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Established in 1978, the UC San Diego Moores Cancer Center is the only National Cancer Institute (NCI)-designated Comprehensive Cancer Center in the San Diego region.

Learn more about  clinical trials  at UC San Diego Moores Cancer Center.

The UC San Diego Moores Cancer Center at the University of California, San Diego employs a multi-disciplinary team approach to patient care. We have 10 disease teams, all of which are highly interactive and collaborative in delivering care. Subspecialty cancer care includes surgical oncology, medical oncology, gynecologic oncology, radiation oncology, world-renowned minimally invasive surgery, interventional radiology, molecular cancer imaging, palliative care, integrative medicine, psychology and nutrition. A major new care initiative is genomics/personalized medicine, including a new Center for Personalized Cancer Therapy. Ancillary services include a robust patient and family support program. We have more than 200 clinical trials to treat cancer and many other studies to prevent cancer and improve cancer survivorship.

Moores Cancer Center and the UC San Diego Health System have won many quality awards, and our commitment to quality cancer care is further reflected by our participation in the Quality Oncology Practice Initiative (QOPI) for the past four years and QOPI certification in 2012. The Moores Cancer Center Quality Program oversees quality audits of the Infusion Center and quality improvement projects.

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NCCN Member Institution Profile

In 25 years, the CU Cancer Center has grown to a comprehensive cancer center with a consortium designation from the National Cancer Institute..

The University of Colorado Cancer Center is the hub of cancer research in Colorado. We are a consortium of more than 400 researchers and physicians at three state universities and six institutions, all working toward one goal: translating science into cancer survivorship. Through collaboration and innovation, CU Cancer Center members discover, develop and deliver breakthroughs that improve cancer care for people and companion animals. We focus on:

• Personalized care that embraces the best clinical practices of prevention, diagnosis, treatment and survivorship.
• Innovative interdisciplinary research.
• Premier clinical and scientific training.
• Creative partnerships.

Member institutions include University of Colorado Denver, University of Colorado Boulder, Colorado State University, University of Colorado Hospital, Children’s Hospital Colorado, Denver VA Medical Center, Denver Health, National Jewish Health and the Kaiser Permanente’s Institute of Health Research. Our clinical outreach program extends throughout Colorado and neighboring states.

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Although thyroid cancer is highly treatable and not very common, the American Cancer Society reported that in 2012 approximately 56,500 cases were diagnosed; of those, two-thirds were women and one-third were men. The thyroid, a gland weighing 15 to 25 g, is found at the lower aspect of the front of the neck. It has been described as being a “butterfly” or “bow tie” shaped structure and has a left and right lobe connected by a bridge (isthmus) that sits on top of the windpipe (trachea) in the lower neck. “The thyroid produces two active thyroid hormones, thyroxine (T4) and triiodothyronine (T3). They are essential for various functions in the body. Primarily, the body’s metabolism and normal neural and skeletal development,” says Tom Thomas, MD, MPH, otolaryngology surgeon at Dana-Farber/Brigham and Women’s Cancer Center in Boston

Types of Thyroid Cancers

According to Dr. Thomas, thyroid neoplasms are relatively uncommon, accounting for approximately 2.5% of all malignancies. However they account for almost 95% of all endocrine tumors, estimated to be around 37,340 cases in the United States. Four main pathologies are encountered in thyroid cancer (listed here from most to least common): papillary thyroid carcinoma, follicular thyroid carcinoma, medullary thyroid carcinoma, and anaplastic thyroid carcinoma. In addition, other malignancies encountered in the thyroid gland are lymphoma, squamous cell carcinoma, and metastatic carcinomas.

What are the Symptoms?

At the early stages of thyroid cancer, patients usually do not have any alarming symptoms. “Many [of these cancers] are discovered incidentally during a routine physical examination of the head and neck area,” Dr. Thomas says. “Also, it is incidentally found during imaging studies such as ultrasound, CT scan, or MRI scans obtained for other reasons.” Discovering a neck lump is one of the early symptoms. “Patients usually present with a solitary, mobile thyroid nodule. It is usually not painful. Most often, thyroid hormone levels are within normal limits,” he adds. “As the disease progress, patients can feel neck nodes become more prominent, difficulty with swallowing, noisy breathing, shortness of breath and or changes in their voice.”

Who is at Risk?

Dr. Thomas says that several patient and environmental factors have been studied over the years. Age, gender, environmental exposure to radiation, and family history of thyroid cancers are of importance. He says that in terms of age, well-differentiated thyroid carcinoma with aggressive behavior tend to be seen most often in patients younger than 20, men older than 40 years, and women older than 50 years. Women are 3 times more likely than men to develop differentiated thyroid cancer, and 2 times more likely to have anaplastic thyroid cancer, Dr. Thomas says.

The peak age of thyroid cancer diagnosis is from 45 to 49 years in women and 65 to 69 years in men.

Numerous genetic and molecular abnormalities have been described in thyroid neoplasms, Dr. Thomas says. “Similar to other head and neck cancers, an accumulation of genetic alterations seems to be required for progression to a thyroid carcinoma. The specific molecular events and their order continue to be defined,” he adds.

How is it Detected?

J. Leonard Lichtenfeld, MD, MACP, deputy chief medical officer for the American Cancer Society in Atlanta, says that a family doctor may be able to find cancer of the thyroid during a normal examination. “Sometimes, enlargement can be found by examining the neck. The doctor can notice a mass, or notice swelling or a distortion in size or placement, “ says Dr. Lichtenfeld. “If something is suspected, further testing is warranted and will be ordered.”

Dr. Thomas says that ultrasonography is very useful and sensitive in characterizing the nodule. This is followed by a fine needle aspiration (FNA) biopsy. The FNA will provide an accurate diagnosis of the nodule most of the time. If the FNA biopsy does not provide a diagnosis, a thyroid surgeon can help with other modalities for obtaining a diagnosis, says Dr. Thomas.

What are the Treatments?

According to Dr. Thomas, once someone has been diagnosed with thyroid malignancy, surgical removal of the thyroid gland is the first line of treatment. “Furthermore, depending on the type, size, and lymph node involvement, surgery will include lymph node removal from the immediate vicinity of the thyroid and neck. Once recovered from the surgery, depending on the type of thyroid cancer, patients will receive radioactive iodine treatment and thyroid hormone suppression,” Dr. Thomas says. “This is usually determined by the patient’s endocrinologist. External-beam radiation and chemotherapy have been used as adjunct treatment in patients with advanced disease.”

Outlook is Good

Compared with other malignancies, Dr. Thomas reports that well-differentiated thyroid carcinomas with accurate and timely diagnosis and management will have an excellent prognosis. The 10-year disease-specific mortality rate is less than 7% for papillary thyroid cancer and less than 15% for follicular thyroid cancer.

Many cancer treatments can cause nausea and vomiting, making daily tasks challenging or impossible. "From a quality-of-life standpoint, patients say nausea and vomiting is a top concern of getting therapy," reports Barbara Todaro, PharmD, administrator, Investigational Drug Services, Roswell Park Cancer Institute, Buffalo, NY. It can cause you to feel weak, lose weight, and become malnourished.

But the good news for cancer patients is if they take medications for these unpleasant side effects before, during, and after treatment, nausea and vomiting can be minimized or even avoided.

Chemotherapy and radiation are the most common treatment culprits. But other factors related to disease can also cause nausea and vomiting, such as anesthetics used for surgery, pain medications, emotional distress about upcoming treatment, or a tumor in the abdomen, gastrointestinal tract, or brain.

Onset at Anytime

If you have cancer, nausea and vomiting can strike at any time. "Some patients get nervous before receiving treatment and anticipate getting sick, which can actually make them ill," says Todaro, who also serves on NCCN's Antiemesis Panel. Called anticipatory nausea and vomiting, this is most likely to occur in individuals who already had treatment and got sick as a result.

With chemotherapy, acute nausea and vomiting can occur within the first 24 hours after treatment is administered. Delayed nausea might not occur until several days after treatment, which is common with some agents given during a bone marrow transplant.

Delayed nausea and vomiting can also be caused by constipation, a bowel obstruction, or a tumor in the gastrointestinal tract. "When processes stagnate, it can cause nausea," says Chris Rimkus, RN, MSN, AOCN, clinical nurse specialist, Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO.

Breakthrough nausea and vomiting occurs even if medication is given to prevent it. When this occurs, additional or different medications are given to stop it.

Risk Factors

Following is a breakdown of factors that increase susceptibility to nausea and vomiting:

• Dose intensity. The more frequently a patient gets treatment, the more severe nausea might be. "We try to give treatments as close together as possible. This dose intensive therapy is better at curing cancer, but can also increase the severity of side effects," says Misty Lamprecht, RN, MS, CNS, AOCN, clinical nurse specialist for BMT, Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH. The same goes for the amount per dose. "It tends to be a cumulative effect; the more treatment you're given, the greater the nausea can become."

• Agents. Certain drugs tend to cause more nausea and vomiting than others. Among the worst culprits are Platinol (cisplatin) and Adriamycin (doxorubicin). Both are given intravenously.

• Target site. Treatment in the brain and gastrointestinal tract--which runs all the way from the mouth to the anus--causes more nausea and vomiting than in other areas of the body. "The nerve impulses that trigger nausea and vomiting are in the brain," Rimkus explains.

• Administration. Chemotherapy delivered intravenously tends to cause more nausea than oral medications.

• Gender. Women are more apt to experience nausea than men. "This might be due to women's hormonal changes and emotions," Rimkus says. "Your mental state can have a big impact."

• Hyperemesis. Women who had significant nausea and vomiting during pregnancy are more likely to have these same side effects when undergoing cancer treatment.

• Age. Patients younger than 30 years tend to experience more nausea than older folks. "Perhaps older people have a higher tolerance because of previous exposure to various toxins over their lifetime," Rimkus says. "Your body can become more tolerable to foreign substances over time."

• Alcohol and drug use. People who don't drink alcohol or take prescription drugs might have more nausea because they are not used to chemical alterations occurring in their bodies. A few types of chemotherapies actually contain alcohol.

• History. Individuals who are prone to motion sickness may have a higher incidence of nausea and vomiting during treatment.

Complications

Although nausea can make patients very uncomfortable, vomiting is more likely to cause complications. "Patients can get into a vicious cycle where they become nauseated and weak from treatment, have more chemotherapy, and then get even more nauseated and weaker," Lamprecht says. Sometimes treatment is delayed, and in rare cases, some patients choose to stop treatment.

Another bad cycle to get into is becoming dehydrated due to vomiting. Vomiting is more problematic than nausea because vomit contains food you ate and the chemicals in your body that break food down. "If you lack these chemicals, you can experience heart arrhythmias, muscle cramping and muscle weakness," Lamprecht says. Dehydration can also cause lowered blood pressure. Ultimately, these side effects can increase your risk for dizziness and falls and even cause kidney failure or heart problems if left untreated

Prevention

Once you begin vomiting, it can be difficult to control. "The key is to be proactive by taking steps before nausea and vomiting get out of control," Lamprecht says.

Most patients are given antinausea medication, called an antiemetic, before chemotherapy is administered. Antiemetics are used to block the nerve impulse that travels from the blood or stomach to the brain (where the vomiting center is located). There are several classes of drugs used to block different signal pathways. 

"We look at a patient's risk factors for nausea as well as the chemotherapies a patient is taking to determine the likelihood of him or her becoming nauseated. Then we develop a premedication plan before chemotherapy begins," Lamprecht says. After chemotherapy, patients are given antiemetic medication to take home.

Patients getting radiation may not receive an antiemetic before treatment. "It depends on the location of the treatment," Rimkus says. "If the abdominal area or brain is getting treatment, an antiemetic is advised."

Antiemetic Medications

Todaro says among the most common antiemetic medications are serotonin receptor blockers, also known as 5-hydroxytryptamine receptors or 5-HT3 receptor antagonists. "The biggest improvement came when Zofran (ondansetron) came on the market in 1991," she says. Zofran was the first commercially available 5-HT receptor. Another common drug in this family is Aloxi (palonosetron).

Emend (aprepitant), a neurokinin receptor blocker, is another drug that is added to the 5HT3 blockers to prevent nausea and vomiting that results from chemotherapy.

Treating Nausea and Vomiting

A combination of medications is usually most effective for treating nausea and vomiting. Inpatients oftentimes prefer to get medications intravenously, particularly if they have a port or central line to receive chemotherapy. Adopamine blockers such as Prochlorperazine (compazine) are common choices. Outpatients, on the other hand, usually take medications orally.

People with anxiety, who have anticipatory nausea, should take an antianxiety medication such as Ativan (lorazepam) before or after treatment. This is also a good choice for breakthrough nausea and vomiting.

If you are already vomiting, a suppository may be a good way to get medication into your body to stop it.

In addition to traditional medications, Lamprecht says some patients say ginger products, such as ginger ale or tea, help relieve nausea. Before, during and after treatment, she advises eating small frequent meals and avoiding foods with a strong odor such as pizza or Chinese dishes and choosing cold foods over hot ones, since the latter have a stronger smell.

Lamprecht also advises playing soothing music or using guided imagery to relax all of your muscles. "Envision yourself in a place you enjoy, such as the beach," she says.

The physical side effects of chemotherapy are well-known, often including fatigue, nausea and vomiting, and hair loss, among others. But the implications of undergoing chemotherapy reach beyond just the body; patients must prepare themselves for treatment physically and otherwise. Treatment of cancer involves taking care of a patient not only physically, but also from a holistic standpoint. “We need to focus on their physical, emotional, sexual, financial and spiritual needs sometimes at the same time,” says G. Lita Smith, RN, ACNP, nurse practitioner supervisor, University of Michigan Comprehensive Cancer Center in Ann Arbor. She says patients should use all of the resources available to them, including social work and psychiatry, which are integral to helping patients and their family members throughout their cancer journey. Being in as good shape as possible before embarking on cancer treatment can help make the process smoother and more comfortable, and reduce the amount of stress placed on the body.

Making a few appointments and implementing good lifestyle choices can help reduce the risk of medical complications during and after cancer treatment. For example, getting a flu shot prior to chemotherapy and seeing a dentist for a checkup and teeth cleaning are advisable. “It is not good to have a tooth problem during chemotherapy when your body is immune-suppressed,” says Lillie D. Shockney, RN, BS, MAS, administrative director, Johns Hopkins Cancer Survivorship Programs in Baltimore. She also says you should not plan on losing weight before undergoing treatment and should start making healthy meal choices. Fatigue, a common side effect, can be diminished by engaging in exercise. “So, power walk regularly,” she adds. And, she says, you should celebrate the completion of each cycle of chemotherapy, because it leads further up the survival curve.

Side Effects

The most common concerns for patients about to begin chemotherapy are nausea, vomiting, fatigue, hair loss, and skin changes. According to Smith, the treatment for nausea/vomiting has vastly improved over the past 15 years with the advent of 5HT3 antagonists such as Zofran, kytril, anzemet, and the NK inhibitor emend. Although patients still do experience nausea/vomiting, it is much less of a problem than in the past, she says.

Short-Term Effects

Fatigue is a common short-term side effect of chemotherapy. This effect is individualized and based on factors such as a patient’s age, other comorbid conditions, the type of chemotherapy they will receive, and number of cycles, says Smith. Some patients find it is manageable to still go to work and perform most of their normal daily activities, she says, whereas others can find chemotherapy extremely fatiguing, requiring a leave of absence from work, and that it has a great impact on their normal activities of daily living. Getting adequate sleep, reducing stress, and not taking on more than you are able is a good way to combat fatigue.

Long-Term Effects

Side effects of chemotherapy depend on lots of factors related to the patient, such as other comorbid conditions, as well as the chemotherapy regimen and number of cycles being given.

Smith lists some long-term side effects:

• Increased risk of second malignancies
• Long-term cognitive dysfunction
• Changes in hormonal function and increased risk of osteoporosis, such as early menopause in women undergoing certain chemotherapy regimens
• Long-term depression
• Hair Loss  

Hair loss is dependent on chemotherapy dose and schedule.

Louanne Roark, executive director, Personal Care Products Council Foundation in Washington, DC, a non-profit service that teaches patients how to manage the appearance side effects of cancer treatment to help create normalcy in a life that has been disrupted by a life-threatening illness, recommends that to prepare for hair loss, patients should consider developing a proactive plan so that they are ready if they do lose their hair, thereby diminishing their stress over the hair loss. “They should consider understanding and identifying wig options, and look in their closets for or purchase a few scarves, hats, and turbans that will work together or separately to camouflage hair loss, keep the head warm, and, if the hair is falling out, catch the falling hair to help diminish distress or embarrassment about the hair loss,” she says.  

For loss of facial hair, specifically eyebrows and eyelashes, Roark says cosmetic products can be very helpful to recreate the appearance of having brows or lashes. 

Losing one’s hair is a significant loss for most patients. “Many often report that it is the first visible sign of having cancer; the first change that makes what is happening real,” says Mary E. Turney, LCSW, manager, Patient and Family Services, Moffitt Cancer Center in Tampa, Florida. “This is compounded by fears of the anticipated reactions of loved ones, friends, acquaintances, and passersby, and uncertainty about how they will respond.” How each person will deal with this is unique and requires great sensitivity on the part of professional staff and loved ones.

Turney says there are no specific guidelines for preparing for this loss. Some individuals seek as much information as possible about impending changes and want to be prepared for what will happen. “They may cut or shave their hair, ask for resources to wig shops, or purchase hats or scarves, while others resist any discussion of this dreaded side effect,” she says. “Generally speaking, preparing for these changes can prove very beneficial in giving patients a sense of some control in the midst of so many overwhelming transitions,” she adds.

An article from the Annals of Oncology recently cited the use of scalp cooling caps. The article explored the small studies that have been done. Because there are no prospective large randomized trials of cooling caps versus none, scalp cooling remains an option that still needs to be explored and is not routinely recommended at many large cancer centers

Skin Changes

Patients going through chemotherapy may notice changes in skin texture, pigmentation, or tone. In general it’s advisable to avoid sun exposure, keep skin moisturized, practice good hygiene, and eat a well-balanced diet. For more severe skin complications or adverse reactions, you should seek medical attention.

Although there are no official guidelines determining the length of time to wait after cancer treatment before attempting pregnancy, clinical nurse specialist Joanne Frankel Kelvin, RN, MSN, AOCN , of Memorial Sloan-Kettering Cancer Center in New York, who established a program called Cancer and Fertility, says it is generally recommended to wait at least one year. “There are generally three factors for a woman to consider. These include making sure that (1) eggs that have been exposed to chemotherapy or radiation and may have been damaged are no longer in her body, (2) she is fully recovered from her treatment and its effects, and (3) she has been ‘cleared’ by her oncologist because an acceptable period of time has passed in which she is not likely to have a recurrence.”

Discussions With A Cancer Care Team Are Important

Kelvin also says that it is important for women to discuss the safety of pregnancy after treatment with their oncologists. Although many women treated for cancer are able to carry a pregnancy without any problems, some treatments have late adverse effects on some organs, such as the heart, lungs, or uterus, that can put her at risk of complications during pregnancy.

Must A Pregnancy After Cancer Be High-Risk?

In general, most pregnancies in cancer survivors are managed the same as pregnancies in other patients of similar age. “However, some women may have medical problems related to prior cancer treatment exposures, including hypothyroidism, or problems with heart or lung function, and may require the care of a maternal fetal medicine specialty obstetrician. Initial consultation with a woman’s OB/GYN can help in making this decision,” says Erica L. Mayer, MD, MPH, medical oncologist, Dana-Farber Cancer Institute in Boston. “Patients who become pregnant after a cancer diagnosis do not need routine specialized obstetrical monitoring compared with other same-age women who are pregnant. An obstetrician may consider evaluating baseline heart function in a woman who has had exposure to a potentially cardiotoxic medication, and will monitor fetal growth closely. However, pregnant cancer survivors also need to continue routine oncologic follow-up care throughout pregnancy and postpartum periods.”

There are two primary risks a woman must consider when deciding about pregnancy after a cancer diagnosis. Dr. Mayer says the first consideration is what is her risk of cancer recurrence? “In general, most women prefer not to attempt pregnancy unless their personal risk of cancer recurrence is low,” she says. “Also, will the pregnancy increase the chances of cancer coming back? This is a relevant concern for hormonally driven cancers, such as some forms of breast cancer, or cancers that require prolonged oral therapy that cannot be taken during pregnancy.”

 More than any other cancer type, breast cancer is the type of cancer that typically complicates a woman’s plans to get pregnant. Although research on the safety of pregnancy after a breast cancer diagnosis is limited, says Dr. Mayer, the available data suggest no apparent increased risk of breast cancer recurrence in women who choose to get pregnant after their cancer diagnosis. In general most providers encourage women to wait 2 to 3 years after completion of therapy or, if possible, until completion of any oral cancer therapy, such as tamoxifen.

How Does Cancer Treatment Impact A Woman’s System?

According to Dr. Mayer, systemic chemotherapy can be toxic to ovary function and can lead to temporary or permanent menopause. The risk of permanent menopause depends on a woman’s age as well as the type and amount of chemotherapy. Radiation therapy to the pelvic area can affect ovary function, but radiation elsewhere should not have an effect.

Planning Ahead

For patients interested in fertility preservation, a visit to a reproductive endocrinology specialist is encouraged prior to embarking on therapy. Techniques offered can include sperm banking as well as embryo harvesting via in vitro fertilization. “In vitro fertilization is a technique offered to female patients prior to initiation of cancer therapy to harvest eggs for fertilization,” Dr. Mayer explains. “Although there are theoretical concerns about exposure to hormonal agents in patients with a new breast cancer diagnosis, in the majority of cases providers believe a single cycle of in vitro fertilization is safe and acceptable.”

Being diagnosed with cancer is scary and stressful enough, but being diagnosed with cancer during pregnancy, also called pregnancy-associated cancer, can be a game-changer. Special considerations come into play in this case to protect the health of both mother and child.

“Pregnancy, then a cancer diagnosis---this is as stressful as it gets,” says Lillie D. Shockney, RN, BS, MAS, Administrative Director, Johns Hopkins Cancer Survivorship Programs in Baltimore. “The woman's goal, of course, is survival to raise her child.”

Cancer Diagnosis During Pregnancy

Receiving a cancer diagnosis during a pregnancy is an unusual occurrence, occurring on about 1 in every 1,000 pregnancies. However, because age is a significant risk factor for cancer, it may be increasing in frequency as more women are having children at an advanced age.

Often cancer is not diagnosed during pregnancy because many of the side effects can be misinterpreted as being common symptoms of pregnancy, such as headaches, bloating, and fatigue. For breast cancer, small tumors in the breast are often not detected because a woman’s breasts often become enlarged during pregnancy. However, sometimes pregnancy can help reveal a cancer that went previously undetected because of the special tests that are performed during obstetric checkups, such as a pap test or an ultrasound.

If cancer is suspected, however, many of the diagnostic tests can still be performed without concern, such as MRI and ultrasound, and even x-rays, which deliver too low a level of radiation to be dangerous to a developing fetus.

Treatment

“Theoretically, treatments that are designed to treat cancers, such as chemotherapy, may be harmful for a developing fetus,” says Erica L. Mayer, MD, MPH, a medical oncologist at Dana-Farber Cancer Institute in Boston. “However, discovering that a pregnant patient has cancer does not mean the pregnancy has to end for cancer treatment to start. Careful analysis of outcomes after experiences treating cancer in pregnant women has demonstrated that the majority of our modern cancer therapies, including surgery and chemotherapy, can be given during pregnancy without apparent toxicity to the fetus.” Women with pregnancy-associated cancer are capable of giving birth to a healthy baby, even if they received certain treatments. And most cancers will not spread from the mother to the fetus, so the baby is rarely affected by the cancer itself.

In general, during the first trimester of pregnancy, when much of the important fetal development occurs, cancer therapies can be dangerous. “However, after the first 12 weeks, both surgery and chemotherapy appear to be safe for both the patient and the developing fetus,” says Dr. Mayer. Some important cancer therapies remain too dangerous to give at any time during pregnancy, including hormonal medications, the antibody trastuzumab, some newer chemotherapies, and the majority of radiation therapies. Treatment of each pregnant patient with cancer is very individualized and requires careful discussion and planning with a multidisciplinary treatment team to weigh the risks and benefits of therapy, Dr. Mayer says .

The most common pregnancy-associated cancers include breast cancer and lymphoma. Cancers in the reproductive system, such as ovarian or cervical cancer, are more unusual. “Surgical resection of cancers in these regions can be challenging, and requires careful consideration with the treatment team,” says Dr. Mayer.

For pregnancy-associated breast cancer, optimal breast surgery, including lymph node sampling, can be safely performed in a pregnant patient, although usually it is delayed until the second trimester. The safety and timing of surgical resection of other cancers during pregnancy must be carefully considered with the surgical team, says Dr. Mayer.

Dr. Mayer says sometimes women with a pregnancy-associated cancer must be induced to deliver the baby sooner to facilitate and/or expedite cancer therapy. “Although in some situations early delivery is advisable, delivering a baby prematurely can introduce other risks to the health of the fetus,” she adds. “Identifying the best time for delivery requires careful consideration by obstetrics and oncology.”

Breastfeeding

Doctors advise new mothers who have undergone certain cancer treatments to avoid breastfeeding. Chemotherapy agents can be transmitted through the breastmilk to the fetus, as can some components of radiation treatment.

Future Pregnancy

Future pregnancy and fertility preservation are dependent on the primary cancer site and the prescribed course of care. “These are definitely discussions that should occur for all patients of childbearing age,” says Marie Catherine Lee, MD, FACS, Assistant Member, Comprehensive Breast Program, Moffitt Cancer Center, Tampa, Florida. Some treatments can affect a woman’s fertility. Before a woman undergoes any treatment for cancer, she should discuss its risks to her fertility and her fertility preservation options.

Furthermore, some cancer treatments can affect other organs, such as the heart, and therefore a woman’s overall health should be assessed before pregnancy can be considered safe.

Depression

Depression may be a variable for the expectant mother. Stress, worry, anxiety, and uncertainty are among the emotions she may be experiencing. “Early involvement of social support and psychological/psychiatric care and counseling are integrated into the care of each of these patients,” adds Dr. Lee.

Testicular cancer occurs when cells become malignant in one or both testicles. The testicles are the male sex glands that store and produce sperm and also are the source of testosterone. According to David Y.T. Chen, MD, associate professor of surgical oncology at Fox Chase Cancer Center in Philadelphia, testicular cancer, when detected early, is highly treatable and curable. Symptoms include pain in the testes or scrotum, a lump or swelling in one or both of the testes, or pain in the groin, lower back, or lower abdominal region. Regular self-exams are suggested, says Dr. Chen.

One risk factor for testicular cancer is being born with undescended testicles, which Dr. Chen said occurs when one or both testicles do not fall into the correct position. He said that this condition has been linked to a higher incidence of testicular cancer even if the testes have been surgically corrected.

Catching It Early

When detected in stage I, the cancer is highly treatable. “Surgery is generally performed to remove the entire testicle where the mass is found,” Dr. Chen says. If the cancer has spread to lymph nodes, then a course of chemotherapy or radiation will be needed.

A family history of testicular cancer may play a role in increased risk, he says. “Men with a positive family history for testicular cancer have higher risk for developing it, although there is no formal guideline or recommendation for greater surveillance or screening for it in the male relatives of men with testicular cancer.”

Treatment

 The first type or testicular cancer is seminoma: a slow-growing form of testicular cancer usually found in men in their 30’s and 40’s. The cancer is usually just in the testes, but it can spread to the lymph nodes. Seminomas are very sensitive to radiation therapy. The second is nonseminoma: this is a more common type of testicular cancer tends to grow more quickly than seminomas. Non-seminoma tumors are often made up of more than one type of cell.

Christopher Sweeney, MBBS, medical oncologist, Dana-Farber Cancer Institute and associate professor at Harvard Medical School in Boston, says treatment depends on the type of cancer and extent of cancer. “The first treatment is most often removal of the testicle through the groin and then the testicle is examined to see if it is seminoma or nonseminoma,” says Dr. Sweeney. “If a patient is found to have seminoma limited to the testicle, they can be watched, and further treatment can be limited to only the 15% who relapse. An alternative approach is to give 1 cycle of chemotherapy to decrease rate of relapse after the orchiectomy (ie, removal of the testes) to decrease the rate of relapse from 15% to about 2%. If the patient is found to have nonseminoma and no cancer is detected beyond the testicle, there is on average a 30% chance of recurrence and patients can opt to have surgery to remove the draining lymph nodes (which will be found to be positive for cancer in about 30% of the cases) and undergo surveillance and chemotherapy only if relapse occurs, or they can have 1 cycle of chemotherapy to prevent relapse. The choice depends on each patient’s particular cancer and their life circumstances,” he says.

He added that if a patient is found to have cancer beyond the testicle either at the time of diagnosis or on relapse during surveillance, the cancer is very curable. For example, if the cancer is limited to the draining lymph nodes and smaller than 5cm, a patient with seminoma can be cured with radiation or chemotherapy. “Patients who have nonseminoma or more advanced seminoma are cured at a very high rate with 3 or 4 cycles of chemotherapy,” Dr. Sweeney adds.

How the Cancer Affects Fertility

As long as there is a normal contralateral testicle, hormonal function usually remains normal. “Consequently, sexual drive, function, and ability are expected to be normal,” says Michael S. Cookson, MD, co-director of urologic oncology and a urologic surgeon at Vanderbilt-Ingram Cancer Center in Nashville. “About half of men with testicular cancer are subfertile at diagnosis, and about a quarter of men will remain so after treatment.” In addition, he says treatment with surgery, radiation therapy, or chemotherapy may all negatively impact on fertility. “For example, chemotherapy may impair the function of the remaining testicle and reduce or eliminate sperm production. Surgery to remove lymph nodes may interfere with nerves involved in ejaculation.” For these reasons, treatments should be performed by experienced physicians who properly counsel patients and administer evidence-based treatment. Finally, men who desire future fertility are recommended to undergo sperm cryopreservation. After treatment, if the patient is subfertile, he may opt for assisted reproductive techniques using the frozen sperm.

In Summary

 Dr. Cookson says most patients are curable, even in when the cancer is advanced at presentation. Appropriate anxiety and depression are expected at the time of diagnosis, but given that treatment is curative in 98% of patients, most fully recover physically and emotionally to live healthy normal lives.

The pancreas has primarily two functions. The first is to produce the enzymes of digestion and the second is to produce insulin, which lowers blood glucose. “Cancer growing in the pancreas literally destroys the normal pancreatic tissue which becomes replaced with cancer,” according to Gregory M. Springett, MD, PhD, assistant member of the Experimental Therapeutics Program and Department of Gastrointestinal Oncology, Moffitt Cancer Center in Tampa, Florida. “Therefore, fewer pancreatic enzymes are made. As a result, digestion is impaired and there is malabsorption of fat, leading to weight loss.” Furthermore Dr. Springett says destruction of the insulin-producing portion of the pancreas leads to less insulin and diabetes. “For about 10% of patients with pancreatic cancer, new diabetes within the previous year was the initial early symptom of pancreatic cancer.”

Risk Factors

According to Dr. Springett, more than 42,000 cases are diagnosed annually. It is increasing due to the aging of the baby boomers as they entering their 60s. In about 3% to 5% of cases there is an inherited predisposition associated with BRCA2 mutation, P16 mutation, and others. The remainder is sporadic cases, says Dr. Springett.

Robert J. Mayer, MD, a gastrointestinal oncologist at Dana-Farber Cancer Institute in Boston, says some risk factors may increase the likelihood of getting cancer of the pancreas. “Smoking has been proven to increase the risk. Smoking cessation reduces the risk, although not to the level of those who have never smoked,” he says.

Another risk factor is obesity. Obesity can create more risk for the development of type 2 diabetes, and this has been shown in studies to cause greater production of insulin, which can cause carcinogenesis.

Symptoms

Cancer of the pancreas manifests itself in three different parts of the organ: the head, middle, or tail. Symptoms are sometimes pain, becoming jaundiced, discomfort, bloating in the abdomen, lack of appetite, and unexplained weight loss. “The challenge of pancreatic cancer is that symptoms are really nonspecific and the cancer is hard to catch early since the warning signs are general ones. We do know that a good number of patients have diabetes, so that’s a risk factor to keep an eye on,” Dr. Mayer said.

According to Laura Williams Goff, MD, assistant professor of medicine, Division of Hematology-Oncology, Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, pancreatic cancer is the fourth leading cause of cancer death in men and women. It most commonly affects patients older than 50 years.

“It is very difficult to detect early, says Dr. Williams Goff. “Pancreas cancer can present as painless jaundice or with belly pain radiating directly through to the back. There is no agreed-upon screening test. Even in high-risk families, it is hard to know the best way to screen for this disease, but clinical trials are ongoing to evaluate ways to detect pancreas cancer earlier.”

In summary, Dr. Springett said roughly 80% of patients are diagnosed at stage 3 and 4. Initial symptoms are abdominal pain, jaundice, and weight loss, which worsen over time if untreated. “Early detection remains a major problem to be solved,” he added.

Treatment

For pancreatic adenocarcinomas, surgery is necessary for cure, but this is only a possibility for cancer that has not already spread. In addition, chemotherapy, and sometimes radiation therapy is used to improve the cure rate with surgery, says Dr. Goff. “Chemotherapy alone is used if pancreas cancer has spread.”

Dr. Goff says a new aggressive combination of chemotherapy drugs known as FOLFIRINOX was shown to help patients with pancreas cancer live longer than the standard drug, Gemcitabine. “However, this combination can be very tough on patients, and we are always looking for ways to make treatments better,” she explains. “There are many clinical trials in pancreas cancer because we really need to find better treatments for this disease.”

Caregiver’s Role

The role of a caregiver after a diagnosis is one of support, encouragement, and optimism, says Dr. Mayer. “My advice is to seek out a major cancer center in your area and find doctors who are incorporating the new therapies that are available.,” he said “Every patient’s case should be dealt with individually and seriously. Yes, this is a tough cancer but in the last 10 years research has come a long way.”

If your doctor has recommended that proton therapy be part of your cancer treatment program, you probably have many questions and concerns about it.

Proton therapy, a noninvasive, painless treatment, is a type of radiation used to treat malignant tumors.

Proton therapy has been used to successfully treat pediatric cancers, head and neck cancers, brain cancer, lung cancer, lymphoma, prostate cancer, and sarcomas and malignancies in the gastrointestinal tract. Any cancer that appears as a solid mass could potentially be treated with proton therapy, and many types are currently being evaluated.

Although proton therapy has been used at specialized research facilities for the past 30 years, it was only available at one hospital-based center (Loma Linda) until the past decade. As of March 2012, 10 medical facilities in the United States offered proton therapy. Within the next 5 years, another 20 U.S. centers should either open or be under construction. To date, more than 70,000 people worldwide have received proton therapy at centers in the United States, Europe, and Asia.¹

How It Works

The most common type of radiation is called photon therapy, or conventional x-rays. Proton therapy works in the same way--it destroys cancer cells by preventing them from dividing and growing.

Patients who undergo proton therapy will have an MRI and/or CT scan before treatment to pinpoint the tumor's exact location and personalize treatment. During treatment planning, computer modeling will determine the best direction to aim the radiation beam to avoid damaging normal tissue.

Patients will be fitted for immobilization devices (usually a foam-type mold) to ensure that they don't move during treatment and are in the same position for every treatment. If they will receive treatment for their head, they will be fitted for a mask. These devices also help to move healthy tissue out of the path of the radiation beam.

Before treatment, the patient will lie on a table in a comfortable but stable position. Then the immobilization devices will be placed around him or her. Imaging will ensure that the patient is properly positioned. When treatment begins, a machine directs the proton beam toward the tumor from different angles for several minutes.

"Unlike photon therapy, which penetrates healthy tissue around the tumor as well as the tumor itself, proton therapy goes directly to the tumor," explains Jeffrey Bradley, MD, S. Lee Kling Professor of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. This is because photons and protons deliver radiation differently due to differences in their physical properties. Photons are electromagnetic waves that have no mass or charge and penetrate completely through tissue. Protons are large, positively charged particles that penetrate matter to a finite depth.²

According to Steven Frank, MD, director of Advanced Technologies, Proton Therapy Center at The University of Texas MD Anderson Cancer Center, Houston, TX, "Our ability to deliver this technology in a pinpoint fashion makes it novel and extremely effective."

Typically, patients receive treatment 5 days a week for 6 to 8 weeks. That amounts to between 30 and 40 treatments.

Fewer Side Effects, Faster Recovery

Fewer protons than photons are needed when delivering therapy because protons deposit most of their radiation directly into the tumor and then stop. Consequently, patients can receive higher doses, which can be more effective.

In addition, the intensity of side effects and the risk of a second malignancy are reduced compared with photon treatment because healthy tissues are only minimally affected. "This enables patients to return to a normal life [sooner than with photon therapy] and have a better quality of life," says Eugen B. Hug, MD, professor of proton-radiotherapy, and medical director, ProCure Proton Therapy Centers, New York, NY. ProCure has partnered with the Seattle Cancer Care Alliance to build a proton center that will open in Spring 2013 in Seattle.

Side effects depend on the area being treated. If you're treated on your head or neck for example, you may experience loss of taste, difficulty swallowing, oral pain, nausea, and/or vomiting. You may require a feeding tube for nutrition and hydration. If you're treated for prostate cancer, you may experience more frequent urination, burning while urinating, or diarrhea.

After completing treatment, you may feel fatigued and experience acute side effects for up to 1 month. "Then the healing process progresses even faster," says Dr. Frank. Typical follow-up includes imaging every several months for 1 or 2 years, then every 6 months for 5 years, and then annually after that.

Positive Outcomes

"We are at an exciting time of an exponential take off of this technology," says Dr. Hug. "Many studies are underway and the data look promising."

Already it has been shown that the ability to treat skull-based and paraspinal tumors has improved 15% to 20% with proton treatment. In addition, data comparing proton therapy with photon techniques in chordoma, chondrosarcoma, and uveal melanoma show that proton therapy can extend life even longer.   

A major benefit of treating with proton therapy is the reduced amount of radiation dose delivered to large parts of the surrounding healthy body tissues and organs.

Proton therapy is a highly preferred radiation treatment for children because they are susceptible to injury from standard x-ray radiation because their tissues and organs grow rapidly.¹

Fewer side effects may allow for better completion of treatment and tolerance of chemotherapy, and less toxicity later on, including secondary tumors and heart disease. "These benefits may allow patients to actually survive longer," Dr. Frank says.

One study showed that of the patients treated with photons, 12.8% of them developed secondary malignancies, whereas only 6.4% of the proton therapy patients developed secondary malignancies.³

Time to Grow

Despite its promising benefits, hospitals that offer proton treatment are only slowly being built. This is because of multiple factors, including:

• Constructing massive centers to house equipment and treat patients takes a substantial amount of financial investment. The cost is decreasing, however, and new technologies are allowing for single proton therapy rooms that require less space.

• Some insurance carriers do not cover proton treatment because it is new. Insurance carriers are more likely to reimburse technologies under evaluation. By increasing the number of patients in clinical trials, more insurance carriers should begin to cover this treatment.

• Physicians, physicists, and therapists need to be trained to use this technology.

• Awareness of proton therapy's use and benefits needs to continue to grow among physicians and patients.

"I think this is the treatment of the future," Dr. Bradley says. "Using a proton beam (rather than photon therapy) makes fundamental sense because it causes fewer side effects, the cost is decreasing and its efficiency is improving. I think it will change cancer care for the better."

References

1. National Association for Proton Therapy Web site. http://www.proton-therapy.org/facts.htm. Accessed October 18, 2012.

2. Fowler JF. What can we expect from dose escalation using proton beams. Clin Oncol. 2003;15(1):S10-S15.

3. Chung CS, Keating N, Yock T, Tarbell N. Comparative analysis of second malignancy risk in patients treated with proton therapy versus conventional photon therapy. Int J Radiat Oncol Biol Phys. 2008;72(1):S8.

Osteoporosis occurs when bone mass is deficient. Risk factors can include being female, family history, advanced age, low body weight, sedentary lifestyle choices, and insufficient calcium and vitamin D levels. More than 10 million Americans have osteoporosis and as many as 40 million more have low bone mass and are at high risk of developing the disease.

“When most people think of bones, they do not think of them as living and growing organisms; however, this is exactly what they are. Bones are made up of active cells that are constantly replaced and growing,” says Andrew Bunta, MD, vice chairman of the department of orthopaedic surgery Northwestern Memorial Hospital and at Northwestern University Feinberg School of Medicine in Chicago. He says a healthy lifestyle that includes regular exercise and a nutritious diet is a key component to promoting bone health. Consuming a sufficient amount of calcium and vitamin D is among the best ways to prevent osteoporosis. Calcium, a mineral that is stored primarily in the bones and teeth, aids in the expansion of blood vessels and muscles. “Our bodies continually remove and replace calcium as we grow, and vitamin D aids in its absorption and incorporation into our bones so it is important to get enough of both,” adds Bunta.

How Cancer is a Factor

People undergoing cancer treatment are even more susceptible to the risk of osteoporosis.

Treatments including radiation, chemotherapy, and medications may pose bone health risk, says Richard Theriault, DO, MBA, professor, Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston. “Radiation may have direct toxic effects on bone but remains a mainstay of treatment for bone metastases and local therapy post primary breast surgery. Radiation techniques have been designed to minimize risks to bone health,” he says. Chemotherapy, says Dr. Theriault, has a predominant effect on bone health through inducing ovarian failure/premature menopause for premenopausal women. “This results in a hypoestrogen state with negative impact on bone density,” he says. Further, Dr. Theriault explains that some premedications, such as steroids, used to prevent nausea and vomiting may also have a negative impact on bone health. “In postmenopausal women, aromatase inhibitor agents used for adjuvant therapy to reduce the risks of cancer recurrence result in profound hypoestrogen states and thereby increase risks of osteopenia/osteoporosis and fractures,” Dr. Theriault says.

Even surgery can play a part in increasing bone health risk. “Surgery usually results in permanent scarring; radiation can result in changes in skin and soft tissues as well as lymphedema; chemotherapy can effect various organ functions, depending on drug, doses, and tolerance,” he addd. “Bone health, cardiac health, hematologic toxicities and premature menopause are a few long term effects that are possible. The biggest long term effects in the setting of primary breast cancer are delay or prevention of cancer recurrence.”

Risk by gender

Kenneth W. Lyles, MD, professor of medicine and medical director of Medicine Site-Based Research at Duke University Medical Center in Durham, North Carolina, says there are two large populations that are susceptible to increases osteoporosis risk: women with breast cancer and men with prostate cancer.

With regard to women battling breast cancer, studies have shown that chemotherapy, radiation therapy, and medications, including glucocorticoids and aromatase inhibitors, increase the risk of bone mass and subsequent fractures. Dr. Lyles says a discussion with their doctors is warranted before treatment begins, to assess the risk of osteoporosis based on lifestyle factors, family history, and other health conditions, including rheumatoid arthritis. “Accelerated bone loss is a real issue in cancer care,” he says. “With frailty increasing and from other illnesses, the risk of falling increases and therefore patients are at risk for falls and fractures.” Osteoporosis can also cause depression, says Dr. Lyles, as the patient experiences back pain, loses height, becomes stooped, develops a protruding stomach, and may experience trouble performing daily life tasks.

 Men being treated for prostate cancer can also be affected by androgen depletion therapy, which makes them more vulnerable to boss loss and diminishing bone density. “For men, if they suffer a hip or spine fracture, it can be a big setback; it can send them on a path toward more health problems,” he says. Dr. Lyles says that 15% to 25% of patients who experience a hip fracture have a higher risk of mortality.

Healthy lifestyle choices, including regular exercise, not smoking, taking vitamin D and calcium, and maintaining a healthy body weight, may offset the risk, says Dr. Lyles.

Managing Side Effects

Both cancer and cancer therapy can have a negative impact on quality of life, says Catherine Van Poznak, MD, Assistant Professor, University of Michigan Comprehensive Cancer Center, Ann Arbor. “It is important to have an open discussion with one’s health care provider to address symptoms and toxicities so that steps can be taken to mitigate those toxicities,” she says. “The goals of care can vary by the tumor condition and by the individual’s preferences. A patient may open a dialog with their provider by addressing what is important to them, and determine whether therapy side effects are interfering with their other priorities.”

The Web site of the National Institute of Dental and Craniofacial Research cited that most people are aware of common side effects of cancer treatment, such as nausea and hair loss, but many may not realize that more than one-third of people treated for cancer develop complications that affect the mouth. These problems may interfere with cancer treatment and diminish the patient's quality of life.

Head and neck radiation, chemotherapy, and blood and marrow transplantation can cause oral complications ranging from dry mouth to life-threatening infections, says Jane C. Atkinson, DDS, director, Center for Clinical Research, National Institute of Dental and Craniofacial Research in Bethesda, Maryland. “While some of these adverse side effects only occur during cancer therapy, other complications are permanent,” Dr. Atkinson says. “For example, radiation therapy to the head and neck can permanently damage the salivary glands and dramatically reduce the amount of saliva a person makes. Individuals with too little saliva are much more likely to develop dental decay, and need to be followed closely by their dentist formouth the rest of their lives.”

Before Treatment

It’s a good idea to visit a dentist before starting treatment to assess any complicated issues or create a baseline of dental care. Sol Silverman, Jr., MA, DDS, professor of oral medicine, University of California School of Dentistry in San Francisco says this proactive treatment can promote optimal oral health (caries, periodontal) and prevent or minimize complications during or after treatment, which may include infection, pain/comfort, alterations in function (mouth opening, chewing, swallowing).

Dental Health Effects of Cancer Therapy

Dr. Silverman says that with regard to surgery, there are no great problems; any issues are mainly related to hygiene. However, patients being treated with radiation therapy may be at risk for complications related to dental health. “These may include mucositis (inflammation, ulceration), dryness from hyposalivation, difficulty in swallowing, poor hygiene, periodontal flare, pain, altered taste, dryness, dysphagia, and depression,” Dr. Silverman says.

Further, he adds that radiation/chemotherapy can also lead to complications, such as mucositis (inflammation and ulceration of mucous membranes); pain and bleeding preventing adequate or any oral hygiene; dysphagia (difficulty swallowing or almost inability to do so); nausea; dryness interfering with hygiene, speech, swallowing, and oral comfort; and chemoimmunosuppression that causes bleeding problems (platelet depression) and minimizes white cell numbers/function, leading to infections (eg, thrush) and mucosal breakdown/mucositis.

What Can the Patient Do?

One thing patients can do to maintain oral health, Dr. Silverman says, is maintain a steady calorie intake. He cautions that alterations in taste, mouth dryness, oral pain, and dysphagia must be controlled, because when out of control, oral hygiene declines and dental and periodontal infections rise.

Long-Term Issues

Long-term effects can vary, according to Dr. Silverman.

Surgical problems can include esthetics, speech, mastication, swallowing, and trismus. Radiation therapy may include dryness (xerostomia from decreased saliva production), chronic or recurring fungal infections (candidiasis), dental decalcification and caries from xerostomia, decreased appetite from dryness, pain, alterations in taste, trismus (difficulty in mouth opening), maintaining hygiene because of mucosal and dental sensitivity, risk of bone and soft tissue necrosis from alterations in blood flow (this can occur spontaneously, but the risk is higher after invasive procedures such as extraction). With regard to chemotherapy, concerns include maintaining hygiene, prolonged mucositis and pain, and improper caloric intake.

Use Your Dentist as a Partner in Care

Dr. Silverman recommends you have a frank discussion with a dentist about side effects of treatment and concerns regarding your oral health. “Dental professionals are an integral part of the treatment team from treatment planning, during treatment, and in rehabilitation,” says Dr. Silverman. “This is taught in dental schools, and many continuing education courses are dedicated to this part of oral health care.” Further, he suggests that a dental hygienist is an integral part of the oral team and often takes a leading role in orienting patients to radiation and chemotherapy and helping prepare them for what to expect and how to cope. “All dental factors affect quality of life, and the dental team can be very helpful in orienting the patient to the main focus of tumor control and [reassuring them] that the dental/oral issues that are problematic can be modified—at least to a degree—during the rehabilitation phase, and some even during the treatment phase,” Dr. Silverman says.

Many experts in cancer care agree that there are documented and recognizable cognitive changes during and following chemotherapy. This phenomenon is often termed “chemo brain.”

“Chemo brain does not have a specific medical definition,” says John Ward, MD, professor of medicine and chief of the Oncology Division in the Department of Medicine at the University of Utah School of Medicine in Salt Lake City. “It is a term widely-used to describe cognitive changes, depressive symptoms, and fatigue after chemotherapy.” Dr. Ward says it is difficult to precisely define because of the variety of regimens, varying duration of therapy, accompanying stress of the diagnosis, variety of cancers, presence of depression, and variety of stages and comorbid illnesses among patients.

Chemo brain may not only be the result of chemotherapy. “It may occur following chemotherapy, radiation therapy, and/or such adjuvant therapies and hormonal therapy,” says Terri Ades, DNP, FNP-BC, AOCN, Director, Cancer Information, American Cancer Society’s National Home Office in Atlanta. “Most define it as not being able to remember certain things or having trouble finishing tasks or learning new skills.”

Symptoms

Ades, who is also a doctorally prepared advanced practice oncology nurse, says symptoms are very subtle, but patients who report the changes are very aware of the differences in their abilities to think clearly. “The symptoms make it very difficult for patients to carry out normal activities in their personal and professional life,” she says.

Symptoms, she adds, are usually associated with changes in memory, concentration, and executive function. “Executive function would be such things as planning, decision-making, judgment, and the ability to shift between activities in a flexible way,” Ades clarifies. “So, yes, this would mean multitasking might be difficult. Patients have difficulty staying focused or organized. Changes in concentration might be evidenced by a shortened attention span. And ‘feeling scatterbrained’ might nicely describe how some people might feel.”

Effects on a Patient

Side effects can vary in intensity from patient to patient. "Among other side effects, chemotherapy treatment may cause problems with mental abilities," says Paul Jacobsen, PhD, associate center director for population science at Moffitt Cancer Center in Tampa, Florida. “We can’t pinpoint the exact causes of the effects of chemotherapy on brain function; however, common problems can include forgetfulness, problems with concentration, and difficulty handling multiple mental tasks at the same time.” He says once the patient perceives changes in mental abilities, it’s worth a discussion with a doctor. “There are both medical and nonmedical approaches that can help with these issues,” he advises.

Coping With Chemo Brain

Some strategies might help a person sharpen their mental abilities and manage some of the problems associated with chemo brain, says Ades. “For example, using a daily planner to keep everything in one place makes it easier to find the reminders a person might need. Tracking memory problems through keeping a diary of when problems occur and the events that are going on at the time can help the person prepare for future problems,” she says. It may also help reveal what is triggering the problem.

She suggests exercising the brain by taking a class, doing word puzzles, or learning a new language. She also recommends getting enough rest and sleep, and engaging in some physical activity. “Regular physical activity not only is good for the body, but also improves mood, makes us feel more alert, and decreases tiredness,” she says Slowing down and realizing these limitations are also warranted. “Don't be hesitant to ask for help,” she suggests. “Don't multitask, but rather focus on one task at a time,” Ades adds.

Another helpful suggestion from Dr. Jacobsen is to strengthen a support system of friends and caregivers and to attend support group meetings. “Sometimes it’s helpful and therapeutic to discuss challenges and experiences with others,” he adds. “Most major cancer centers have resources to help match patients with groups.”

Involve Your Doctor

Ades stresses that patients must always discuss any new symptom with their doctor without delay. Cognitive changes can have a number of causes, some not related to the cancer or treatment. “The brain is a site where cancer can spread to, so a patient's doctor will first want to be certain that this has not occurred as well as rule out non-cancer–related causes,” Ades says.

Going to the dentist twice a year for a checkup can do more than prevent cavities; it can help detect oral cancer early, when it is most treatable, because most of these cancers are diagnosed by the dentist.

If caught early, oral cancer can be treated and cured in most patients. Oral cancer discovered late can require extensive—often disfiguring—surgery to the tongue, jaw, and other areas of the mouth that can make it difficult to talk, eat, and swallow.

When found early, patients require less extensive surgery to remove the cancer; therefore, most activities like talking, eating, and swallowing are closer to normal after the surgery.

The moral of this story: go to the dentist twice a year for a checkup and make sure the dentist performs a screening exam to evaluate for precancerous and cancerous oral lesions, as well as gum disease and cavities.

Be Your Own Advocate

Unfortunately, not every dentist automatically checks the mouth for cancer, so patients might have to ask for this additional examination. The exam doesn’t hurt; so speak up!

“Most dental insurance plans pay for regular dental checkups, which is great. Screening twice a year is a wonderful way to pick out these lesions before they become cancer,” says Susan Mallery, DDS, PhD, a professor in the College of Dentistry at The Ohio State University.

“The dentist should take the time to examine the whole mouth and look at the tongue, floor of the mouth, roof of the mouth, back of the mouth, even the lips. Early detection of the precancerous lesions would be the best way to save people’s lives. If your dentist doesn’t take the time to do that, find a new dentist.”

Types of Oral Cancer

Doctors separate oral cancers into two general categories based on their location. Oral cancers occur in the front portion of the mouth, such as on the tongue, cheek, roof and base of the mouth, jaw, and gums—all areas that you can see when you look in the mirror. The second type of oral cancer is called oropharyngeal cancer, and these occur in the back of the mouth, including the soft palate, the base of the tongue, and the tonsils.

“These are anatomically different sites, and they are associated with different risk factors,” says Miriam N. Lango, MD, a head and neck surgeon at Fox Chase Cancer Center in Philadelphia.

The leading risk of oropharyngeal cancer is human papillomavirus (HPV), a virus that causes genital warts. People become infected by having oral sex with someone who has HPV. Unfortunately, there may be no sign that the person is infected.

Risk Factors

The leading cause of oral cancer is using tobacco products, particularly any kind of smoking (cigarettes, cigars, and pipe smoking). Chewing tobacco can also cause cancer, but the risk is lower. Heavy drinking, especially among smokers, increases the risk of getting oral cancer.

Other risk factors include too much sun exposure, and perhaps a family history of cancer. Oral cancers have been diagnosed in people who don’t smoke or drink, so doctors think there can be a genetic association, but they have not found a specific gene, or set of genes, for oral cancer yet.

Not smoking is the best way to prevent oral cancer. An estimated 42,000 Americans will be diagnosed with oral cancer this year and most of them are smokers. If you already smoke, quit. Quitting can decrease your risk dramatically. Every year that you don’t smoke, your risk is lowered. After 15 years of not smoking, your risk becomes similar to the general population, according to Lango.

Smoking marijuana is also a risk factor, but it is not as high as cigarette, cigar, and pipe smoking.

Some people like firefighters worry that occupational exposures—inhaling smoke while fighting fires—increases their risk, but studies have not shown any correlation.

Signs and Symptoms

You should consider getting your mouth checked if you have a mouth sore or ulcer that doesn’t heal within a reasonable time, usually within 2 weeks. Sometimes people feel a small bump or have lacy white patches or sores that can be painful, called lichen planus (LIE-kun PLAY-nus).  It is important to distinguish between lichen planus (a reaction of the immune system) and precancerous oral lesions.

Another sign is thickened, white patches that can form on the gums, cheeks, bottom of the mouth or tongue, called leukoplakia (loo-ko-PLAY-key-uh). Although most leukoplakia lesions are not painful or serious, they can sometimes signal cancer, which is called precancer or dysplasia.

Some patients also feel unexplained numbness or tingling in the face, mouth, or neck. If the cancer is advanced, patients might have problems chewing, speaking, or swallowing.

If your dentist or doctor suspects that you have oral cancer, a biopsy will be recommended, in which a small portion of the area will be removed and examined under a microscope to determine whether abnormal cells are present.

Treatment

Surgery is the usual treatment for oral cancers. Surgeons will remove the cancer or precancer and some surrounding unaffected tissue (to make sure they remove all the cancer). If the cancer is large, aggressive, or more advanced, your surgeon might also order radiation therapy after surgery.

A head and neck surgeon is usually on the team that treats oral cancers because treatment requires surgery to remove the cancer or precancer (abnormal tissue that could become cancer). Some patients also require radiation therapy, and sometimes chemotherapy.

But many oral cancers can be treated just by surgery, and these patients usually do quite well.

“How well the patient does depends on the stage of the disease,” says Lango. “If it's localized, most institutions recommend surgery as the initial treatment approach because after the surgeon removes the cancer, the pain goes away, and function is frequently well preserved.”

After surgery, patients do best if they are enrolled in a rehabilitation program early. Speech and swallowing therapy will improve the ability to articulate words and help patients adjust to any swallowing changes. 

If the surgery is disfiguring, reconstructive surgery can improve the way the person looks. Doctors have made great strides in some reconstructive surgery for extensive mouth cancers. For instance, if the cancer spreads into the jawbone area, in many cases the jaw can be reconstructed.

“Fortunately, we have very good reconstruction techniques available today. A jaw can be recreated using other structures in the body. For instance, a bone in your leg can be used to reconstruct a jawbone,” says Lango.

Patients who have the most trouble are those that lose very large portions of the tongue, because the tongue is so essential to being able to talk and eat. Unfortunately, surgeons cannot reconstruct a usable tongue when the entire tongue was sacrificed to remove the cancer. However, using new reconstructive techniques and a good rehabilitation program after surgery, removal of even three-quarters of the tongue can result in good speech and swallowing function.

“The goal of the cancer treatment team is always to cure the cancer with as much preservation of function as possible,” Lango added.

No matter how well a person does after surgery, he or she will probably notice some changes in speech and swallowing. And patients may experience problems with dry mouth, especially if some salivary glands had to be removed or they received radiation treatment.

This is definitely a case where prevention is better than cure. So get in the habit of visiting the dentist twice a year, and stop smoking and drinking.

Duke oncologist Neil Spector, MD, is co-director of the Experimental Therapeutics Program at the Duke Cancer Institute (DCI). He is recognized internationally for his leadership in the development of cancer drugs such as Tykerb. Spector came to Duke in 2006 from GlaxoSmithKline to direct the DCI’s efforts to translate basic science discoveries in the laboratory into advanced care for our cancer patients.

What is translational research?

Translational research is taking knowledge developed and insight gained in the laboratory, and applying it in the clinic in order to enhance detection, treatment, prediction of outcomes, and prevention of disease in people. Essentially, it is bridging the gap between the science being done in the lab, and the clinic where patients are treated.
We often hear in the media about great scientific discoveries, like a new gene identified in fruit flies, for instance. And the researchers always say, “At some point, we hope this will help people with cancer.” Since most of us will be touched by disease at some point in our lives, we all want see those great discoveries applied to advancing treatment and outcomes. That’s what translational research is all about.

Who does this type of research, and why is it important?

 You never know where the next big advances in cancer treatment are going to come from. The key is to have people who are thinking: “How does that discovery potentially apply to patient care?”

Traditionally there have been excellent basic scientists hard at work in university and corporate laboratories, and then there have been excellent physicians working in hospitals and clinics, but it was difficult to bridge that gap. It’s essential that we can think in both worlds—so we can understand the science and say, “Well, maybe that discovery in Alzheimer’s disease has some bearing on bladder cancer,” or vice versa. And increasingly, through physician-scientist training programs and through the addition of translational research training in medical schools and doctoral programs, we are gaining more people from both the medical and science worlds who have that mindset and that ability to bridge the divide.

This content was originally published in the Spring 2012 issue of Duke Cancer Institute Notes.

Answer provided by:
Neil Spector, MD
Co-director of the Experimental Therapeutics Program
Duke Canccer Institute
Durham, North Carolina

The time period during treatment can be very busy. Afterward, you may wonder what to do. Besides having follow-up tests, it is important to follow a survivorship care plan. Talk with your doctor about making a plan together. NCCN suggests the following as part of your plan:

This is an extract from the NCCN Guidelines for Patients^®. NCCN Guidelines for Patients^® on specific cancers are available to view or print out.

• Get exams and tests of your general health. After going through treatment for cancer, it may be hard to think about taking care of “less important” issues. However, your general health can have a big impact on your well-being.
• Take steps to prevent other diseases. Such steps can include getting immunization shots and screening tests for other cancers.
• Months after treatment, you may still develop problems from the cancer or its treatment. Tell your doctor if any new symptoms appear.
• Start or keep a healthy lifestyle. There is proof that healthy behaviors can improve your treatment results. If you are a smoker, see your doctor for help to stop. Your doctor may also be able to help you achieve a healthy body weight. Regular exercise and healthy foods may also improve treatment results.
• You are encouraged to have a primary care doctor throughout your life. Share your survivorship care plan with your primary doctor. Your cancer doctors should also tell your primary doctor about your prognosis, treatments, recovery time, lasting side effects, possible new side effects, and suggested follow-up tests.

Elderly people with cancer face unique challenges as they battle cancer. The normal aging process and its effects on the body, in addition to the psychological stress that accompanies the diagnosis and subsequent surgery and/or treatment, may adversely affect an aging patient’s ability to heal or cope with having cancer. Some of the larger issues elderly patients face include the existence of risk factors, awareness of possible clinical trials and advances in research related to their cancer, planning for palliative care, and financial implications.

Risk Factors

The process of growing older increases the likelihood of cancer. “Older tissues are more susceptible to environmental carcinogens,” says Lodovico Balducci MD, Chief of Geriatric Oncology at H. Lee Moffitt Cancer Center in Tampa, Florida. “Some changes in body environment—decreased immunity, increased resistance to insulin, chronic inflammation—may accelerate the growth of cancer.”

Dr. Balducci outlined several risk factors and their relationship to age.

• Smoking and alcohol consumption: Smoking is definitely a cause of most cancers, such as lung, head and neck, bladder, and pancreas. Screening for lung cancer is very effective in preventing death from lung cancer, and elderly smokers should be encouraged to quit and be screened. Alcohol may have a role in cancer ofthe upper digestive tract and the breast, but the role is less well defined. Still, alcohol should be consumed in moderation.
• Comorbidities: Comorbidities may prevent some forms of cancer treatment. Heart disease may make surgery more risky and may exclude the use of some chemotherapy drugs, such as anthracyclines. Diabetes may increase the risk of peripheral neuropathy (damage to nerves that could result in symptoms ranging from pain and numbness to bladder problems), which in older individuals may be disabling. In addition, comorbidities may reduce the life expectancy of a person, and consequently the benefits of cancer treatment.
• Physical and mental condition/possible frailty: Dr. Balducci reported that recent studies done at his institution have shown that people who are dependent on others for performing the so-called “instrumental activities of daily living,” such as using transportation, takingmedications, preparing meals, shopping, using the phone, and managingfinances have an increased risk of experiencing toxicity associated with chemotherapy. Frailty is an important concept. The frail person is one who is still independent but may become dependent after experiencing a stress such as elective surgery or chemotherapy.

Are Seniors Savvy on Treatment, Clinical Trials, Research?

Stuart M. Lichtman, MD, Medical Oncologist at Memorial Sloan-Kettering Cancer Center in Commack, NY, says the older population has a number of ways they can access information about cancer treatment and cancer centers, and help with finding doctors and clinical trials. “They are increasingly becoming more savvy and self-reliant but still use traditional methods of obtaining information, such as television, newspapers, and family,” he said. “Access to accurate information is an important goal for older patients as they face a greater number of health issues, and use prescription drugs and health care services at a higher rate than younger patients.”

However, Dr. Lichtman cautions, education and income may play a role in access to or understanding of these data. “Older adults are not using the Internet in place of other traditional media channels; they use the Internet in addition to other media channels,” he says. Therefore, he suggests that older adults be given health information in writing. “Additional studies show that despite the use of the Internet, older individuals do not use the information from the Internet to change the way they participate in health care; when it comes to decision-making, older individuals prefer a physician-centered model of care,” Dr. Lichtman added. “They also place reliance on their family and friends.”

Palliative Care

Planning palliative and hospice care are important issues for cancer patients to discuss with their physicians. Palliative care options for the elderly should include goals of care, which may include keeping the patient’s pain under control, managing side effects, managing depression, and incorporating the patient’s personal wishes. “As with patients of any age, there are those who are prepared for their death and those who are not,” says Roma Tickoo, MD, MPH,a geriatrician at Memorial Sloan-Kettering Cancer Center in New York.“I find that most elderly patients are ready to face their death. This is particularly true if the patient has lost loves ones and/or friends and is feeling alone.” Dr. Tickoo says often elderly patients will express the opinion that it is “my time to go and I am ready.”

Challenges often arise with elderly patients in the advanced stages of cancer, such as those who are incapacitated and have not left directives specifying their desire (or lack thereof) for the use of aggressive life-sustaining measures. “Family members frequently wish to protect patients who are frail or who have cognitive deficits, taking on decision making about care,” she says. “If the patient has not expressed their end-of-life wishes, family and/or health care providers may feel compelled to press for more aggressive treatment than might be advisable and desired by the patient.” Therefore, she advises that “every patient should discuss their wishes about end-of-life with their family and health care providers while they are able to ensure that everyone is on the same page.”

Financial Strain

Barbara A. Murphy, MD, Professor of Medicine, Director of Pain and Symptom Management and Program Leader of the Head and Neck Research team at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, says elderly patients often have financialissues. “Most are retired and no longer working, thus disability is no longer an issue,” she says, and therefore time off from work is not a factor. But that does not mean the disability will not impact a patient’s financial situation in many cases. “A cohort of patients is financially stable in retirement and has sufficient funds for any medical circumstances that arise. Another group of patients has sufficient funds to deal with most medical issues that arise but do not have sufficient wherewithal to provide for custodial care should they require substantial assistance with daily care.” There is yet another group, she continues, of those who live on a small, fixed income. “They may have difficulty dealing with day-to-day finances,” Dr. Murphy adds. “The addition of an illness may cause severe hardship due to insufficient funds. These are patients who may need to make a decision about where to spend their money: daily expenses versus medical expenses.”

Social workers can sometimes help by providing financial counseling and information about community support services. They can also help patients set priorities and find information on pharmaceutical companies that provide assistance programs. Furthermore, Dr. Murphy adds, “a network of families and friends can help by providing meals, transportation, emotional support, and a shoulder to help with the burden.”

Although aging caregivers have the best intentions, and a lifetime of love, the physical condition of an elderly caregiver may play a role in cancer care for a patient. “The caregiver may affect the quality of care,” says Lodovico Balducci, MD, Chief of Geriatric Oncology at H. Lee Moffitt Cancer Center in Tampa, Florida. “Right now the most common types of caregivers are aging spouses with health problems of their own or a child (more often a daughter) who has to support both his/her own family and the sick parent.” Dr. Balducci says caregivers of older individuals are subjected to decreased survival, increased risk of depression and other diseases, and increased risk of divorce.

Physical and Mental Limitations

If a patient has an elderly caregiver, the health care provider must be very alert to the caregiver limitations because these may impact the patient’s safety, saidBarbara A. Murphy, MD, Professor of Medicine, Director of Pain and Symptom Management, and Program Leader of the Head and Neck Research team at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee.

“For example, an elderly caregiver may have poor eyesight, limiting the ability to administer shots that require the medication to be drawn up and measured in a syringe. Elderly caregivers with arthritis may have trouble with mechanical devices, such as feeding tubes, tracheostomy tubes, and ostomies,” says Dr. Murphy. “Short-term memory declines with age; an aging caregiver may have trouble remembering complex supportive care regimens or tasks. High-functioning caregivers may be able to problem-solve and still provide good supportive care, [but] others may have limited problem-solving capacity and may need additional services and support. The elderly frequently try to hide incapacity. Thus the health care provider must be watchful.”

Depression is also common in the elderly. This may affect the caregiver and the patient. “It may mask itself as a slowing in cognition,” Dr, Murphy says. “Furthermore, it may limit motivation to follow medical recommendations. Treatment with pharmacologic agents remains the standard of care. That being said, one must be careful to monitor for side effects.” Counseling is advocated and has been shown to be effective.

Another distinct issue to consider is frailty, a geriatric syndrome characterized by slow gait, low physical activity, weight loss, fatigue and weakness, says Beatriz Korc-Grodzicki, MD, PhD, Chief of the Geriatrics Service in the Department of Medicine at Memorial Sloan-Kettering Cancer Center in New York. Affecting the patient and their caregiver, it is a form of pre-disability, very prevalent in older adults, and often not recognized. “It increases the vulnerability to worsening balance, falls, and an array of complications that may end in loss of independence, worse quality of life, and institutionalization of the patient,” says Dr. Korc-Grodzicki.

Battling their own health issues 

Now that people are living longer, it’s not uncommon to see the elderly and frail function as caregivers. “Often the older adult/elderly caregiver is simultaneously a patient themselves coping with their own cancer diagnosis or other illness while caring for their partner/spouse/loved one who also has cancer,” says AnnammaAbraham Kaba, LCSW-R, Senior Social Worker at Memorial Sloan-Kettering Cancer Center. “Being a caregiver—and an elderly caregiver—takes a toll on the body; therefore, [these individuals] may be prone to injuries, fatigue, and weakness than their counterparts.”

Another variable may be the impact on a patient’s care if the caregiver is hospitalized. “Often, caregivers who are told they need another level of care become noncompliant or reluctant to accept the medical team’s recommendations (ie, rehab or nursing home) despite it being unsafe medically to return home if they are hospitalized,” Kaba says.

Support

Caregiving, even for healthy and able-bodied adults, takes a toll on health and well-being. When the caregiver is elderly and has physical and/or mental health implications, the situation can become unsafe. Many cancer centers have social workers who can provide resources or support to assist. Support groups can also provide a forum of other individuals with experience or who are in a similar situation to act as a sounding board. A support system of family and friends who may be able to provide respite care may also be of benefit. Senior service organizations, retirement communities, the local Office on Aging, and other community outreach centers may have caregiver services in the community. Furthermore, community transportation services are often available for rides to medical appointments, treatment appointments, adult day care, or other activities. Some are offered free or on a sliding-scale.

Helpful Web sites

• http://www.aoa.gov/AoA_programs/HCLTC/Caregiver/index.aspx
• http://www.cdc.gov/aging/caregiving/