A gastroenterologist may treat the condition by inserting tubes called stents, which allow fluid to flow through the body's ducts and blood vessels. Or say a patient is losing weight after constant bouts of nausea and vomiting, caused either by treatment or a tumor blocking the GI tract. A gastroenterologist may work with a dietitian to develop a nutrition plan to help get the patient eating again and prevent malnutrition, which a leading cause of cancer deaths. A GI specialist may also use cryotherapy to remove blockages caused by tumors in the esophagus that may prevent patients from eating or swallowing. 

Gastroenterologists also play important roles in cancer prevention, as well as the diagnosis and staging of GI tract cancers. And their role is continuing to evolve, according to John M. Carethers, MD, of the University of Michigan. A gastroenterologist may have once been called on simply to diagnose and treat a GI-related condition. But as cancer care has advanced and patients’ needs grow more complex, the gastroenterologist is emerging as a key player offering a wide range of skills and expertise."The gastroenterologist is evolving from a pure diagnostician to an endoscopic surgeon, a geneticist, a nutritionist, an immunologist and chemotherapist, and palliative care physician," he writes in an article published on PubMed Central. "This transformation allows the gastroenterologist to be a larger part of the continuum of care for cancer patients."

“ Grocery shopping can become overwhelming, and standing for long periods of time to shop and prepare meals can be burdensome.” - Crystal Langlois, RD, CSO, LD - Director of Nutrition at our hospital near Atlanta

But choosing the right foods is important to cancer patients’ recovery. Proper nutrition helps the body maintain a healthy weight, preserve strength and combat certain side effects after treatment. Developing a shopping strategy and bringing a list of nutrient-rich foods may help ease the stress in getting this chore crossed off the list—no matter your cancer type, Langlois says.

The first steps: Make a list in advance, pay attention to labels and stick to the perimeter of the store as much as possible, because that’s where the healthiest options—meat, dairy, produce—tend to be located. Langlois offers a section-by-section tip list for making your grocery shopping experience more effective and efficient, from fresh to frozen:

PRODUCE SECTION

• Choose fruits and vegetables that are in season because they’re typically cheaper.
• Avoid fruits and vegetables that look wilted, dented or damaged. Air exposure over time may cause these foods to lose nutrients.
• Buy organic if you can, but if organic produce is too expensive, make sure you wash your fruits and vegetables well with water and some vinegar.

MEAT SECTION

• Buy organic.
• Choose meats and poultry from grass-fed animals, and seafood caught in the wild.
• Order organic meats and cheeses at the deli, or request nitrate-free options.

DAIRY SECTION         

• Buy organic, skim, almond or soy dairy products.  
• Choose organic, low-fat yogurt, and, when possible, Greek yogurt because it typically contains more protein than other options.

FROZEN SECTION

• Look for organic meals.
• Select pre-chopped vegetables that are flash-frozen, so they don’t lose nutrients as quickly as their fresh-produce counterparts.

CENTRAL AISLES

• Avoid the soda and chip aisle.
• Buy whole-grain breads, not just whole-wheat options.
• Choose healthy oils like olive and canola oils instead of corn and vegetable oils.
• Try a variety of seasonings. Studies have found that spices like ginger and garlic have antioxidant, anti-inflammatory and immune-stimulating properties. Plus, experimenting with different flavors and tastes may enhance your appetite.
• Plan ahead for healthy recipes by stocking up on relevant staples, such as low-fat chicken soup, low-sodium broth, brown rice, raisins, tomato paste and whole-grain pasta.

Also, think about what you may be able to repurpose. If you need chicken breast for a recipe, for example, buy extra and use the leftover to top salads later in the week. And if you have extra mushrooms, consider adding them to the meatloaf or spaghetti sauce you make the next day.

Other tips include using a rice cooker, blender or slow cooker to do the cooking for you whenever possible, or signing up for meal-delivery options like Blue Apron or HelloFresh, or grocery-delivery programs like those offered by Amazon or Walmart. “These short cuts are useful if you don’t have the energy to grocery shop, and so you don’t have to worry if your caregiver will pick the right thing,” Langlois says.

Given all the talk about cancer prevention these days, it may surprise you to know that screening tests have been developed for some but not all cancers, and a variety of considerations must be weighed by both doctor and patient when determining whether screening for a particular cancer type is warranted. Risk factors such as lifestyle habits, family history, comorbidities (other serious medical conditions, such as diabetes or heart disease) and environmental exposures all play pivotal roles in the decision-making process.

Cancer screenings are of increasing importance, especially as cancer diagnoses continue to rise. The U.S. Centers for Disease Control and Prevention (CDC) estimates that between 2010 and 2020, 24 percent more new cancer cases will be diagnosed in men (rising to 1 million a year) and 21 percent more new cases will be diagnosed in women (rising to more than 900,000 a year). At the same time, though, National Cancer Institute figures show that survival rates are at an all-time high—with nearly 14.5 million survivors living in the United States in 2014. That number is projected to reach 19 million by 2024. Cancer-related deaths also continue to drop steadily, falling 26 percent between 1991 and 2015. Many experts attribute the improved outcomes to treatment advances, prevention awareness efforts—and screenings designed to detect cancer in the early stages, when interventions tend to have the most impact.  

So which cancers should you be screened for, and when? It depends. Below is your guide to the three R’s of cancer screenings—risk factors, recommendations and rationale—by cancer type. We’ve compiled a list based on the recommendations of the leading cancer organizations—the American Cancer Society (ACS), the U.S. Preventive Services Task Force (USPSTF), the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncology (SGO).

Breast cancer

Risk factors: When it comes to breast cancer, women are typically categorized as high-, moderate- or low-risk (the last category representing most women).

• You are considered high risk if you have:
  • A family history of breast and/or ovarian cancer with two or more close relatives on the same side of your family, especially when diagnosed before age 50
  • Any of the following inherited genetic mutations: BRCA1, BRCA2, CDH1, PALB2, PTEN or Tp53
  • Breast biopsy showing atypical cells, lobular carcinoma in situ or atypical lobular hyperplasia.
• You are considered moderate risk if you have:
  • Dense breasts
  • A family history of breast cancer in distantly related relatives, especially if diagnosed in their 50s
• You are considered average risk if you have both:
  • Good health
  • No family history of breast cancer

Recommendations: The leading cancer organizations differ on screening guidelines.

• The USPSTF recommends that average-risk women under age 50 make individual decisions, and that women between 50 and 74 years old get a mammogram every other year. Those who have a first-degree relative with breast cancer may benefit from annual mammograms starting in their 40s.
• The ACS recommends yearly mammograms beginning at age 45 through age 54. At 55, the ACS recommends the tests every other year, though women may choose to have them annually. Women considered high risk should get an MRI and a mammogram every year.
• The ACOG recommends a mammogram yearly or every other year for women considered average risk, beginning at age 40 through age 75. For women who have the BRCA1 or BRCA 2 mutation, or who have one or more family members with the mutation, ACOG recommends twice yearly clinical breast exams, annual mammograms, annual breast MRIs, and regular breast self-exams.

Rationale: The ACS now recommends against breast exams, either performed routinely by a doctor or as a self-exam, urging women to know how their breasts normally look and feel and to report any breast changes to their health care provider. But many experts encourage women to perform breast self-exams frequently enough to be able to detect changes.

“ Check yourself enough so you know your normal texture and contours and can notice something out of the ordinary. There’s no longer the need for a ritual of self-exam, but a self-awareness of what you’re normal is. ” - Steven Standiford, MD, FACS - Surgical Oncologist at our hospital in Philadelphia

For healthy women with no family history of breast cancer, Dr. Standiford recommends beginning annual mammograms between ages 40 and 45 and continuing until age 70, then getting the tests every other year. He also urges women to get a 3D mammogram whenever possible because it provides a clearer picture, especially of dense breasts.

Dr. Standiford only recommends MRI screening for “very high-risk women” who carry inherited gene mutations, such as BRCA1, BRCA2 or Li–Fraumeni Syndrome. In those cases, he recommends both an annual mammogram and MRI, spaced six months apart. Women of Ashkenazi Jewish heritage who have no family history of breast cancer and are not carriers of a BRCA mutation should follow the same screening guidelines for women of average risk. He strongly recommends, however, that these women undergo genetic testing since Ashkenazi Jewish women are at an increased risk of having a BRCA mutation.

The most important recommendation, he says, is if a woman has a family history of breast cancer, she should have her first mammogram 10 years before the youngest age at which breast cancer was diagnosed in her family.

“If Mom had breast cancer at 40, daughter should start at 30 and then continue annually after that,” he says. “Keep getting mammograms annually until 70, and then stretch it out. If the breast cancer was in a second-degree relative, it’s not as significant, but if there are multiple relatives in one generation, I’d tend to screen the patient more often.” 

Gastrointestinal (GI) cancers

GI cancers affect the tissue and organs in the digestive system, which starts at the mouth and ends at the anus. Guidelines on screenings and risk factors have been developed for several GI cancers: colorectal, esophageal, liver, and pancreatic.

Colorectal cancer

Risk factors: Your risk of developing colorectal cancer increases with:

• Age (more common in patients 50 and older)
• Obesity and type II diabetes
• Sedentary lifestyles
• Moderate to heavy alcohol use
• Personal history of colorectal polyps or family history of colorectal cancer
• African American or Ashkenazi Jewish heritage
• History of inflammatory bowel disease (IBS), colitis or Crohn’s disease
• Lynch syndrome or other inherited gene mutations

Recommendations: Guidelines vary according to risk:

• For those considered average risk—patients with good health and no family history of the disease—the ACS recommends colonoscopy screening beginning at 50 and repeated tests every 10 years if no polyps are found.
• For those with a family history of colorectal cancer, the ACS recommends getting your first colonoscopy at age 40 or 10 years before the youngest case in the immediate family, and then repeat colonoscopies every five years.
• If you have Lynch syndrome, you’re considered high risk and the ACS recommends you have your first colonoscopy between ages 20 and 25, or 10 years before the youngest case in the immediate family, and then every one to two years.
• For those with IBS, ulcerative colitis or Crohn’s disease, also in the high-risk category, the ACS says the risk of cancer becomes significant “eight years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis.” Colonoscopies should be performed on these patients every one to two years.

Rationale: Colorectal cancer—cancer of the colon and/or rectum—is the third most commonly diagnosed cancer in the United States, but in many instances, colorectal cancer may be prevented with regular screenings. “Colonoscopy is the gold standard for screening, followed by Cologuard^® (an FDA-approved stool sample kit) or CT colonography,” says Pankaj Vashi, MD, Chair of the Department of Medicine at Cancer Treatment Centers of America^® (CTCA)

The goal of a cancer screening is to identify cancer at an early stage, or as with some colonoscopies, to prevent it altogether by detecting and removing pre-cancerous cells. During a colonoscopy, doctors may remove polyps, which if left intact, may later develop into cancer.

Esophageal cancer

Risk factors: Those with a higher risk of esophageal cancer are:

• Caucasian men
• Aged 50 or older
• Smokers
• Those with a history of chronic acid reflux
• Those who  have been diagnosed with Barrett’s esophagus

Recommendation: The ACS recommends high-risk patients have a regular upper endoscopy, which uses a thin tube to view the lining of the esophagus, stomach and duodenum.

Rationale: A key study on risk factors, screening and endoscopic treatment in Western and Eastern countries concluded that patients whose esophageal cancer was detected during endoscopic surveillance for Barrett’s esophagus “are more likely to have early-stage cancer, receive curative therapy, and survive longer” than patients who are not diagnosed until they have symptoms.

Liver cancer

Risk factors: You are considered high risk for liver cancer if you:

• Have chronic viral hepatitis B or C
• Have cirrhosis
• Have type II diabetes
• Have had long-term exposure to aflatoxins (cancer-causing  substances made by a fungus)
• Use or have used an anabolic steroid for an extended period of time
• Smoke

Recommendation: The ACS recommends screening only for those at highest risk, defined as patients with cirrhosis or chronic hepatitis B infection. Those patients should have a liver ultrasound and alpha-fetoprotein tumor marker (AFP) blood test performed every six to 12 months.

Rationale: Screening has been linked to improved survival rates in some studies.

Pancreatic cancer

Risk factors: Your risk increases for pancreatic cancer if you:

• Have been diagnosed with late-onset diabetes (after age 40)
• Are obese
• Smoke
• Use alcohol heavily
• Have a family history of pancreatic cancer
• Have a genetic mutation that is known to increase risk

Recommendation: Only people considered high risk—defined by the ACS as those with a strong family history of pancreatic cancer or a known genetic syndrome that increases the risk—are candidates for endoscopic ultrasound screening.

Rationale: Endoscopic ultrasound has identified “early, treatable pancreatic cancers in some members of high-risk families,” according to the ACS. Dr. Vashi also recommends that patients who meet all the risk factors undergo CT scans.

Gynecologic cancers

The risk factors and recommendations for cervical, ovarian, endometrial (uterine), vaginal and vulvar cancers vary widely by cancer type. However, some gynecologic cancers are caused by HPV (human papillomavirus) infections, which are sexually transmitted. The HPV vaccine, approved in 2006, is designed to protect against cervical, vulvar and vaginal cancers, as well as several other non-gynecologic cancers.

Cervical cancer

The Pap smear, a routine cervical swab performed in the doctor’s office, is “one of the most reliable and effective cancer screening tests available,” according to the ACS. Before the test’s introduction in the 1950s, cervical cancer was the “No. 1 cause of all cancer deaths in women,” says Julian Schink, MD, Chief of Gynecologic Oncology at Cancer Treatment Centers of America^® (CTCA). “The Pap smear has been remarkably successful in the developed world, not just to prevent cervical cancer but for interventions before you get cancer. In the United States today, the biggest risk of cervical cancer is lack of screening.”

Risk factors: Your risk of developing cervical cancer increases if you have a history of:

• Smoking
• Multiple sexual partners
• Multiple childbirths (three or more)
• Long-term use of birth control pills (five years or longer)
• HIV or another condition that compromises the immune system

Recommendations: The USPSTF recommends:

• Pap smears every three years for women between 21 and 65 years old
• Or, combined testing for women aged 30 to 65, including a Pap smear and HPV testing every five years

Rationale: “The Pap smear is really the prototype of screening tests because cervical dysplasia is a precancerous condition that women have if they have a persistent HPV infection,” says Dr. Schink. The combination of the HPV vaccine and the Pap smear has significantly decreased the rate of cervical cancer, according to the CDC.

Endometrial (uterine) cancer

Endometrial cancer is a form of uterine cancer that develops in the lining of the uterus. It accounts for more than 95 percent of uterine cancers.

Risk factors: The risk for developing endometrial cancer is higher in women who:

• Are older (60 is the average age at diagnosis)
• Are morbidly obese, defined as being 100 pounds overweight and having a body mass index (BMI) of 40 or more; or a BMI of 35 or more, combined with obesity-related health conditions, such as high blood pressure or diabetes
• Have polycystic ovarian syndrome
• Have hormone-level fluctuations resulting from estrogen use after menopause, birth control pills, the breast cancer drug tamoxifen or other factors.
• Lynch syndrome

Recommendation: The ACS recommends that women who have or may have Lynch syndrome consider getting an endometrial biopsy every year beginning at age 35.

Rationale: To lower risk, ACOG and the SGO recommend women in their early to mid-40s consider a prophylactic hysterectomy and bilateral salpingo-oophorectomy, which removes the ovaries and the fallopian tubes.

Ovarian cancer

Risk factors: The ovarian cancer risk is highest in women who:

• Are older (most cases are diagnosed in post-menopausal women)
• Have a family history of ovarian cancer
• Carry a BRCA1 or BRCA2 mutation, have Lynch syndrome or have any of the following other mutations: BRIP1, RAD51C or RAD51D
• Have had endometriosis
• Have never given birth or have had difficulty becoming pregnant

Recommendation: No reliable test has been developed to screen for ovarian cancer, but for women with an inherited gene mutation, the American Society of Clinical Oncology (ASCO) recommends discussing with your health care provider ways to reduce your risk, including:

• Prophylactic (preventive) surgery to remove both ovaries (oophorectomy)
• Prophylactic surgery to remove both the ovaries and the fallopian tubes (salpingo-oophorectomy)
• Hysterectomy (removal of the uterus)
• Tubal ligation

Vaginal and vulvar cancers

Risk factors: Your risk for vaginal and/or vulvar cancer increases if you have had:

• A human papillomavirus (HPV) infection
• History of cervical cancer or pre-cancer
• Conditions or illnesses that compromised your immune system
• Chronic vulvar itching or burning

Recommendations: The National Cancer Institute recommends the two-dose HPV vaccine series for:

• Girls and boys beginning at age 11 or 12 (it can be given as early as age 9)
• Females aged 13 through 26 and males 13 to 21 who were not previously vaccinated
• Gay and bisexual men who have sex with other men, transgender people, and those with compromised immune systems

Rationale: The HPV vaccine provides protection against the deadly HPV subtypes 16 and 18. Some HPV vaccines also protect against other HPV subtypes, such as those that cause anal and genital warts. Getting the vaccine before being exposed to the virus is key. The vaccine cannot treat HPV once you become infected.

Lung cancer

Risk factors: The risk for developing lung cancer is categorized as high, moderate and low.

• You are considered high-risk if you are:
  • At least a 30 pack-year smoker aged 55 to 74
  • A heavy smoker aged 55 to 74 who quit smoking fewer than 15 years ago 
  • At least a 20 pack-year smoker aged 50 or older with additional risk factors, such as radon exposure or prior treatment with radiation for another cancer, particularly head and neck cancer or lymphoma

• You are considered moderate-risk if you are:
  • At least a 20 pack-year smoker aged 50 or older

• You are considered low-risk if you are:
  • Younger than 50 and smoked less than 20 pack-years

While exposure to second-hand smoke is currently not included in the screening guidelines, Dr. Rich says that passive smoking, also known as second-hand smoke, increases the risk of lung cancer. The National Cancer Institute agrees, noting that "living with a smoker increases a nonsmoker's chances of developing lung cancer by 20 to 30 percent" and that some 3,000 nonsmokers die each year "as a result of exposure to secondhand smoke."

Recommendations: The USPSTF recommends low-dose CT scans for:

• People aged 55 to 80 who have a 30 pack-year smoking history and currently smoke
• Former smokers who quit smoking within the past 15 years (“Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery,” the task force says.) 

In addition to the official recommendations, Patricia Rich, MD, Medical Oncology Director of the Lung Cancer Institute at CTCA^®, says that if a nodule is found, low-dose CT scans should continue yearly, twice yearly or quarterly, depending on the size. Once the nodule is 1.5 cm or larger, it should be removed.

Rationale: Low-dose CT scans are used to detect nodules, or nodes, which are abnormal growths in the lung tissue. Dr. Rich says that preliminary diagnostic scans may help detect lung cancer in its early stages, instead of waiting until symptoms develop, which typically occurs when the disease has already progressed to advanced stages.

“In general, most lung cancer is diagnosed as advanced disease because there may not have been symptoms,” says Dr. Rich. “If someone comes to their primary care doctor with a chronic cough, and they are a heavy smoker, and a round of antibiotics doesn’t get rid of the cough, I’d do a low-dose CT scan. If they are coughing, short of breath and losing weight for no reason, that’s highly suspicious. Even if they’ve quit smoking.”

Prostate cancer

Risk factors: Those at higher risk for prostate cancer:

• Are African American
• Are at an advanced age
• Eat a high-fat diet
• Have a sedentary lifestyle
• Have an immediate blood relative with prostate cancer
• Have been exposed to Agent Orange
• Have a BRCA1 or BRCA2 mutation

Recommendation: The ACS recommends that all men discuss with their doctor the risks and benefits of screening, including prostate specific antigen (PSA) blood tests and/or a digital rectal exam (DRE). These screening discussions should begin at age 50 for men at average risk who are expected to live at least 10 more years. Men at high risk—African Americans and men with a first-degree relative diagnosed with prostate cancer before age 65—should have these conversations at age 45. Those at an even higher risk—men with more than one first-degree relative who had prostate cancer at an early age—should initiate those talks even earlier, at age 40.

Rationale: Until 2012, a PSA test and a DRE had long been the standards in screening for prostate cancer, performed on men 40 and older. But on the heels of three large studies, the USPSTF concluded that screening was not warranted because the potential harms—false-positives, biopsy complications and over-diagnosis in 20 percent to 50 percent of men with clinically insignificant disease—outweighed the benefits. Over-diagnosis results in unnecessary treatment. Patients who undergo radiation therapy or surgery are at higher risk of chronic urinary issues and erectile dysfunction, and they may be at risk of a secondary cancer later in life, says Scott Shelfo, MD, Medical Director of Urology at our hospital near Atlanta. “It may not be an issue of over-screening, but an issue of over-treating," Dr. Shelfo says. "It's important to identify patients who are at the highest risk for prostate cancer and focus on treating those patients."

Another key: Know your genetic risks

It’s important to gather your family history and share the information with your doctors, says Eric Fowler, MS, LGC, Manager of Genetics Counseling at our hospital near Chicago. Clues that there may be an inherited risk for cancer in a family include: 

• Two or more close relatives on one side of the family with the same or related cancers (such as breast and ovarian or colon and endometrial)
• Cancers diagnosed before age 50
• More than one cancer diagnosed in the same relative
• A generation-to-generation pattern of cancer
• Breast, ovarian or pancreatic cancer in someone with an Ashkenazi Jewish heritage

“If any of the above family history criteria are met, Fowler recommends seeing a licensed genetic counselor. A genetic counselor may help you understand how your personal and family history may impact cancer risks, help you measure your chances of an inherited risk in a family, and provide comprehensive information about genetic testing,” says Fowler.

The analysis screens for three genetic mutations, found on BRCA1 and BRCA2 genes, that are linked to a significantly higher risk for breast, ovarian and prostate cancers. The company does note, in a press release on the approval, that the test does not account for all genetic mutations that raise cancer risk, that most cancers are not hereditary, and that people should continue their regular cancer screenings. Still, experts worry that the message won’t reach consumers, and they’ll be misled by the results.

“They may think if they get a negative result, they're in the clear. But that may not be the case.” - Maurie Markman, MD - President of Medicine & Science at Cancer Treatment Centers of America 

More than 1,000 known genetic mutations have been found on BRCA1 and BRCA2 genes, but the three mutations the 23andMe test screens for are more common among a very small population in the United States: people of Ashkenazi Jewish descent from Eastern Europe. Even among the Ashkenazi Jewish population, only 2 percent of women have one of these three mutations. Among the rest of the U.S. population, these mutations are extremely rare—representing close to 0 percent. So if someone with a strong family history of breast cancer, for example, receives a negative result on the test, she may feel a false, and dangerous, sense of relief. “People will think that despite their family history, they’re fine, but that test only showed a negative result for three out of 1,000 possible mutations,” Dr. Markman says.

Dr. Markman also cautions consumers against believing that a negative result means they don't have a higher risk for breast, ovarian or prostate cancer—because most cancers are not caused by inherited mutations. “The message that is constantly being given, which is incorrect, is that most breast cancers are associated with an inherited genetic mutation,” says Anita Johnson, MD, FACS, Breast Surgical Oncologist at our hospital near Atlanta. “In reality, that association is the case for less than 10 percent of all breast cancers.”

The field and study of genetics is extremely complex, and the average consumer does not have the background, knowledge or training to fully grasp the limitations of an at-home test or the meaning of the results. That’s why it’s dangerous for a medical test to be offered over the counter, with its results left to each individual to interpret and decide next steps, Dr. Markman says. “I just don’t think it’s realistic to believe people are going to follow up with a doctor afterward, and that’s scary,” he says. “If you have a strong family history of cancer or are concerned about your risk, your doctor can order a test for you that screens for all the possible genetic mutations for these cancers. A huge part of this is interpreting results responsibly.”

Allowing the public increased access to genetic information is a laudable goal, as long as the information is delivered in full context and with medical oversight, Dr. Markman says, adding that genetic testing should be more accessible to more people. “It’s just doing it in a way that limits any risk of misunderstanding,” he says.

A genetic counselor can help you review your personal and family history of cancer and discuss appropriate genetic testing and screening recommendations for you.

Despite the optimism, though, it’s important to know that CAR T-cell therapy has significant downsides: It’s not available to most patients, its approvals have strict limitations, and it often triggers serious side effects in some patients.

Most cancer therapies work by triggering cells to attack cancer. CAR T-cell therapy removes a patient's T-cells, the white blood cells that are key to immune function, then modifies them in a lab and infuses them back into the patient’s body. The re-engineered T-cells are designed to recognize and attack cancer cells. The American Society of Clinical Oncology (ASCO) named the treatment its Advance of the Year for 2018. "A new and unique new way to treat cancer, CAR T-cell therapy is poised to transform the outlook for children and adults with certain otherwise incurable cancers," ASCO said in a statement.  

CAR (chimeric antigen receptor) is named for the chimera, a mythical creature made from the parts of different animals—the head of a lion, the body of a goat. True to their name, CAR T-cells have key extra parts on their surface: manmade cell receptors that are designed to attach themselves to cancer cells and kill them. "I'm extremely excited about the potential for CAR T-cell therapy," says Alan Tan, MD, Medical Director of Hematology & Immunotherapy and Medical Oncologist and Hematologist at our hospital near Phoenix. "This is a major landmark in how we may treat many cancers in the future."

“ I'm extremely excited about the potential for CAR T-cell therapy. This is a major landmark in how we may treat many cancers in the future.” - Alan Tan, MD, - Medical Oncologist and Hematologist

Here are five things you should know about CAR T-cell therapy:

It is only approved to treat a small number of patients.

The treatment has been approved to treat just two cancers to date: leukemia and non-Hodgkin lymphoma. And both approvals significantly limit the type of patients who can undergo the treatment:

It seems to work better on blood cancers.

CAR T-cell therapy has been approved only for blood cancers, and clinical trials measuring its performance on solid tumors have not been encouraging.  CAR T-cells treat leukemia by targeting a specific type of B-cell (white blood cells that produce infection-fighting antibodies). But many solid tumors have multiple genomic mutations that drugs may try to target in prompting an immune response, and identifying the one target driving the tumor's growth is difficult. Also, some solid tumors recruit immune cells to perform destructive behaviors, often making the tumor more resistant to treatment. "The difficulty with solid tumors is, what do you target and how do you program that target into the T-cell?” Dr. Tan says. “That's going to take some time." 

CAR T-cell therapy may cause severe side effects.

The side effects of CAR T-cell therapy, especially a condition known as cytokine release syndrome (CRS), may be life-threatening. Cytokines are proteins that help regulate the immune system. In some cases, CAR T-cell therapy patients are flooded with cytokines that begin to attack healthy cells and tissue, resulting in flu-like symptoms, high fever, life-threatening neurological side effects and other serious conditions. The FDA requires that hospitals that use CAR T-cell therapy have staff certified and trained to recognize and manage CRS. CAR T-cells may also attack healthy B-cells, increasing the risk of infections in some patients.

It takes weeks for the full treatment to be completed.

The process of making CAR T-cells is extremely complex. After the T-cells are removed from the bloodstream, they are frozen and shipped to a lab. There, the T-cells are processed, re-engineered, reproduced, frozen again and shipped back to be reinfused in the patient. From start to finish, the process may take up to three weeks. The complexity of the process has limited the treatment's availability and has raised questions as to whether it can be reproduced on a larger scale so it can be made available to more patients.

CAR T-cells are designed to work forever.

When T-cells attack harmful cells or viruses, they are programmed to remember them if they attack again. CAR T-cells are no different. If the process works correctly, they are meant to be on 24/7 duty for the rest of the patient's life. Theoretically, if cancer cells re-emerge, the CAR T-cells will recognize them and kill them, even without the patient knowing it. "CAR-T cells are designed to have long-lasting effects with one treatment," Dr. Tan says. "In general, once you infuse the engineered T-cells, they remain in your body. It’s akin to having a 'living drug' in your body for the rest of your life."

“ It's important to know the risk, and what you can do to prevent malnutrition from occurring, or to reverse the trend if you already have it.” - Pankaj Vashi, MD, AGAF, FASPEN - Chair of the Department of Medicine at Cancer Treatment Centers of America^® (CTCA)

The vast majority of GI cancer patients—up to 90 percent—experience malnutrition at some point in their cancer journey. The condition occurs when patients don’t get enough calories, proteins or other nutrients, either because they don’t feel like eating, or can’t, or because their body isn’t processing food and waste normally. This may happen for a number of reasons. When cancer develops, for example, it produces chemicals that change the way the body absorbs nutrients, making it difficult to maintain muscle mass and often leading to weight loss. As it grows and spreads, the disease also causes the body to use up much of its energy, and patients often experience weakness and fatigue. Gastrointestinal cancer patients have additional concerns: Their tumors may block areas of the gastrointestinal tract and interrupt nutrient absorption.

Treatments like chemotherapy and surgery often compound the issue by causing nausea, vomiting and diarrhea, as well as appetite loss. “All of this makes you more susceptible to malnutrition during cancer,” Dr. Vashi says. He cautioned patients not to let body types or excess weight fool them into believing malnutrition isn’t a concern for them. “It’s not only a danger for people who are thin,” he says. “Even people who are obese can be malnourished. It’s caused by a deficiency in necessary nutrients.”

A nutritional assessment may help determine your risk for malnutrition, and help you prevent the condition from worsening if you’ve already developed it. “Early detection and intervention are vital to treating malnutrition and reversing its effects,” Dr. Vashi says. A dietitian may help diagnose the cause of your nutrient deficiency and develop a meal plan tailored to getting you back on track. If you are unable to swallow, chew or otherwise eat normally, you may require a feeding tube that can deliver nutrients directly to the stomach.

Malnutrition may cause far-reaching and often severe impacts, such as weakness, fatigue and an inability to fight off infection or continue treatment. That’s why it’s critical to educate patients on the importance of proper nutrition, says Mary Parker Davis, MS, RD, LD, and Andrea Laney, RD, both registered dietitians at our hospital near Atlanta. It’s also important to understand that overcoming the condition won’t happen overnight, and that there are right ways and wrong ways to gain weight. Just eating junk food, for example, won’t give you the healthy fats, complex carbohydrates and proteins your body needs. But drinking high-protein nutritional supplements may help add some of those necessary nutrients back into your diet. “We tell people to think of food as medicine,” Parker Davis says. “We schedule time to take medicine each day. So we need to schedule time to eat healthy foods each day, too.”

Do I really need a colonoscopy when I can take a stool test?

Technology has improved the accuracy of stool tests in detecting DNA mutations or signs of blood that may indicate cancer. That comes as a relief for patients who simply refuse to get a colonoscopy. "I feel stool tests, such as Cologuard^® or others, are appropriate for someone who is unwilling to have a colonoscopy," Dr. Weber says, adding that a stool test is better than no test at all. But for Dr. Weber, and many other doctors, the stool tests are not enough. Seeing is believing. Stool tests may detect signs of cancer, but negative results miss the possibility that small polyps may be lurking, posing a risk of developing into tumors later on. "And if you get a positive result on a stool test, you're going to need a colonoscopy anyway," Dr. Weber says. Also, stool tests also are not for patients with a high risk of colon cancer.  Stool tests are not recommended for patients who have a history of polyps, previous positive stool tests or a family history of colon cancer.

“ If you get a positive result on a stool test, you're going to need a colonoscopy anyway." Jeffrey Weber, MD - Gastroenterologist

How should I prepare for my colonoscopy?

Patients often dread the colonoscopy prep more than the procedure itself. But times have changed, and no longer are prescribed laxatives or harsh bowel cleansers necessary in many cases. Talk to your doctor about options. Some doctors may suggest over-the-counter laxatives that are easier to swallow. "Every doctor has his or her own ways of having patients prep for a colonoscopy," Dr. Weber says. "You should be given a choice of preps. There are some preps that aren't that bad."

How will I be sedated for my colonoscopy?

For years, doctors used a combination of sedation drugs such as fentanyl, meperidine (Demerol^®) and midazolam (Versed^®) during a colonoscopy. But the drugs last for hours, far longer than needed, and have shown not to work in some younger patients or in patients with a history of alcohol or drug use, Dr. Weber says. The sedation drug Propofol, he says, may be a better option because it works quickly before the procedure and may take less recovery time after. "You come in, get the procedure done, and a half hour later, you can walk out," Dr. Weber says. Some patients even ask not to be sedated during the procedure, Dr. Weber says, though he does not recommend that approach. "You shouldn't be awake or semi-conscious for any procedure that's painful," he says. "And colonoscopies are painful.”

Is it important that my doctor be board certified in gastroenterology?

Given the invasive nature of colonoscopies, they should only be performed by doctors with specific training, experience and professional credentials, Dr. Weber says. "Weekend courses on how to perform colonoscopies are offered, and that’s all some states require for training," he says. Board-certified gastroenterologists undergo extensive training on colonoscopies and other diagnostic and treatment procedures and are required to take ongoing medical education classes. "If you want quality assurance, you should go to someone who is board certified," Dr. Weber says. "A board certification says that these experts went through the full training programs, took the appropriate exams and passed."

“ If you want quality assurance, you should go to someone who is board certified.” - jeffrey Weber, MD - Gastroenterologist

Why should I ask my doctor for his or her adenoma detection rate (ADR)?

Adenomas are polyps, or outgrowths, on the inner wall of the colon. Some develop into malignant tumors. Given the history of colonoscopy results over time, experts know that in patients older than 50, colonoscopies will detect adenomas in at least 25 percent of men and 15 percent of women. Based on this standard, all gastroenterologists are assigned an ADR measuring their ability to detect these growths, according to the American College of Gastroenterology. "Doctors who meet or exceed that detection rate are generally considered knowledgeable and capable of performing colonoscopies," Dr. Weber says. According to an editorial in the medical journal of the American Society of Gastrointestinal Endoscopy, ADRs have become "widely accepted by expert groups as an important colonoscopy quality measure."

Is room air or carbon dioxide used in the procedure?

During a colonoscopy, a process called insufflation is used to inflate the colon with air, allowing the doctor to navigate the scope around the organ’s multiple curves. "For years, we used room air, and that was fine," Dr. Weber says. "But room air needs to be expelled from the body." It may take some patients hours to pass gas, he says. In the meantime, they may feel bloated, crampy or distended. Dr. Weber recommends using carbon dioxide to inflate the colon. "Your colon lining absorbs the CO², and you breathe it away," he says.

How much time should I expect the colonoscopy to take?

Count on spending at least four hours in the hospital or outpatient center where the procedure is taking place, to account for pre-op preparations and recovery. Dr. Weber says he usually brings patients in 90 minutes before the scheduled test, so they have time to fill out paperwork, provide necessary information to the doctor and/or nurse, undress and have an IV inserted. A colonoscopy typically takes about 45 minutes (longer if an endoscopy also is performed). Recovery often takes as little as 30 minutes, depending on the sedative and the type of insufflation gas used. But even after returning home, patients should take time before going back to their normal routine. "Take it easy for 10 to 12 hours," he says. "Don't sign any important papers. Don't do anything dangerous. And don't drive for at least 10 hours."

“ This is the holy grail of cancer treatment—finding what makes these patients unique. It’s the silver bullet that may help fight cancer in a specific patient.” - Arturo Loaiza-Bonilla, MD, MSEd, FACP - Chief of Medical Oncology and Medical Director of Research at our hospital in Philadelphia

In the past, if only one in 10 patients responded to a new drug, researchers assumed the therapy wasn’t effective for that cancer type and would discontinue that line of research. But a study published in 2012 changed conventional thinking on exceptional responders. The study noted that an advanced bladder cancer patient participating in a clinical trial had such an “impressive response” to a targeted therapy that she stood out starkly from the other 44 trial participants. So the researchers decided to dig deeper. After performing molecular testing on the DNA of the woman’s tumor, researchers discovered two genetic mutations that are uncommon in most bladder cancer patients. But when the mutations are present, they make the tumor more receptive to treatment. The study, the first to delve into the biology of an exceptional responder, prompted the National Cancer Institute to launch the Exceptional Responders Initiative, a pilot study focused on researching how specific genetic features in exceptional responders’ tumors could help advance cancer treatment.

Already, researchers have learned that between 10 percent and 20 percent of tumors in exceptional responders have unusually high numbers of genetic mutations, which may make the tumors more likely to respond to immunotherapy drugs. That means that identifying predictive biomarkers, or unique DNA mutations in the tumor cells of exceptional responders, may help researchers design drugs to target those same mutations in other patients’ tumor, regardless of where the tumor is located in the body. “We now know that when your tumor has a certain feature, you’re more likely to respond to immunotherapy, and you’re going to do much better because of that,” Dr. Bonilla says. “Patients have this advantage that they didn’t have before.”

Armed with this new knowledge, experts are encouraging patients to talk to their doctor about advanced genomic testing if their cancer is not responding to standard-of-care treatments. “Patients need to be their own advocates,” Dr. Bonilla says. “When I’ve tested some patients who weren’t responding to chemotherapy, for example, I’ve found they have a specific DNA mutation in their tumor that meant they were a candidate for a specific type of immunotherapy drug, which we wouldn’t have known otherwise.” Testing the patients’ tumors has an added benefit for the world of research, and potentially, other patients, Dr. Bonilla adds: The more biomarker testing researchers perform, the more exceptional responders the science community is likely to identify. “The more exceptional responders we study, the more we can tailor treatments to help more people,” Dr. Bonilla says.

Recognizing the toll the process can take on passengers with medical conditions and disabilities, the federal government’s Transportation Security Administration launched the TSA Cares program, complete with a toll-free helpline, 877-787-2227. Travelers can call the number to ask about alternative screening options for specific conditions, or to arrange for a trained passenger support specialist to help them through the security process.

Those who didn’t call ahead, and who don’t want to discuss their medical condition in front of strangers, have another option: TSA notification cards. A traveler’s medical condition is written on the card and handed to the TSA officer. The card is designed as a way to inconspicuously alert TSA personnel of the traveler’s medical condition, allowing for the screening to take place in private. The card does not exempt anyone from being screened, and it won’t necessarily expedite the screening process, but it offers a discreet, respectful way to notify officers at the checkpoint that additional accommodations are needed.

Because the TSA Cares program has proven to be a valuable resource for cancer patients, but knowing that downloading even one more form can prove taxing to patients who are already juggling so much, Cancer Treatment Centers of America^® (CTCA) hospitals provide laminated notification cards to patients who need one. “We’ve been doing it for three years,” says Jenny Dodd, manager of travel logistics at our hospital near Chicago. “Rather than asking our patients to navigate the TSA site and print it out, we do it for them.”

“ A cancer patient's infection-fighting capabilities are not the same as those of a normal individual. Infections in cancer patients are serious, and protecting yourself is critical.” - Mashiul Chowhury, MD - Chief of the Division of Infectious Disease at CTCA

Certain cancer treatments weaken patients’ immune system, making them more vulnerable than the average person to getting sick, whether it’s from contaminated food, germs spread through the air, or viruses on unclean surfaces. Practicing healthy hand hygiene is the first step in protecting yourself, because many infections are spread by touching dirty surfaces, Dr. Chowdhury says. See other tips below for protecting yourself during common social scenarios:

RUNNING ERRANDS

In their day-to-day lives, cancer patients are often in public places, touching tables, chairs, doors and doorknobs contaminated with other people’s germs. “That’s why cancer patients need to be very careful about what they do each day,” Dr. Chowdhury says. “It’s very easy to catch germs in public areas.”

He advises patients to avoid crowded places, like malls, grocery stores, airports, public swimming pools and restrooms, if possible. If you must go out in public, wash your hands often and use hand sanitizer if you don’t have a sink nearby. Dr. Chowdhury also recommends wearing a mask to protect yourself from airborne bacteria.

AT WORK

When you have cancer, you may need to take time off work for appointments and treatments, so it’s often necessary to tell a supervisor or someone in human resources that you’re undergoing medical treatment. But it’s up to you whether and how much you choose to tell your co-workers or employer about your diagnosis. If you do decide to open up, you have options, such as sharing your news in an e-mail, during a meeting or one-on-one.  

Also, be deliberate about protecting yourself at the office. Consider bringing hand sanitizer with you to meetings, and avoid co-workers who exhibit signs that they may be coming down with a bug. Telling those at work about your diagnosis may help open up those lines of communication, letting co-workers know they should take certain precautions, like staying home when they’re sick, to avoid spreading germs.

AT YOUR PLACE OF WORSHIP

Because many religious settings are social in nature—involving, say, hugging, shaking hands or standing close to fellow parishioners—cancer patients may struggle with whether they should attend services. But Rev. Percy McCray, Director of Faith-Based Programs at Cancer Treatment Centers of America^® (CTCA), cautions patients not to let cancer get in the way of their faith. Because avoiding illnesses is of paramount importance, each patient should decide what makes the most sense for his or her situation. “There are emotional and physical aspects to each individual’s decision,” he says. “Some people may feel more comfortable not attending social worship. Others may feel comfortable only if they wear a mask and explain to those around them that they have cancer. Still others may prefer to not share that personal information at all and simply refrain from contact with others.”

If you feel more comfortable avoiding social worship, consider asking members of the congregation to pray for you in your absence, or the leader of the congregation to visit you at home or at the hospital so you may still feel connected to your faith during treatment. 

AT A FRIEND'S HOUSE

After a cancer diagnosis, many patients make a conscious decision about whether to tell more casual acquaintances at social gatherings about their diagnosis. Whether you choose to share your diagnosis or not, consider bringing your own dish to parties and other food-based outings, says Carolyn Lammersfeld, Vice President of Integrative Medicine at CTCA^®. That’s important, not only because you may have to follow a certain diet, but also because it may be the only way to know that the food has been safely prepared and kept at appropriate temperatures, which is important in preventing food-borne illnesses. “Especially during this time of year, when the flu and colds are rampant, it’s critical to protect yourself as much as possible from illnesses that could derail your treatment,” Lammersfeld says.

It’s also important to make sure you and your loved ones get the flu shot, and, if anyone close to you does come down with the flu, to keep your distance. In cancer patients, the flu can quickly become severe, Dr. Chowdhury says. If you are exposed to the flu during treatment, ask your doctor whether you should take an antiviral medication to reduce your risk of getting sick.

In an analysis of multiple tumor samples from nine women with HGSOC, researchers at the Dana-Farber Cancer Institute and the Johns Hopkins Kimmel Cancer Center found that the majority of gene mutations in the tumors actually developed years before, as abnormal changes in the fallopian tissue, called fallopian tube lesions. Experts hope the findings help advance developments in early detection, treatment and even prevention.

“ Cells that line the fallopian tube are called serous cells, and they produce watery, serous fluid. Serous ovarian carcinoma is the most common type of ovarian cancer. It turns out that most serous ovarian carcinomas probably actually start in the serous cells that line the fallopian tube. All of a sudden, the way ovarian cancer behaves starts to make a lot more sense. The cells in the fallopian tube can float out and implant anywhere in the abdominal cavity.” - Julian Schink, MD, Chief of Gynecologic Oncology at Cancer Treatment Centers of America^® (CTCA)

The fallopian tubes connect the ovaries to the uterus, and because the organs are so intertwined, the disease is usually diagnosed as ovarian cancer. “This is because the organs live side by side, and once the fallopian tube is involved, cancer spreads quickly to the ovary, and then it’s impossible to tell where it started,” Dr. Schink says.

Ovarian cancer causes more deaths than any other gynecologic cancer, so understanding how it evolves may be game-changing, particularly since about 70 percent of ovarian cancer patients are not diagnosed until the disease has already progressed to an advanced stage. “For so long, people have been frustrated that ovarian cancer spreads so early, but of course it does, because it’s a free-floating cell in the fallopian tube,” Dr. Schink says. “These studies continue to give us new strategies for early detection, which hopefully leads to better treatments.”

It makes sense, he says, that fallopian tube lesions may be a harbinger for ovarian cancer, considering that ovarian cancer incidence rates are far lower in women who have had their tubes removed, or who have undergone a hysterectomy or a tubal ligation, a surgical procedure that cuts or ties the fallopian tubes together to permanently prevent pregnancy.

Dr. Schink recommends that women who carry an inherited BRCA mutation, or who have a family history of ovarian cancer, talk with their doctor about options to reduce their ovarian cancer risk. “Be aware that removing the fallopian tubes at a younger age significantly reduces the risk of cancer,” Dr. Schink says. “The data says there’s at least a 50 percent reduction. Anyone considering surgical tubal ligation should consider having their entire fallopian tubes removed to further lower their risk.” The fallopian tubes act as a conduit between the ovaries and the uterus, which is important to women who want to conceive. But, thanks to advances in reproductive medicine, in vitro fertilization allows some women of child-bearing age to become pregnant even after  having their tubes removed.  

Since ovarian cancer is rarely detected during a Pap smear, and no other screening tools have been developed for the disease, Dr. Schink recommends women pay close attention to their bodies for possible symptoms. “About 95 percent of women with ovarian cancer report symptoms,” including bloating, a distended abdomen, abdominal pain, changes in bowel movements and more frequent urination, says Dr. Schink. By the time these signs develop, the disease has often advanced beyond the early stages, so women should talk to their doctor as soon as they notice the changes.

Researchers in the Johns Hopkins and Dana-Farber study found that a fallopian tube lesion took an average of six-and-a-half years to develop into ovarian cancer, but it took just two years for the cancer to metastasize, or spread to another part of the body.  The study’s lead author, Victor Velculescu, MD, PhD, co-director of Cancer Biology at Johns Hopkins University School of Medicine, noted that with nine patients, the sample size was small­­, but added that "if studies in larger groups of women confirm our finding that the fallopian tubes are the site of origin of most ovarian cancer, then this could result in a major change in the way we manage this disease for patients at risk.”

Cancer develops when changes, or mutations, in a cell’s DNA cause the cell to grow out of control. Sometimes, the mutations are caused by chemicals and other toxic substances in the environment—classified as carcinogens because of their cancer-causing potential. While such chemicals are toxic, they don’t always cause cancer. Your risk for developing the disease depends on several factors—including how long and how often you’re exposed, your genetic makeup, your diet and lifestyle, your overall health, and your age and gender.

The International Agency for Research on Cancer (IARC) and the U.S. National Toxicology Program (NTP) group carcinogens into categories based on how likely they are to cause cancer. While most people think environmental cancer risks are strictly external toxins like air and water pollution and chemicals like radon, the IARC, NTP and others also count lifestyle factors like nutrition and tobacco use and natural exposures like ultraviolet light in the mix. Known environmental risk factors include:

TOBACCO

The most significant environmental risk factor for cancer is tobacco, whether they’re using products like cigarettes, pipes, cigars, chewing tobacco, snuff or vaping, or being exposed to secondhand smoke. In fact, tobacco accounts for 80 percent to 90 percent of all cases of lung cancer, which is the second most common cancer in both men and women.

To reduce your risk of lung cancer, avoid tobacco altogether—don’t start the habit, and if you have, quit as soon as possible, and steer clear of secondhand smoke.

“ I think it's safe to say that any tobacco use will increase your risk of getting cancer.” - Jeffrey Hoag, MD, MS, FCCP - Vice Chair of the Department of Medicine at CTCA

ALCOHOL

Research has found that the more alcohol someone drinks—especially regular use over time—the higher the risk of cancer. For example, people who have three-and-a-half drinks or more a day are two to three times more likely to develop head and neck cancer than those who don’t drink. Alcohol consumption also has been linked to liver, esophageal, colorectal and breast cancers.

Alcohol increases cancer risk by damaging cell DNA and proteins, as well as the body’s ability to break down nutrients, and by increasing estrogen levels. People who use both alcohol and tobacco have much higher risks of developing head and neck cancer than those who use alcohol or tobacco alone.

OBESITY

Obesity is linked to 13 types of cancer, including two of the most common—breast and prostate—but only a little more than half of Americans are aware that it’s a risk factor for cancer. In fact, physical inactivity and obesity together account for 25 percent to 30 percent of colorectal, breast, uterine, kidney and esophageal cancers, which are among the most common types. “Obesity has become so important in the field of oncology today that maintaining an appropriate weight is one of the most important ways you can protect yourself from cancer,” says Anthony Perre, MD, Chief of the Division of Outpatient Medicine at Cancer Treatment Centers of America^® (CTCA).

To help avoid obesity-related cancers, experts recommend you lose excess weight through diet and exercise, if possible, and with the help of behavioral and dietary counseling, if necessary.

ULTRAVIOLET RADIATION

Ultraviolet (UV) rays from the sun, sunlamps or tanning beds may damage cell DNA and lead to melanoma or other forms of skin cancer. Skin cancer is the most common form of cancer, affecting more than 3.5 million Americans each year, and melanoma accounts for the most skin cancer deaths. And its incidence is on the rise. In fact, if melanoma rates continue to increase at the same pace, 112,000 new cases of the disease will be diagnosed in 2030.

To reduce your risk, limit your exposure to UV rays—both from the sun and indoor tanning—and wear sunscreen and protective clothing when outdoors.

ASBESTOS

Asbestos occurs in rock and soil, and is often found in building construction materials for insulation. The mineral fiber increases the risk of lung cancer, mesothelioma, laryngeal cancer and ovarian cancer. Asbestos exposure accounts for the largest percentage of occupational cancer risks, with the highest risk among affected workers who also smoke. The Occupational Safety and Health Administration regulates asbestos levels in workplaces, but because the fiber is present in the air, water and soil, avoiding asbestos is nearly impossible. Most people who are exposed to the fiber don’t develop disease, but the greater the exposure, the greater the risk.

If you are planning to remodel your home, which may disturb building materials, or if your home contains damaged materials, such as crumbling drywall or insulation, you may consider hiring someone to inspect it for asbestos-containing materials. If your home does contain asbestos, an inspector can give you recommendations for correction or prevention. And make sure to wear a mask and other protective gear while doing any of your own remodeling.

VIRUSES

Certain viruses are linked to several types of cancer. Human papillomavirus (HPV), for instance, is responsible for almost all cervical cancers. But in November, a study published in The Annals of Internal Medicine journal found that HPV-related head and neck cancers in men (7.8 per 100,000) are even more prevalent than HPV-related cervical cancers in women (7.4 per 100,000).  The Centers for Disease Control and Prevention recommends that 11- and 12-year-old boys and girls receive two doses of the HPV vaccine six months apart, and that young men and women ages 15 to 26 receive three doses.

Chronic infection with hepatitis B or hepatitis C virus is the most common risk factor for liver cancer. Both viruses are spread by sharing contaminated needles, unprotected sex and childbirth. Also, the Epstein-Barr virus, which causes mononucleosis, is linked to some types of lymphoma. Currently, there are no vaccines for hepatitis C or Epstein-Barr, but there is a vaccine for hepatitis B.

IONIZING RADIATION

Ionizing radiation is thought to cause about 1 percent of all cancers. It comes from cosmic rays that enter the Earth’s atmosphere, the radioactive gas radon—found naturally at low levels in soil—and from certain medical procedures, such as X-rays and radiation therapy. When cancer treatments increase your risk of developing another cancer later in life, the decision-making process often involves weighing the risks against the benefits, says Glynis Vashi, MD, Intake Physician and Chief of Medicine at our hospital near Chicago. “It takes years for a cancer to develop,” she says. “So you do what you have to do at the time, and then you take as many preventive steps as possible to improve the chance that you won’t develop another cancer in the future.”

As medicine continues to evolve, scientists may discover more environmental substances that we should avoid, or at least limit in use. Today, some possible but unproven risk factors include fluoride in water, radiation from power lines and electrical devices, chemicals in certain hair dyes and cosmetics, lead, the mineral talc in talcum powder, diesel exhaust and the chemical BPA in some plastics. “My advice is to avoid or limit even these unproven risk factors now, especially if doing so doesn’t affect your quality of life,” Dr. Perre says.

The significance of environmental risk factors is underscored in cancer rate disparities throughout the world and how those rates fluctuate when people move from place to place. For example, people who live in Asia tend to have low rates of prostate and breast cancer and high rates of stomach cancer, but when they emigrate to the United States—where prostate and breast cancers are prevalent—their prostate and breast cancer rates rise over time.

Still, if everyone took all the known precautions in reducing environmental exposure to cancer-causing substances, some would still develop the disease—because environmental risk is only part of cancer’s story. For example, one man may smoke for 30 years and never develop lung cancer, while another who only smoked in college may develop the disease years later. “Many people believe that if they’re exposed to a carcinogen, they’ll get cancer,” Dr. Vashi says. “But you always have to question why, out of two people in the same environment, one will develop cancer and one will not. That is when you realize that there is something at play beyond the environment. It’s the interplay between the environment and what’s going on within us.”

Understanding the relationship between the environment and genetics is vital to lowering your cancer risk, Dr. Vashi says. “It’s education, education, education,” she says. “Every doctor should help his or her patient realize that a poor diet, excessive alcohol consumption and certain medications may affect chemical levels in the body that break down cancer-causing substances, for instance. It’s imperative that we help our patients learn how to decrease their environmental risks for cancer.” Researchers today are working to identify the unique combinations of gene alterations and environmental exposures that explain why one person develops cancer and another does not.

At the end of the day, you have the power to reduce potential exposures to substances in the environment, Dr. Hoag says. “I think the take-home point I would want to convey is that there may be a lot in your environment you can’t control, but the more you learn about what’s there, the more you learn about what you can control.”

"In general, cancer cells have larger nuclei than normal cells," says Fernando U. Garcia, MD, Pathologist at our hospital in Philadelphia. "This is mainly due to alterations in the DNA that have resulted in the development of cancer. This alteration in the DNA gives cells a property called hyperchromasia, meaning the cells appear darker than normal cells, and pleomorphism, meaning cells with different shapes and sizes."

“ It's not just the shape that's important, but the number of cells and the variety of shapes. In most high-grade III cancers, for instance, you see cells that are big, round, square, triangular. You're seeing an array of shapes and sizes.” - Fernando U. Garcia, MD, Pathologist

This chaotic collection of mutated and misshapen cells may allow pathologists to almost instantly determine whether a tissue sample is cancerous, Dr. Garcia says. "It's not just the shape that's important, but the number of cells and the variety of shapes," he says. "It most high-grade III cancers, for instance, you see cells that are big, round, square, triangular. You're seeing an array of shapes and sizes." Scientists are also researching what these cell shapes may tell them about possible gene mutations in some cancers and whether shapes may help predict how cancer travels through the body.

Cell shape may also help determine the specific type of cancer. For instance, cell shape helps determine if a patient’s lymphoma is a Hodgkin or non-Hodgkin variety. Patients with Hodgkin-lymphoma have enlarged, double-nucleus cells called Reed-Sternberg cells, which are shaped like owls' eyes and are not found in non-Hodgkin lymphoma patients. Brain tumors called glioblastomas are also referred to as astrocytomas because they originate in star-shaped cells called astrocytes.

In recent years, several clinical trials have studied whether cell shapes may help doctors predict the likelihood a cancer is more likely to metastasize, or travel to distant organs. Using computer algorithms and digital image analysis, Dr. Garcia and a team of researchers from Drexel University have determined whether breast cancer in some patients had traveled to the lymph nodes. "We may predict lymph-node metastasis just by looking at cells in the slide and running the digitized image through an algorithm," Dr. Garcia says. "We look at the shape of the cells, their relation to each other and interaction with normal structures, among other factors."

Scientists at the Institute of Cancer Research in the United Kingdom also are studying whether cancer cell shapes may be linked to gene mutations. By studying melanoma cells in mice, researchers were able to identify several genes they believe may influence cell shape. Among them is a gene called PTEN, which when turned off allowed cancer cells to become either round or elongated—perfect shapes to help them metastasize. Round cells travel more easily through the bloodstream; elongated cells are better able to pierce bone marrow or invade organs.

Lead researcher Chris Bakal, PhD, says learning more about cell shapes and the genes associated with how shapes determine the behavior of cancer cells may eventually lead to new therapies. "Changing the shape of cancer to make it less aggressive could be effective in combination with other therapies," Dr. Bakal says, "giving them a better chance to work."

“ Chronic pain can affect all areas of a person’s quality of life. That’s why interventional therapies to reduce or relieve pain are essential.” - Nathan Neufeld, DO - Chief of the Division of Pain Management at Cancer Treatment Centers of America^® (CTCA)

Opioids—oxycodone, hydrocodone, fentanyl and others—are narcotics prescribed to manage moderate to severe pain. They work by sending signals to the brain that block pain and produce a calming effect. In the 1990s and early 2000s, pharmaceutical companies began aggressively marketing opioids as an efficient way to manage pain. Long-term use may cause a host of side effects, ranging from constipation to hyperalgesia, an increased sensitivity to pain. But the drugs’ addictive properties and long-term consequences for patient safety are the side effects that have concerned the medical community the most, Dr. Neufeld says. That’s why today’s approach to treating cancer-related pain uses opioids more cautiously. Pain management specialists have found that other treatments may control pain with fewer side effects than oral narcotics, Dr. Neufeld says.

Lidocaine, a local anesthetic, for example, may temporarily block pain when injected into a joint or the spine. For longer-term relief, doctors may recommend a neurolytic block, which involves injecting a neurolytic agent near specific nerves. The agent is designed to reduce pain impulses as it flows from the nerves to the brain. Sometimes, Dr. Neufeld says, the nerves regenerate and the pain returns, but the procedure may be repeated as needed.

Some patients may also find relief with a pain pump, a tiny, surgically implanted device that delivers small amounts of medicine to the spinal cord, allowing the dose to be adjusted with a handheld device. This minor surgical procedure may be used for pain in the back, neck, limb, abdominal or pelvis, and for certain types of headaches.

These and other treatment options are often used in conjunction with supportive care therapies, such as physical therapy, mind-body medicine and acupuncture, and may provide a more comprehensive pain management strategy than opioids, says Abed Rahman, MD, MA, Interventional Pain Medicine Physician at our hospital near Chicago.

Because all patients experience pain and respond to treatments differently, strategies for addressing and managing pain must take into account a number of factors specific to them, including their pain tolerance level, their health history, other medical conditions and the source and severity of their pain.

With a record 15.5 million cancer survivors in 2016, effectively managing pain associated with the disease is more important than ever. “The goal is for the patient to control the pain, not the other way around,” says Dr. Rahman. “The combination of integrative and conventional pain management strategies offers a more balanced approach.”

“ Once you get to a core of cells that don't budge, you know those cells are resistant and those cells are going to start to grow. It's very frustrating.” - Arturo Loaiza-Bonilla, MD, MSEd, FACP

A tumor may be resistant to treatment for many reasons. In some cases, the tumor’s makeup has always contained resistant cancer cells, but they went undetected, even with a genomic test or pathology exam. But in other cases, the cancer adapts by developing new mutations or reproducing protective genes, either as part of its natural evolution or as a reaction to ongoing treatment.

Picture cancer as a bus barreling down the road with few obstacles ahead. Over time, it picks up new cells along the way and finds ways to refuel itself. "You have a driver mutation that's driving that bus," says Ashish Sangal, MD, Medical Oncologist and Medical Director of the CTCA^® Lung Cancer Center at our hospital near Phoenix. The driver mutation is the dominant genetic feature in the cells of that tumor, allowing it to thrive. By identifying that driver, doctors may be able to match a cancer drug that targets specific mutations. "We have to identify the driver and target that driver. Eventually, it loses control, lets up on the gas, and sometimes, the bus shuts down." Other times, one of the passengers takes over and a new driver allows the tumor to survive and grow. "That's where the cancer has adapted, and you have to try something new," Dr. Sangal says.

Healthy cells rely on several genes to help regulate growth and division, among them the epidermal growth factor receptor (EGFR). But when that gene mutates, it may lead to uncontrolled cell growth that causes tumors to form. Some cancers with an EGFR mutation may respond to targeted therapy drugs such as erlotinib (Tarceva^®), afatinib (Gilotrif^®) or gefitinib (Iressa^®) for several months before resistance kicks in. "We have seen a second mutation develop that is actually protecting the original EGFR mutation," Dr. Sangal says. "So even if we continue targeting the primary receptor, this new mutation is blocking it." That mutation may be targeted with the drug osimertinib (Tagrisso^®). "That's the counterpunch,” Dr. Sangal says, adding that that mutation may also become resistant to treatment over time.

Researchers are learning more about proteins known as drug transporters, enzymes that carry drugs into and out of cells. One particular transporter of interest is a substance called P-glycoprotein (P-gp), described in a National Cancer Institute article as a "garbage chute that pumps waste, foreign particles, and toxins out of cells." P-gp is meant to protect cells from toxins, but researchers have also determined that they may flush out chemotherapy drugs that are considered lethal to cells. P-gp is a member of the multidrug resistance (MDR) gene family. In a process called gene amplification, researchers believe some cancer cells may produce hundreds of MDR genes that overwhelm drug treatments and prevent them from working. Some researchers theorize that developing drugs that inhibit P-gp may allow treatments to remain inside cells longer, giving them more time to work.

Undaunted, doctors and researchers are constantly looking for new ways to combat cancer's resistance to treatment drugs. Ongoing research is studying potential new therapies designed to attack genetic features that are not yet targeted by existing drugs. Drug combinations have shown to be another option in attacking multiple targets simultaneously or in succession. "We're hitting cancer from many different sides," Dr. Sangal says. "That’s where clinical trials come into play. We are treating cancer with what we have, but what can we add to that treatment to get the best results?"

“ It's so common for people to have their lives flash before their eyes when they are told they have cancer. It is traumatic for a lot of people, and obviously, people deal with it in different ways.”
- Katherine Puckett, PhD, MS, MSW, LCSW, Director of the Department of Mind-Body Medicine at CTCA^®

According to research conducted at the University of Malaysia in Kuala Lumpur, 13 percent of the 469 cancer patients studied met the full criteria for PTSD the first six months after their cancer diagnosis. Another 8 percent experienced some symptoms of PTSD during that time. The study, which sparked international headlines when it was released in November, found that 6 percent of patients still suffered from PTSD when the four-year study concluded. "While PTSD is more often associated with traumatic events such as violent physical and sexual attacks, serious accidents and natural disasters, this includes being diagnosed with cancer, the experience of undergoing cancer treatment and surviving cancer," study author Caryn Mei Hsien Chan told the Reuters news service.

But Robert W. Bloom, MD, Psychiatrist at our hospital in suburban Chicago, cautions patients not to "glom on to that PTSD diagnosis.” “It's become a favorite label," he says. "PTSD is becoming over-diagnosed." The disorder is a specific condition, with distinct symptoms and criteria defined by the American Psychiatric Association. "There are lots of people who have lots of stress who wouldn't necessarily meet the criteria for true post-traumatic stress disorder," Dr. Puckett says. Patients may instead be dealing with similarly distressing conditions, such as acute stress disorder or cancer-related post-traumatic stress. It's also possible, Dr. Bloom says, that a cancer diagnosis may not be the primary source of a patient's stress. "Usually, if you see PTSD in a cancer patient, it's the activation of a trauma that happened previously," he says.

PTSD originates in the amygdala, a pair of almond-shaped lobes deep inside the brain that reacts to threats to life or safety, putting the brain into escape mode. The amygdala (named after the Greek word for almond) also retains memory of traumatic events and triggers responses when stimulated by memories or external stimulus, such as a loud bang. When the amygdala is stimulated, it may also release cortisol, a steroid that may cause increased heart rate, high blood pressure and other stress-related symptoms. "Sustained and persistent stress can become deleterious to people’s health," Dr. Bloom says. "They may wind up with hypertension. They could develop diabetes, sleep apnea or sleep disorders. There are a whole host of consequences." Many of those consequences may hinder a cancer patient's ability to handle treatments and fight off disease, he says. Some cancer patients with PTSD may develop a behavior known as "learned helplessness." These patients behave as if they have collapsed under the weight of their condition and appear to have given up the fight. "They can be non-adherent with their cancer treatment," Dr. Bloom says. "They might be smoking or drinking, and they may abuse their narcotic prescriptions."

Whatever the diagnosis, Dr. Bloom stresses the importance of getting a thorough psychological examination that explores events and other conditions that may be contributing to stress. "PTSD is almost never seen in isolation," he says. "It's usually associated with a mood disorder, an anxiety disorder, substance disorder, even sleep disorder." It's also important, he said, for patients embrace their journey in life. Reliving and sharing experiences, be they joyful or traumatic, may help patients get to the root of their stresses and find better ways to cope with them. "Don't lose yourself as a person," he says. "Don’t define yourself as a cancer patient. Instead, identify yourself as a person who has cancer. You can get through this and survive emotionally, which will help improve your physical strength, too."

The study, published in December in The New England Journal of Medicine, followed 1.8 million women for an average of about 11 years, finding that those on hormonal contraception had a 20 percent higher risk of breast cancer—no matter the dose of estrogen—than women who never used those birth control methods. It’s an important discovery, especially with an estimated 140 million women across the globe using some form of hormonal contraception. Now, the findings have experts taking a closer look at another hormone singled out by the study: progestin.

Hormonal birth control methods, which include pills, patches, shots, and vaginal rings or intrauterine devices, prevent pregnancy by delivering combinations of synthetic estrogen and progestin, or just progestin alone, into the body. Estrogen and progestin stop the ovaries from releasing eggs, thicken the cervical mucus to keep sperm from entering the uterus, and thin the lining of the uterus to prevent implantation. Because high estrogen levels may cause certain types of cancer cells to grow, experts have long believed estrogen was the main hormonal culprit linking the contraceptives to an increased breast cancer risk, says Justin Chura, MD, Chief of Surgery and Director of Gynecologic Oncology and Robotic Surgery at our hospital near Philadelphia.

“ Now we see that the progestin plays a role, as well in the risk. We definitely had a faulty assumption going in.” - Justin Chura, MD - Chief of Surgery and Director of Gynecologic Oncology

There’s no reason for panic, Dr. Chura says, since the risk of breast cancer from hormonal contraception remains relatively small for most women. “Oral contraceptives are still a great class of drugs,” he says. “There is no ‘free lunch’ in terms of any of the medications we prescribe. There are always risks and benefits.” Such risks for hormonal contraception include blood clots, strokes and heart attacks. Benefits typically include a reduced risk of other types of cancer, including ovarian and endometrial cancers, as well as lighter or more regulated menstrual cycles, and, of course, help with family planning.

But each woman should weigh her individual risks, Dr. Chura says. Because breast cancer risk increases with both age and the length of time hormonal contraceptives are used, women already at higher risk for breast cancer, and those who are older and no longer planning to have children, may want to consider switching to a hormone-free birth control method, such as a diaphragm or condoms. Older women who have been on hormone-based birth control for a number of years may also consider getting screened for breast cancer at the earliest age that guidelines recommend. And women who are on progestin-only contraception may consider talking to their doctor about changing their birth control method.

For women in their 20s, the benefits of hormonal contraception often outweigh the risks, but medical and family histories still come into play. “Even if you’re 25, if you’re a BRCA mutation carrier, it makes sense for you to factor in the breast cancer risk that comes with hormonal contraception because you’re already at a higher risk for breast cancer than people without that mutation,” Dr. Chura says. Oral contraceptives, though, are also known to decrease the risk of ovarian cancer for patients with and without a BRCA mutation.

Despite the new findings, Dr. Chura says women should talk to their doctor before making any changes to their birth control. “Now women can have more educated discussions with their doctors,” he says.

Vaccines play a vital role in the prevention of some cancers and in the treatment of others, and they are an essential tool in protecting cancer patients during treatments that may make them more vulnerable to illnesses.

Still, vaccines play a vital role in the prevention of some cancers and in the treatment of others, and they are an essential tool in protecting cancer patients during treatments that may make them more vulnerable to illnesses. Scientists are also researching new personalized cancer vaccines that have shown positive results in clinical trials as a potential treatment for some patients with melanoma, among the most challenging cancers.

While some vaccines are being used to help prevent and treat certain cancers, some scientists doubt whether those uses can be expanded in a meaningful way, especially since research into new cancer vaccines has not yielded the results many hoped. "The history of cancer vaccines is a history of failure," writes one author who chronicled the decades-old frustration over cancer vaccine research. Other researchers, though, are not giving up, and a variety of clinical trials are exploring potential new vaccines for a variety of cancers.

Still, they continue to be stumped by a persistent question: What should the cancer vaccine target? Scores of cancers are caused by a multitude of gene mutations, so developing a vaccine to target all possible mutations is likely impossible. And since cancer cells are the body's own cells gone rogue, many cancer cells are able to hide in plain sight from the immune system. That’s why, even when the immune system is stimulated by certain drugs, it doesn't always know what targets to attack. "First of all, you have to identify something that's targetable for your immune system," Dr. Lynch says. "The intent of the vaccine is to generate an immune response, to have soldiers on watch to attack when presented by an antigen, bacteria or a virus. So you have to identify a pathogen that you can target with a vaccine. That's the great mystery."

New research

Buoyed by advances in immunotherapy, cancer vaccine research is back in the spotlight. Several research projects are exploring personalized cancer vaccines, similar to sipuleucel-T, that use specialized dendritic cells to trigger an immune response. Dendritic cells are messenger cells that alert T-cells to the presence of antigens, which are proteins found on many cancer cells, differentiating them from normal cells. Researchers take pieces of proteins from cancer cells, called peptides, from a patient, attach them to dendritic cells and inject them back into the patient. When the vaccine works as designed, the dendritic cells reveal the peptides to T-cells, which seek out those proteins and attack them.

Researchers in Boston are exploring a similar approach, using neoantigens specific to cancer cells to create a vaccine for patients with advanced melanoma. Neoantigens are new antigens that may develop on cancer cells. Researchers identify several neoantigens and use computer algorithms to determine potential targets that may be used to develop a treatment vaccine. "Neoantigens are a very attractive target as a vaccine because they are novel antigens similar to a virus that are potentially much more visible to the immune system than antigens previously used in cancer vaccines. The mutated antigen is present only in the tumor, not in normal cells," researcher Patrick A. Ott, MD, PhD, told Ascopost.com.

An essential tool

Separate from vaccines designed to treat and prevent cancer are those that are being used as a critical tool in helping cancer patients stay healthy during and after treatment. Some cancer treatments, such as chemotherapy and stem cell or bone marrow transplants, may severely compromise the patient's immune system. That’s why it’s so important that cancer patients, and their caregivers and family members, receive vaccines for the flu and other preventable illnesses. "Cancer patients who have suppressed immune systems need certain vaccines to prevent infection," says Mashiul Chowdhury, MD, Chief of the Division of Infectious Disease for CTCA^® and Internist at our hospital in Philadelphia. "We encourage cancer patients to receive certain adult immunizations, because if they have pneumonia or a viral disease, it’s usually much more severe in cancer patients, and the outcome can be very more serious."

“ We encourage cancer patients to receive certain adult immunizations, because if they have pneumonia or a viral disease, it’s usually much more severe in cancer patients, and the outcome can be very more serious.”
-Mashiul Chowdhury, MD, Chief of the Division of Infectious Disease for CTCA^®

Dr. Chowdhury recommends doctors and patients follow the immunization protocol for adults established by the Centers for Disease Control and Prevention (CDC). That includes an annual flu vaccine. Cancer patients may also need to avoid live vaccines, or those that use live viruses to inoculate against disease. "If you give live virus vaccines to an immune-suppressed patient, the virus can duplicate and the patient can get those infections instead of preventing infections," Dr. Chowdhury says. Patients should also avoid contact with people who have received live vaccines for the same reason. Also, patients who have had stem cell or bone marrow transplants may need boosters or new vaccinations at some point after treatment, because such transplants often reverse the immunization effect of previous vaccines.

One of the biggest challenges in keeping patients healthy during treatment, though, is convincing them to actually get vaccinated. "A significant number of people are afraid of vaccines," Dr. Chowdhury says. Conspiracy theories linking vaccines to autism or other conditions have prompted some parents to refuse vaccinations for their children. But the risks of avoiding vaccinations are high. In 2017, a measles outbreak in Minnesota sickened 79 people, many of them unvaccinated children. And more than 125 people infected in California were linked to trips to Disneyland. A survey by the CDC showed that 28 of those patients were intentionally unvaccinated because of personal beliefs. "There is absolutely no scientific evidence of vaccines causing autism," Dr. Chowdhury says. "It's very frustrating."

Despite overwhelming evidence that the HPV virus may prevent cancer, the numbers of girls and young adult women getting the HPV vaccine are still very low. And the number of boys and young men who are vaccinated is even lower—less than 11 percent of male candidates for the HPV vaccine have received it. As a consequence, the rate of HPV-related head and neck cancers in men has surpassed that of cervical cancer in women. "It's a serious problem," Dr. Markman says, "when we have vaccines that have been shown to reduce cancer rates, and people will not use them."

“ With the International Space Station, we have a lab that doesn't exist anywhere else. It's an exciting platform for discovery.” - cell biologist Jeanne Becker

The future also has arrived in the field of cancer research, where scientists are taking their experiments into the final frontier. Already, research in the microgravity of space has contributed to the evolution of existing cancer treatments, like chemotherapy. Now, astronauts on the International Space Station (ISS) are conducting research on at least one potential cancer therapy, called an antibody drug conjugate (ADC). In the process, the experiments are taking cancer research where it's never gone before. "With the International Space Station, we have a lab that doesn't exist anywhere else," cell biologist Jeanne Becker of Nano3D Biosciences in Houston tells Space.com. "It's an exciting platform for discovery."

The ADC research, conducted by scientists on Earth in collaboration with astronauts on the ISS, involves a type of immune-stimulating therapy. ADCs are hybrid cells with the potential to combine the targeting skills of an antibody with the cancer-killing ability of a chemotherapy drug, in this case azonafide. In theory, ADC molecules would seek out and attach themselves only to cancer cells and deliver their cytotoxic payload directly to the cell membranes, killing them from within while sparing nearby healthy cells. By conducting the research in space, scientists can experiment with cells grown in microgravity, which better replicates the shape and behavior of cells in the body. "In space, you can grow larger and larger cancer tumors spherical in shape, so you have a better model of what’s happening in the human body," research associate Luis Zea, tells NASA. "The chances of having false negatives or false positives are decreased."

In years past, scientists have launched ovarian, colorectal, kidney and other cancer cells into space aboard space shuttles and rocket ships headed to the ISS, where they can mature and be used later for research on Earth. NASA credits cancer research in space with identifying new genetic features called biomarkers in some cancer cells, and with developing new surgical and diagnostic techniques. Technology developed for space exploration is now being used in breast cancer research. The successes recently prompted the space agency's Jet Propulsion Laboratory to extend its research partnership with the National Cancer Institute through 2021.

Ironically, research suggests space travel may increase an astronaut's risks of developing a variety of diseases and conditions, including heart disease and cancer. While TV space explorers are often seen walking through gravity-controlled ships in color-coded uniforms without concern, real astronauts are exposed to high levels of cosmic radiation and proton radiation that may damage DNA. This exposure accounts for the high rates of cardiovascular disease found in astronauts, researchers have concluded. Researchers have also found chromosome aberrations in lymphocytes taken from crew members after their space missions.

According to Scientific American, NASA grounds astronauts whose cancer risk exceeds 3 percent of the general population. A University of Nevada, Las Vegas, study concluded that, with current technology, a trip to Mars would double a space traveler's cancer risk. So, while space research is making significant leaps in cancer treatment and other advancements, much more must be done to find ways to take care of the men and women boldly taking those experiments into space.

“ When the rate of endometrial cancer's biggest risk factor increases, it's only natural that the incidence of endometrial cancer would rise, too.” - Julian Schink, MD - Chief of Gynecologic Oncology

Endometrial cancer, the most common form of uterine cancer, is the fourth most common cancer in women in the United States, and the most common cancer of the female reproductive system. The disease forms in the lining of the uterus, with an estimated 80 percent of cases linked to high levels of estrogen. Body fat produces estrogen, and excess amounts of the hormone may cause the uterine lining to thicken. When that happens, cancer is more likely to develop.

Shifts in reproductive trends may also be contributing to the growing endometrial cancer rates, Dr. Schink says. For example, more women are having fewer children, and more women are delaying childbirth until later in life. Endometrial cancer is also more common in postmenopausal women, and women are living longer than prior generations, which may also factor into the rising rates. In fact, in all the countries included in the Journal of the National Cancer Institute study, incidence rates were four to 20 times higher in women aged 50 and older.

Still, obesity is the single most defining cause, and concern, Dr. Schink says. Women can help lower their risk for the disease by losing weight, and by taking progesterone, a female hormone that regulates how the inner lining of the uterus forms. “Progesterone may cause hunger, though, and that’s not helpful in women who are already dealing with obesity,” Dr. Schink says. “It also causes vaginal bleeding and spotting, and makes many women feel bloated and depressed. So it’s not ideal.”

The link between obesity and endometrial cancer presents an important opportunity, Dr. Schink says. “A preventive health study needs to be conducted on this patient population,” he says. “People have talked about it, but it hasn’t gotten off the ground yet. We need to have some targeted interventions or strategies for people who are obese. And they need to include screening for endometrial thickness, so we can intervene when precancerous changes have been detected.”

Along the way, though, another concern has emerged: the number of women who receive false positive Pap results and undergo further unnecessary testing. That’s why public health officials are shifting their focus in the fight against cervical cancer, zeroing in on women with HPV, which is responsible for almost all cervical cancers. A key government agency’s decision to change its recommendations on cervical cancer screening reflects HPV’s principal role in the disease.

“ If women receive an abnormal result on a Pap test, they're often caused undue anxiety and additional testing when, in reality, unless they test positive for high-risk HPV, they have nothing to worry about.” - Julian Schink, MD - Chief of Gynecologic Oncology

In September, the U.S. Preventive Services Task Force modified its cervical cancer screening guidelines, encouraging women between the ages of 30 and 65 to receive HPV testing every five years, instead of getting a Pap test every three years or a combination of a Pap test and an HPV test every five years. “The story isn’t so much what’s changed, but what’s new and why,” Dr. Schink says. “This new screening strategy, coupled with the HPV vaccine, presents a great opportunity to make further strides toward the prevention of cervical cancer.”

Pap tests use samples from the cervix to test for cell changes that could lead to cancer. While the Pap test is considered a widely reliable screening tool for detecting the disease, some women receive inaccurate results that indicate their cellular sample was abnormal, which may cause them unnecessary worry and stress. Knowing the emotional impact false positive Pap results may have, gynecologic experts say it is more important to screen women who are at high risk for the disease—those with high-risk HPV. “When you conduct a Pap test and an HPV test together, you pick up women who have some cell changes on the cervix but who also test negative for high-risk HPV,” he says. “According to the screening guidelines, when that happens, women are told they had an abnormal Pap and have to repeat the test next year. What that does is create a lot of tension and lead to a lot of unwarranted testing, when what really matters is whether women have high-risk HPV or not.”

HPV is a group of more than 200 related viruses that affect 79 million Americans. The virus, spread through sexual transmission, typically doesn’t cause symptoms and most often goes away on its own. But in some cases, it leads to cell changes that may develop into cancer. Knowing that many younger women will test positive for an HPV virus that will most likely turn out to be harmless, the task force recommends those between the ages of 21 and 29 receive Pap tests every three years, and not undergo HPV testing, Dr. Schink says. “In most of these younger women, the HPV is going to go away on its own and not cause any problems,” he says. “That’s why we can’t use HPV testing as a screening tool for cervical cancer in these cases. However, if women take advantage of the HPV vaccine, they’ll be more protected because HPV is much less likely to cause infection and stick around to cause problems.”

The vaccine is designed to prevent infection by high-risk HPV strains that cause most cervical cancers. In guidelines meant to target kids before they become sexually active, the Centers for Disease Control and Prevention recommends that 11- and 12-year-old boys and girls receive two doses of the HPV vaccine six months apart, and that young men and women ages 15 to 26 receive three doses.

“ We get so many questions from patients asking us about immunotherapy and breast cancer. There are so many clinical trials, but so far, it is not an FDA-approved treatment.” - Sramila Aithal, MD -Hematologist-Oncologist and Medical Oncologist at our hospital in Philadelphia

Checkpoint inhibitors work by blocking signals that cancer cells use to hide from the immune system. Most of these drugs target the PD-1 or PD-L1 signal receptors, either on immune cells or cancer cells. Research shows that patients with triple-negative breast cancer, which accounts for up to 20 percent of all cases, appear to respond better to checkpoint inhibitors than patients with other types of breast cancer. Other studies indicate that some breast cancers may have high levels of PD-L1.

But scientists don't fully understand why some cancers respond to these drugs and others don't. "The question is: What makes the triple-negative cancer more prone to respond?" says Shayma Kazmi, MD, Medical Oncologist at our hospital in Philadelphia. "Not all lung cancers respond to immunotherapy. Not all melanomas respond. There is a subsection of cancers that tends to be responsive. And there are multiple ways to assess that sensitivity. PD-L1 is just one of them, and it's not perfect."

Triple-negative breast cancers also tend to have high levels of T-cells called tumor-infiltrating lymphocytes (TILs), which may become activated by a checkpoint inhibitor. In an article published in the Journal for ImmunoTherapy of Cancer, researchers theorized that "tumors with high TILs may also have increased PD-L1 expression, which might be the reason that triple-negative breast cancer seems to demonstrate the most robust clinical response to immune checkpoint inhibitor therapy, but further investigation is needed."

Still, some breast cancer patients may be treated with a checkpoint inhibitor in certain situations. For instance:

The patient qualifies for approved immunotherapy treatment because her tumor has a specific genetic feature. In May 2017, the FDA took the historic step of approving a cancer drug based not on a tumor's primary location but on a specific genetic feature found in the cancer’s DNA. The approval allows pembrolizumab (Keytruda^®) to be used to treat patients with tumors that have one of two specific genetic features: microsatellite instability-high (MSI-H) or mismatch repair deficiency (dMMR). These gene mutations are more commonly found in gastric cancers, but are occasionally found in breast and other cancers.

Some patients may qualify for a clinical trial. Currently, dozens of trials are researching several checkpoint inhibitors as potential breast cancer treatments. The drugs are being tested by themselves, in combination with other checkpoint inhibitors and in addition to other treatments such as chemotherapy.  A trial may allow a doctor to prescribe drugs as off-label treatment. This is the practice of prescribing the drug to treat a cancer type that has not approved for immunotherapy treatment by the FDA. Patients participating in the Targeted Agent and Profiling Utilization Registry (TAPUR) study, for instance, may be prescribed anti-cancer drugs by matching them to specific genomic mutations found in the patients’ tumors.

"The published data shows there seem to be more responses in triple-negative breast cancer than in other types, but the data is still premature," Dr. Aithal says. "We still need more time. But there are a ton of studies that are ongoing."

Katherine Puckett, PhD, MS, MSW, LCSW, Director of the Department of Mind-Body Medicine at our Chicago-area hospital, suggests that we try a different approach to starting the new year. One idea is to take a page from the Japanese, who consider New Year the most important holiday of the year. They traditionally view each year as a distinct time period, with each new year offering a fresh start. Many Japanese families even hold bonenkai parties— or “year forgetting parties”—to celebrate leaving the old year’s worries and troubles behind.

To help you welcome the new year with a positive outlook and a fresh start, Dr. Puckett offers these tips:

Pick a word or theme for the year. “Think about your overall goals for your life, how you want to live your best life,” Dr. Puckett says. “Focus on what’s really important to you as a human being, and make that your theme for the year.” Your goal can be as simple as a single word—kindness, freedom, generosity—or it can be theme, like: a healthier you.

Be kind to yourself. “Don’t be rigid in setting goals,” Dr. Puckett says, “and don’t ‘should’ on yourself. Leave room for flexibility, and don’t beat yourself up if you don’t get to everything on your list.” Dr. Puckett suggests treating yourself as kindly as you would treat your best friend.

Make yourself a priority. “Take some down time, indulging in things you love to do,” Dr. Puckett says. “Think of this as the gift you give yourself.”

Despite the challenge of meeting goals we set for ourselves, many Americans seem determined to try and try again. That can be a good thing, Dr. Puckett says, if you don’t let the past get you down. “If we approach New Year—every day, really—as a new day, a new chance to live up to our ideals, we are much more likely to be successful, and happier, too,” she says.

“ Benign tumors don't generally invade. They usually push the normal tissue to the side.” - Fernando U. Garcia, MD, Pathologist

Tumors grow because of a malfunction in cells' DNA, mainly in genes that regulate cells' ability to control their growth. Some damaged genes may also prevent bad cells from killing themselves to make room for new, healthy cells. "The regulation of cell death so important," Dr. Garcia says. "If your programmed cell death is altered, the cell does not knows when it's time to die and persists. If the cell learns how to block that, and it develops the ability to proliferate, tumors grow more rapidly." Some of these mutations lead to rapid, unchecked growth, producing tumors that may spread quickly and damage nearby organs and tissue. "Malignant cells have the ability to produce enzymes that dissolve the native tissue. This is known as invasiveness," Dr. Garcia says. Other mutations are less aggressive, forming slow-growing tumors that are not cancerous. "Benign tumors don't generally invade," Dr. Garcia says. "They usually push the normal tissue to the side."

Many people carry benign tumors their entire life. Nevi, or moles, are types of benign tumors that may never need treatment. Other types of benign tumors include:

• Adenomas: These bumps form on the surfaces of G-I tract. "A colon polyp, a classic adenoma, has only a 1 percent chance of becoming cancer in the patient's lifetime," says Jeffrey Weber, MD, Gastroenterologist at our hospital near Phoenix.
• Fibromas: These tumors of connective tissue may be found in any organ. Fibroid tumors are named for where they form in the body, such as uterine fibroids.
• Desmoid tumor: These are often more aggressive than most benign tumors and may invade nearby tissue and organs. But they do not metastasize.
• Hemangiomas: These tumors are a collection of blood vessel cells in the skin or internal organs. They may appear on the skin as a birthmark-like discoloration and often disappear on their own.
• Lipomas: These soft, round, fatty tumors are often found on the neck or shoulders.
• Leiomyomas: The most common gynecologic tumors in the United States, these may be found in the uterus. Their growth is fueled by hormones.

The only way to be certain if a tumor is benign or malignant is with a pathology examination. While benign tumors rarely become malignant, some adenomas and leiomyomas may develop into cancer and should be removed. Desmoid tumors and fibroids also may cause damage if they are allowed to grow and may require surgery or a polypectomy. But while benign tumors may require some treatment, the cells that form them share few of the characteristics of aggressive cancer cells, Dr. Garcia says. 

"Cancer is an evolution," he says, adding that benign tumors do not evolve in the same way. "A cancer cell learns how not to die. Then it learns how to proliferate. Then it learns how to invade. Then it learns to metastasize. Cells are the building blocks of cancer."

Attempting to deal with the upcoming holidays while coping with grief can feel daunting, but there are a few ways to prepare yourself.

Give yourself room. Understand that it is OK to grieve as you go through the holiday season without your loved one. Have a plan to visit with friends, meet with family and let yourself be loved. But if the idea of being surrounded for a long period of time is overwhelming, give yourself some room. Respect your own needs, and bow out accordingly. Sometimes, acknowledging that a fallback option is available will comfort you enough to stay at the gathering.

Honor your loved one: Just because your loved one isn’t physically present, his or her memory will still be a large part of any family gathering. Consider sharing a favorite story about your loved one or create a tribute. Perhaps you honor his or her memory with a single candle on the dinner table or by hanging a stocking on the mantle. A donation to one of his or her favorite causes or charities is also a wonderful way to remember your loved one and help others in his or her name. Putting your loved one at the forefront of your mind will not disrupt your grief progress; in fact, it solidifies the momentous part that person played in your life.

Make new traditions: It may be hard to face past traditions with the knowledge your loved one isn’t around to enjoy them. It may be necessary to make a few traditions of your own. Perhaps your loved one didn’t care for the hubbub of the shopping mall, but you enjoy window shopping. Maybe Christmas music is energizing to you, so let it be a source of holiday cheer. Making the holidays “your own” creates new memories that acknowledge the power of being yourself.

Reach out to others: For many, this time of year is about being surrounded by those we love. Often, we don’t want to burden those around us, so we hide our disappointment, fear or emptiness, but this is the time to let loved ones help. Sharing your emotions is a cathartic way for others to know how much you cared for the person you lost. In that honesty, let them know that this time is difficult and be in agreement on the holiday plans about how you wish to honor a loved one’s memory.

Write it down:  The grief process can invoke such varied feelings that it can be hard to work through them. While it feels like a juggling act, give them all their own space to be understood and acknowledged. A great place to be brutally honest without judgement is a journal. This is where genuine feelings can be unleashed. Its beauty also lies in its ability to be a time capsule, showing how far you’ve come. Also, make it a point to list what you’re thankful for once a day. It can be simple or grand, but the important part is finding it.

Find help: If you feel this time is too much for you to bear and the overwhelming sense of loss seems to swallow you whole, seek a professional. Many therapists are well versed in grief and can assist you in navigating this time. They may be able to comfort, guide and channel feelings in a way that is productive and assistive. Perhaps just one or two sessions with someone who understands grief can help release many distressing emotions, allowing you to enjoy your holidays without the emotional weight. In the end after all, the loved ones who have gone before us would hope we continue celebrating this time of joy in the healthiest way possible. Throughout the process, I encourage you to seek love, light and hope during this season.

Nuances in cancer types, terms and titles may indicate deep differences in the diseases, diagnoses and treatments. The small-cell prefix "non" can make huge differences in a patient's care plan and prognosis. To help cut through the confusion, the CTCA Blog developed an occasional series called, “What's the difference?” This compilation of blogs is designed to help clear up some of the confusion in cancer vocabulary and help increase your cancer IQ. Below are summaries of the series installments from 2017.

Genetics and genomics

Although commonly used interchangeably, the terms “genetics” and “genomics” are not synonyms. Both involve the study of genetic material, and both are derived from the Greek word gen, which means birth or origin. But the similarities largely end there. Though genetics and genomics are each complex topics, the difference between them is much simpler: Genetics is the study of the genes people inherit at birth, passed on from their family through the generations. Genomics refers to the study of mutations in the tumors themselves that may drive various cancer behaviors. Tests—those mapping a person’s DNA profile and those analyzing a tumor’s genomic abnormalities—may be helpful in treating cancer.

Read the blog
Learn more about advanced genomic testing.

B-cells and T-cells

When the body is invaded by bacteria, a virus or parasites, an immune alarm goes off, setting off a chain reaction of cellular activity in the immune system. The body may deploy macrophages or other innate immune cells, such as basophils, dendritic cells or neutrophils, to help attack the invading pathogen. Those cells often do the job, and the invader is destroyed. But sometimes, when the body needs a more sophisticated attack, it turns to its T-cells and B-cells. These cellular troops are the special ops of the immune system—a line of defense that uses past behaviors and interactions to learn to recognize specific foreign threats and attack them when they reappear. They may also play a critical role in the development and treatment of cancer.

Read the blog
Learn more about the immune system.

Small cell and non-small cell lung cancer

Diagnosing and treating lung cancer require far more than measuring the size of cancer cells under a microscope. But those sizes are a critical first step in understanding the distinction, scope and extent of the disease and its treatment options. That’s because, even today, lung cancers are generally divided into two categories: small cell (SCLC) and non-small cell (NSCLC), named when pathologists first differentiated lung cancers by the size of the affected cells. "The traditional diagnosis was based on pure pathology," says Shayma Master Kazmi, MD, RPh, Hematologist-Oncologist and Medical Oncologist at our hospital in Philadelphia. "They found that the cancer cells were either small cells, or they were larger cells, such as adenocarcinomas or squamous cells. And so they simply got grouped into those separate categories, small cell or non-small cell cancer."

Read the blog
Learn more about treatments for lung cancer.

Hodgkin lymphoma and non-Hodgkin lymphoma

With a common origin, similar symptoms and a shared name, Hodgkin lymphoma and non-Hodgkin lymphoma are easy to confuse. Both cancers originate in the lymphatic system, the body's network of lymph nodes that dispatch white blood cells called B lymphocytes. These cells produce antibodies that help us fight off infections. Patients with either cancer may experience extreme fatigue, weight loss and loss of appetite, fever and sweats and other common symptoms. And both are named for Dr. Thomas Hodgkin, the groundbreaking researcher who chronicled symptoms of the diseases. But the differences between the two are telling, too.

Read the blog
Learn more about the types of non-Hodgkin lymphoma.

Endometrial cancer and uterine sarcoma

Gynecologic cancers do not get the kind of public attention other cancer types do. September is Gynecologic Cancer Month, but you’re unlikely to see many purple ribbons, fundraisers or walks to raise awareness for the cause. Compared to breast cancer and its pink takeover during its awareness month in October, gynecologic cancers—cervical, ovarian, uterine (endometrial), vaginal and vulvar— are much lesser known. And yet, more than 100,000 women will be diagnosed with gynecologic cancers in 2017.

Read the blog
Learn more about why boys should get the HPV vaccine.

Skin cells: melanocytes and basal, squamous and Merkel cells

Consider the remarkable functions the skin performs every day. It's only 1.5 millimeters at its thickest point, but it protects the muscles and organs from outside threats. It can take a pounding, enduring bumps and bruises, the sun’s burning rays and the grime left by dirt and dust. It moves and stretches when you do, but even when the body is at rest, the skin is a bustle of cellular activity. The skin is the body's largest organ, and like other organs, it can develop cancers. Skin cancer is the most common cancer in the United States, affecting more than 3 million people a year. But treatments and prognoses vary greatly, depending on the affected cells.

Read the blog
Learn more about treatments for melanoma.

“ It's important to not only eat healthy during the holidays to maintain your nutritional status, but also to stay well.” - Crystal Langlois, RD, CSO, LD, Director of Nutrition at our hospital near Atlanta

When heading out to a gathering, Langlois has a few suggestions on how to make healthy choices.

Another key ingredient to eating healthy during the holidays is making sure your food is fully cooked and doesn’t spoil. “Many cancer treatments leave patients with impaired immune systems, so they are more prone to food-borne illnesses,” Langlois says. “That’s why it’s critical to practice food safety when dining out and reheating food.”

Video recipe: Oven-Roasted Turkey

Total cook time:
90 minutes to two hours

Total Calories: 146
8 Servings

Langlois offered a number of tips she says may help guide your food care habits.

Modifying some family recipes so they’re healthier may help you stay on track, as well, Langlois says. Consider our recipes for oven-roasted turkey breast or grilled chicken with fresh herbs. For a side, swapping mashed potatoes for mashed cauliflower with light sour cream may cut calories. Also consider our recipes for black bean salad and sautéed eggplant for nutritious additions to holiday entrées. And for dessert, try chocolate vegan truffles and chocolate avocado mousse for healthier versions of party favorites.

Video recipe: Chocolate Avocado Mousse

Total cook time:
15 minutes

Total Calories: 323
4 Servings

Langlois also suggests making these changes to popular recipes.

Individual needs may vary. Always discuss your diet with your care team.

But researchers have discovered that sometimes, cancer cells take advantage of this off switch, recruiting armies of T-regs to protect them from the immune system. In fact, identifying T-regs in tumors often means those patients can expect poor outcomes, research shows. "T-regs are involved in maintaining a working immune system and protecting us from developing autoimmune disease and allergies," Dr. Tan says. "From a cancer standpoint, however, they can help tumors grow by suppressing an effective immune response."

“ T-regs are involved in maintaining a working immune system and protecting us from developing autoimmune disease and allergies. From a cancer standpoint, however, they can help tumors grow by suppressing an effective immune response.” - Alan Tan, MD, Medical Oncologist

T-cells are members of the adaptive immune family. Unlike innate immune cells, which automatically attack viruses and bacteria, adaptive immune cells adjust over time to specific threats, attacking pathogens and remembering them should they attack again. T-cells are also critical players in immunotherapy cancer treatments. Drugs known as checkpoint inhibitors allow T-cells to better recognize and attack cancer cells. And CAR T-cell therapy, recently approved for some blood cancers, uses a patient’s re-engineered T-cells to attack cancer. 

The various types of T-cells protect the body in different ways:

• Killer T-cells, also called cytotoxic cells, kill damaged cells or those that have been infected by a virus. 
• Helper T-cells support various aspects of an immune response, stimulating B-cells to make antibodies and helping killer T-cells develop. 
• Memory T-cells recognize antigens they’ve previously attacked. These are the cells vaccines use to recognize specific viruses, such as measles or polio.
• Natural killer T-cells, which are different than killer T-cells, are hybrids, launching an initial attack like an innate immune cell, but also remembering and recognizing certain viruses like an adaptive immune cell.

Regulatory T-cells work differently than all those above. When functioning properly, T-regs kick in just as an immune response is winding down. Like chaperones at a school dance, they turn on the lights when the party is over and clear out the hall. If not for T-regs, the immune system would run amok and start attacking healthy cells and organs. Malfunctioning T-regs have been linked to a range of diseases, including diabetes and arthritis. "Lupus is a classic example of regulatory T-cell dysfunction," Dr. Tan says. "We all need that off switch so we don’t have too much immune stimulation."

Scientists in 2003 found evidence that melanoma cells may secrete a substance called heavy-chain ferritin, or H-Ferritin, that may activate regulatory T-cells to protect tumors from the immune system. In a 2004 article published in Nature Medicine, researchers suggest that ovarian tumor cells are able to recruit regulatory T-cells, describing their presence as a "smoking gun" that "predicts a marked reduction in patient survival." And a paper published in April in The Journal of Immunology, discusses the prevalence of T-regs in aggressive breast and pancreatic tumors, concluding that "invasive cancer in humans is associated with an expansion of T-regs that suppress a tumor-specific immune response."

In an article published in January, researchers in Austria suggest that targeting regulatory T-cells may prove promising for new immunotherapy treatments or in improving the outcomes of patients taking existing immunotherapy drugs. But, experts say, they should be treated with caution. Because T-regs are primarily responsible for preventing autoimmune diseases, depleting them to help fight cancer may produce devastating side effects. For instance, one strategy being explored targets a molecule called CCR8, which is found on T-regs inside tumors. But CCR8 is also found in cardiac muscle and in the liver. So targeting those cells may cause serious immune-related problems in those organs.

Still, Dr. Tan says, reducing the T-reg population in cancers remains a promising area of immunotherapy research. "The existence of regulatory T-cells in the tumor microenvironment is a major obstacle to improving the outcomes for cancer patients taking immunotherapy," he says. "If we could selectively deplete tumor-infiltrating T-regs, then we may be able to unleash potent anti-tumor responses."

Learn why immunotherapy may work for some patients but not others.

“ It’s problematic because women have heard that drinking some alcohol may help them prevent cardiovascular risk. But it’s more important for them to know that even four drinks a week can increase their risk of breast cancer.” - Anthony Perre, MD, Chief, CTCA Division of Outpatient Medicine

Women on average are smaller than men, so a woman’s body typically absorbs more alcohol and takes longer to break it down than a man’s. That leaves women more at risk for alcohol’s long-term effects, such as liver damage and cardiovascular disease. Even though low to moderate drinking may help protect the heart from the damaging effects of free radicals in the body, drinking too much alcohol may lead to high blood pressure and heart failure. Because of the dangers associated with drinking, including cancer risk, the American Heart Association (AHA) recommends that those who drink alcohol do so in moderation—an average of two drinks per day for men and one drink per day for women. The AHA also recommends that if you don’t drink alcohol, don’t start because the risks outweigh the potential cardiovascular benefits.

This is especially true because cancer risk increases with the amount of alcohol you drink. According to a May report from the American Institute for Cancer Research, one daily glass of wine or other alcoholic drink significantly raises the risk of breast cancer in women. Drinking one small glass of wine, beer or other alcoholic drink a day—or about 10 grams of alcohol—increases the risk of breast cancer by 5 percent in pre-menopausal women and 9 percent in post-menopausal women. Women who have two to three alcoholic drinks a day have a 20 percent higher breast cancer risk compared to women who don’t drink.

Alcohol may raise cancer risk because it contains ethanol and acetaldehyde, which are chemicals that damage the DNA of healthy cells. Alcohol also may affect the breakdown of estrogen, causing more estrogen to build up in the body. Women with more than normal levels of estrogen may have an increased risk of developing breast, ovarian and uterine cancer. Because alcoholic drinks are often high in calories and may cause weight gain, alcohol may also raise cancer risk by leading to obesity, which has been linked to 13 types of cancer.

The health dangers come amid 21^st century statistics showing that women are drinking more than ever—especially white women ages 35 to 54, whose rate of alcohol-related deaths has more than doubled since 1999. Experts worry that the trend points to a looming health crisis, and that women’s risk of cancer, particularly breast cancer, will rise exponentially. “There really is no such thing as non-risky drinking when it comes to cancer,” Dr. Perre says. “Even moderate drinking can raise the risk of breast cancer and other cancers. So women with other risk factors for cancer, especially breast cancer, should cut down on how much they drink, or stop completely.”

Learn more about how drinking alcohol may raise your cancer risk. 

Any swelling in the breast is worrisome, no matter what it looks or feels like, although only tumors that are at least a half-inch in diameter can be felt by hand.

“ If you notice an area of your breast that feels different from the surrounding tissue or corresponding tissue on the opposite breast, that is a concern.” - Dennis Citrin, MD, PhD, Medical Oncologist at our hospital in Suburban Chicago

Typically, a breast mass occurs for one of three reasons: tissue changes related to the hormonal fluctuations common before and during a woman’s menstrual cycle, a benign tumor or a cancerous tumor. “There aren’t a hundred different things it could be,” Dr. Citrin says. That’s why women who are premenopausal are advised to wait a cycle or two before calling their doctor, to see whether the lump goes away, and women who are postmenopausal are urged to call immediately. “In postmenopausal women, hormone fluctuations related to menstruation aren’t at play, so it eliminates one of the three options,” Dr. Citrin says.

Although your doctor will likely perform a physical examination of the area, he or she cannot tell whether a lump is cancerous just by feeling it. Your doctor may order a mammogram if cancer is suspected, but the screening tool isn’t considered the most reliable in diagnosing breast cancer because the test may not detect an abnormality, and because the test may report a false positive. If you notice a mass in your breast, it’s important to have an ultrasound, which should determine whether a biopsy is necessary, Dr. Citrin says.

If breast cancer isn’t caught early, the lump will typically grow larger before spreading to multiple areas. “That doesn’t happen overnight, though,” Dr. Citrin says. “Most breast cancers grow relatively slowly.” And there is no basis to the common misperception that breast tumors are more likely to be cancerous if they don’t move under the touch of a finger. A cancerous breast tumor that doesn’t move is likely so large that it’s grown into the chest wall, Dr. Citrin says. “The more typical case is a patient who notices a moveable lump in her breast, which means it’s not attached to the chest wall and not attached to the skin,” he says. “If a lump in the breast is immobile, meaning it can’t be moved, or the skin over the lump contains small nodules or is bleeding or inflamed, then this almost certainly represents advanced breast cancer, and has to be addressed by your doctor immediately.”

Being familiar with your breasts and understanding how they change is important to recognizing changes that deserve further testing. That’s how breast cancer is most often caught and diagnosed early. Although the American Cancer Society has moved away from encouraging women to perform regular breast self-exams, the organization does encourage women to be familiar with the way their breasts look and feel, and to report any changes to their doctor immediately. “Your breasts probably feel differently at different times of the month,” Dr. Citrin says. “Women should know those differences so they can tell if something changes. The worst thing that could happen is that you may go to the doctor once or twice unnecessarily, but I’d much rather see that happen than have a woman ignore a cancerous mass.”

Learn more about the signs of breast cancer.

“ A cancer often has distinct characteristics, with its own unique biology, its own unique DNA. And while there are a lot of similarities, no two cancers are the same, and they respond differently and have different outcomes.” - Diego Muilenburg, MD, Surgical Oncologist

The differences in cancer surgeries range from removing tumors for diagnosis and staging, to removing just enough to improve a patient's quality of life. Below are some examples of surgeries that are commonly performed on cancer patients, and why.

Diagnostic and staging procedures

A biopsy is a surgical procedure designed to diagnose a tumor’s type and stage. The operation may range from an outpatient procedure performed with a small needle that captures a sample of a tumor, to a major procedure that requires anesthesia and stiches. Biopsies may be performed during other types of surgery and as part of an initial diagnosis, or to help gauge the progression of the disease. In some cases, lymph nodes and organs around the cancer may be biopsied so they can be examined to determine the extent of the disease and whether it has spread.

Primary or curative surgeries

"The goal here is to leave the patient with no evidence of disease," says Derrick Beech, MD, FACS, Surgical Oncologist and Chair of Surgery at our hospital near Phoenix. This surgery may be performed when cancer is found in only one part of the body and no evidence suggests it has spread locally or metastasized. Patients with stage I colorectal cancer, for instance, may undergo a primary surgery that removes all evidence of disease and requires no further treatments. In some cases, surgery may be performed before or after other treatments like chemotherapy or radiation therapy.

Prophylactic or preventive procedures

Some patients opt for surgery even if they don't have cancer, because they have a family history of the disease or carry a gene mutation that raises their cancer risk. For example, women with an inherited mutation in their BRCA1 or BRCA2 genes are at a higher risk of breast and ovarian cancers. They may choose to have a prophylactic mastectomy and/or have their ovaries removed to reduce their cancer risk. "It can be a very difficult decision for some people," says Melanie Corbman, MS, LCGC, Licensed Certified Genetic Counselor at our hospital in Philadelphia. "In some cases, I've recommended counseling to help them make a decision. Some people may not be ready to make that decision, so I suggest they start with screening and see what works for them. There are options."

Cytoreductive or debulking surgeries

These procedures are intended to reduce the size of a tumor or remove visible masses from an area, often prior to another treatment, such as radiation therapy or chemotherapy. This type of surgery may be performed just prior to hyperthermic intraperitoneal chemotherapy (HIPEC), a treatment—typically for advanced colorectal, ovarian or appendix cancer—in which a surgical oncologist delivers a heated chemotherapy solution directly to the abdomen after removing multiple tumors from the area.

Palliative procedures

As with any type of palliative care, the goal of these surgeries is to relieve discomfort and improve quality of life. For example, surgery may be performed to remove a blockage in the colon or an obstruction in the lungs.

Reconstructive or restorative surgeries

As its name suggests, reconstructive surgery is intended to rebuild or restore a part of the body that has been disfigured by surgery. These procedures are especially common after surgery to remove breast or head and neck cancers.

Supportive procedures

These surgeries are performed to insert catheters, ports or devices that allow patients to receive medication directly into the bloodstream rather than having to receive repeated injections.

Learn how flexible robotic surgery may help head and neck cancer patients.

Oncologists lump lung cancer into two categories: non-small cell, which makes up nine out of 10 lung cancers, and small cell, which represents less than 20 percent of lung cancers. A decade ago, treatment decisions required little additional information. Each type was treated with basically the same techniques, typically surgery for early-stage lung cancers and chemotherapy for those in the advanced stages. Today, lung cancer treatments are determined by far more than the type and stage of the disease. If the cancer is non-small cell, for example, oncologists determine whether it is squamous cell or adenocarcinoma, the two main subtypes of non-small cell lung cancer. They also perform genomic testing on some patients to look for mutations that may be driving the tumor’s behavior. “Once we know all of these things, we can determine how to treat the cancer,” says Patricia Rich, MD, Medical Oncology Director of the CTCA Lung Cancer Institute and Medical Oncologist at our hospital near Atlanta.

Treatments for early-stage non-small cell lung cancer have changed little over the years—the go-to first-line treatment is still surgery, with radiation and chemotherapy among the common alternatives. But more recently, oncologists and drug developers have begun expanding treatment options for patients whose cancer has spread to other areas of the body. The vast majority of these efforts have targeted non-small cell lung cancer, which accounts for 85 percent of cancer in the lungs.

New drug approvals

Over the past few years, the U.S. Food and Drug Administration (FDA) has approved new drugs developed to target specific genomic changes that help non-small cell lung cancer cells grow. Some of these targeted therapies work by stopping the cancer cells from forming new blood vessels; others are designed to neutralize DNA mutations in certain protein receptors, such as EGFR, ALK and BRAF, in order to stop the cancer cells from growing and dividing. “It’s a very small subset of people that these targeted drugs can help, unfortunately,” Dr. Sangal says. “Only about 15 percent of non-small cell lung cancer patients have an EGFR mutation, and only about 5 percent have an ALK mutation, for example. But you get such a good response from these patients with these drugs that it’s a no-brainer.”

Oncologists also recognize they have more to learn about how targeted therapies can be used as the patient’s cancer changes and evolves. “Even if a targeted therapy works and a person’s cancer goes away for a year or two, it may come back because the cancer forms a second or even a third mutation,” Dr. Sangal says.

“ It's almost like a punch and a counterpunch. Cancer forms new mutations, and we have to find new drugs to block those new mutations." - Ashish Sangal, MD

The FDA has also recently approved several immunotherapy drugs called checkpoint inhibitors to treat non-small cell lung cancer: pembrolizumab (Keytruda^®), nivolumab (Opdivo^®) and atezolizumab (Tecentriq^®). These drugs target the PD-1 and PD-L1 cell receptors, which help regulate immune response. The therapies are only approved in patients with certain types of non-small cell lung cancer that hasn’t responded to chemotherapy or other treatments. Pembrolizumab is also approved as a first-line treatment in some patients, either in combination with chemotherapy or by itself.

In addition to treating the cancer, immunotherapies also may mean a better quality of life for some patients, because their side effects, such as fatigue and nausea, are typically less severe than those associated with chemotherapy and other conventional treatments. But for a small number of patients, immunotherapy may cause severe, life-threatening reactions. “Sometimes, when you use immunotherapy to turn off the signal, the immune cells will recognize cells as the enemy, when they are actually good cells, and attack them,” says Daniel Nader, DO, FCCP, FACP, Chief of the Division of Pulmonary Services at Cancer Treatment Centers of America^® (CTCA). In such cases, the liver or colon may become inflamed, and treatment may have to be delayed or stopped altogether.

Exploring combination therapies

Still, despite the drugs’ limitations, oncologists are optimistic about immunotherapy’s future for lung cancer patients. “I see more trials of checkpoint inhibitor drugs and better selections for patients coming,” Dr. Rich says. “The more we know about checkpoints and how to work with them to treat patients, the more and more drugs we’re going to see out there that can treat more and more mutations.” For instance, a September study published in The New England Journal of Medicine found that patients with stage III non-small cell lung cancer who were treated with chemotherapy and radiation, followed by the checkpoint inhibitor drug durvalumab (IMFINZI™), lived longer than those treated with chemotherapy and radiation alone. “I think that application is going to be approved,” Dr. Rich says. “And that’s probably the next thing—sequential immunotherapy for non-small cell lung cancers that have spread and can’t be surgically removed.”

Other combinations showing promising results are on the horizon, Dr. Sangal says. “Treatments are becoming very individualized to what type of cancer the patient has,” he says. “It’s not about just picking a treatment out of a bag. It’s about determining where the patient belongs in the broad spectrum of factors.”

Learn more about how the immune system works in both feeding and fighting cancer.

“ We often end up educating our patients about fact versus fiction. We work hard to explain that certain therapies are not equivalent to conventional treatments when it comes to treating cancer.” - Daniel Kellman, ND, FABNO - Director of Naturopathic Medicine and Rehabilitation Services at our hospital near Atlanta

Patients who chose these types of so-called natural therapies to treat early-stage cancer, instead of opting for recommended standard treatments such as surgery or chemotherapy, doubled their risk of a negative outcome, according to a study published earlier this year in the Journal of the National Cancer Institute. Compared to those receiving evidence-based medical treatments, breast cancer patients who used natural remedies fared the worst, followed by those with colon cancer and lung cancer.

No scientific evidence has shown that nutrition therapy, acupuncture, naturopathic medicine, chiropractic care or any other natural therapy has a medicinal effect in definitively treating cancer or shrinking tumors. On the other hand, these therapies, when used purposefully and responsibly, have a role in a cancer patient’s journey. 

Research has shown, in fact, that such therapies may be key in helping cancer patients manage the side effects of the disease and its treatment, from pain and fatigue to stress, neuropathy and malnutrition.

That’s important because patients who don’t feel good—who are too weak or become malnourished, for example—may be too sick to continue their treatment regimen, delaying or interrupting their fight against cancer. To help reduce or avoid those interruptions, a growing number of oncologists are turning to an integrative approach to care. This approach involves using supportive care therapies to help cancer patients manage their side effects, while also treating the disease with surgery, chemotherapy, radiation therapy, immunotherapy or other conventional methods.

Supportive therapies include naturopathic medicine, nutrition therapy, mind-body medicine, spiritual support,  acupuncture, pain management, oncology rehabilitation and chiropractic care. “These modalities offer ways for patients to improve quality of life and to decrease side effects of the conventional therapies that may be toxic,” says Kellman.

When patients are diagnosed with cancer, many don’t realize how the disease and its treatment will affect how they feel and function. Other patients have heard about various side effects and are now afraid of how they will affect them. “They associate chemotherapy with hair loss, nausea or other digestive issues,” says Kellman. “One of the advantages of having an integrative care program is the ability to address patients’ fear. We can help by teaching them how to have food taste normal during treatment or how to keep their energy levels up. Having energy helps patients stay motivated, capable of performing the normal activities of daily life, able to play with their children or whatever it may be to not throw their life off track.”

According to published studies, a growing number of cancer patients are choosing care plans that combine conventional cancer treatments with supportive care services designed to help manage and avoid  side effects that impair quality of life, during and after treatment.

“We look at what else we can work on, like autoimmune issues, heart disease or obesity,” says Kellman. “Those who embrace this whole-patient model of care often change their diet, their lifestyle, what’s in their refrigerator and their food shopping patterns. This new emphasis on healthier living becomes part of a new mission for them to seek out a healthy mind, body and spirit every day.”

Read more about integrative cancer care.

“ Have a plan of how you are going to get your medication when you need it. Make sure you have a way to get food and water. Keep appropriate records.” - Anthony Perre, MD

Most people in harm's way may want to get out of town, says Dr. Anthony Perre, Director of New Patient Intake & Vice Chief of Staff at our hospital in Philadelphia. "But people don't always have the financial resources to go somewhere else, put themselves up in a hotel for a week," he says. For some cancer patients, moving would be too taxing or logistically impossible. Also, not all disasters are predictable. Even hurricanes, which come with days of warnings, can shift direction at the last minute.

Dr. Perre, himself a cancer survivor, says every patient should be prepared and have a plan to keep treatments on track should circumstances spin out of control. "In many cases, these are steps cancer patients should be taking anyway," Dr. Perre says. "Have a plan of how you are going to get your medication when you need it. Make sure you have a way to get food and water. Keep appropriate records. And make sure you get good direction from your oncologist as to what other steps you'll need to take."

The National Cancer Institute, in partnership with the American Society of Clinical Oncology, recommends that patients carry this wallet card with basic information about their cancer treatment. The card also contains contact information in case patients can't reach their doctor in an emergency or during a natural disaster.

Get a copy of the card ≫

He offers cancer patients additional advice on several fronts:

Medications: Make sure you have access to your medications, Dr. Perre says. "And you should ask your physician if there are options for medications that don't need to be refrigerated," he says. Patients should also make sure they not only have cancer treatment medications, but those that treat side effects, such as pain, nausea, vomiting or diarrhea.

Food and water: Everyone should stock up on non-perishable food and drinking water, but cancer patients, especially those struggling with malnutrition and dehydration, should make sure they have high-protein snacks and drinks that help restore electrolytes.

Power: "If there is any way in to have a generator available, that would be ideal," Dr. Perre says. A generator can keep a refrigerator operational so necessary food, drink and medication remain fresh. "Also, it's important to have heat in the winter and cold air in the summer,” he says, "or have a plan to go somewhere locally if you don't."

Treatment plans: If a storm is approaching, Dr. Perre says, consult with your oncologist on a plan to stay on a treatment schedule. "In the best of all circumstances, it might make sense to delay your treatment so you are not in the middle of a natural disaster with low white counts and a predilection to becoming dehydrated,” he says.

Infection risk: Victims of hurricanes, tornadoes or earthquakes may need to navigate an infection minefield in the aftermath of the disaster. Dirty water, broken glass, sharp debris and smoke from fire may threaten a patient’s already comprised immune system. "It's important to realize you may be vulnerable to infections, so you should take steps to protect yourself," Dr. Perre says. "Try not to be in close quarters with people who may be sick, which may be difficult under the circumstances. Get your rest and sleep. Make sure you are eating, and stay hydrated."

Recordkeeping: Cancer patients should keep good documentation of their cancer journey, including records on their diagnosis, treatments, drug prescriptions and contact information for doctors and caregivers. "When I was diagnosed with cancer, there wasn’t a lot that was stored digitally," Dr. Perre says. "Now we can store things digitally, on a memory stick or even something like Google Docs. Of course, if the Internet is out, that would be an issue. I had a three-ring binder that I kept all my records in. It's old-school, but it works."

Learn more about how the immune system works.

The main difference between carcinomas and sarcomas comes down to tissue.

A carcinoma forms in the skin or tissue cells that line the body’s internal organs, such as the kidneys and liver. A sarcoma grows in the body’s connective tissue cells, which include fat, blood vessels, nerves, bones, muscles, deep skin tissues and cartilage.

Carcinomas are the most common type of cancer. 

Symptoms and treatments for carcinoma depend on the subtype. Common symptoms of basal cell carcinoma include open sores, red patches, pink growths, and shiny bumps or scars. Squamous cell carcinomas, on the other hand, tend to crust or bleed, and may appear as scaly patches, open sores or warts. Treatment for carcinoma often includes surgery, radiation therapy and/or chemotherapy.

Sarcomas have more than 50 subtypes. 

The first sign of a sarcoma in an arm, leg or the torso is typically a painless lump or swelling. In general, sarcomas are treated with surgery, and are harder to treat than carcinomas.

New research, though, has found that some sarcomas have a greater immune response than others, and may respond to certain checkpoint inhibitors. These drugs are a type of immunotherapy that works by disrupting the communication signals that allow cancer cells to hide from the immune system, exposing the tumor to the body’s defenses. The study identified immune response patterns in common sarcoma subtypes, including leiomyosarcoma and liposarcoma, both soft tissue sarcomas. “Because ‘sarcoma’ is a general term and encompasses many different cancer subtypes, different sarcomas look different under a microscope, and treatment can’t be one-size-fits-all,” says Asha Karippot, MD, Medical Oncologist and Hematologist at our hospital in Tulsa. “That’s where the research is focused on in this area right now—developing treatments that can be individualized to each sarcoma.”

Learn about the difference between endometrial cancer and uterine sarcoma.

“ When it comes to treating lung cancer, an early diagnosis can be crucial. Most lung cancers, at least 80 percent, are picked up when they are at an advanced stage. When lung cancer is diagnosed at stage IV, it is harder to treat.” - Bruce Gershenhorn, DO Director of the CTCA Lung Cancer Center in Suburban Chicago

"If the disease is diagnosed at an early stage and a patient begins treatment early, there is a higher likelihood of survival," Dr. Gershenhorn adds. 

About 14 percent of all new cancers are lung cancers, according to the American Cancer Society. Lung cancer largely affects older people, with two out of three diagnoses occurring in people ages 65 and older. While heavy smokers are at the highest risk for lung cancer, former smokers also have an elevated risk. Tobacco and tobacco smoke cause cancer because they contain thousands of chemicals with more than 60 known carcinogens. 

Because lung cancer tumors develop inside the chest cavity, they often have a chance to grow and spread before symptoms develop. For people at high risk for developing lung cancer, low-dose CT scans may detect the cancer at an earlier stage. And yet, despite the availability of this potentially lifesaving tool, most high-risk current and former smokers are not being screened for lung cancer, according to a study published earlier this year in the peer-reviewed publication JAMA Oncology. Researchers estimate that of the nearly 7 million current and former smokers eligible for screening in 2015, only 262,700 received it.

Annual lung cancer screenings for current and former smokers are recommended by the U.S. Preventive Services Task Force, the National Comprehensive Cancer Network, the American Cancer Society, the American Lung Association and others. A CT scan may detect tiny spots (also known as nodules) on lungs years before they would ever be seen on a regular chest X-ray. These tiny nodules may be signs of early lung cancer. 

“Our view on lung cancer screening needs to evolve,” says Dr. Gershenhorn. “In the same way we do routine mammograms to look for breast cancer and colonoscopies to look for colon cancer, we should screen for lung cancer with CT scans. An enhanced screening program would catch more lung cancers early.”

Learn why you shouldn’t let fear get in the way of your lung cancer screening.

“ I use logic, I use science when I treat patients. But when I paint or take photographs, it’s a complete opposite. There's no logic. It's just from the heart.” - Mashiul Chowdhury, MD, Director of Infectious Disease Control at CTCA^®

A native of Dhaka, Bangladesh, Dr. Chowdhury took up painting and photography nearly simultaneously more than 20 years ago. His art, he says, is an "expression of living in urban culture." He looks for the abstract in the ordinary. He studies the ravages of time on the urban landscape. He looks for stains that form interesting shapes or texture and colors that pop from a city bus or a nondescript wall. Nothing is posed or propped. "I don't do conventional photography," he says. "I take photographs of something that may not be commonly noticed or recognized. You may see some graffiti or some paint or a poster peeling off the wall, and over time, it develops textures. If you go very close, very tight, you might see an abstract language that can be very appealing. The technical aspect and execution of my paintings come from my experience with photography. The visual experience of roaming around the city, carefully observing the surface of walls, pavements and the architectural layout of buildings, constantly stimulates my inner feelings. The chaotic character of urban culture is expressed in my work with paintings."

The subjects of his images, he says, represent the passage of time. Each dent on a city bus or faded letter on a sign is part of human history. And each has a story—often untold. "That texture, that image was created over time. Maybe months, maybe years, and with some of my images, maybe 100 years," he says. "They are the stories of human beings. I generally don’t photograph any natural object. There has to be some touch of human activity." Dr. Chowdhury’s work has been displayed at our Pennsylvania hospital and in several galleries in Philadelphia. It can also be viewed on his personal website and in several YouTube videos.

While painting and photography often are an escape from his professional life, Dr. Chowdhury has found common ground. In his world, art and science are both humanities—grounded in improving the human condition. "When I approach a patient, it's logic and math and science," he says. "But there's also humanity. When I go back to my studio every single day and I work on my paintings, it actually takes me closer to humanity. And then when I come back to a patient in the morning, I see the world in a different way. It is a humbling experience. We have to learn to appreciate life more, learn to take time to enjoy the moment. Stop and smell the roses."

Learn how one CTCA surgeon draws on music to find the rhythm of medicine.

“It’s easy to fall victim to claims on TV, on the Internet and in articles regarding foods or drinks that cause cancer.”
- Crystal Langlois, RD, LD - Director of Nutrition

For a food or drink to be considered a carcinogen, strong evidence must link its consumption to an increased cancer risk and show how cancer may develop as a result. The World Health Organization’s International Agency for Research on Cancer (IARC) classifies carcinogens by determining how likely they are to cause cancer, with the scale divided into five groups: known, probable, possible, unclassifiable and probably not carcinogenic.

Foods and drinks the IARC considers carcinogenic to humans include:

Alcohol

• When the body metabolizes alcohol, it produces acetaldehyde, a chemical compound that may damage DNA, which may lead to cancer.
• Research has found that the more alcohol you drink, the higher your risk for developing certain kinds of cancer, such as head and neck, esophageal, liver, breast and colorectal cancers.
• Although experts recommend abstaining from alcohol to avoid the risk, Langlois says that if you choose to indulge, limit your alcohol consumption to no more than one serving per day if you are a woman, or no more than two servings per day if you are a man. A serving is defined as 12 oz. of beer, 5 oz. of wine or 1.5 oz. of liquor.

Processed meats
or those that have been preserved by curing, salting or smoking, or with chemical preservatives

• Examples include bacon, sausage, hot dogs, pepperoni, prosciutto, beef jerky and salami.
• Research has found that eating 50 grams of processed meat—the equivalent of four strips of bacon or one hot dog—every day increases the risk of colorectal cancer by 18 percent.
• If you do eat processed meats, look for nitrate- and nitrite-free versions, which don’t have added preservatives, Langlois says.

Foods and drinks that the IARC classifies as probably carcinogenic to humans include:

Charred meats
or those cooked at high temperatures

• Meats cooked at high temperatures form chemicals that may cause changes in your DNA, which may lead to cancer.
• Eating a large amount of well-done, fried or barbecued meats has been linked to an increased risk of colorectal, pancreatic and prostate cancer.
• When preparing meat, Langlois recommends braising, baking or boiling it. Also, marinating meats before cooking may help reduce the risk of carcinogens forming.

Red meat

• Examples are beef, veal, pork, lamb, mutton, horse and goat.
• Eating a large amount of red meat has been linked to colorectal, pancreatic and prostate cancer.

Very hot beverages
defined as hotter than 65 degrees Celsius or 149 degrees Fahrenheit

• In the United States, drinks like coffee, tea and hot chocolate are typically prepared at lower temperatures, so they’re generally not a concern.

Sugar is not on these lists because it has not been directly linked to cancer, but the sweetener does add empty calories, which may lead to weight gain, and possibly obesity. Obesity has been linked to 13 types of cancer, which is a growing concern in a country where the average American consumes an estimated 89 grams of added sugars per day—two to three times the recommended amount. Cutting added sugars is one of the easier changes you can make to your diet to improve your waistline, while also helping to reduce your cancer risk, Langlois says. “A registered dietitian who specializes in oncology may also be useful in helping you make appropriate diet choices,” she says. “And, remember, it’s OK to indulge in these foods and drinks from time to time. The key is moderation, and following a well-balanced diet that’s rich in fruits, vegetables, whole grains, and low in saturated fats.”

In the early 1990s, about 105,000 women were living with metastatic breast cancer, according to an analysis released earlier this year by the National Cancer Institute (NCI). This year, that number has jumped to nearly 155,000.

The disease, the most aggressive form of breast cancer, is progressive and does not typically go away with treatment.

“ Whenever we're dealing with cancer that's left the original site and has spread, it poses a challenge because simple surgical removal will not be enough. But metastatic breast cancer is not a hopeless situation.” - Dennis Citrin, MD, PhD - Medical Oncologist

To develop a more accurate estimate of the total number of women living with the disease, researchers used data from the NCI's Surveillance, Epidemiology, and End Results (SEER) Program.

Metastasis

The most common sites are bone, brain, liver and lung

• 
• 
• 

Researchers discovered that despite the usual prognosis, more women initially diagnosed with metastatic breast cancer have been surviving the disease for longer periods of time, especially women diagnosed at younger ages.

The researchers estimated that between 1992-1994 and 2005-2012, the five-year relative survival rate among women initially diagnosed with metastatic breast cancer at ages 15 to 49 doubled from 18 percent to 36 percent.

Based on their calculations, the researchers also estimated that the number of women living with the disease increased by 4 percent from 1990 to 2000 and by 17 percent from 2000 to 2010. They project that the number will increase by 31 percent from 2010 to 2020.

One major improvement in breast cancer treatments was the introduction of trastuzumab (Herceptin^®) in 1998 for treating certain tumors.

Targeted Therapy

is designed to attack specific genetic mutations found in some cancer cells.

• 
• 
• 

Other targeted treatments have been developed since then, including one approved by the Food and Drug Administration last month. "The goal of treatment for someone with metastatic breast cancer is to essentially turn it into a chronic illness," says Dr. Citrin. "I always use the analogy of somebody with diabetes. Every day, a person gives herself an injection of insulin or takes a pill to control her diabetes. Day to day, she's still diabetic; she's not cured of her disease, but as long as she takes her medication on a regular basis, she is not going to die of her disease. Also, the disease is not going to cause severe symptoms to interfere with the quality of her life. That's really where we're at with metastatic breast cancer for a growing number of patients."

It's also is purported to have medicinal qualities, with claims across the Internet that soursop extract can slow the spread of cancer or make traditional cancer therapies work better.

Experts warn against using the fruit to treat cancer. While research suggests soursop can fight cancer, it has not been studied in humans. As a result, there is no evidence of its safety or efficacy.

Soursop has been associated with many unsubstantiated claims, says Daniel Kellman, Clinical Director of Naturopathic Medicine at our hospital outside Atlanta.

The long, prickly fruit comes from the graviola tree, an evergreen native to Mexico, the Caribbean, and Central and South America. It's also known as custard apple, guanabana and Brazilian paw paw. Practitioners of herbal medicine use soursop fruit and graviola tree leaves to treat stomach ailments, fever, parasitic infections, hypertension and rheumatism. It's used as a sedative, as well.

But claims of the fruit's anti-cancer properties have attracted the most attention. A study published in the Journal of Medicinal Chemistry in 1997 suggests that soursop compounds tested on breast cancer cells in culture were more effective than chemotherapy in destroying the cells. But, without clinical trials, there is no data to support the claim.

Most studied are soursop's fatty acid derivatives called annonaceous aceteogenins. The predominant acetogenin is annonacin, which, because of its toxicity, likely would not be studied in clinical trials.

When used orally, soursop is classified as likely unsafe, said Kellman, citing two studies. Eating the fruit could lead to movement disorders similar to Parkinson's disease, according to a case-control study in the French West Indies. In addition, a study suggests tea made for the leaves and stems of graviola is associated with neurotoxicity.

In general, some cancer patients use herbal supplements to relieve their symptoms and to treat their cancer. Herbal supplements, though, are not a substitute for mainstream cancer care. What's more, using herbal supplements while undergoing chemotherapy could reduce the efficacy of chemotherapeutic agents due to possible herb-drug interactions.

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Many cancer patients spend much of their time traveling to and from appointments, whether by car or by air, and eating healthy often isn’t always top of mind. Plus, when you travel, nutritious options aren’t as easy to come by as when you’re home, especially when it comes to snacking. So when it’s mid-afternoon and you’re looking for a quick energy boost but you’re stuck in an airport or your car, you may be limited to whatever fast food you can find. But healthy snacking on the go doesn’t have to be such a challenge.]]>webmanager@cancercenter.com12/8/2016http://www.cancercenter.com/discussions/blog/healthy-snacking-on-the-go/http://www.cancercenter.com/discussions/blog/endometrial-cancer-what-to-know-after-journalist-gwen-ifills-death/When long-time journalist Gwen Ifill passed away recently after a battle with endometrial cancer, her unexpected death cast an immediate spotlight on a disease that doesn’t get enough attention. A form of uterine cancer, endometrial cancer is the most common cancer of the female reproductive organs among U.S. women, according to the American Cancer Society (ACS)—yet much of the general public knows little about it.]]>webmanager@cancercenter.com12/7/2016http://www.cancercenter.com/discussions/blog/endometrial-cancer-what-to-know-after-journalist-gwen-ifills-death/http://www.cancercenter.com/discussions/blog/how-does-cancer-do-that-attacking-cancer-cells-where-they-hide/Like B-movie gangsters running from the cops, cancer cells sometimes go on the lam. They dodge capture (avoiding the surgeon’s scalpel) or death (surviving chemotherapy drugs) and find a hideout to cool their molecular heels until the heat is off. ]]>webmanager@cancercenter.com12/1/2016http://www.cancercenter.com/discussions/blog/how-does-cancer-do-that-attacking-cancer-cells-where-they-hide/http://www.cancercenter.com/discussions/blog/should-cancer-patients-get-the-flu-shot/Many patients may not realize it, but cancer and its treatments may affect your immune system’s ability to fight off infection. This can put cancer patients who develop the flu at a higher risk for developing complications from the virus, so Dr. Mashiul Chowdhury says they should make getting a flu shot a top priority each fall.]]>webmanager@cancercenter.com11/30/2016http://www.cancercenter.com/discussions/blog/should-cancer-patients-get-the-flu-shot/http://www.cancercenter.com/discussions/blog/tips-for-overcoming-the-holiday-blues/The holiday season is nearly upon us. Plans for social gatherings are in the works. The malls are filled with the sights and sounds of the season. Families are mapping out their holiday meals. But for people fighting cancer, the joy of the holidays may be tempered by stress, sadness and worry over your diagnosis and treatment. The chaos of the coming weeks does not help. But there are ways for you to de-stress and take the time to enjoy the season.]]>webmanager@cancercenter.com11/23/2016http://www.cancercenter.com/discussions/blog/tips-for-overcoming-the-holiday-blues/http://www.cancercenter.com/discussions/blog/dr-bruce-gershenhorn-answers-your-questions-about-lung-cancer/Dr. Bruce Gershenhorn, Director of the Lung Center at our hospital in Suburban Chicago, took time out of his schedule to answer your questions on lung cancer. Lung cancer is the second most common non-skin cancer among American men and women, and we know there are many questions about the disease, from how it develops to how it’s treated.]]>webmanager@cancercenter.com11/22/2016http://www.cancercenter.com/discussions/blog/dr-bruce-gershenhorn-answers-your-questions-about-lung-cancer/http://www.cancercenter.com/discussions/blog/study-exposes-damage-caused-by-smoking/It’s no earth-shattering revelation that smoking is bad for you—it has been linked recently to nearly 30 percent of cancer deaths in the United States, for starters. But a new study reveals for the first time that smoking does more than harm your health; it actually damages the body’s DNA.]]>webmanager@cancercenter.com11/15/2016http://www.cancercenter.com/discussions/blog/study-exposes-damage-caused-by-smoking/http://www.cancercenter.com/discussions/blog/video-how-to-tie-a-headscarf/Chemotherapy patients often talk about the emotional impact that comes with losing their hair during treatment. But many don’t anticipate the physical effects—like trying to stay warm when your head is bare. Treatments, infections and cancer itself often play a role in disrupting your body temperature. Add in chemotherapy-induced hair loss, known medically as alopecia, and you may be looking for ways to cover up. Many patients have found that headscarves help, offering both comfort and style. But how to tie them?]]>webmanager@cancercenter.com11/8/2016http://www.cancercenter.com/discussions/blog/video-how-to-tie-a-headscarf/http://www.cancercenter.com/discussions/blog/dont-let-fear-get-in-the-way-of-your-lung-cancer-screening/Fear of the unknown often dictates how we respond to situations thrown at us. Fear that we won’t succeed, fear that we won’t be accepted, and fear of anticipatory bad news may cause an emotional paralysis. But fear can hinder us. When it comes to lung cancer, or the suspicion of lung cancer, I have often seen this fear hold patients back from screening. ]]>webmanager@cancercenter.com11/1/2016http://www.cancercenter.com/discussions/blog/dont-let-fear-get-in-the-way-of-your-lung-cancer-screening/http://www.cancercenter.com/discussions/blog/tips-for-sleeping-better-during-cancer-treatment/Getting a restful night’s sleep is important even for the healthiest of people. According to the National Institutes of Health (NIH), getting enough sleep is vital to physical health, brain function, mental well-being, quality of life and more. ]]>webmanager@cancercenter.com10/20/2016http://www.cancercenter.com/discussions/blog/tips-for-sleeping-better-during-cancer-treatment/http://www.cancercenter.com/discussions/blog/how-does-cancer-do-that-new-insights-into-glioblastomas-diabolical-behaviors/All cancer cells are bad, but few behave as aggressively evasive and invasive as those that make up a glioblastoma, a form of brain cancer. Now, new research is offering clues into how glioblastoma cells hide from the body’s immune system, giving scientists hope that the insights may lead to more accurate diagnoses and better treatment options.]]>webmanager@cancercenter.com10/18/2016http://www.cancercenter.com/discussions/blog/how-does-cancer-do-that-new-insights-into-glioblastomas-diabolical-behaviors/http://www.cancercenter.com/discussions/blog/ben-stiller-reveals-how-early-screening-helped-him-battle-prostate-cancer/Actor Ben Stiller has cast himself in a new role—advocate for early prostate cancer screening, after revealing recently that he was diagnosed with the disease in 2014. In a humor-filled essay posted online, he also wrote about the positive effects of his prostate specific antigen (PSA) tests and the controversy surrounding it. ]]>webmanager@cancercenter.com10/11/2016http://www.cancercenter.com/discussions/blog/ben-stiller-reveals-how-early-screening-helped-him-battle-prostate-cancer/http://www.cancercenter.com/discussions/blog/from-angiogenesis-to-zoledronate-a-primer-on-cancer-jargon/Of all the challenges that may accompany a cancer diagnosis, learning a new vocabulary shouldn't be one of them. But cancer has a dictionary all its own—words and phrases you may never utter or hear if you or a loved one were not dealing with the disease. ]]>webmanager@cancercenter.com10/6/2016http://www.cancercenter.com/discussions/blog/from-angiogenesis-to-zoledronate-a-primer-on-cancer-jargon/http://www.cancercenter.com/discussions/blog/integrative-cancer-treatments-role-in-the-whole-patient-journey/[:Video(4722913219001,large,false):]When they are first diagnosed with cancer, many patients’ immediate priority is finding a treatment plan. Learning about their disease and the options available to fight it often takes center stage. But what many don’t realize is that treating the cancer itself is only part of the battle.

Statistics from the Prostate Cancer Foundation reveal the disparity:]]>webmanager@cancercenter.com9/6/2016http://www.cancercenter.com/discussions/blog/screenings-key-to-catching-prostate-cancer-early/http://www.cancercenter.com/discussions/blog/getting-back-to-work-after-cancer-treatment/If you are thinking about returning to work after cancer treatment, you aren’t alone. Over 70 percent of Americans go back to their job after they’ve completed treatment. Sometimes, cancer patients make the decision because of income or health insurance needs. Others are looking for a sense of normalcy and routine. With the proper planning, returning to work doesn’t have to be a difficult transition.

We wanted to explore the difference between these sugar types as a follow-up to our post about whether sugar drives the growth of cancer, which has received several comments. We again turned to one of our clinical oncology dietitians for expertise on the issue.

Understanding sugars

Natural sugars are found in fruit as fructose and in dairy products, such as milk and cheese, as lactose. Foods with natural sugar have an important role in the diet of cancer patients and anyone trying to prevent cancer because they provide essential nutrients that keep the body healthy and help prevent disease.

Learn more about how nutrition may help cancer patients manage side effects.
Call (877) 402-5687 or chat with a member of our team.

Refined sugar comes from sugar cane or sugar beets, which are processed to extract the sugar. It is typically found as sucrose, which is the combination of glucose and fructose. We use white and brown sugars to sweeten cakes and cookies, coffee, cereal and even fruit. Food manufacturers add chemically produced sugar, typically high-fructose corn syrup, to foods and beverages, including crackers, flavored yogurt, tomato sauce and salad dressing. Low-fat foods are the worst offenders, as manufacturers use sugar to add flavor.

Most of the processed foods we eat add calories and sugar with little nutritional value. In contrast, fruit and unsweetened milk have vitamins and minerals. Milk also has protein and fruit has fiber, both of which keep you feeling full longer.

Metabolism matters

How the body metabolizes the sugar in fruit and milk differs from how it metabolizes the refined sugar added to processed foods. The body breaks down refined sugar rapidly, causing insulin and blood sugar levels to skyrocket. Because refined sugar is digested quickly, you don’t feel full after you’re done eating, no matter how many calories you consumed. The fiber in fruit slows down metabolism, as fruit in the gut expands to make you feel full. 

But there’s a caveat. Once the sugar passes through the stomach and reaches the small intestine, it doesn’t matter if it came from an apple or a soft drink.

How much sugar is already in your blood will determine how the body uses the sugar,. If you already have a lot of sugar in your system, then what you just digested will form either fat or glycogen, the storage form of glucose that’s used for quick energy. It doesn’t matter if it’s junk food or fruit.

Cancer connection

We eat more refined sugar today than our parents and grandparents did three decades ago, which has resulted in increasing obesity rates among adults and children. Obesity has been associated with certain cancers, including breast, prostate, uterine, colorectal and pancreatic. On the flip side, fruits high in antioxidants—blueberries, blackberries, raspberries, strawberries and apples—may reduce your cancer risk. The fiber in fruit, found mainly in its skin, suppresses your appetite to prevent overeating and weight gain.

Our clinical oncology dietitians recommend eating whole foods that are low in refined sugars. Whole foods refer to foods that are either unprocessed, such as fruit and vegetables, or minimally processed, such as whole grains.

The big picture is being a healthy weight and making healthy food choices. It’s about eating a diet with whole foods, lean proteins, complex carbohydrates like quinoa rather than white bread, and non-starchy vegetables. Focus on making good food choices every day on a consistent basis, not on the one piece of cake you had as a treat.

Learn about the benefits of good nutrition during cancer care.

]]>webmanager@cancercenter.com4/12/2016http://www.cancercenter.com/discussions/blog/do-carbs-increase-the-risk-of-lung-cancer-one-study-weighs-in/http://www.cancercenter.com/discussions/blog/probiotics-may-help-immunotherapy-drugs-fight-cancer/Some patients with melanoma, lung and head and neck cancers are responding strongly to a new class of immunotherapy drugs called checkpoint inhibitors, research shows. But other patients aren’t responding at all. The effort to explain the disparity between cancer patients who benefit from the drugs and those who don’t has led scientists to an unexpected place: the gut—specifically, the microbes taking up residence there. 

Eating healthy is important during and after cancer treatment. It’s also critical to a healthy lifestyle overall. The American Institute for Cancer Research recommends eating a plant-based diet and maintaining a healthy body weight, which may help reduce the risk of certain cancers. With a little will power and adequate knowledge of how fruits and vegetables can support good health, anyone can make healthier meal choices.]]>webmanager@cancercenter.com3/22/2016http://www.cancercenter.com/discussions/blog/spring-clean-your-recipes-with-healthy-food-substitutions/http://www.cancercenter.com/discussions/blog/e-cigarette-dangers-lurking-in-a-smokescreen-experts-say/E-cigarettes are a smoking-hot $3 billion business in the United States. In fact, data shows that, for the first time, e-cigarette use has outpaced every other tobacco product, including regular cigarettes, according to the Centers for Disease Control and Prevention (CDC). Even more troubling, considering their documented health risks, e-cigarettes have become the most popular nicotine product used by teens, and the majority of adult smokers have tried them, the American Lung Association has reported.

When you have cancer, pain often develops as a side effect of the disease or in response to treatment. But many medications, therapies and techniques are available, and it’s important to speak up about any discomfort you may be feeling—because getting relief is important to your treatment. ]]>webmanager@cancercenter.com2/18/2016http://www.cancercenter.com/discussions/blog/tips-for-controlling-cancer-related-pain/http://www.cancercenter.com/discussions/blog/understanding-chiropractic-care-for-cancer-patients-5-myths-busted/Cancer patients often experience a number of side effects, caused by either the cancer or the treatment used to fight it—sometimes both. Research has shown that, in many cases, supportive therapies may help patients manage those side effects and reduce the risk of treatment delays. One such therapy involves chiropractic care. ]]>webmanager@cancercenter.com2/11/2016http://www.cancercenter.com/discussions/blog/understanding-chiropractic-care-for-cancer-patients-5-myths-busted/http://www.cancercenter.com/discussions/blog/a-new-treatment-paradigm-for-early-stage-breast-cancer/Nearly 5,000 women are newly diagnosed with breast cancer every week in the United States. Today, early-stage breast cancer may be treated thanks to advances in the medical community’s understanding of the biology of breast cancer. As a result of these advances, breast cancer treatment has become more precise and survival rates are improving. ]]>webmanager@cancercenter.com2/4/2016http://www.cancercenter.com/discussions/blog/a-new-treatment-paradigm-for-early-stage-breast-cancer/http://www.cancercenter.com/discussions/blog/preventive-measures-that-may-help-reduce-cancer-risk/Every year, over 1 million Americans are diagnosed with cancer. While some risk factors, such as inherited genetic mutations, seem beyond our control, a number of relatively simple preventive measures and lifestyle changes may help reduce your risk. Here are some examples:

"There’s not a person in our country that has not in some way been affected by this disease, cancer,” award-winning documentarian Ken Burns says in Cancer: The Emperor of All Maladies, an in-depth biography of a disease that has afflicted over 20 million adults in the United States.

For a reminder of the importance of diet and exercise to help prevent disease, look no further than a recent study in The Lancet Oncology. Researchers attributed 500,000 new cancer cases worldwide in just one year to obesity. Carrying too much weight is already a known risk factor for certain cancers, including breast, colorectal and pancreatic. But the findings suggest obesity may play an even greater role.