Q & A (Cancer)

Are there any actions or medications that can help prevent cancer?

Fortunately this is an area of active investigation and there is a growing list of medicines, supplements and behavioral changes which can be effective.

The first group of medicines includes aspirin and other NSAIDs (non-steroidal anti-inflammatory). NSAIDs are a large group of medicines primarily marketed to treat arthritis such as ibuprofen and Celebrex to name two. A variety of cancers may be prevented by long term use of this family of drugs primarily by their ability to block a specific pathway of inflammation called cox-2. Aspirin at doses of 81-325mg daily over a period of 3-5 years has been shown in large populations of people to decrease the risk of developing cancers of the colon, rectum, breast, lung, prostate, esophagus and stomach.

For gastrointestinal cancers the risk of cancer occurrence can be cut in half by regular use of these medications. Even more impressive to me is the demonstration that patients who have already undergone surgical resection for colon cancer can further cut their risk of cancer recurrence by regular use of aspirin of other NSAID’s. This study included patients with stage III colon cancer who received chemotherapy to decrease the risk of cancer recurrence. In those that also took aspirin or another NSAID regularly for greater than 3 years a further reduction in the development of cancer recurrence by 50% was realized. Additional studies are ongoing to verify this benefit.

Statins are a class of drugs used primarily to lower blood cholesterol levels. Many people are taking these drugs daily of years to prevent heart attacks and strokes. Studies have shown a surprising additional benefit from these medicines in the reduction of the development of cancers of the breast, colon and rectum.

We all know that smoking tobacco is a major cause of lung cancer. You may not know that it is also a major risk for head and neck cancer (cancers of the mouth, throat, voice box and surrounding structures) as well as esophagus, stomach and pancreatic cancers. Patients who have been cured of one of these cancers remain at high risk of developing another tobacco smoke related cancer. Smoking cessation in this group can cut the risk on a new cancer developing dramatically. In patients treated for head and neck cancers, stopping smoking has resulted in an improved cure rate compared to those who continue to smoke.

Smoking cessation benefits all but the tobacco companies. Aspirin, NSAIDs, and statin drugs all have potential adverse side effects. Before starting one of these agents make sure you consult with your doctor or other health care provider.

An Ounce of Prevention, by Robert McCroskey, MD, published in Climbing R.O.P.S., Oct. 2005, p. 2.

Why do patients with the same cancer respond to treatment in such different ways?

For many years, the only way tumors could be identified was by the pathologist looking at a biopsy through a microscope. Although this method gives a diagnosis in most cases, it does not tell us anything about the behavior of the tumor, its responsiveness to treatment, growth rate, etc. The advent of antibodies that recognize proteins on a cancer cell’s surface allows us to see at a molecular level. For example, two women both have breast cancer, and both have biopsies that look identical. However, one biopsy binds an antibody that identifies the estrogen receptor and the other does not. The woman with the tumor positive for estrogen receptor can be treated with hormonal treatments with a likely response.

Currently, researchers are close to characterizing tumors by the genes they express. This tells physicians even more about a tumor than antibodies do. A tumor can literally be finger printed, showing which of hundreds of genes it expresses. Using this technology, lung cancers that are responsive to the oral drug Tarceva can be identified. Whether a patient needs chemotherapy after surgery can begin to be predicted by determining the pattern of gene expression. This technology will soon allow the selection of chemotherapy individualized for each patient. It will also identify which patients need chemotherapy.

Message from the Master, by Richard Ostenson, M.D. published in Climbing R.O.P.S., June 2005, p. 2

Does obesity contribute to the prospect of developing cancer?

Obesity has been linked to an overall increase in developing cancers of the breast, colon, endometrium (uterine lining), kidney, esophagus and liver. Studies have shown that excess body weight is associated with an increased risk of developing breast caner in postmenopausal women. Surprisingly the opposite is true with premenopausal women.

Obesity is associated with higher estrogen levels in the blood and breast tissue and post menopausal women are more likely to have breast cancers which are stimulated by estrogen then with premenopausal women. Another suspected link between obesity and cancers is the insulin-like growth factor. Obese individuals tend to have higher insulin levels. These higher insulin levels cause the tissues to become resistant to the effects of insulin. Furthermore, there is a presence of insulin-like growth factors that are known to stimulate the growth of some cancers.

A study of nearly 4000 women treated for breast cancer in the early 1980’s showed obesity was associated with an increased risk of breast cancer recurrence and death from breast cancer. However, it was also found that use of adjuvant chemotherapy or hormonal therapy diminished this risk. The benefit of weight loss after breast cancer is not well known, but until more evidence is gained, most breast cancer specialists advise against weight gain after developing breast cancer.

The link between obesity and endometrial, colon (primarily men), kidney, pancreatic and hepatocellular cancers is thought to be related to increased estrogen or insulin levels. In esophageal cancer, obesity and the promotion of cancer is more likely due to an increased risk and severity of acid reflux from the stomach into the esophagus.

Interestingly, obesity is associated with a decreased risk of developing prostate cancer. On the down side, men who have had treatment for prostate cancer, have a greater risk of recurrence as measured by a rising prostate specific antigen (PSA).

Obesity and cancer risk has been studied far more than the effects of individual foods, nutrients, food additives, and exercise. This is in part because of the difficulty of performing dietary studies. Fortunately much interest in this field will likely yield more information in the future.

Obesity and Cancer, An Ounce of Prevention, by Robert McCroskey, MD, published in Climbing R.O.P.S., Dec. 2005, p. 2.

What is a CBC?

It stands for complete blood count, and it is performed regularly on the majority of patients who come to our clinic. It looks at the three blood cell lines: white cells, red cells, and platelets. White blood cells (WBC’s) are the major infection-fighting cells in the body. We look at the WBC differential which is a breakdown of which types of white blood cells are present: neutrophils, lymphocytes, monocytes, eosinophils, basophils, blasts, etc. This helps us assess risk for infection or other causes for symptoms, such as allergies. Red blood cells (RBC’s) are evaluated in several different ways on the CBC. We most commonly refer to hematocrit when looking for anemia. Hematocrit is simply the percentage of whole blood which is occupied by red blood cells. There are several other numbers on the CBC related to the red blood cells that tell us the size, color, and variability in size of the these cells. Knowing this information helps point us in different directions to determine causes for low red cell counts (anemia). Last, but certainly not least, are the platelets. These are an essential part of normal blood clotting. They clump together to form plugs to stop areas that are bleeding in the body. If you have questions about CBC’s or other blood counts, please ask any of your healthcare providers.

Gibberish Translator, by Beth Turney, ARNP, published in Climbing R.O.P.S., June 2005, p. 3.

What is chemotherapy and how does it work?

Chemotherapy is the use of medicines (or drugs) to treat disease. Sometimes this type of treatment is called just “chemo.” Although surgery and radiation therapy remove, destroy, or damage cancer cells in a specific area, chemotherapy works throughout the body. Chemotherapy can destroy cancer cells that have metastasized, or spread to parts of the body far away from the primary (original) tumor.

More than 100 chemotherapy drugs are used in various combinations. Although a single chemotherapy drug can be used to treat cancer, generally they are more powerful when used in combination with other drugs. Your chemotherapy treatment probably will consist of more than one drug. This is called combination chemotherapy. A combination of drugs with different actions can work together to kill more cancer cells and reduce the chance that you may become resistant to a particular chemotherapy drug.

You and your doctor will decide what drug or combination of drugs, what dosages, how it will be given, and what frequency and length of treatment are best for you. All of these decisions will depend on the type and location of the cancer, the extent of its growth, and how it is affecting your normal body functions and overall health.

What is the goal of chemotherapy?

Depending on the type of cancer and its stage of development, chemotherapy can be used to achieve these goals:

• Cure your cancer
• Keep the cancer from spreading
• Slow the cancer’s growth
• Kill cancer cells that may have spread to other parts of the body from the original tumor
• Relieve symptoms caused by cancer

Your doctor will discuss with you the goal of your chemotherapy before you start treatment.

Will chemotherapy be my only treatment for cancer?

Sometimes chemotherapy is the only treatment you will need. More often, chemotherapy is used in addition to surgery or radiation therapy or with both. Here’s why:

• Chemotherapy may be used to shrink a tumor before surgery or radiation therapy.
• It may be used after surgery or radiation therapy to help destroy any remaining cancer cells.
• It may be used with other treatments if your cancer returns.

When chemotherapy is given after surgery to destroy any cancer cells that may still be present, it is called adjuvant therapy. When chemotherapy is used to shrink a tumor before surgery or radiation therapy, it is called neoadjuvant therapy.

A checklist of questions to ask your doctor or nurse

Before choosing chemotherapy as a treatment option, you should understand the expected benefits, side effects, and risks. Consider asking your doctor or nurse the following questions. In fact, take written questions with you to your next appointment. Our information and the information you receive from your doctor should provide you with what you need to know about your treatment and give you realistic expectations about the outcome.

• What is the goal of chemotherapy for my cancer?
• What are the chances that the chemotherapy will work?
• After chemotherapy, will I be cured, in remission, or relieved of my symptoms?
• Are there other ways to achieve the same goals?
• How will I know if the chemotherapy is working?
• If the chemotherapy does not work, are there other treatments for me?
• What are the potential risks and side effects of the chemotherapy I will be taking?
• How do side effects of this chemotherapy compare with side effects of other treatments?
• How will I receive chemotherapy, how often, and for how long?
• Where will I be given the drugs?
• Are there ways to help me prepare for treatment and decrease the chance of side effects?
• Will my diet be restricted in any way? My activities? My work? Exercise? Sexual activities?
• Will I be treated with surgery, radiation, or both? If so, when and why? What are the expected results of each type of treatment?
• If chemotherapy is to follow surgery or radiation, will it destroy any remaining cancer cells? Could chemotherapy be used alone?
• Are there any clinical trials I could take part in?
• How much will chemotherapy cost? Will it be covered by my insurance or health plan? If the insurance company requests a second opinion, or if I would like one, whom do you suggest I see?

Here are some tips for remembering your doctor’s answers:

• Take notes during your appointments.
• Don’t feel shy about asking your doctor to slow down if you need more time to write.
• If you can, use a tape recorder during your visit so you won’t miss anything.
• Consider taking a friend or relative to your appointment to help you understand what your doctor says during your visit and to refresh your memory afterward.

For more information you and your family need to know after a cancer diagnosis, please see the American Cancer Society booklet, After Diagnosis: A Guide for Patients and Families.

Should I get a second opinion?

One way to find out if a suggested treatment is the best for you is to get the opinion of at least one other doctor before you have your first treatment. Your doctor should not mind if you get a second opinion. In fact, some insurance companies require you to get one. Often, the results of any tests you have already taken can be sent to the second doctor, so you won’t have to repeat any of them.

If your insurance is provided by a managed care group, such as a health maintenance organization (HMO), find out about the company’s coverage concerning second opinions before you get one.

Where will I get chemotherapy?

The location depends on which chemotherapy drugs you are getting, dosages of each drug to be given, your hospital’s policies, your insurance coverage, your preferences, and what your doctor recommends. You may be treated with chemotherapy in these locations:

• Home
• Your doctor’s office
• A clinic
• Your hospital’s outpatient department
• A hospital

Some of these settings may offer private treatment rooms, while others have many patients treated together in one large room. It is important to be in a setting that is comfortable for you. Discuss this with your doctor ahead of time so that you can make your preferences known and know what to expect your first day.

How often will I receive chemotherapy treatment? How long will it last?

How often you take chemotherapy drugs and how long your treatment lasts depend on the kind of cancer you have, the goals of the treatment, the drugs that are used, and how your body responds to them. You may receive treatments daily, weekly, or monthly, but they are usually given in on-and-off cycles. These breaks allow rest periods so that your body can build healthy new cells and regain its strength.

Many people wonder how long the actual drugs stay in their body and how they are removed. Most chemotherapy drugs are broken down by your kidneys and liver then removed from your body through your urine or stool. The time it takes your body to get rid of the drugs is dependent on many things including the type of chemotherapy you receive, other medications you take, your age, and your kidney and liver functions. Your doctor will tell you if any special precautions need to be taken because of the drugs you receive.

If your cancer returns, chemotherapy may be used again. This time, different drugs may be given to relieve symptoms or to slow the cancer’s growth or spread. Side effects may be different, depending on the drug, the dose, and how it is given.

How will the chemotherapy treatment be given to me?

Most chemotherapy drugs are given to you through a tiny plastic tube, or catheter, which is inserted into a vein in your forearm or hand. This method is called intravenous, or IV. Intravenous drugs are given in the following ways:

• The drugs can be given quickly through an IV infusion tubing directly from a syringe over a few minutes; this is called an “IV push.
• An IV infusion can last 30 minutes to a few hours. A mixed drug solution flows from a plastic bag.
• Continuous infusions are sometimes necessary and usually last 1 to 7 days. Catheters and needles can scar or weaken veins after several chemotherapy sessions. An alternative is the central venous catheter (CVC). The CVC is a catheter that is surgically implanted in the chest or upper arm area, and can remain painlessly in place to provide access to a large vein. Routine blood work can be drawn from these catheters and drugs can be injected directly into the CVC, or through an IV connected to the CVC, whenever you go for your chemotherapy. There are many different kinds of CVCs available. Many people discuss this option with their doctor even before beginning treatment. Some find out during treatment that they must have a CVC because their hand and arm veins are not good enough to complete the planned chemotherapy. Your doctor can help you determine the need for and the right type of CVC for you.

Depending on the drug and where the cancer is located, your chemotherapy also may be given in one or more of the following ways:

• Orally, PO – This means “by mouth.” You swallow the drug in a pill, capsule, or liquid form just as you do many other medicines. This method is usually more convenient and may be less expensive because the drugs can be taken at home. If you take chemotherapy drugs orally, it is very important to take the exact dosage at the right time, for as long as it has been prescribed for you.
• Intravenous, IV – The chemotherapy is injected through a needle or catheter into a vein.
• Intrathecal, IT – The drug is injected into the spinal canal. You may either get an injection directly into your spine or into an indwelling cerebrospinal fluid reservoir under your scalp. This method involves placing a small device surgically into the scalp that connects to the cerebrospinal fluid in your spinal canal.
• Intra-arterial, IA – The chemotherapy drug is injected directly into an artery to treat a single area (such as the liver, an arm, or leg). This method limits the effect of the drug on other parts of the body.
• Intracavitary, IC – Chemotherapy drugs are given through a catheter into the abdominal cavity or chest cavity.
• Intramuscular, IM – The drug is injected through a needle into a muscle.
• Intralesional – The drug is injected through a needle directly into a tumor in the skin, under the skin, or in an internal organ.
• Topical – The medication is applied directly to a cancerous area on the skin.

Does chemotherapy hurt?

You already know how it feels to take a pill or rub a medicine on your skin. And you’ve probably felt a slight but brief discomfort with injections before. IV medicines should not hurt after the initial needle stick to insert the catheter. If you feel any pain, burning, coolness, or other unusual sensations, tell your doctor or nurse immediately.

What are clinical trials?

Clinical trials are carefully designed research studies that test promising new cancer treatments. You will want to discuss this option with your doctor. Patients who participate in research studies will be the first to benefit from these treatments. These patients can make an important contribution to medical care because the study results will also help other patients.

In a clinical trial, you receive either standard treatment or an experimental treatment. This is not a study to see if you would recover without treatment at all. As in any medical treatment, you are free to withdraw from a clinical trial at any time and seek other treatment options. To learn more about clinical trials:

• The American Cancer Society has a document on Clinical Trials – Patient Participation. Call 1-800-ACS-2345 for more information.
• The National Cancer Institute (NCI) can provide a listing of clinical trials based on the type and stage of your cancer. Call 1-800-4-CANCER or visit the NCI’s Web site.

Can I take other medicines while I am getting chemotherapy?

Some medicines may interfere with the effects of your chemotherapy. To ensure that your treatment is the most effective that it can be

• Tell your doctor or nurse about any and all prescription and nonprescription medicines you are taking.
• Make a list of the name of each drug, who prescribed it, how often you take it, the reason you take it, and the dosage.
• Be sure to include some of the preparations you may not think of as medicines. These would be aspirin, herbal and dietary supplements, vitamins, and over-the-counter medicines.

Your doctor will tell you if you should stop taking any of these medicines before you start chemotherapy. After your treatments begin, check with your doctor before taking any new medicines, or supplements and before stopping the ones you already take.

Can I be around my family and friends while I am getting chemotherapy?

Only a few treatments require you to avoid close contact with loved ones for a short amount of time. If this is necessary, your doctor will talk to you about this possibility when discussing treatment options.

Most chemotherapies do, however, cause a decrease in your ability to fight infection. It is very important that you stay away from anyone who is sick. The best way to prevent infection is by washing your hands often and having your family and friends do the same when they are with you. For more information, see the section “How Will Chemotherapy Affect My Blood Cell Count?”

For more information on being at home with family and friends during treatment, please see the American Cancer Society booklets, Helping Children When A Family Member Has Cancer: Dealing with Treatment and Caring for the Patient with Cancer at Home.

Will I be able to work during treatment?

Whether you can continue work, school, and other activities depends on your treatment and how it affects you. For some treatments, a hospital stay of one or more weeks is needed, but most people are able to continue working during treatment. You might be able to schedule your treatments late in the day or right before the weekend so that they interfere with work as little as possible.

If your chemotherapy makes you tired, try to adjust your work schedule for a while. You may be able to arrange a part-time schedule or work at home. Federal and state laws may require some employers to allow you to work a flexible schedule during your treatment.

To find out more about your rights as an employee, call your local American Cancer Society office or our toll-free number at 1-800-ACS-2345, or email us by clicking on the “contact us” button at www.cancer.org. You may also find out about employment-related rights by contacting your congressional or state representatives.

How will I know If my chemotherapy is working?

Your cancer care team will measure how well your treatments are working through frequent tests, including physical exams, blood tests, bone marrow biopsies, scans, and x-rays. Ask your doctor about the test results and what they show about your progress. Although you may experience side effects, these side effects do not indicate whether treatment is effective.

How Do I Give My Permission for this Treatment?

You will be asked to give your written permission to receive chemotherapy based on your understanding of the drugs your doctor recommends. Know the answers to all of these questions before you sign the consent form.

• Which chemotherapy drugs will be given to me for my cancer?
• How will the drugs be given to me?
• How often will I be given chemotherapy drugs?
• How long will my treatments last?
• What side effects might I experience from these drugs?
• How likely is this treatment to be successful?

Although the specifics of the consent form may vary from state to state, the form usually states that your doctor has explained your condition to you, how the chemotherapy will benefit you, the risks, and the other options available to you.

Your signature means that you have received this information and that you are willing to be treated with chemotherapy. This process is called giving informed consent.

How do I pay for my chemotherapy?

The cost of chemotherapy varies with the kinds of drugs used, how long and how often they are given, and whether you get them at home, in a clinic, office, or hospital. Most health insurance policies, including Medicare Part B, cover at least part of the cost of many kinds of chemotherapy.

To reduce their costs, private insurance companies more often are deciding not to pay for the use of some chemotherapy drugs, even if those drugs are effective cancer therapies. Before you begin treatment, find out whether your insurance company or Medicare will pay for your care.

For more information on how to maintain control of your finances so you can better focus your energies on treatment and recovery, see the American Cancer Society booklet, Financial Guidance for Cancer Survivors and Their Families: In Treatment.

What You Need to Know About Insurance Coverage

Insurance companies deny payment for chemotherapy for these reasons:

• They may not be aware of new treatments.
• They may limit the selection of drugs that physicians can use for chemotherapy.
• They may restrict payment to the uses initially approved by the Food and Drug Administration.
• If you are going to participate in a clinical trial, find out if your insurance will cover the cost of patient care. In some situations, insurers may deny payment. Coverage may vary by state.
• If your insurer denies payment for your treatment, don’t give up. Most people do get payment eventually.

What to Do If Your Claim Is Not Paid:

• Tell your health care team if you have been denied payment so that they can consult with your insurer and help answer any questions.
• Ask your doctor’s office staff to provide insurance companies with the results of scientific studies showing that a particular drug is effective for your type of cancer.
• Ask hospitals and cancer centers to provide similar information. These actions are often sufficient for your claim to be paid.
• Contact reimbursement specialist hotlines at pharmaceutical companies.

In some states, Medicaid (which makes health care services available for people with financial need) may help pay for certain treatments. Contact the office that handles social services in your city or county to find out if you are eligible for Medicaid and whether your chemotherapy is a covered expense. Medicaid approval can take a long time, so begin the process as early as possible.

You can also contact your hospital’s social service office which may be able to direct you to other sources of help.

A last alternative may be to sue the insurance company to get payment for your chemotherapy. In many cases, courts have sided with patients and ordered insurance companies to pay for a patient’s treatment.

If I already have a port placed in my arm, why do I have to have my blood drawn through a separate vein?

If you have or are going to have a port placed, we will ask that you continue to have your blood drawn via a vein in your arm. This will allow for greater port longevity as well as decrease infection risks. The port will need to be flushed every 4 – 6 weeks.