Cancer General Information

What Is Cancer? Cancer is the general name for a group of more than 100 diseases in which cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because abnormal cells grow out of control. Untreated cancers can cause serious illness and even death. How a normal cell becomes cancer Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more quickly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all of the cell's activities. Most of the time when DNA becomes damaged, either the cell dies or is able to repair the DNA. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a persons DNA gets damaged by things in the environment, like, chemicals, viruses, tobacco smoke or too much sunlight. How cancers differ Cancers can begin in many different parts of the body. But, different types of cancer can act very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That's why people with cancer need treatment that is aimed at their particular kind of cancer. How cancer spreads (metastasis) Because cancer cells keep growing and dividing, they are different from normal cells. Instead of dying, they outlive normal cells and continue to grow and make new abnormal cells. Cancer usually forms as a tumor (a lump or mass.) Some cancers, like leukemia, do not form tumors. Instead, these cancer cells involve the blood and blood-forming organs, and circulate through other tissues where they grow. Cancer cells often travel through the bloodstream or through the lymph system to other parts of the body where they begin to grow and replace normal tissue. This spreading process is called metastasis. Even when cancer has spread to a different part of the body, it is still named for the place in the body where it started. For example, breast cancer that has spread to the liver is metastatic breast cancer, not liver cancer. Prostate cancer that has spread to the bone is called metastatic prostate cancer, not bone cancer. Remember that not all tumors are cancerous. Benign (non-cancerous) tumors do not spread to other parts of the body (metastasize) and are very rarely life- threatening. How common is cancer? Half of all men and one-third of all women in the US will develop cancer during their lifetimes. Today, millions of people are living with cancer or have had cancer. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking, limiting time in the sun, being physically active, and eating a better diet. The sooner a cancer is found and treated, the better the chances are for living for many years. Who Gets Cancer? Anyone can get cancer at any age; however, about 77% of all cancers are diagnosed in people age of 55 and older. Today, millions of people are living with cancer or have been cured of the disease. The sooner a cancer is found and the sooner treatment begins, the better a patient's chances are of a cure. That's why early detection of cancer is such an important weapon in the fight against cancer. What Are the Risk Factors for Cancer? A risk factor is anything that increases a person's chance of getting a disease. Some risk factors can be changed, and others cannot. Risk factors for cancer can include a person's age, sex, and family medical

history. Others are linked to cancer-causing factors in the environment. Still others are related to lifestyle choices such as tobacco and alcohol use, diet, and sun exposure. Having a risk factor for cancer means that a person is more likely to develop the disease at some point in their lives. However, having one or more risk factors does not necessarily mean that a person will get cancer. Some people with one or more risk factors never develop the disease while other people who do develop cancer have no apparent risk factors. Even when a person who has a risk factor is diagnosed with cancer, there is no way to prove that the risk factor actually caused the cancer. Different kinds of cancer have different risk factors. Some of the major risk factors include the following:

Cancers of the lung, mouth, larynx, bladder, kidney, cervix esophagus, and pancreas are related to tobacco use, including cigarettes, cigars, chewing tobacco, and snuff. Smoking alone causes onethird of all cancer deaths. Skin cancer is related to unprotected exposure to strong sunlight. Breast cancer risk factors include several factors: age; changes in hormone levels throughout life, such as age at first menstruation, number of pregnancies, and age at menopause; obesity; and physical activity. Some studies have also shown a connection between alcohol consumption and an increased risk of breast cancer. Also, women with a mother or sister who have had breast cancer are more likely to develop the disease themselves. While all men are at risk for prostate cancer, several factors can increase the chances of developing the disease, such as age, race, and diet. The chance of getting prostate cancer goes up with age A high-fat diet may play a part in causing prostate cancer. Also, men with a father or brother who have had prostate cancer are more likely to get prostate cancer themselves.

Overall, environmental factors, defined broadly to include tobacco use, diet, and infectious diseases, as well as chemicals and radiation cause an estimated 75% of all cancer cases. Among these factors, tobacco use, unhealthy diet, and physical activity are more likely to affect personal cancer risk. Research shows that about one-third of all cancer deaths are related to dietary factors and lack of physical activity in adulthood. Certain cancers are related to viral infections and could be prevented by behavior changes. Can Cancer Be Prevented? Smoking and drinking alcohol cause some people to get certain types of cancer. These cancers might be prevented by avoiding tobacco and alcohol. The best idea is to never use tobacco at all. Cigarettes, cigars, pipes and smokeless tobacco cause cancer and should not be used. People who already smoke should try to quit. Former smokers have less risk of cancer than do people who continue to smoke. The chances of getting skin cancer can be lowered by staying in the shade as much as you can, wearing a hat and shirt when you are in the sun, and using sunscreen. We know that our diet, (what we eat) is linked to some types of cancer, although the exact reasons are not yet clear. The best advice is to eat a lot of fresh fruits and vegetables and whole grains like pasta and bread, and to cut down on high fat foods. There are tests, called screening examinations that adults should have in order to find cancer early. If cancer is found early it can often be cured. What Causes Cancer? Some kinds of cancer are caused by things people do. Smoking can cause cancers of the lungs, mouth, throat, bladder, kidneys and several other organs, as well as heart disease and stroke. While not everyone who smokes will get cancer, smoking increases a person's chance of getting the disease. Drinking a lot of alcohol has also been shown to increase a person's chance of getting cancer of the mouth, throat, and some other organs. This is especially true if the person drinks and smokes. Radiation (x-rays) can cause cancer. But the x-rays used by the doctor or dentist are safe. Too much exposure to sunlight without any protection can cause skin cancer. In many cases, the exact cause of cancer remains a mystery. We know that certain changes in our cells can cause cancer to start, but we don't yet know exactly how this happens. Many scientists are studying this problem.

Signs and Symptoms of Cancer A symptom is a signal of disease, illness, injury, or that something is not right in the body. Symptoms are felt or noticed by the person who has them, but may not be easily seen by anyone else. For example, chills, weakness, aches, and feeling short of breath may be symptoms of pneumonia. A sign is also a signal that something is not right in the body. But signs are signals that can be seen by a doctor, nurse, or other health care professional. Fever, fast breathing, and abnormal breathing sounds heard through a stethoscope may be signs of pneumonia. Having one symptom or sign may not be enough to figure out what's causing it. For example, a rash in a child could be a sign of a number of things, such as poison ivy, an infectious disease like measles, a skin infection, or a food allergy. But if the child has the rash along with other signs and symptoms like a high fever, chills, achiness, and a sore throat, then a doctor can get a better picture of the illness. In many cases, a patient's signs and symptoms alone do not give the doctor enough clues to figure out the cause of an illness. Then medical tests, such as x-rays, blood tests, or a biopsy may be needed. How does cancer cause signs and symptoms? Cancer is a group of diseases that may cause almost any sign or symptom. The signs and symptoms will depend on where the cancer is, how big it is, and how much it affects nearby organs or tissues. If a cancer has spread (metastasized), symptoms may appear in different parts of the body. As a cancer grows, it can begin to push on nearby organs, blood vessels, and nerves. This pressure creates some of the signs and symptoms of cancer. If the cancer is in a critical area, such as certain parts of the brain, even the smallest tumor can cause early symptoms. But sometimes cancer starts in places where it will not cause any symptoms until it has grown quite large. Pancreas cancers, for example, do not usually grow large enough to be felt from the outside of the body. Some pancreatic cancers do not cause symptoms until they begin to grow around nearby nerves (this causes a backache). Others grow around the bile duct and block the flow of bile. This causes a yellowing of the eyes and skin called jaundice. By the time a pancreatic cancer causes these signs or symptoms, it is usually in an advanced stage. This means it has grown and spread beyond the place it started the pancreas. A cancer may also cause symptoms like fever, extreme tiredness (fatigue), or weight loss. This may be because cancer cells use up much of the bodys energy supply, or they may release substances that change the way the body makes energy from food. Or the cancer may cause the immune system to react in ways that produce these symptoms. Sometimes, cancer cells release substances into the bloodstream that cause symptoms which are not usually linked to cancer. For example, some cancers of the pancreas can release substances which cause blood clots in veins of the legs. Some lung cancers make hormone-like substances that raise blood calcium levels. This affects nerves and muscles, making the person feel weak and dizzy. How are signs and symptoms helpful? Treatment is most successful when cancer is found as early as possible. Finding cancer early usually means it can be treated while it is still small and is less likely to have spread to other parts of the body. This often means a better chance for a cure, especially if the cancer can be removed with surgery. A good example of the importance of finding cancer early is melanoma skin cancer. Skin cancer can be easy to remove if it has not grown deep into the skin. The 5-year survival rate (percentage of people living at least 5 years after diagnosis) at this stage is nearly 100%, Once melanoma has spread to other parts of the body, the 5-year survival rate drops below 20%. Sometimes people ignore symptoms. They may not know that symptoms could mean something is wrong. Or they may be frightened by what the symptoms might mean and don't want to get medical help. Some symptoms, such as tiredness, are more likely to have a cause other than cancer and can seem unimportant, especially if there is an obvious cause or the problem only lasts a short time. In the same way, a person may reason that a symptom like a breast lump is probably a cyst that will go away by itself. But no symptom should be ignored or overlooked, especially if it has been there for a long time or is getting worse.

Most likely, any symptoms you may have will not be caused by cancer, but its important to have them checked out by a doctor, just in case. If cancer is not the cause, a doctor can help figure out what is and treat it, if needed. General cancer signs and symptoms You should know some of the general (non-specific) signs and symptoms of cancer. But remember, having any of these does not mean that you have cancer many other things cause these signs and symptoms, too. Unexplained weight loss Most people with cancer will lose weight at some point. An unexplained weight loss of 10 pounds or more (when you're not trying to lose weight) may be the first sign of cancer. This happens most often with cancers of the pancreas, stomach, esophagus, or lung. Fever Fever is very common with cancer, but it more often happens after cancer has spread from where it started. Almost all patients with cancer will have fever at some time, especially if the cancer or its treatment affects the immune system. This can make it harder for the body to fight infection. Less often, fever may be an early sign of cancer, such as blood cancers like leukemia or lymphoma. Fatigue Fatigue is extreme tiredness that does not get better with rest. It may be an important symptom as cancer grows. It may happen early, though, in cancers like leukemia, or if the cancer is causing blood loss, which can happen with some colon or stomach cancers. Pain Pain may be an early symptom with some cancers such as bone cancers or testicular cancer. A headache that does not go away or respond to treatment may be a symptom of a brain tumor. Back pain can be a symptom of cancer of the colon, rectum, or ovary. Most often, pain that is linked to cancer is a symptom of cancer that has already metastasized (spread from where it started). Skin changes Along with cancers of the skin (see the next section), some other cancers can cause skin symptoms or signs that can be seen. These signs and symptoms include:

darker looking skin (hyper pigmentation) yellowish skin and eyes (jaundice) reddened skin (erythema) itching excessive hair growth

Signs and symptoms of certain cancers Along with the general symptoms, you should watch for certain other common symptoms and signs which could suggest cancer. Again, there may be other causes for each of these, but it is important to see a doctor about them as soon as possible. Change in bowel habits or bladder function Long-term constipation, diarrhea, or a change in the size of the stool may be a sign of colon cancer. Pain when passing urine, blood in the urine, or a change in bladder function (such as needing to pass urine more or less often than usual) could be related to bladder or prostate cancer. Any changes in bladder or bowel function should be reported to a doctor. Sores that do not heal Skin cancers may bleed and look like sores that do not heal. A long-lasting sore in the mouth could be an oral cancer and should be dealt with right away, especially in people who smoke, chew tobacco, or often

drink alcohol. Sores on the penis or vagina may either be signs of infection or an early cancer, and should not be ignored. White patches inside the mouth or white spots on the tongue White patches inside the mouth and white spots on the tongue may be leukoplakia. Leukoplakia is a precancerous area that is caused by ongoing irritation. It is often caused by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at high risk for developing leukoplakia. If it is not treated, leukoplakia can become oral cancer. Any long-lasting mouth changes should be checked by a doctor or dentist right away. Unusual bleeding or discharge Unusual bleeding can happen in early or advanced cancer. Blood in the sputum (phlegm) may be a sign of lung cancer. Blood in the stool (or a dark or black stool) could be a sign of colon or rectal cancer. Cancer of the cervix or the endometrium (lining of the uterus) can cause unusual vaginal bleeding. Blood in the urine may be a sign of bladder or kidney cancer. A bloody discharge from the nipple may be a sign of breast cancer. Thickening or lump in the breast or other parts of the body Many cancers can be felt through the skin. These cancers occur mostly in the breast, testicle, lymph nodes (glands), and the soft tissues of the body. A lump or thickening may be an early or late sign of cancer and should be reported to a doctor, especially if youve just found it or notice it has grown in size. Indigestion or trouble swallowing While they most often are caused by other things, indigestion or swallowing problems may be signs of cancer of the esophagus (the swallowing tube that goes to the stomach), stomach, or pharynx (throat). Recent change in a wart or mole or any new skin change Any wart, mole, or freckle that changes color, size, or shape, or loses its definite borders should be reported to a doctor right away. Any new skin changes should be reported as well. A skin change may be a melanoma which, if found early, can be treated successfully. Nagging cough or hoarseness A cough that does not go away may be a sign of lung cancer. Hoarseness can be a sign of cancer of the larynx (voice box) or thyroid. Although the signs and symptoms listed are the ones more commonly seen with cancer, there are many others that are less common and are not listed here. If you notice any major changes in the way your body works or the way you feel, especially if it lasts for a long time or gets worse, let a doctor know. If it has nothing to do with cancer, the doctor can find out more about what's going on and treat it, if needed. If it is cancer, you'll give yourself the best chance to have it treated early, when treatment is most likely to be effective. What Is Remission? Remission is a period of time when the cancer is responding to treatment or is under control. In a complete remission, all the signs and symptoms of the disease disappear. It is also possible for a patient to have a partial remission in which the cancer shrinks but does not completely disappear. Remissions can last anywhere from several weeks to many years. Complete remissions may continue for years and be considered cures. If the disease returns, another remission often can occur with further treatment. A cancer that has recurred may respond to a different type of therapy, including a different drug combination. What Is Staging? Staging is the process of finding out how far the cancer has spread. Staging the cancer is a vital step in determining your treatment choices, and it will also give your health care team a clearer idea of the outlook for recovery. Staging can take time, and people are usually anxious to begin treatment soon. Do not worry that the staging process is taking up treatment time. Keep in mind that by staging the cancer, you and your health care team will know which treatments are likely to be the most effective before beginning the treatment.

There is more than one system for staging. The TNM system is the one used most often. It gives three key pieces of information:

T describes the size of the tumor, and whether the cancer has spread to nearby tissues and organs. N describes how far the cancer has spread to nearby lymph nodes. M shows whether the cancer has spread (metastasized) to other organs of the body.

Letters or numbers after the T, N, and M give more details about each of these factors. For example, a tumor classified as T1, N0, M0 is a tumor that is very small, has not spread to the lymph nodes, and has not spread to distant organs of the body. Once the TNM descriptions have been established, they can be grouped together into a simpler set of stages, stages 0 through stage IV (0-4). In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious, widespread cancer. After looking at your test results, your doctor will tell you the stage of your cancer. Be sure to ask your doctor any questions you might have about what the stage of your cancer means and how it will impact your treatment options. How Is Cancer Treated? The number of treatment choices you have will depend on the type of cancer, the stage of the cancer, and other individual factors such as your age, health status, and personal preferences. You are a vital part of your cancer care team - you should discuss with them which treatment choices are best for you. Don't be afraid to ask as many questions as you have. Make sure you understand your options. A cancer diagnosis usually gives people a sense of urgency in making choices about treatment and services. However, take the time to consider all the options available to you so you will be as well informed as possible. The four major types of treatment for cancer are surgery, radiation, chemotherapy, and biologic therapies. You might also have heard about hormone therapies such as tamoxifen and transplant options such as those done with bone marrow. What Treatment Will Be Best for Me? Your cancer treatment will be entirely based on your unique situation. Certain types of cancer respond very differently to different types of treatment, so determining the type of cancer is a vital step toward knowing which treatments will be most effective. The cancer's stage (how widespread it is) will also determine the best course of treatment, since early-stage cancers respond to different therapies than later-stage ones. Your overall health, your lifestyle, and your personal preferences will also play a part in deciding which treatment options will be best for you. Not all types of treatment will be effective in your situation, so be sure that you understand your options. Don't be afraid to ask questions; it is your right to know what treatments are most likely to help you and what their side effects may be. Palliative versus Curative Goals: Before starting treatment, ask about the goal of treatment. Is the purpose of the treatment to cure the cancer, control it, or treat symptoms? Sometimes the goal of treatment can change. Biologic Therapies There is a lot of evidence that suggests that the immune system, the body's natural defense mechanism, plays a major role in the body's response to cancer. At least some forms of cancer occur when the immune system fails to destroy cancer cells or to prevent their growth. Biologic therapy is an effective treatment for certain cancers. It is sometimes called immunotherapy, biotherapy, or biological response modifier therapy. Biologic therapies use the body's immune system to fight cancer or to lessen the side effects of some cancer treatments. Biologic therapies can act in several ways in cancer treatment. These include interfering with cancer cell growth, acting indirectly to help healthy immune cells control cancer, and helping to repair normal cells damaged by other forms of cancer treatment. There are several kinds of biologic therapy now in use. More than one kind of biologic therapy may be used, or biologic therapy may be combined with chemotherapy or radiation therapy to treat cancer.

Chemotherapy While surgery and radiation therapy are used to treat localized cancers, chemotherapy is used to treat cancer cells that have metastasized (spread) to other parts of the body. Depending on the type of cancer and its stage of development, chemotherapy can be used to cure cancer, to keep the cancer from spreading, to slow the cancer's growth, to kill cancer cells that may have spread to other parts of the body, or to relieve symptoms caused by cancer. Chemotherapy is treatment with powerful medicines that are most often given by mouth or by injection. Unlike radiation therapy or surgery, chemotherapy drugs can treat cancers that have spread throughout the body, because they travel throughout the body in the bloodstream. Often, a combination of chemotherapy is used instead of a single drug. Chemotherapy is given in cycles, each followed by a recovery period. The total course of chemotherapy is often about six months, usually ranging from three to nine months. After a cancer is removed by surgery, chemotherapy can significantly reduce the risk of cancer returning. The chances of cancer returning and the potential benefit of chemotherapy depend on the type of cancer and other individual factors. Side effects of chemotherapy Side effects of chemotherapy depend on the type of drugs, the amounts taken, and the length of treatment. The most common are nausea and vomiting, temporary hair loss, increased chance of infections, and fatigue. Many of these side effects can be uncomfortable or emotionally upsetting. However, most side effects can be controlled with medicines, supportive care measures, or by changing the treatment schedule. If you experience side effects, ask your doctor about ways to help ease or eliminate them. Also, keep your doctor informed of all side effects that you experience, as some may require immediate medical attention. Fatigue is one of the most common side effects of radiation and chemotherapy. Like most other side effects, it will disappear once the treatment is complete. You can help yourself by getting enough rest, eating a wellbalanced diet, drinking plenty of liquids, and by planning your activities to include frequent rest periods. Though it is not medically harmful, hair loss can be an upsetting side effect. Most people feel that their hairstyle is a part of their identity, so it is only normal that hair loss is distressing. Some people experience hair loss during chemotherapy treatments (and sometimes with radiation treatment to the head) while others do not, even with the same drugs. Not all drugs cause hair loss. When it does occur, the hair almost always grows back after the treatments are completed. If hair loss does occur, it usually begins within two weeks of the start of therapy and gets worse 1-2 months after the start of therapy. Hair regrowth often begins even before therapy is completed. Most people are able to find suitable ways of managing the hair loss until it grows back, with specially designed hats, scarves, and wigs. People having chemotherapy sometimes become discouraged about the length of time their treatment is taking or the side effects they are having. If that happens to you, talk to your doctor. There are ways to reduce the side effects or make them easier to manage. Keep in mind that the expected benefits of the treatment should outweigh any problems you might have because of it. Clinical Trials The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions: Is the treatment helpful? How does this new type of treatment work? Does it work better than other treatments already available? What side effects does the treatment cause? Are the side effects greater or less than the standard treatment? Do the benefits outweigh the side effects? In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are 3 phases of clinical trials in which a treatment is studied.

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug. Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesnt cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The cancer care team also looks for side effects. Phase III clinical trials: Phase III studies involve large numbers of patient often several hundred. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others have. If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you. However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial. Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need. Among the questions, you should ask are: Is there a clinical trial for which I would be eligible? What is the purpose of the study? What kinds of tests and treatments does the study involve? What does this treatment do? Has it been used before? Will I know which treatment I receive? What is likely to happen in my case with, or without, this new treatment? What are my other choices and their advantages and disadvantages? How could the study affect my daily life? What side effects can I expect from the study? Can the side effects be controlled? Will I have to be hospitalized? If so, how often and for how long? Will the study cost me anything? Will any of the treatment be free? If I am harmed as a result of the research, what treatment would I be entitled to? What type of long-term follow-up care is part of the study? Has the treatment been used to treat other types of cancers?

Complementary and Alternative Therapies Complementary and alternative therapies are a diverse group of health care practices, systems, and products that are not part of usual medical treatment. They may include products such as vitamins, herbs, or dietary supplements, or procedures such as acupuncture, massage, and a host of other types of treatment. There is a great deal of interest today in complementary and alternative treatments for cancer. Many are now being studied to find out if they are truly helpful to people with cancer. You may hear about different treatments from family, friends, and others, which may be offered as a way to treat your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit. The complementary medicine or methods as those that are used along with your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven not to be useful or even to be harmful, but are still promoted as cures. If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying, replacing, or interfering with regular cancer treatment.

Before changing your treatment or adding any of these methods, discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it's important to talk with your doctor. Cancer Pain Pain is one of the reasons people fear cancer so much. If someone you know has cancer, it is normal to be afraid of witnessing pain. In fact, there are some cancers, which cause no physical pain at all. When it does occur, cancer pain can happen for a variety of reasons. Some people have pain as a result of the growth of a tumor or as a result of advanced cancer, while others may experience pain as a result of treatment side effects. You should also know that doctors can treat and manage cancer pain with modern techniques and medicines. A great deal of progress has been made in pain control, so pain can be reduced or alleviated in almost all cases. Even patients with advanced disease can be kept comfortable. You may also be concerned that someone taking pain medication for cancer will become addicted to the medication. However, all evidence shows that people who take prescribed drugs for cancer pain do not become addicted. In addition, some methods of pain reduction, such as acupuncture and guided imagery, do not involve drugs. Fatigue in People with Cancer What is fatigue? Fatigue is feeling tired -- physically, mentally, and emotionally. It means having less energy to do the things you normally do or want to do. It can be caused by cancer, cancer treatment, and other factors. Fatigue can last a long time and can affect your day to day activities. The fatigue that comes with cancer is different from the fatigue of everyday life. Everyday, normal fatigue is most often a short-term problem that gets better with rest. Cancer-related fatigue is worse and it causes more distress. Rest does not make it go away. And even a small amount of activity may make you feel exhausted. For some people, this kind of fatigue can cause even more distress than pain, nausea, vomiting, or depression. Cancer-related fatigue can: differ from one day to the next in how bad it is and how much it bothers you be overwhelming and make it hard for you to feel well make it hard for you to be with your friends and family make it hard for you to do your normal activities, including going to work make it harder for you to follow your cancer treatment plan last different lengths of time, which makes it hard to guess how long yours will go on

Cancer patients say fatigue is the most distressing side effect of cancer and its treatment -- it can have a major affect on a person's quality of life. Fatigue is very common in people with cancer Cancer-related fatigue is the most common side effect of cancer and cancer treatment. Research suggests that anywhere between 70% to 100% of cancer patients getting treatment have fatigue. And about 30% to 50% of cancer survivors have reported fatigue that lasts for months or even years after they finish treatment. Even though fatigue is a very distressing symptom, doctors and nurses seldom focus on it, and patients and caregivers rarely report it. It may be hard to talk about, but fatigue is normal and common for people with cancer. There are things that can be done to help if your health care team knows you are having this problem.

Talk about your fatigue Treating fatigue is an important part of care for you and your family. But before anything can bedone to help you, your health care team must know about your level of fatigue, or how bad your fatigue is. People with fatigue describe it in many ways. They may say they feel tired, weak, exhausted, weary, wornout, or slow; have no energy; and cannot concentrate. They also talk about having heavy arms and legs; little drive to do anything; being unable to sleep or sleeping too much; or feeling moody, sad, irritable, or frustrated. Patients rarely describe their symptom as "fatigue" unless their health care team suggests it. Only you know if you have fatigue and how bad it is. No laboratory tests or x-rays can diagnose or show your level of fatigue. The best measure of fatigue comes from your own report of your fatigue level to your health care team. But fatigue can be hard to describe. You can describe your level of fatigue as none, mild, moderate, or severe. Or you can use a scale of 0 to 10, where a 0 means no fatigue at all, and a 10 means the worst fatigue you can imagine. Talk to your doctor or nurse about how to describe your fatigue so they can understand how it is affecting your everyday life. How bad is your fatigue? If you have moderate (4 to 6) to severe (7 to 10) fatigue, your doctor may ask you to give as much information as you can about your fatigue. You may be asked questions like: When did the fatigue first start? When did you first notice that this fatigue is different than usual for you? How long has it lasted? Has it changed over time? How so? Does anything make it better? Worse? Do you have any other problems or concerns? How has the fatigue affected the things you do every day or the activities that give meaning and enjoyment to your life?

In planning how to treat your fatigue, your doctor may take into account your cancer, the type and length of treatment, how likely the treatment is to cause fatigue, and your response to treatment. What causes fatigue in people with cancer? Cancer itself can cause fatigue directly by spreading to the bone marrow, causing anemia (low red blood cell count), or indirectly, by forming toxic substances in the body that change the way normal cells work. Fatigue is also very common with many cancer treatments, such as chemotherapy, radiation therapy, bone marrow transplant, and immunotherapy. Cancer treatments often kill fast-growing healthy cells, especially the blood-making cells in the bone marrow. This causes fatigue because red blood cells carry oxygen to fuel all the cells in the body. Too few red blood cells (anemia) means too little energy to meet the body's needs. Treatments can kill normal cells and cancer cells, which leads to a build-up of cell waste. The body needs extra energy to clean up this waste and repair damaged tissue. Here are some questions about fatigue and your cancer treatment that you may want to ask: Will the cancer treatment that I am getting cause fatigue? How bad will my fatigue likely get? Are there ways to control my fatigue or make it better? If my fatigue gets bad, how will you decide how to treat it? What can be done if the treatment does not make my fatigue better?

10

What are the likely side effects of the treatments for fatigue? What other health care professionals can help manage my fatigue? Is my fatigue caused by anemia? If so, how will it be treated?

Other things that can affect fatigue Fatigue is different for every cancer patient. Many treatment-related and disease-related factors have been linked to fatigue, but doctors still do not know exactly what causes cancer-related fatigue. There are some other factors that often worsen fatigue, and you should be checked for them. Managing these factors can greatly help reduce the fatigue. anemia pain emotional distress (including depression and anxiety) sleep problems medicines you are taking that could worsen your symptoms other medical problems (such as infection; low thyroid function; and heart, lung, liver, kidney, or nervous system disease) nutrition problems low level of physical activity

Anemia A low red blood cell count is called anemia (uh-nee-me-uh). Your red blood cell count will be measured with a blood test called a CBC. (CBC stands for complete blood count.) Doctors often define anemia as a blood hemoglobin (Hb) level of less than 12 g/dL (grams per deciliter). But many people do not feel much different until the hemoglobin level falls below 11 g/dL. Symptoms of anemia get worse as the hemoglobin gets lower. These symptoms can include: rapid heart beat shortness of breath trouble breathing on exertion (such as when walking or climbing stairs) dizziness pale skin fatigue

There are many different causes of anemia. Your doctor will try to find out the cause of your anemia so they can give you treatment that makes it better. Pain Cancer pain can make you less active; decrease your appetite, cause sleep problems, and cause depression -- all of which can lead to fatigue. Cancer pain should not be accepted as part of cancer treatment. There is always something that can be done to make pain better. Emotional distress People diagnosed with cancer go through many unpleasant emotions. There are many different types of feelings, from anger to depression, but their overall effect is distress. Distress can include a feeling of sadness about the loss of good health or fear of what will happen in the future. These are normal feelings. But sometimes the distress becomes so great that it causes physical problems like fatigue. Depression and anxiety are common types of distress that can cause the physical symptom of fatigue. Sleep problems If you wake up often during the night, have trouble falling asleep, or wake up early in the morning and cannot go back to sleep, you are most likely not getting the rest you need. This change in your sleep can lead to fatigue. Tell your doctor or nurse about your sleeping problems. They will try to find out why you are having trouble sleeping so they can help plan the best treatment for this problem. Medicines

11

Many medicines can cause symptoms of fatigue and problems with thinking. This includes over-the-counter drugs, vitamins, herbs, and other supplements, as well as prescription medicines. The drugs most likely to cause fatigue are pain medicines; sleep medicines; anti-depressants; and anti-nausea and anti-seizure medicines. Some heart medicines can also cause fatigue. The degree of sleepiness varies from patient to patient. Taking many drugs with many side effects may make fatigue worse, too. It is important to tell your health care team about all vitamins, herbs, supplements, and medicines you are taking. Keeping a journal may help you keep track of your medicines and symptoms. Other medical problems Many people have other medical problems or illnesses that are not related to cancer, but may add to fatigue. These illnesses should be identified and treated. Examples of other medical problems that may be part of fatigue are: heart problems, such as congestive heart failure lung problems, such as emphysema or shortness of breath kidney problems, such as kidney failure brain problems, such as seizures or dementia infections, such as pneumonia or viral illnesses low thyroid function

Low thyroid gland function is very common in people in the United States. Anyone with fatigue should be tested for this. Blood tests are done to find out how much thyroid hormone is present in the blood. If the level of thyroid hormone is low, treatment can be given to replace the thyroid hormone so that the body gets what it needs. Poor nutrition The body needs protein, carbohydrates, fats, vitamins, minerals, and water to do its work. In people with cancer, changes in nutrition can affect fatigue. These changes include how well the body can process nutrients; the need for more energy than usual; and poor intake of food, fluids, and certain minerals. The changes can be caused by: changes in metabolism (the body's ability to break down and use food) the need to repair damaged cells uncontrolled tumor growth competing for nutrients poor appetite nausea and vomiting diarrhea

You may have blood tests to measure things like sodium, potassium, calcium, and magnesium -- these are important minerals that your body needs. You may ask to be referred to a registered dietitian who can help you learn how to best meet your nutrition during this time. Inactivity Cancer treatment along with less physical activity can make you less able to do the things you used to do. And you may find that it takes much more effort and more energy to do the things you need to do. This can worsen fatigue. Physical exercise can help you build up your energy level. If you have more energy, it can help you do your usual activities and have less fatigue. Talk to your doctor before you start any exercises. A careful work-up by a physical therapist can help plan the right exercise program for you. Treating fatigue Education and counseling are part of the treatment and help you learn how to save energy, reduce stress, and use distraction to think about things other than the fatigue. Fatigue is often caused by more than one problem. Treating a certain problem, like anemia, may make you feel better, but other things may still need to be done. For this reason your doctor may have you try many different things to ease your fatigue. These may or may not include medicines. If the cause of fatigue is known, treatment will focus on the cause. For example, if anemia is adding to your fatigue, the anemia can be treated. In another patient, treatment may include correcting fluid and mineral imbalances. A program of regular exercise, managing your stress, and finding ways to deal with anxiety and

12

depression seem to work the best in dealing with fatigue. Still, treating sleep problems and correcting nutrition problems can help decrease fatigue, too. Tips for managing fatigue Save your energy Saving or conserving energy is one way to make sure you have enough energy to do what needs to be done on a daily basis. You may need to accept the fact that you can't do everything you want to do at your current level of energy. Each day, decide which things are the most important to do and focus on those tasks. Do things slowly, so that you will not use too much energy as you go. Let others help you. This can help them feel useful and get your tasks done, too. Distraction Sometimes feeling tired can become so discouraging and frustrating that it's easy to let it become the focus of your thoughts. Try to distract yourself with other things, like listening to music, having relaxing visits with friends or family, or reading a book. These things can give you an escape from your fatigue without using up too much energy. Attention-restoring activities Certain activities can help you relax, focus better, and direct your attention under stress. These activities include things like walking on a beach, sitting in a peaceful setting, gardening, doing volunteer activities not related to your illness, or bird watching. Reduce stress Having cancer is stressful and cancer treatment can cause even more stress. Talk with a social worker or nurse on your health care team about your level of stress. This can help you know if it is "normal" stress or more worrisome anxiety or depression. Feeling tired may be related to feeling depressed and anxious. Support groups, mental health counseling, stress management training, and relaxation exercises are some ways you can improve the feelings related to fatigue and help you overcome the tiredness you feel. Exercise Research has shown that there are some ways to improve your energy and activity level that do not involve medicine. An aerobic exercise program -- started only with your doctor's OK -- can lead to better heart and lung function, as well as more positive feelings about your life and well-being. You may need to see a physical therapist to learn the best exercise routine for you to follow at this time. You must be careful about any form of exercise if you have any of these: bone metastasis (cancer that has spread to your bones) a low white blood cell count a low platelet count a fever anemia

These factors can lead to more physical problems if they are not taken into account when planning an exercise program. Not only can the right amount and type of exercise help fatigue, it can also help you sleep better. Another benefit of exercise is that it may make your mood better, too. Nutritional counseling Many cancer patients have changes in the way they eat, swallow, and taste during treatment. Talking with a registered dietician may help you learn ways to manage problems like loss of appetite, diarrhea, nausea, or vomiting. A nutritionist also can make sure you are getting enough fluids and nutrients so that your blood chemistry is balanced. Sleep improvement Sleep problems are common during cancer treatment. You may have trouble falling asleep or sleep too much. Sleep experts tell us that having a regular time to go to bed and get up helps us keep a healthy sleep routine. Avoiding caffeine in fluids (like coffee or soda), or even in foods (like chocolate) can help, too. Do

13

not exercise too late in the evening; this may cause sleep problems. Naps may be needed, but try to keep them short (less than 45 minutes long) and early in the day so they don't interfere with nighttime sleep. Medicines There is no magic pill that can make you less tired and give you more energy. But there are some medicines that may help you with your fatigue. In some cases, fatigue may be bad enough that your doctor or nurse may recommend a stimulant medicine for a short period of time. Examples of this type of medicine are methylphenidate hydrochloride (Ritalin) or modafanil (Provigil). Anti-depressant drugs and steroids have also been used to ease fatigue. If you are having problems sleeping, your doctor or nurse may suggest a medicine to help you sleep. More research is needed and is being done in this area, but there are drugs available that may give you relief if your fatigue gets bad. Coping with fatigue Learning about fatigue patterns, how bad it might be, and how long it may last are key parts of dealing with fatigue. Many times, a family member who learns with you can help you talk to your health care team about your fatigue. Here is a recap of things you can do to manage and reduce your fatigue:

List your activities in order of how important they are to you, so you can do the more important ones when you have the most energy. Ask for help and have other people do tasks for you when possible. Put things that you often use within easy reach. Set up and follow a structured daily routine, keeping as normal a level of activity as possible.

Balance rest and activity. Too much time in bed can make you weak. Try to avoid it. Schedule activities so that you have time for plenty of rest that does not interfere with nighttime sleep. Shorter rest periods are reported to be better than one long one.

Learn ways to deal with your stress. Try to reduce it using things like deep breathing, imagery, meditation, prayer, talking with others, reading, listening to music, painting, or any other things you like to do. Keep a record of how you feel each day. Take it with you when you see your doctor. Talk to your doctor about how to manage any pain, nausea, or depression you may have. Talk to your doctor about physical exercise before you start an exercise program. Get fresh air, if possible. Unless you are given other instructions, eat a balanced diet that includes protein (meat, milk, eggs, and beans) and drink about 8 to 10 glasses of water a day.

The best thing you can do for fatigue is talk to your doctor or nurse about it. Let them know how bad it is so you can get the help you need to deal with it. Watch for signs of fatigue Here is a list of some signs of fatigue that you and your family can watch for. Talk to your doctor if you have any symptoms of fatigue. You feel tired and it does not get better, it keeps coming back, or it becomes severe. You are more tired than usual during or after an activity.

14

You are feeling tired and it is not related to an activity. Your tiredness does not get better with rest or sleep. You sleep more. You become confused or cannot concentrate or focus your thoughts. You have no energy. You are unable to get out of bed for more than 24 hours. Your tiredness disrupts your work, social life, or daily routine. You have no desire to do the things you normally do. You feel negative, sad, or irritable.

Fatigue can lead to distress. It can interfere with your daily activities and keep you from doing the things you need and want to do. Fatigue can make you unable to take care of yourself, affect your will to do things, and sometimes make you feel like you cannot continue your cancer treatment. Work with your health care team to find and treat the causes of your fatigue. Remember: There is no one way to diagnose or treat fatigue. The best treatment for you is most likely to be found through open discussions with your doctor and your nurse. Feeling Tired vs. Cancer-Related Fatigue If you are fighting cancer, chances are you're also fighting fatigue. Fatigue is the most common side effect of cancer treatment, and it often hits without warning. Everyday activities -- talking on the telephone, shopping for groceries, even lifting a fork to eat -- can become daunting tasks. Cancer-related fatigue is different Cancer-related fatigue feels very different from everyday fatigue, said Lillian Nail, PhD, RN, a cancer survivor who has studied this side effect at the University Of Utah School Of Nursing. "'Overwhelming' is the most common description," said Dr. Nail. "When compared with the fatigue experienced by healthy people, cancer-related fatigue is more severe, it lasts longer, and sleep just doesn't bring relief." The causes of cancer-related fatigue are not fully known. Problems like low blood counts, sleep problems, stress, eating too little, lack of exercise, and other factors may be linked to this type of fatigue. A common, frustrating problem About 90% of patients have fatigue during chemotherapy or radiation therapy treatment, added Dr. Nail. For patients getting chemotherapy in cycles, fatigue often peaks within a few days and then gets better until the next treatment when the pattern begins again. For patients getting radiation, fatigue usually gets worse as the treatment goes on. Fatigue may last from 3 months to a year after treatment ends. And it may last even longer for patients who had bone marrow transplants. For these patients, their personal definition of what is normal changes; being tired becomes the new normal, said Barbara Piper, DNSc, RN, associate professor of nursing at the University of Nebraska. Mental fatigue often results from the intense mental effort and attention that is part of coping with a serious illness. "For example, a woman with newly diagnosed breast cancer must absorb the impact of the diagnosis as well as make treatment decisions to go on with her life. Left untreated, fatigue can upset the patients quality of life. Is it fatigue or depression? Because some fatigue symptoms look a lot like those of depression, health care providers often confuse the two, said Dr. Nail. Depression involves an inability to feel pleasure people who are depressed feel sad, unworthy, despair or guilt. "It's entirely possible to be fatigued but not depressed," she explained, adding that patients sometimes have trouble finding a label for what they are feeling. They just know they can be overwhelmed with fatigue at any time, no matter what they are doing.

15

What are some signs of cancer-related fatigue? feeling tired, weary or exhausted even after sleeping lacking energy to do your regular activities having trouble concentrating, thinking clearly, or remembering feeling negative, irritable, impatient, or unmotivated lacking interest in normal day-to-day activities spending less attention on personal appearance spending more time in bed or sleeping

What causes cancer-related fatigue? At times, there may be physical causes of fatigue, like infection or pain that disrupts sleep. It is important that people talk to their doctors about any unpleasant side effects they are having. This way the health care team can monitor and treat those problems, both during active cancer treatment and afterward when some physical problems can linger. When there are no obvious physical causes for a patient or survivor's excessive fatigue, doctors may want to run tests to rule out hidden medical problems. When medical issues are ruled out, certain practical methods have been developed to manage and minimize cancer-related fatigue, including good "sleep hygiene," approved physical activities, and smart use of your time and energy. Dr. Nail added, "It's a matter of identifying the times of day when you have more energy than others," she explained. "It means finding alternative ways of doing things, deciding what you can give up, setting priorities, and then getting help." Home Care for the Person with Cancer: Fatigue Fatigue is when a person has less energy to do the things he or she normally does, or wants to do. Fatigue is the most common side effect of cancer treatment. This is different from the fatigue of everyday life. Fatigue related to cancer treatment can appear suddenly and can be overwhelming. Rest does not relieve it. It can last for months after treatment ends. This type of fatigue can affect many aspects of a persons life, including the ability to do usual activities. Cancer fatigue is real and should not be ignored. It can be worse when a person is dehydrated, anemic, in pain, not sleeping well, or has an infection (see sections on fluids and dehydration, blood counts, pain, sleep problems, and fever). Recent studies have shown that exercise programs during treatment can help reduce fatigue. What to Look For Feeling like you have no energy Increased sleeping Not wanting to or being able to do normal activities Less attention to personal appearance Feeling tired even after sleeping Trouble thinking or concentrating Trouble finding words and speaking

What the Patient Can Do Balance rest and activities. Tell the doctor if you are not able to get around as well as usual. Plan your important activities for when you have the most energy. Schedule necessary activities throughout the day rather than all at once. Get enough rest and sleep. Short naps and rest breaks may be needed. Remember that fatigue caused by treatment is short-term and that energy will slowly get better after treatment has ended. Ask others to help you by cooking meals and doing housework, yard work, and errands. Eat a balanced diet that includes protein (meat, eggs, cheese, and legumes such as peas and beans) and drink about 8-10 glasses of water a day, unless your care team gives you other instructions.

What Caregivers Can Do

16

Help schedule friends and family members to prepare meals, clean house, do yard work, or run errands for the patient. Try not to push the patient to do more than he or she is able. Help the patient to set up a routine for activities during the day.

Call the doctor if the patient: is too tired to get out of bed for more than a 24-hour period becomes confused (see section on confusion) has fatigue that keeps getting worse feels out of breath or has a racing heart after just a little activity

Seven Ways to Manage Cancer-Related Fatigue Just as every cancer patient's treatment is different, the fatigue felt will be different, too. While one person may feel very tired, another may not. And one person's fatigue may last longer than another person's. But there are things cancer patients can do to help combat fatigue. Here are 7 tips to manage cancer-related fatigue: 1. Rest, but not too much Plan your day so you have time to rest. Take short naps or breaks, rather than one long rest period. Sleep and rest are important, but don't overdo it. Too much rest can decrease your energy level. In other words, the more you rest, the more tired you will feel. If you have trouble sleeping, talk to your health care team. 2. Stay active Stay as active as you can. Regular moderate exercise -- especially walking -- has been found to be a good way to ease fatigue. Add other activities that are less strenuous, like bird watching, listening to music, or reading. To help you plan your activities, keep a diary of how you feel each day. In assessing your fatigue, doctors or nurses may ask things like how bad it is (rated from 0 - 10), what are the patterns to it, and what makes it better or worse? Keep a record of how you feel to make it easy to answer these questions. 3. Save your energy Plan ahead. Spread your activities throughout the day. Don't push yourself by standing too long or by doing activities in extreme temperatures. Even long, hot showers or baths can drain your energy, Store items within easy reach, so you wont have to strain to get them from overhead storage. Take rest breaks between activities to save your energy for the things you want to do. Most of all prioritize. Decide which activities are really important to you and which ones aren't. 4. Get help Ask your family or friends to help with the things you find tiring or hard to do. This may be things like mowing the lawn, preparing meals, doing housework, or running errands. Do not force yourself to do more than you can manage. It may be hard for others to understand if rest does not make your fatigue go away. Try to explain that the fatigue you feel is different from "normal" fatigue-- this may help them understand. Finding "low-maintenance helpers" is also important says Dr. Nail. "Even when it comes to getting your lawn mowed, you need someone who will just do it and sneak away quietly, not someone who wants to make conversation." She also says picking a "job coordinator" can help. This is someone who can get helpers organized, so you do not have to deal with routine chores. 5. Get support Think about joining a support group. Sharing your feelings with others can ease the burden of fatigue. You can learn coping hints from others by talking about your situation. 6. Eat well Drink plenty of water and juices. Eat as well as you can. Try to eat at least 5 servings of fruits and vegetables each day.

17

7. Call your doctor Call your doctor if you feel too tired to get out of bed for a 24 hour period, if you feel confused, dizzy, lose your balance or fall, have a problem waking up, have a problem catching your breath, or if the fatigue seems to be getting worse. Fatigue caused by cancer treatment is short-term, experts say. Your energy will slowly come back, especially if you stay active. What Should I Ask My Doctor About Cancer? Your relationship with your doctor is a critical part of your care. Ideally, you will have one doctor who coordinates all of your care. This doctor should be someone with whom you feel comfortable, someone you feel listens to your concerns and answers all of your questions thoughtfully and thoroughly. Your doctor will explain your diagnosis, health status, treatment options, and progress throughout treatment Like all successful relationships, your relationship with your doctor is a two-way street. It is your responsibility to ask questions and become educated about your treatment and health - to become an active part of your cancer care team. Doctors differ in how much information they give to people with cancer and their families. Likewise, people who are newly diagnosed also differ in the amount of information they need or want. If your doctor is giving you too much or too little information, let them know. Ask them whatever questions you have, and keep them informed of your needs. As in any relationship, clear and honest communication is the key to success. Your doctor will discuss your treatment plan with you. The following are examples of questions to ask during the discussion: What type of cancer do I have? What is the stage or extent of my cancer? What is my prognosis, as you view it? What treatment do you recommend and why? What is the goal of treatment; cure or control of my symptoms? What are the possible risks or side effects of treatment? What are the pros and cons of my treatment? Are there other treatments for me to consider? How often will I need to come in for treatment or tests? How long will my treatments last? What if I miss a treatment? Will my life change? Will I need to make changes in my work, family life, and leisure time? What are the names of the drugs I will take? What are they for? What other drugs or treatments may I have to take? How will you know that my treatment is working? Why do I need a blood test and how often? If other specialists take part in my care, who will coordinate my entire treatment program? What symptoms or problems should I report right away? If I do not feel sick, does that mean the treatment is not working? What are the chances that my cancer may recur (come back), with the treatment programs we have discussed? What can I do to be ready for treatment? Will I still be able to have children after treatment? Are there any special foods I should or should not eat? Can I drink alcoholic beverages? What costs will I have? What is the best time to call you if I have a question?

Make sure that all your concerns and questions, no matter how small, have been answered. It may take more than one visit to discuss all of your concerns, as new questions may come to mind. It may be hard to remember all your doctor says to you. Some people find it helpful to take notes, bring a family member or friend, tape record the conversations, and/or bring a prepared list of questions and write down the doctor's answers. Remember that you have the right to a second opinion about your diagnosis and the recommended treatment. Asking for a second opinion does not mean that you don't like or trust your doctor. Doctors understand you need to feel that every possibility for the best

18

treatment is being explored. You can also ask your doctor if they have consulted with other specialists at their treatment center.

19