Category Archives: CANCER PHOBIA

GIVING THE DIAGNOSIS PART 3

PART THREE OF DIAGNOSIS

Cultural Differences

Focus on Symptomatic Relief

Introduction to Clinical Trials

Complementary And Alternative Medicines Overview

Media Matters

Antidotes For Anecdotes

Prognosis And The Future

Taking Your Time, Avoid Timelines

Second Opinions

The Contract

Autonomy; Everything Begins And Ends There

A Final Few Words

Cultural Differences

 

Doctors must pay attention to cultural differences. People from different backgrounds and parts of the world have very different ways of relating to the physician. This may range from deification, rarely some level of disdain and even total acquiescence and deference. Despite the variability, it always remains wise for doctors to engage their patients as the folks in charge and the doctor as the expert consultant who will not allow avoidable errors in decision-making. Patient autonomy is pivotal to a successful treatment road.        Providers must stress who is and is not God and make it clear that it is not the doctor. This is at times unnerving but usually surprisingly very well received.

 

Focus On Symptomatic Relief

 

A difficult scenario arises when in rendering the diagnosis it is also clear that only symptomatic or so-called palliative care is available. Sometimes diseases are so advanced or resistant to treatment that the discussion may need a predominant focus on relief of symptoms. Sometimes, the patients’ general medical condition makes it reasonable to have such a focus. On occasion, a well-informed, competent patient may choose only symptomatic relief for any number of reasons. Thus, discussing the option of symptomatic care is always germane.

`The patient and physician must be mutually clear as to what the odds are for a response, its duration, the odds and nature of relapse or progression and the costs- psychologically, physically and financially. The first step is making it clear that such care refers to improvements in symptoms, irrespective of temporary changes in blood tests or other diagnostic studies. Otherwise, expenses and anxiety can grow exponentially and perhaps unnecessarily while temporarily inflated hopes die on the rocks of reality.

 

Introducing Clinical Trials

 

Although I cover clinical trials separately later, the issues initially arise when explaining either the diagnosis or the rationale for proposed treatment. Trials are a perfect match for some personalities, but the whole idea of “experiment” or randomization (explained later), no matter how carefully couched, can be frightening. This is a major dilemma for medicine in general as clearly this is a major way in which treatments are developed yet less than 5% of all eligible patients enroll in clinical trials. This is particularly sad when considering that these trials are the only valid means of determining a treatment’s effectiveness.

When there is an opportunity to offer a patient a trial, it is wise to follow a common sense rule; be sure the patient knows exactly what is happening at all times and always provide a  copy to the patient, their primary care provider as well as place one in their chart. One cannot predict who will volunteer for trials. The ethical rule is straightforward as all ethical rules should be. Physicians should present the trial in terms of a balance of what other therapy is available with possible results, the goods that the trial may offer and the harms that the patient may experience from either the trial or other therapy. Secondly, the patient must give a fully informed consent after significant time to reflect and have their questions answered.

The trials have to go through all manner of review boards and must be among the next best questions to ask. Your credentialed physician or anywhere near you may not have a trial for which you are qualified. No worries, the issue is to receive at least the standard of care and happily essentially all U.S. trained U.S. board certified oncologists deliver it. Sadly, fewer than 15% of those who could be on a trial enroll but that is getting better. You get all manners of scrutiny from being on one for obvious reasons and if they are level three or higher you are guaranteed receiving a treatment as good as the standard of care. The trial is asking if there is something we can do better.

 

 

 

Introduction to Complementary and Alternative Medicine

 

It is imperative that physicians explain, using every form of metaphor, simile, parable, analogy or allegory, how medicine has learned what it has about a disease over the years and that this occurs usually because of carefully planned research. There are notable unplanned observations leading to breakthroughs, but in cancer care, they are the exception. Patients need to understand when there is certainty based on vast data versus when there is only suggestive information.  Successful clinical trials involved many patients and showed how groups similar to an individual patient fared. However, individual patients, although likely to behave like the ones in a similar group, are still individuals

Sadly, largely owing to desperation, non-approved (non-FDA, non-National Cancer Institute) treatment regimens can find an easy mark in the cancer patient owing to unscrupulous practitioners offering savory hints of wondrous results. Patients are often easy prey for quackery. That is why I have included a special section on Complementary and Alternative Medicine (CAM). Patients and families spend billions on unproven therapies every year. Significant portions of cancer patients try CAM while most at least listen to if not solicit information regarding it. There are rarely corroborated results of success that can withstand scientific scrutiny. The reason is simple. There is no financial or political-legal pressure to do so. The “claims” that do exist regarding wondrous results from CAM raise more questions than answers. The questions they raise are of massive importance. Each must be addressed at the time of rendering the diagnosis to a patient or shortly thereafter as the issue of trying CAM will undoubtedly arise.

Quackery always has a pitch which many cancer patients will struggle with if left on their own such as “ “medicine is hiding the real cure because of profit and bad pharmaceutical companies”; “we have the secret”; “you can do this only by fresh air, diet and exercise; there is no need for ‘bad’, nasty, poisonous medicine or radiation. That is sheer nonsense if one calmly walks through this both in this section and the one that follows. I also refer the reader to the NCI site, Mayo clinic’s cancer site and www.QuackWatch.org .

The major issues CAM raises are these. How do we know if responses that are real are due to the alleged CAM therapy? How do we know if these alleged responses are durable and are reproducible in most patients and can be applied to a given patients’ situation? What monitoring is necessary? What are the toxicities of these therapies and are they compatible with conventional therapy? How do these CAM therapies truly compare to conventional therapy? Head to head well-done comparisons are rare.

At the very least, I recommend knowledge of everything that enters a patients’ body. Although I stand firm as regards the right of a patient to autonomy, I believe the right of these purveyors of unproven potions to hawk their wares must remain under constant scrutiny. I sometimes simply refuse therapy and state it must be one or the other and patients must chose. Although the patient may abandon conventional therapy, the physician should give assurances that they will not abandon the patient. The best way to fight quackery is with facts and calm, critical thinking. It is sometimes an uphill battle in appearing as physicians protecting their own turf. So be it.

There is little complimentary (with an “I”) to say about complementary and alternative medicine in patients with diagnosed malignancy. Level heads with tens of years of experience cannot say, I know this cannot harm you. Proponents also cannot say I know this is safe and effective to take against your cancer. They cannot say they know the exact ingredients in their concoction. Supporters of CAM may not even know the purity, other ingredients, and effects from processing (since none of this is required) and they do not know how it interacts with all other chemotherapy drugs as tested under the rigors of clinical trials. Wake up, hear the call of your anxiety and stop the craziness. CAM adherents cannot tell you any of those things because they do not know them.

Sellers of CAM routinely do not do any testing except making sure your credit cards and checks are good. Harsh? Not harsh enough. With rare exception, you will not see them go through complete scrutiny of the FDA. At best, they will get FDA statements of purity of ingredients but that is all. One hundred percent of nothing that works is not necessarily nothing. Fact is, it may be something that hurts you and unless the FDA has thoroughly investigated them and stated they are safe and effective, beware.

Be aware that once a drug is proven safe and effective by the FDA for one indication it is not illegal to use it as doctors see fit to use it for other off label uses based on well-scrutinized peer reviewed literature. This has lead to well reasoned application of drugs off label. This is not wrong and you will find these are all building blocks for the most part of intelligent studies showing their benefit.

When some substance looks promising from the plant and animal kingdom it is tested, not held back by some evil conspiracy. Think about how self-defeating that is. If it is sufficiently non toxic and has some mechanisms of action that make sense and some minimal response rate, it will find its way into early level trials described later. A number of our front line drugs exists today from the plant and animal kingdom. However this is after extensive years of testing. Ignore the shaman and the gurus hawking claims they may really believe as they have no high quality data nor relevant training. If what they had worked, it would not be complementary medicine, it would be front line.

There is also no rational reason to support any of the nonsense that “the man” or “Big Pharma” or whatever is holding CAM back. Ridiculous! Capitalism is doing just what one wants it to do; reward the real deal that will go the distance and not kill people or usurp their hope and resources. The system is not perfect but it is, without any equivocation, the best in the world for declaring a new drug as safe and effective. Moreover, our system does the right thing by limiting patents, expediting highly promising drugs and creating special tracks for enormously promising ones. The “Man” or “Big Pharma” would be idiots and bankrupt to proceed in any other way.

Furthermore, those of you who know how to read an annual report or balance sheet should ponder this. It takes almost 7 years for a new drug to go to marketing as safe and effective and over $600 million dollars. Consider how much is spent on non-winners. Profit margins, not profits but the real numbers  such as how much is finally left after everything is paid for range from negative 7-10% in bad years and 5-20% in good and overall about  average 6-9%. Nobody is routinely getting ripped off.

The cost in lives, pain and suffering, manpower, health care cost dollars wasted and clogging up the system because of CAM barkers and naive folks exercising their admittedly free choice is outrageous. Many put it as a ratio of one out of every 6 dollars is wasted in Oncology by the pursuit of, application of, and costs from using complementary or alternative medicine.

 

Media Matters

 

Beware mass media, they are often hit and run news du jour artists without the time, temperament or talent to clearly put any news or breakthroughs in perspective let alone in individualized terms . Sometimes they get a lot right, especially when they are fact based stories and not predominantly emotional content. Some incredible network as well as cable television shows highlight the exception of a bad physician and run the story without comments of the overwhelmingly good data out there when it comes to the constancy and quality of Oncology care.

Yes, the media have a crucial and welcome role to help watch, encourage and support and in a sense, police the field for the betterment of all. But remember their job is not meet you in the E.R., take your calls at three a.m., work with other consultants, calculate your chemotherapy, talk with the family and be the responsible individual from rumor to tumor to treat and beyond.

 

Antidotes For Anecdotes

 

One of the biggest poisons in our field is the anecdote. It is the irresponsible presentation without hard verified, in-context data of some patient response or treatment with an against all odds outcome or surprise ending ( such things happen rarely) that the storyteller or listeners then wrong headedly thinks present new rules and lessons to all broadly or especially to them.

Anecdotal medicine frequently causes suffering and in oncology where margins are slimmer, it can cause death.

For example- all seem to think if you flip a penny ten times and get 3 heads and then 7 tails in a row that tails is favored. No, not even if you got the same ratio doing it again.

 

Prognosis and the Future

 

It may or may not be premature to discuss prognosis early on. This is a case-by-case situation. It can be very confusing at first to present to individuals how groups have handled highly similar situations. Using comparative hypothetical or historical groups to predict an individual’s prognosis can be relevant and helpful but it is not a crystal ball into the individual patients’ future. No one is to be hopeless. I have seen enough surprise turns to the positive to jewel a crown with joy rather than be jaded by some anchor around my heart. Odds are things patients’ beat from time to time.

Oncologists and patients would be wise to outline and explain the potentially long list of experts needed in future care early in the journey. The list may be long, confusing and frightening. It may include ostomy nurses and physicians needed to perform further biopsies, diagnostic tests or radiation. Oncologists must prepare their patients for the entourage in their service; rather than position patients for a frightening flood of new doctors and procedures.

Take the Time and Avoid Timelines

 

Most importantly and least easily done, rendering the diagnosis takes time. The vagaries of managed care and reimbursement issues have private oncologists seeing enormous numbers of patients per day. This can be insane and inhumane. It is easy and understandable to state that there simply is not the time. Somehow, some way, there must be. In the end, spending the time will eventually save time. After all, it may be all the doctor has to give at some point.

Oncologists must not give Hollywood time lines. The best approach is to refer to the literature and the ranges that a patient most likely fits while stressing once again that patients are individuals, not statistics. Patients and providers should avoid attempting to quote dates or make dramatic pronouncements. That is pandering to fear and fatalism.

Odds should be explained, both as relative and absolute odds. As an example of this explanation, I will relate what I do to illuminate these crucial concepts to the patient. I take out a dime, a penny, and a one and ten dollar bill in front of the patient. The difference between the penny and the dime in “relative” value is that the penny is one tenth of the dime. The same is true for one and ten dollars. The one dollar is one tenth of the ten dollars. However, the difference between the “absolute” amount of ten cents and one cent is nine cents. The difference in absolute terms between the ten dollars and one dollar is nine dollars. Nine dollars is absolutely much larger than nine cents yet nine cents is 90%, relatively speaking, of ten cents as nine dollars in 90%, relatively speaking, is of ten dollars. However, the absolute difference between nine cents and nine dollars is absolutely quite large.

Why care? A ten percent improvement in survival or response or duration of response can vary greatly depending on what odds you started with. This concept is crucial when discussing adjuvant therapy. This is treatment given when statistics say there are high odds of recurrence of unseen lurking disease after apparent removal of the primary cancer and no visible evidence of cancer cells remaining anywhere. If adjuvant therapy is given, it is because it has a certain relative and absolute risk of preventing recurrence at some future point in time.

Oncologists offer many breast cancer patients adjuvant therapy, treatment after the primary surgery to kill hidden distant disease. The concepts of absolute and relative risk play a large role in this decision. It is crucial to know what the real difference, the absolute difference is between those treated adjuvantly and those not. A ten percent improvement in the odds of recurrence, when the odds of recurrence are only ten percent, is just an improvement from ten to eleven percent. However, a ten percent improvement of odds of recurrence when the odds of recurrence were eighty percent is the difference between eight and eighty-eight. That is eight percent. That is eight more people potentially alive out of one hundred.

Understanding basic statistical language does not end there and the education to build understanding begins at the time of giving the diagnosis. Patients must be able to understand what the percent improvement stated above really refer. Is it an improvement in the odds of response to therapy or the risk of recurrence? Does it translate into a ten percent improvement in the time to recurrence? Is it referring to a ten percent improvement in the odds of survival? Does it translate into how long one lives before eventually dying from the disease? On the other hand, and as is commonly the case, does the ten percent apply to some, but not all, of these very different notions? These are all very large, quality of life, practical issues and they are very different concepts.

 

Remember Statistics Can Be Your Friends

 

Statistics tell us number needed to treat to tell you if a study had any ability or power to tell you anything.

Statistics also give us wondrous definitions like the level of power ( predicting the truth) of published studies. They tell you if you can definitely say yes or no is true with some degree of certainty and if the type of study is rock solid and the evidence for it.

They tell you if you can know the odds of an outcome by others are likely or not for you.

They are so important they are discussed in multiple areas of the book.

 

Second Opinions

 

I address second opinions in the legal section in detail but a few points are germane when initially discussing the diagnosis. They should be encouraged for all patients and families who broach the subject. A word to the wise; such second opinions may be for therapy that is either far more or less aggressive than what was originally offered. Even more rarely, some who render second opinions may libel or slander the primary physician to the family and not condone what the primary doctor has done so far. Therefore, prudence, candor and pre planning is wise when assisting the patient obtain second opinions or commenting on them. The only significant problems I have ever encountered in this regard were when complementary or alternative medicine practitioners get into the mix. This dilemma is addressed more fully in a later chapter.

 

The Contract

 

Although stated later in the legal section, it bears mentioning here that patients are expecting a contract and the list of what is required is long: They expect doctors to listen, to teach, to be available, and to address pain (almost all pain can be effectively treated), get help with sleep and bowel habits and prevent nausea, and vomiting. Patients need to hear that we now have medications that may increase appetite and stamina. Providers must tell the truth and be clear on the schedule of progress reports. An often-overlooked area is the golden rule that doctors must never “keep secrets” from the patient no matter what the significant other or family says. Patients must always be clear on what their policy is regarding messages and answering machines and receivers of physician calls who are other than the patient.

 

Remember Autonomy – It Begins And Ends There

 

Will the real patient stand up? It is you but you are not your disease. YOU must have a relationship with your disease built on knowledge to lower your burden. There is immense power in the gift of autonomy as described earlier in the book. Go back and read the first few chapters again and remember this is your journey and you call the steps.

 

 

A Final Few Words

 

One of the deadliest weapons both against the cancer and unwittingly against the patient and family is not chemotherapy; it is the physicians’ mouth. The clinician must not only think about what they are about to say, but say only what they are thinking-no more and no less.  For example, more than once, I have heard stories of the devastating blow caused by an answering machine message thoughtlessly left for all to hear and often misunderstand.

In sum, this chapter is simply saying that the tongue, as well as the cancer, can be the “enemy of the neck” or the liberator of the patient’s autonomous license to engage fully and vigorously in their treatments.

 

Advertisements

WHEN YOU SUSPECT THE DIAGNOSIS OF CANCER

SUSPECT THE DIAGNOSIS

 

 

HI THIS IS DR KEVIN RYAN, PROFESSOR OF MEDICINE AND BOARD CERTIFIED IN BLOOD ( HEMATOLOGY) AND CANCER( ONCOLOGY) AS WELL AS BEING AUTHOR OF THE BOOK WHEN TUMOR IS THE RUMOR AND CANCER IS THE ANSWER A COMPREHENSIVE TEXT FOR NEWLY DIAGNOSED CANCER PATIENTS AND THEIR FAMILIES AVAILABLE ON AMAZON IN EVERY FORMAT OR THE BOOKS WEB SITE WHICH IS THE SAME AS THE NAME  OF THE BOOK AND THIS SHOW

 

I AM A CANCER SURVIVOR, I GET IT AND MANAGED IT FOR OVER THIRTY YEARS

 

THIS SECTION IS PROFOUNDLY RICH AND VERY INTENSE AND ABSOLUTELTY NECESSARY….   WHAT DO YOU DO WHEN YOU SUSPECT BUT ARE NOT YET SURE OF THE DIAGNOSIS….   THE PANIC TIME 

 

I WILL GO SLOWLY AND INTENTIONALLY REPEAT AND RESTATE MYSELF WHEN NEEDED…I KNOW I NEEDED TO WHEN IT WAS MY TURN

 

 

 

As said in the true short stories “The Enemy” and was reiterated later in “The Telling”, few things can take a patient on a psychological and emotional rollercoaster from conjuring fear and loathing as well as becoming embraced in love, deep understanding and insights than the diagnosis and treatment of cancer.

Each of the major steps of the journey of when tumor is the rumor until cancer is the answer will hold this to be true.  The lymph node found on physical exam, the new skin growth, the time when the not so routine clinical complaint; and the everyday “oh it’s nothing”“becomes something and with it comes anxiety. For millions each year, the words are said and the stage is set that something needs further examination, eventually some type of biopsy for tissue will be needed and in short time your nothing may be the something that puts your heart in your hand and a lump in your throat on the journey to the oncologist.

The oncologist may first enter the picture when the diagnosis is suspect but not confirmed. This is a tricky situation and dealt with case by case on the fly, in a careful manner customized for the individual patient and family. To be sure, there are some fundamental and universal ground rules when approaching that point where suspicions of a cancer diagnosis are dismissed or founded. Perhaps the most important of rules is the time proven adage “Although Tumor Is the Rumor and Cancer May Be the Answer, Tissue Is the Issue and No Meat, No Treat”. Yes, it is crude, but right on target.

Oncologists never, ever, label a patient with a diagnosis of malignancy without absolute certainty and as much evidence as time and safety allow. They always have tissue confirmation from a biopsy of some manner unless it is simply too dangerous or not possible to get to the area of concern. Usually, the broad array of tools and superb clinical skills make obtaining tissue usually safe and quick with little lasting discomfort. It logically follows that one never pronounces a recurrence without the same degree of certainty. It is important to note, however, that not all recurrences require or can be biopsied.

In most situations the notion of a clinical presentation consistent with recurrence by the patient with known malignancy being very apparent is common and not requiring invasive techniques. Nonetheless, when the odds of recurrence are low owing to the typical personality or original early stage of the primary tumor or the long time since treatment or a remission, biopsy may be needed. Rarely, in some cancers, a second biopsy is needed because some cancers actually change, needing a different approach than the original treatment.

When we suspect the diagnosis, oncologists often have to work quickly behind the scenes. Not only do we not wish to step on the toes of the primary physician while nonetheless guiding the primary physician as to what the best diagnostic route may be for those for whom tumor is the rumor, but we want to avoid missteps or statements by those who go before us. Thus a delicate balance must be struck as the entrance of the oncologist prior to the diagnosis being certain can understandably be quite evocative of enormous anxiety for the patient and family. Thus, it is essential for the primary, or soon to be referring physician, to identify for the patient and family what roles the many future consultants have. An individual who serves as the “quarterback” must be identified quickly with full consensus and understanding of their role by all.

This concept of focusing the attention on the right professionals applies to the family as well. It is the patient, not the family, who has the disease. The role of the family is enormously important. However, family and friends, the Internet and media as well as other health care providers, frequently inadvertently or overtly inundate the patient with stories that are either inappropriate or way off base. Their influence must be anticipated and never underestimated.

This is a time of reinforcing the message of the autonomy and individual nature of the patient. A good analogy is the vehicle identification number of cars of the same make and model. Theses vehicle may have enormous similarities but run differently based on age and other factors. This is precisely the situation with each patient. Patients are individuals with a disease and they are not their diseases. It is never just another case of non-small cell lung cancer. The philosophic point raised above has enormous practical applications. Oncology is not a one size fits all endeavor.

The health care team must decide early if the oncologist leads or is initially behind the scenes. Sometimes the oncologist does not take over until there is definitive diagnosis or a diagnostic dilemma evolves at which point they step forward. Once again, one must never underestimate the importance of timing the oncologists’ entrance into the world of the patient and family. The comfort zone of the referring provider, of course, will largely affect this. There is great variability in this regard. Some primary referring providers remain very involved and others wish to pass the reins on to the oncologist as rapidly as possible.

Once it is clear that sufficient information exists that it is time to state the diagnosis and begin to put anti anxiety lassos around the beast, here are some insights that may be enormously helpful for patients and their supporters:

    • The first few days being a daze is to be expected. Confusion, upheaval, immense sadness and disbelief, anger and crisis of faith that can be challenged and thought lost or in some cases, galvanized.
    • A powerful sense of loss of control and even greater fear of that ensuing is common place. This is something Oncologists may assume up front and address directly with the facts as they become evident and their reasoning behind diagnostic or treatment algorithms in advance of crossing those bridges.
    • Empathy builds trust and greater patient engagement in the process. It must real, not feigned and not dispensed off to clinical staff (the norm) as the emotional bond of therapeutic alliance is best with the physician as well as the treatment administering oncology nurses. Patients trust less empathetic providers less and not being capable of being their own doctor they can be left to themselves; not a satisfactory situation for anyone.
    • Patients may think it is the worst thing to have ever happened to them. It may not be. But anxiety paralyzing you from action would be the worst. It is very therapeutic to have anger and it is very therapeutic to fight. However, it is soul sucking to roll over before fully informed and well-reasoned decisions can be made. Patients would be wise to transform anxiety into fear, fear of the known through knowledge and never stop learning all they can, as that knowledge is power in your fight. God has hard wired you for heroics; unbelievably so as it may seem. I have not seen a cowering cancer patient yet who totally collapsed refusing to being informed when it was offered to them.
    • It is a myth that in life or oncology any meaningful portion of your decision must be made spontaneously with no time for reasoned reflection and rational thought.
    • It is not a myth that it is unhealthy to rant, rave and react angrily. I see plenty of reason to be very angry whether it be at altered life’s plans, unhealthy personal behaviors leading to this or sheer damn bad luck as in “why me?” You have my permission, and I am confident God’s, to be simply initially angry.
    • It is very real to be shocked and when smacked in the face, reeling from the blow is natural, normal, and expected. Retreating from life or retreating from the fight before all the information needed to make wise decisions once calm, or just giving up the ghost is not O.K. Your life is your own and your anxiety is to be honored, not discarded when frightened most. Even if you seem most alone, and rarely anyone is, let knowledge be your friend and counsel. You also must eat, exercise if possible and attend to the activities of daily living as you are very much alive and the journey has barely begun. You need not go right back to work unless you know you cannot; there is no rule. If you need a little time, take it. If you need family, get them involved right away and if you need alone time, take it.
    • Own the disease and your reaction. Do not become the caretaker of others who swoon or swing into inappropriate and certainly not helpful reactions over your news. This is your news and your life. This is your trauma and trek; own it. For now, you are the star of this show. Believe me as to the necessity of my stressing this. You do not live or die for others. If you want to handle all communications with others, fine. If you wish to delegate, fine as well. It is your call. This is a time in your life where the most frightening of all scenarios dropped on your doorstep. For the moment, you are not as in control of your destiny as you were before. Understand and fight the overwhelming panic of the diagnosis and your morbid imagination trying to rip the helm from your hands. You have barely set sail and your disease is not, and shall not be you. Your diagnosis may try to direct the show. You must not rest until you wrest from every opportunity the control God intended you to have over these moments. Get knowledge. Demand information and experience your feelings but do not let them define you. This book will help, I promise.
  • You have heard the theme before, the next step is knowledge. It is the best anti-anxiety medicine in the world

 

    • Although knowledge will be your greatest pal, if you can, muster up an army of at least one other who forms an allegiance with you to conquer ignorance and face fear. There will be personal business issues needing attendance as well as the new administrative and secretarial assistance needed to stay on top of all the tests and appointments and their results and inevitable questions they will engender. I often encouraged that either a small hand held recording device or better yet a trusted friend or family member act as a scribe to objectively write what was said, not felt, and what needs remembering, not fearing. This is wise to do with every consultant, your primary Oncologist and of course, your original referring primary care provider if that is how all this started. Such a scribe must understand that this is not about their feelings or interpretations; they are a robotic scribe capturing all that was said in context and without error or asking from the source until it is correct. Even in our aggressive American culture, there is still too much reluctance of patients to take such an initiative.
    • Avoid blind trust. The relationship you want most, initially, is with the truth; the facts and figures expressed in as much detail in context and relationship to your diagnosis that help you understand what is your disease, what does that mean, what can be done and what decisions are next:
  • Never surrender autonomy. Your scribe is a partner there to assist you so that through the frenzied fog of anxiety you can muster yourself for the fight..and have your facts straight.
  • Author Jessie Gruyman, president of the Center for the Advancement of Health and survivor of many a life threatening diagnosis wrote “After shock: What To Do When The Doctor Gives You-Or Someone You Love- A devastating Diagnosis. She offers the concept of a contract of sorts with a partner. I support the notion as well as have used it in my practice for years. Key issues Jessie covers are for the partner to agree to attend appointments, confirm in advance of their attendance, always re evaluate and check in with the one diagnosed as to what role they have and should play and in detail address whether one is a passive listener or authorized to ask tough questions. Make sure the duties of scribe are clearly outlined from the practicalities of paper and pen or laptop all the way to details as to whether a summary transcript would be useful. The partner must always remember that the patient is the one with the disease as they become familiar with laws regarding privacy of medical information and learn to keep their opinions to themselves unless specifically asked. To those who understandably and naively feel this is a waste of precious time and too intense an endeavor, I say think again:
  • The anxiety mitigating impact alone on a now engaged and in control patient is God sent. The literature suggests the diminishing stress gained though being engaged may diminish overall suffering and positively impact quality of life. The more aware and in tune patient will bring in any new signs and symptoms to their team with greater precision and speed and that is always good.

 

  • Patient and health care team are enmeshed in an intricate and not always predictable dance. Suggesting the patient should have no record of emotions, moments, and meanings that give them context in the greater therapeutic meaning borders on cruelty. Listen, learn, engage, and if you cannot understand, bring in that specially selected scribe to help

THE ONCOLOGIST

The oncologist

 

 

This is Dr KEVIN Ryan MD MBA FACP and hematologist oncologist here, medical oncologist professor and retired colonel and cancer survivor and this is when tumor is the rumor and cancer is the answer. This show is Modeled after my nonprofit book of the same name available on the web site of the same name… you can find it on the web site and a lot more, interviews, films excerpts on the site and it is also available on Amazon in all formats All shows are also on my blog off the web site  same name  and on www.w4cs  and in a few days Iheart radio

Think of these next shows as a look into the mind of physicians and especially the oncologist How and why do they so the voodoo that they do

 

 

 

Why Oncology?

 

 

The roads chosen for a career in Oncology are diverse. Some choose research; some enjoy a mixture of the laboratory bench and bedside. Others choose full time private practice as opposed to academics while others go into the big business of biotechnology research and have a path marked by brilliant entrepreneurial zeal. Owing to the military paying for medical school, I had my road chosen for me as a largely clinical route with significant exposure to all of the others-especially clinical research and teaching.

While oncologists are not all the same, most cancer clinicians are quite similar in their heart of hearts, their thought processes and I think in many ways their spiritual view of all of this. I have found that most of my colleagues share an immense sense of purpose and meaning in their practices and research.

The most frequently asked question I have received from trainees and colleagues alike is “How can you do it, Why do you do it?” usually followed by “I could never do oncology”

This is the best answer I have been able to muster.

There is an indefinable but unmistakable nature to being human. It is unique to the species, reproducible and immensely sensitive. The human mind and heart connect as a somewhat huge spider web of the finest silken threads capturing and suspending every experience of life in the chambers of consciousness. Life-threatening situations, such as the diagnosis of cancer, pull upon all of those threads thus bringing ones’ world into unparalleled focus.

I have never seen this nature more vividly than when my patients faced the enormous fear malignancy evokes. I have seen the diagnosis cement the realization that we are all connected and, in a practical sense, underscore the insight that we are and always can be truly knowable. In the practice of oncology, patients and providers alike quickly accede to the marvelously hidden plot, the master illusion whereby we appear to differ.

Cancer respects no organ or person. Furthermore, the oncologist must have intimate knowledge of all the fields of medicine, radiology and pathology as well as a finger on the pulse of breakthroughs in basic science. They have an armamentarium of diagnostic tools unmatched in depth and elegance and the field is perhaps better organized than many internationally in terms of asking the next best clinical question through cooperative research and clinical trials.

Once the team of caretakers and cared-for coalesces, a dance begins. It is a dance whose rhythm is the beat of the patients’ trek to garner knowledge and quell anxiety by doing so. It can be hero making.

Cancer unravels, mocks and challenges the norm more than any other malady. The wonderfully divine plan of human existence at the cellular level is never clearer than in the thick of the battle of fighting cells that mimic the norm.

When tumor is the rumor and cancer is the answer, the sweetness of the privilege of simply being alive is immediate. The solace and comfort offered by the health care team, family and loved ones is more pressing. In facing the possibility of premature death, the pulse and zeal for life as well as perhaps redefining it beats more soundly. What truly matters can become so transparent. There is also a sense of camaraderie in fighting a war of great and personal consequence and not having to do it alone with both people and science as allies. Oncologists have a ringside seat as the heroes and the health care team “box with God”. More than once, although frequently bruised, battered and stunned, the team wins a round, and with increasing frequency, the match. That is some of the  “Why Oncology”…for me.

 

 

MD – What Is In A Name?

 

 

Since the beginning of time, the world sets physicians apart as magnificent demagogues (MD) for many understandable reasons. I am not talking about arrogance, per se. The enormity of knowledge acquired, the responsibility, and immense emotions entailed leads to a very circumspect world for the physician. It is a world that patients really could not understand easily. Enhancing this is the reality that patients often lean more towards being a patient than a participant. Although understandable, other than when the competency of the patient is in question, it is best for all if the patient and family deeply participate in their cancer care. There is always a better outcome when the other “MD” is exposed- the Magic Decoder ring. Becoming the master of our journeys occurs when we all share in the secret handshakes of what initially is overwhelming information and in time everybody gets in the boat, grabs an oar and pulls hard.

However, many physicians are not that eager or aware of the necessity to crack the code and share the secret handshake. There is considerable variance in this regard depending upon medical specialty. It should come as no surprise that some fields attract abstract thinkers more than immediate-action, black and white problem solvers. Some fields of medicine attract urgent “fix it” types; some attract urgent “find it” types. Some medical specialties are appealing to “hand holders” and some physicians prefer a practice more removed from patient contact, let alone in depth emotional engagement.

 

What About Oncologists?

 

Oncology is a mixed bag. It tends to attract deep thinkers but certainly not to the exclusion of all other fields of medicine. Oncologists tend to be folks who like to box with God. They are intellectual problem solvers who love to master immense and diverse amounts of knowledge and who live to ask the next best question. Although it has improved and there are many notable exceptions, oncologists’ strongest suit tends not to be in depth personal emotional or spiritual engagement with their patients. Frequently, oncology support staff, nurses and front office alike soar like angels in this regard. By no means am I implying that oncologists do not feel deeply nor fail to understand the profound emotional aspects of their practice. In fact, I think they do. Rather, owing to time constraints, frequently pressing urgency in diagnosis and treatment, self-protection and an appropriate need to remain somewhat distant emotionally, in depth engagement of patients in manners discussed in this book are not overwhelmingly preeminent.  Furthermore, there is simply not enough time to do so.

Oncologists are not only not immune to stress, they are magnets for it, as are many other physicians. In oncology however, one faces terrorism of the highest and most clever degree every day as discussed in the chapter “The Enemy”. Accrual of new patients to an oncology practice is usually for ominous and frightening reasons. Patients do not become cancer patients for routine, typically reversible diagnoses. It is not largely about some surgical procedure or therapy where of course, “everyone always turns out just fine”. New patients become a lifelong affair and interactions with family and support systems are intense and long term. Loss of patients is often owing to death.  Fear, both physical and spiritual, is commonplace. Thus, stress is frequently a disease that affects the patient, their loved ones and supporters and the oncologist and their staff.

Let us just pull back the protective white coat on this phenomenon of stress for a moment. Hans Selye spent almost five decades studying stress since the 1930’s. A noted psychologist, Herman Feifel observed the intense enmity and perhaps fear physicians characteristically have of death. Sociologist Renee Fox’s work echoed similar conclusions when it focused on those physicians conducting pioneering work. As discussed in the section Clinical Trials, research and implementation of research results are the hallmark and mainstay of this field of medicine more routinely than many others. The tempo and intensity of moving information from the laboratory bench to the bedside is enormous.

Stress is essential for life. Without the eternal struggle between tension and release, joy is muted, passion subdued, biological and personal growth is stunted, and life is a bore. However, out of balance, stress can be damaging. Today’s oncologist must deal with insurance companies and HMO’s exerting various levels of control regarding patient treatments owing to reimbursement issues. Oncologists’ typically work very long hours and the demands for rigorous documentation can be pressing. Fortunately, technology is beginning to ease that burden with digital patients’ records. Compounding this is some natural professional disgust with the everyday business pressure foisted upon the oncologist unlike ever before.

Thus, there are sufficient ingredients in the mix that do not foster an environment allowing lengthy visits with patients. The sheer patient volume necessary to maintain a practice can be overwhelming simply not affording sufficient time to meet the entire emotional, psychological, spiritual and at times, educational needs of the patient and family. All the while, the oncologist is the authority, the mentor, the captain of the ship. To whom do they talk.? Other physicians? Not likely and what little data is out there confirms that.

The intellectual orientation of a physician starts to form early. Medical School is a culture that reinforces the concept of immensely delayed gratification. Loyalty to the guild takes on almost priest like proportions. The sheer level of physical and mental labors is staggering. Governance of the mind is often by way of an addictive technocracy whereby dependence on data, tests and technology tends to supplant other more creative and less didactic techniques of collecting information and solving problems. All of this combines seductively and may lead physicians in training to be unaware of and underestimating personal needs and the power and promise of human relationships. Medical school sentiments of privilege, honorable responsibility and excitement quickly mellow.

Although these notions have broad applicability among many physicians groups, a primary source of tension in oncology is the physicians’ changing role from “curer,” to “life-prolonging champion of the fight against the disease”; and to “sustainer,” when active therapy is no longer useful. This is difficult, heady stuff. Most surveys to date note that “not enough time” is right at the top of challenges and easily competes with the need to keep up with new medical information, dealing with difficult patients or family members, the number of patients who don’t get better, and the amount of paperwork.

In 1991, one survey reported “burnout” in over 50% of the more than 1000 long term clinical practice oncologists responding. The incidence of burnout was lower among university-based oncologists. University oncologists’ time is somewhat protected, their practice entails a large portion of teaching and competent residents and fellows often assist research and physician load. Three of the major stressors identified by the respondents were dealing with dying patients, reimbursement issues, and a heavy workload. The researchers suggested that the lack of preparation for dealing with the emotional aspects of oncology contributed to job stress and burnout.

In a subsequent similarly sized study of British oncologists, the prevalence of psychiatric disorders among this British sample was 28%. Clinicians who felt insufficiently trained in communication and management skills had significantly higher levels of stress than those who felt sufficiently trained. The authors concluded that improved training in communication skills might provide a useful tool to lessen the stress of practice.

As is intuitively obvious, being in the Captains’ chair and dealing with repetitive human suffering and frequent losses takes its toll. Just as one cannot deny their creativity, one cannot escape the pressure of simple human sorrow. The first response of oncologists is to detach in order to remain effective. However, too often this means to become disaffected, unengaged, and non-communicative as regards the issues addressed in this book. In time, everyone loses.

The solution of the physician to detach may lead to losing some of the comfort they sought out in pursuing a career in medicine. They may lose the quiet comfort of knowing they have been effective in alleviating suffering. One is on sacred ground when intimately involved with the sufferer and taking action to alleviate that suffering. Here is the rub. Chemotherapy, potions and pain meds may enormously mitigate distressing symptoms but anxiety and emotional anguish are insidious tormenters not as easily diagnosed or treated by formula. Physicians can have an enormous impact in these areas.

I am not inventing any new ideas. There are no truly new lessons to life or truly original emotions. There are variations on universal themes. Pain, whether it is psychic, emotional or physical, is the same in any language. Effective and broad reaching communication, sympathy and empathy, coupled with dispensation of in depth information are  benign opiates patients and families are happy on which to depend.

Studies have shown that a lack of formal training in communication skills heightens physician’s daily stress. Every day oncologists are bringing bad news, discussing prognosis, complicated therapies, treatments of pain and suffering and a dizzying array of future pitfalls and milestones. So what to do? It starts with enhancing communication skills to decrease stress for all. The key is to engage the patient and family. The time spent reaps immense rewards for all and, in effect maximizes not only the quality life for family and patient, but for the physician and staff. In the final analysis, it actually saves time to invest time.

However, enhancing these skills starts with dissecting and discovering all that needs talking about. Data are easy for the oncologist. It comes as quickly as does fear to patients and families. One first must know what to talk about before teaching how to talk about it. This book informs the patient and presents a wealth of information to help them participate more fully in the journey and perhaps more deeply develop appropriate relationships with their health care team..

Doctors are hard-wired to keep up with the latest advancements through reading, and continuing medical education. Perhaps many can view this book as a form of critical reading and continuing medical education. The syllabus was suggested by excellent experts; a few thousand patients.

Enormously successful politicians, pundits and prophets all know that we can enhance our sense of competence and lessen our feelings of anxiety when we feel understood and understand. The doctor must impart a wealth of information to their patients and families. In like manner, there is an enormous amount of needs and knowledge that the patient wants the doctor to address. What the patient does not know to ask yet can be a source of even greater anxiety.

Let us be reminded that it is hard to feel overwhelmed when you are in familiar territory. It is easy to be overwhelmed when you are on unfamiliar ground no one wants to traverse. This cuts both ways for patients, families and physicians. When there is a canyon of uncovered ground, conflicts and crisis can grow which sadly rarely are brought into the open, let alone the examining room. There are the usual culprits. Fear, time constraints, lack of information on the part of the patient and family and lack of eager engagement and pursuit of patient and family intellectual involvement by the health care team top the list.

Certainly, there is a wealth of information routinely disseminated by the health care team in most encounters. Rather, it is the depth, the intimacy, the focus and the scope that have the greatest positive impact. Granted, there is simply often not enough time to time to engage everything by even the most enterprising, experienced and engaging health care teams, and there are plenty. Thus, this book may help. Consider it a field manual, survival guide and reference.

Patients should never feel abandoned. However, abandonment usually carries a realistic component of personal responsibility. The traveler who refuses to seek direction, the motorist leaving for a journey low on gas, the camper without basic overnight survival gear and the homeowner who leaves the doors unlocked are inviting problems. Patients and families alike must minister somewhat to their own needs. Self-care begins with self-esteem. It is empowered by knowledge; knowledge of needs versus wants and knowledge of enemies versus allies. Patients must have knowledge of resources that are available and the lessons of history by those sufficiently similar to themselves that they may apply to themselves. Others have walked a similar road before and patients must know and truly understand that. Thus, this book.

The past generation has seen enormous advances in technology. Generic medical school training has continued to progress with more in depth education and attention to the nuances of patient and family communication. More attention to interfacing with those who are enormously frightened is the norm. Internal medicine residencies are also moving forward in this regard. Lastly, fellowship training in oncology has begun to pick up the cue of improved communication with families and patients as well as with oneself as the often captain of the health care team. But there is a lot of ground to cover. When one looks in the oncology world at all the presentations from the podium, abstracts presented and published, poster, plenary and “meet the professor” sessions and published articles, one finds a slowly growing but still small body of work such as this book.

So is this really such a big deal? Yes! Cancer is one of the great anathemas. Not too many utterances can whip up a faster frenzy of emotion, thought and agitation than “You have cancer”.  Knowledge is our greatest asset; patient knowledge.

Cancer is both incubus and pariah. The mere mention of the word strikes fear in the hearts, minds, and souls of millions of patients and families per year. These souls are awash in a tumultuous sea of blinding anxiety and pounding waves of enormous ignorance. The vast majority of non oncology providers avert from its care and quickly defer to the too few medical oncologists whose job it is to fight this sort of terrorism on its most personal and persistent level. The patients are not the only ones who carry a burden in the battle. Perhaps if we all understand this, we can pull the oars together and share the journey.

 

Summary of first 8 Lectures Part 1

SUMMARY PART 1

 

Hi DR Ryan here, medical oncologist , PROFESSOR, RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer. THIS IS first of two parts of a summary OF OUR FIRST 9 WEEKS TOGETHER SO I WILL TAKE QUESTIONS AS NEEDED and take them as we go along as the division into two parts will give us more time

We first covered the only set of attitudes that work to improve the quality of life and perhaps even survival because of all the spin off benefits of being more engaged in your care. We also embraced the mind body connection that is not to be denied for all of us. Quality of life improves when attitudes and knowledge improves , anxiety diminishes and most likely so does odds of survival. So listen up,

 

 

There is no grand mystery to the ingredients to be happy no matter what the circumstances but when we have a cancer or a loved one does we tend to panic and forget them when we need them most

 

But if there was ever a time to do so- get real friends close , it is when you are in the worst times , your quality of life largely depends on you and who you surround yourself with.

Equally true is that the mindset, the lifestyle with which you embrace the disease has immense impact. Repeatedly, I have seen families and patients have meaningful improvement in handling the gamut of emotions that occur from rumor of tumor to cancer as the answer when they affect a simple yet profound attitude.

There is good news. Being with those you love

.. Doing so pays for itself. It is its own reward and doing so with those you love is one of the greatest rewards of all

The more you can nourish and sustain yourself in the company and care of those who love you and whom you love, the better

 

. Again the suffering is not to be alone and rarely are you.

SO       GET INFORMED

 

We are hard wired with a blueprint to happiness, a map to finding peace and serenity and we lose our way most when we are most afraid but I assure you the hardwiring and map are there

Beware pretenders and offenders to common sense when it comes to treatments just as you would beware magical promises of cancer cures.. Beware internet promises, rumors, well meaning totally uniformed family or friends, anecdotes, Dr. Google without discernment , unproven therapy, things that seem to be too good to be true and promises of magical cures. Demand high caliber proof  and multisite corroboration with strong statistically valid controls over any new claims of Uncles Joes Kickapoo Joy Juice

. Look to the experts first and foremost,, those who have dealt with folks in your situation hundreds of time and draw on knowledge of folks like you thousands of times and who have been studied in controlled scientifically proven manners. Although you are in charge, do not ignore the VALUE OF THE ultimate truism that you are co captain of your ship

.

. .. Have a purpose in your life when things are dark, a laser focus to get knowledge to kill anxiety born of ignorance. Have a direction

Add productivity...  Don’t just sit there. Be engaged and active in your team. Do not let things happen to you. Be involved.  Be productive in your therapy and in your life- never never ever underestimate the profundity of this

. God made you as the only being truly capable of creativity. It keeps the flame alive. It matters not what it is but make something else other than your misery. You will be amazed at the power of doing so

Be gentle with yourself , there is no timer on your tempering your emotions so move your mind deliberately in the right direction but move

Remember being productive and creative are best pals, they go together. Remember all these things fit together in a wonderful  way …let them

Next is forgiveness giving it gets more then you give-including to yourself. Unpack those bags of a guilt trip

 

Forgive yourself for whatever you may have done to assist this cancer like smoking, alcohol, obesity no exercise and so on . You will tend to feel guilty about many things sometimes. Drop that in the crapper where it belongs and stop the behavior and move forward and do not surround yourself with those who have bad behaviors . Forgiveness of self is mighty powerful when sometimes, not always , it is needed

Laugh at yourself. Humor is a fantastic treatment especially when we look to it early and always.

 

. Never forget the power of music,

Stay active. Fight the weariness. Exercise because it changes not just attitude but response rates and possibly survival. There is more than observational data on this, there is a scientifically explained basis similar to the runners high and the heightened immune system of someone in shape versus a slug. Exercise helps

. Do simple sweet things that bring back fond reminiscences

Remember,. Life is not pain free, especially emotionally and psychologically, pain will happen. Embrace it but do not dwell on it . You will get burned, roll with it and remember the fear of pain can be many times more disabling than the pain itself.

Remember a lot of the non physical pain is a choice, a hard one to be sure, but a choice and choosing mindfulness and positive attitudes towards real body pain due to the cancer or how the therapy can make a difference as well.

Things ranging from hypnosis, to acupuncture, meditation, yoga acupressure massage, and in some cases even pot,( but there is a lot to say about that and it is no panacea at all) all can  assist and even lower needed pain medications and can work

 

Remember you are not in this alone . Others have gone through similar experiences, talk with them in the chemo suites, the waiting rooms, with the nurses, the support groups you should be in/ family friends in most cases but especially those who have travelled the road before you, or are on it now.

 

There is immense power in the connection  that we in cancer medicine, with powerful friendships can form.

If you are open, you probably have a boatload of those capable of rowing a similar boat to the one you are in . You are not alone. Attitude  can bring a better aptitude of how all this treatment goes and as I have said many times…the data  show it in quality of life and remission duration and even survival.

Common sense and life all show that you are not alone . So…. Despite all the weightiness, the sorrow, the guilt , the fear of loss on control and dignity, set the table of your heart and mind with help from others in a beautiful way and bon appétit

 

Now that we have reviewed attitude let’s talk about autonomy

 

You are the center of all your care and you are the co captain of your ship. Remember, your doctors degree, MD, does not mean magnificent demagogue.

I am sure you are familiar with our opening song   from chariots  of fire. A man has a plan and in a day it is crushed…… so it is when you have been told you have cancer ,thoughts of loss of control, soul sucking anxiety, what about your family and the list goes on as it hits  you like a ton of bricks.

In the film he rose above it  …he took control… and so you too will be a hero ………I have seen no exception… no matter how afraid you are, and control is what we are going to talk about today … your AUTONOMY when first diagnosed and through your course of therapy.. What works?

The supreme court said so a long time ago and more than once

 

You need this next topic, autonomy, as part of your repertoire of thinking when suspected of cancer all the way to whatever end.

 

 

 

 Autonomy may come naturally to some but usually not

 

How to achieve being the co captain of the ship as much as possible when diagnosed…. Yes , that seems impossible when everything turns to crap and you are most scared

 

What works?

Trust me you need this…

 

Autonomy.

It is something you must do, something you must demand, ……autonomy.

 

Your quality of life and those that love you will increase dramatically, so will your response to therapy because you are more in tune with your disease, your therapy and your options and……. Your physician is on notice as is the whole team that it is a team effort , you are co captain of your ship;;;

 

Autonomy….so what does it mean especially in oncology

 

This is the single most important word and concept the reader of my book or listener to this show must grasp. Philosophically, it refers to the fundamental principle that all humans are independent moral agents with the personal capacity to make moral decisions and act on them.

In modern days, autonomy most often equates with the phrase, self-determination. Individuals are autonomous when their actions are truly their own without coercion or inappropriate influence.

The final decision of the competent adult is theirs.

Thus, patient autonomy refers to the capability and right of patients to control the course of their own medical treatment and participate in the treatment decision-making process.

Physicians and their teams must fully inform their patients to the best of their ability and the best of the patients’ ability to understand. Health care providers lead the patient to intelligence. However, it is the patient’s job, once lead, to think..

God gave you the gift of choice and the greater gift of sufficient intelligence to make those choices if you are sufficiently informed. That is exactly what I am and the show and the book are attempting to do; inform. That is why this section appeared early on.

 

So empowered , you will be able to transform the pain of anxiety, which is fear of the unknown , into the hero producing powers behind fear which are a god given hard wired set of emotional, physical and intellectual responses that can and do lead us to wise, autonomous personal decisions

It is improving with the advent of integrative medicine and the advent of patient centered care  See comment in PubMed Commons below

The medical practice of patient autonomy and cancer treatment refusals: a patients’ and physicians’ perspective.

The idea that patients should take up an autonomous position in the decision-making process is generally appreciated.

However, what does patient autonomy mean in the case of patients who refuse a recommended oncologic treatment.

In contrast to what is generally believed, decisions of patients to refuse an oncologic treatment do not so much rely on the medical information about disease and treatment options, but are rather inspired by patients’ own experiences or those of close others…or Dr Google. You would be amazed  .

In certain unique circumstances government may have the right to temporarily override the right to bodily integrity and autonomy in order to preserve the life and well-being of the person.

 

Such action can be described using the principle of “supported autonomy”,[13] a concept that was developed to describe unique situations in mental health (examples include the forced feeding of a person dying from the eating disorder anorexia nervosa, or the temporary treatment of a person living with a psychotic disorder with antipsychotic medication).

While controversial, the principle of supported autonomy aligns with the role of government to protect the life and liberty of its citizens. But even then there is some debate…. I fall on the side of government

How about when the disease approaches a terminal phase Perhaps autonomy should have been the guiding principle long before this transpired in case it came to pass and thus avoid ethical quagmires, distressed next of kin and playing god

Medical and social attitudes toward cancer have evolved rapidly during the last 20 years, particularly in north america.1,2 most physicians, most of the time, in most hospitals, accept the ethical proposition that patients are entitled to know their diagnosis.

However, there remains in my experience a significant minority of cases in which patients are never informed that although informed of the diagnosis, are not informed when disease progresses toward a terminal phase..

There are cultural and family differences..

Korean-American and mexican-american subjects are more likely to hold a family-centered model of medical decision making rather than the patient autonomy model favored by most of the african-american and european-american subjects. This finding suggests that physicians should ask their patients if they wish to receive information and make decisions or if they prefer that their families handle such matters.

Nonetheless, You, the patient, are the co captain of the ship. You have a responsibility to know the sails, the keel, the rudder the rigging, the set of the sails, the heading the clinical trials you have been taught about and demanded to know about or learnt how to responsibly find out about trials, You are a co expert on you

It is your body

No your are not an MD but you are a MD on your person in a large sense with your own personal doctorate, not just another case or person with a disease

Think of it.

You make autonomous decisions everyday, where and how you live, what you buy, a new car a mortgage, planning for you or your children’s future,

We are wired with free will and its exercise is manifested in autonomy, not arrogance and  not idiocy ,,,autonomy.

Just like in school,,, the more you know the smarter you get and you progress and the less the anxiety…and it is infectious to those around you

Believe it or not most physicians in oncology love the appropriately autonomous patient , they are partners with you when there are no right decisions as well as when there is . They can unburden themselves and you from the sense of playing god and being the only one in the know which will happen naturally because of their superior training often enough

But rarely are patients so intellectually challenged that they cannot grasp major decisions and make them together with their doctor ,,,

Caretakers are consultants but are not the patient

They are invaluable but are not the patient

They are loving but are not the patient

This is your life and you are dying to live not living to die….

Act like it

You will be more in touch with your signs and symptoms

You will actually trust yourself more and your doctor,

Your will handle therapy better and not surrender yourself into hands you do not know ,

Dying to live not living to die…..   Autonomy

Anxiety

 

Anxiety and fear

It is anxiety that is the killer, NOT FEAR. We humans suffer most when not knowing all that needs known, especially when there is so much to fear. Anxiety is fear of the unknown

Anxiety is not abnormal and may in fact be an emotion that leads to a positive outcome. Nonetheless, it hurts the cancer patient and family.

. It is knowledge that is the oncologists’ first and most precious gift to the patient. It is knowledge that the patient and family must demand. Knowledge delivered through teaching that must be thorough, comprehensible, and empathetic. Physicians must teach patients how to deal with family, friends, sources on the internet, the staging procedures and their meaning, the treatment and the value of second opinions. Patients must learn well that they will not be alone, that thousands have handled this and that others were no less anxious and no braver.

Physicians must speak to their patients of the odds of cure, remission and durability of remission. They must not shy away from discussing spirituality, life’s goals, and the effects of treatment on normal bodily function. Common anxiety-laden patient questions, as “what functions or abilities will I lose” as well as “what will I keep” are essential front burner issues. Discussions must be frank regarding the specter that pain, nausea and vomiting often represent to patients. Moreover, physicians will find the more empathetic time spent the greater the patient’s trust and quality of life.

Patients need to know if research studies hold out a realistic promise. Oncologists must explain the amazing armamentarium of medications they have, the psychological assistance patients will be given and potentially, the beautiful role which hospice may play.

Remember it’s ok to tell someone you are not ok

Other issues are what some have called scanziety and also the issue of telephone messages.

Scanxiety refers to the fear and worry associated with imaging, both before and after a test is performed, and lasts until the test results are communicated to the patient. As described by cancer survivor, “scans are like revolving doors, emotional roulette wheels that spin us around for a few days and spit us out the other side. Land on red, we’re in for another trip to cancerland; land on black, we have a few more months of freedom.”  The root of this anxiety is  related to the uncertainty of the test results and the amount of time that elapses between when the test is performed and the results known. Not surprisingly, most patients report an escalation of anxiety that correlates with longer wait times.

In an ideal world, scanxiety could be alleviated by immediate test results. When scans show no evidence of disease, or a blood test is within normal limits, the phone calls are easy to make. It’s a different story when the scans or tests are abnormal or indicate disease progression. In these cases, face-to-face conversations about treatment options are best.

“phone tag” frustration

So, what can healthcare providers do to reduce scanxiety? Some oncology practices schedule patients for a clinic visit on the same day a scan or test is performed or results known

Every oncology facility should have procedures that reduce the likelihood that patients will “fall through the cracks” and not be followed up.

An option is the doximity dialer, an app that allows healthcare providers to call patients without revealing their personal cell phone numbers. Patients see an office or clinic number instead. The app allows healthcare providers to call patients at any US number, choose the caller id that appears, and send return calls to an office or clinic.

The app can be downloaded for iphones at the app store and for android devices at Google play.

 

The bottom line is that there are a number of strategies to help patients reduce scanxiety and cope with its effects . Being diagnosed with cancer is hard enough; we need to do all we can do to make the journey less stressful. –

The physical changes regarding patient’s anxiety are measurable assessments after chemotherapy included distress, fatigue, and mindfulness.

Researchers have put yoga and mindfulness to the scientific test for years, and the results so far have been impressive. The practice has been shown to lower anxiety.

But it can also help those who are already ill feel better. A new study suggests that doing yoga twice a week may improve quality of life for men being treated for prostate cancer and may help reduce the side effects of radiation, which include fatigue, sexual dysfunction and urinary incontinence.

So again if you have any of these tell your doctor, there is help

  • Difficulty concentrating and making decisions
  • Heart palpitations, sweating, shaking
  • Shortness of breath, feeling faint
  • Numbness or tingling in the hands or feet
  • Heightened sense of alertness
  • Anticipating feeling anxious or a persistent worry
  • Feelings of guilt, worthlessness, and/or helplessness
  • Feeling of unreality or detachment from oneself
  • Fear of dying or losing control
  • Irritability, restlessness
  • Dry mouth
  • Muscle tension
  • Nausea
  • Sleep difficulties
  • Cold or sweaty hands
  • Loss of interest in activities or hobbies once pleasurable
  • Withdrawal from normal activities and friends (avoidance)
  • Appetite change or weight change (usually loss)
  • Persistent aches or pains, headaches, cramps, or digestive problems
  • Lets also give a non scholarly but becoming so, nod to smoked cannabis, the psychoactive form in alleviating anxiety- there are some early trials in the 80’s mostly about control of nauseas and vomiting where it was no better than what was then the standard and inferior to what we have now with exceptions existing on a case by case basis. It being a class 1 drug highly controlled by the FDA has made scholarly work hard but there is a growing body of evidence that supports a possible role in alleviating anxiety, besides improving mood , appetite and pain as well as anticipatory nauseas Mostly we are left with it being no better than standard of care but there are some powerful small studies and of course individual anecdotes. Remember ,anecdote does not equal antidote

 

None of the above is true for any other herbal substance despite what you think or may have heard

Remember anecdote does not equal antidote

 

Family-centered care is crucial to the care of children with cancer,

Challenges associated with a cancer diagnosis, treatment, and adaptation impact the entire family. Recent research has demonstrated that families experience altered family function and may face an accumulation of risk for mental health and severe emotional problems including anxiety over the course of illness,

Other research reports that the experience of cancer increases family cohesion and family resilience. So it can bond as well as break- it is a case by case , family member by family member SITUATION even within the same family .

The nurse’s role

. Oncology nurses directly impact families through communication and can model open, compassionate, developmentally appropriate communication with families. Moreover, coaching and teaching are inherent to nursing care of families. Thus, oncology nurses role can be 2-fold: communicating with families across settings to increase their comfort or to provide education and

 

Coaching in discussing sensitive, emotional topics related to the illness. .

 

Typical anxious fears are

fear of getting recurrence of cancer

Anxiety about having cancer

Constant fear of getting cancer

Fear of cancer diagnosis

Fear of cancer

Cancer and anxiety attacks

Cancer anxiety symptoms

Anxiety after cancer

So, anxiety is soul sucking, it has many forms and presentations, it is harmful and it is treatable in cancer patients and families by MANY approaches

DEPRESSION

The topic, as it is so often, is the “hidden” curse and THE NEVER AND forever lie= it will never change and will forever be this way .

Depression incidence in cancer patients is twice that of the general population, under diagnosed and has twice the suicide rate.

OVERVIEW

Over 15.5 million cancer survivors are alive today in the US, which is similar to the populations of New York City, Los Angeles, and Chicago combined.

The number of survivors continues to grow, not just because of earlier detection and treatment AND AGING OF THE POPULATION , but because of revolutionary new therapies that have been emerging over the past decade.

Now, patients with poor-prognosis metastatic cancers such as lung cancer and melanoma can live many years with good quality of life while on active treatment. For many individuals, this changes the landscape from a terminal illness to more of a chronic illness.

Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. There is documented under-detection and failure to optimally manage psychiatric disorders and psychosocial needs in patients with cancer and their families.

 

Unmet needs can have negative consequences for quality of life, treatment adherence, and survival..

 

GUIDELINES ARE NOT ALWAYS FOLLOWED NOR IS  SCREENING ALWAYS DONE

 

SORRY BUT THAT IS REALITY AND RESEARCH SUPPORTS THAT

 

 

Although most cancer centers provide some psychosocial services AND IT IS IMPROVING , increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals . Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management.

 

Studies have documented that a cancer diagnosis results in high levels of emotional distress. Patients go through an adjustment period for about 4 to 6 weeks after diagnosis. SOME LONGER AND EXPECT THAT.

 

Cancer for many patients is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions—all while continuing to manage family, work, and other responsibilities.

 

However, for the majority of patients, once they receive a plan of action and begin treatment, their emotions tend to level out.

 

Yet, cancer IS a series of crises that may occur at any time in the disease trajectory from diagnosis, treatment, cycles of recurrences and remissions, post-treatment, and sometimes palliative care.

 

Assessment and treatment

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

 

Coordinating with the oncology team. With the patient’s permission, consulting and informing the oncology team of your involvement is critical. As mentioned earlier, psychiatrists need to understand the patient’s cancer diagnosis, staging, treatments, adverse effects of treatment, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life. Medical concerns can cause or MAKE WORSE, BOTH depression and anxiety.

 

Knowing that survival with metastatic breast cancer can be years is critical in providing psychiatric care for the patient.. Psychiatrists contribute to oncology care by providing information to the oncology team regarding the patient’s emotional status and potential barriers to care and treatment adherence.

 

 

Pharmacotherapy. The most prescribed antide­pressants in cancer patients are WHAT YOU HAVE HEARD CALLED ssris OF WHICH THERE ARE MANY, At times the choice of an antidepressant is made based on the antidepressant adverse-effect profile.

 

.

Some psychiatric medications may adversely affect the efficacy, THAT IS , THEY MAY INTERFERE WITH of commonly used systemic cancer therapies.

.

Be aware that some systemic cancer treatments are associated with psychiatric adverse effects. DRUGS TO TREAT leukemia and some lymphomas, may cause depression. Interferon at high doses can cause depression and even suicidal THOUGHTS. SOME CAN CAUSE can cause lethargy, depression, mania, confusion, and hallucinations. THEY can potentiate the effects of alcohol, opiod, and tricyclic antidepressants.

 

Glucocorticosteroids such as prednisone and dexamethasone are widely used in cancer care. They can cause a range of psychiatric symptoms, from emotional lability, depression, anxiety, restlessness, irritability, and insomnia to paranoia, delusions, and hallucinations..

 

Pain management. Suffering from uncontrollable pain is one of the most common fears of cancer patients. Unfortunately, pain is under-recognized and undertreated in patients with cancer. Explaining to the patient that at times she may need to use opiods under the care of her oncologist without fearing addiction can prevent the patient from suffering unnecessarily. Poorly managed pain can lead to depression and anxiety. Once pain is appropriately managed, depressive and anxiety symptoms often diminish or resolve. ONCE THE PAIN MEDS ARE RESPNOSIBLY GIVEN THERE IS OFTEN GREAT RELIEF

 

HOWEVER     While some psychiatrists and oncologists have expertise in pain management, others may not and are reluctant to prescribe the necessary medications at the appropriate doses. AND SOME OVERPRESCRIBE

 

Speaking with the oncology team and helping to get appropriate referral to a cancer pain specialist or palliative care team is crucial to the quality of life of cancer patients, especially those with advanced disease.

 

Before the patient’s visit with the pain specialist, it is helpful for the psychiatrist to provide education and correct some common misconceptions. The following 3 key issues should be considered regarding referral for pain management:

  1. A majority of cancer patients do not have a history of addiction and actually fear becoming addicted to pain medications
  2. Patients view the taking of pain medications as associated with death and dying: “Only a patient who is dying takes morphine”    3)Patients may need education on the difference between addiction and tolerance, in order to comply with prescribed pain medications Psychiatry appointmentsPatients often include their family in oncology visits,. Family members may need support in coping with their own concerns and often need educationThe American Psychosocial Oncology Society (www.apos-society.org) has published quick reference handbooks on psychosocial care for adults, children, and elderly adults with cancer and produces webinars on particular topics, such as sexual health and cancer.
  3.  
  4. The traditional paradigm for psychiatric treatment may require a more flexible approach to scheduling to adjust to the reality of the patient’s needs during treatment. . FLEXIBILITY IS CRUCIAL. SUFFERRING HAS NO TIMECLOCK
  5.  
  6.  

7 Physical Clues You Could Have Depression

 

Many people who suffer from chronic illnesses also suffer from depression. Depression isn’t something that should be overlooked; it should be brought to your doctor’s attention so that it can be treated. But how do you spot depression?  With help from prevention.com, we’ve put together a list of some of the most common physical signs that someone is suffering from depression.

 

Aches and Pains

Although many chronic illnesses have their share of aches and pains, depression can also make muscles and joints feel sore or exacerbate the problem. People who are happy or content generally feel pain less than those who have depression.

Difficulty Sleeping or Waking Through the Night

Not being able to relax enough to fall asleep or frequently waking up during the night and finding it difficult to go back to sleep could both be signs of depression. Lack of sleep or disturbed sleep can have a profound effect on mood and the ability to concentrate.

Changes in Weight

Loss of appetite or comfort eating are both associated with depression, but you may not realize you have either until you step on the scale and notice a difference. In addition, if you’re not sleeping well because you’re anxious or depressed, this can also mess with your appetite leading to weight loss or gain.

Skin Complaints

Because depression affects hormones, this often becomes apparent in our skin. Depression can lead to skin complaints like acne, psoriasis, and eczema and treating the depression can help with the skin complaint.

Stomach Problems

Mood definitely affects the gut, and people with depression may suffer from symptoms like nausea, constipation, diarrhea, heartburn and indigestion.

Headaches and Migraines People with depression are more likely to experience frequent headaches or migraines. Although this could also be a side effect of medication or treatments you take for your chronic illness.

Oral Problems

People with depression are more likely to need dental work such as tooth extractions and cavities than those who don’t. The thought behind this is that if you’re depressed, you’re less likely to be as diligent about oral health.

Suicide is twice the rate as least in cancer patients and in depressed ones some studies say it is 4 times higher

Once again REMEMBER Suicide IN DEPRESSED CANCER PATIENTS WHO HAVE TWICE THE RATE OF DEPRESSION IS ALSO TWICE THE RATE OF NON CANCER PATIENTS

AND STUDIES SUGGEST  THAT FEWER THAN 30% OF ONCOLOGISTS FORMALLY SCREEN FOR IT AND THE PATIENT OR CLOSEST CAREGIVER MORE COMMONLY SILENTLY SUFFERS THAN SPEAK UP

Elderly patients with cancer and depression

Are far less likely to be diagnosed with depression than patients in any other age group for two primary reasons: There is an overlap between cancer symptoms,/treatment side effects and the diagnostic criteria for depression, …….and older adults are more likely to present with anhedonic “depression without sadness,”

“This represents a significant public health concern that will grow in importance as the U.S. population continues to age.”AND THAT IS KEY AS THE BOOMERS ARE HOME TO ROOST

Diagnosing Depression IN THE ELDERLY

Common symptoms of depression—fatigue, diminished concentration, thoughts of death/suicide, weight loss/gain—are confounded with side effects from cancer treatments or, potentially, the cancer itself.

Depressed mood and loss of interest—anhedonia depressed mood without sadness , reduction in social relationships/loneliness, loss of meaning and purpose, and lack of usefulness and sense of being a burden are all common.

Four minor themes also emerge: attitude toward treatment, mood, regret and guilt, as well as physical symptoms and limitations.

. “THIS IS CRITICAL AND PATIENTS GO BACK TO IT (WHAT THEY DID IN THE PAST) OVER AND OVER AGAIN. They perseverate. “The depressed patients seemed to ruminate on their regrets, ,”

Cancer survivors show patients how to overcome the ordeal WITH so called head foods….this is MEDICINE FOR WHICH THERE IS SCANT TO NO PROOF OF POSITIVELY HELPING THE DEPRESSED PATIENT…. REMEMBER ANECDOTE DOES NOT MEAN ANTIDOTE LETS SAY IT AGAIN ANECDOTE DOES EQUAL ANITIDOTE AND NO HEAD FOOD EXISTS

But

New SUGGESTED clinical guidelines on integrative, mind-body therapies for patients with breast cancer finds IMPROVED RATES OF AND TREATMENT OF DEPRESSION AS PART OF INTEGRATIVE MEDICINE WITH :

    • Use of music therapy, meditation, stress management, and yoga for anxiety and stress reduction;
    • Use of meditation, relaxation, yoga, massage, and music therapy for depression and mood disorders;
    • Use of meditation and yoga to improve quality of life;
    • Use of acupressure and acupuncture for reducing chemotherapy-induced nausea and vomiting;
  • NOTE THIS LAST POINT WELL… THIS IS NOT JUST ME TALKING. THERE IS A lack of evidence supporting the use of ingested dietary supplements OR OTHERWISE MANIPULATING THE DIET or botanical natural products as part of supportive care and/or to manage breast cancer treatment-related side effects.

 

Yet Studies show that up to 80 percent of people with a history of cancer use one or more complementary and integrative therapies,

ALSO Patients NEED TO fully understand the potential risks of not using a conventional therapy that may effectively treat cancer or manage side effects associated with cancer treatment, DO NOT GO RUNNING HELTER SKELTER WITH DR GOOGLE OR UNPROVEN THERAPIES WHICH MAY NOT ONLY NOT WORK BUT CAUSE HARM.

 

Patients are using many forms of integrative therapies with little or no supporting evidence and that remain understudied,

Then in the last of part of one of our summary we looked at some of the nuts and bolts of oncology

Overview of Specialty

Let us first look at what is required to become a medical oncologist.

Training requirements:

University (BS or BA)        4 years

Medical school (MD)       4 years*

Internship                          1 year

Internal medicine residency    2 years

Oncology fellowship             or  2 years

Hematology fellowship   or     2 years

Hematology/Oncology            3 years (combined)                                          *Osteopathy degree is also acceptable in place of MD

.

My advice is never be treated by a non-board certified (in medical oncology or only hematology) physicians with few exceptions.( leukemia and lymphoma are often treated expertly by both. The board pass rate is 58-65% with board certification only good for 10 years, as you must re-pass a new exam. As mentioned, many do not sit for the hematology board and remain “board eligible

Specific and related fields

 

Medical oncology involves the management of most cancers in adults and is one of the younger Internal Medicine sub-specialties. The need for a “cancer specialist” did not arise until early 1970’s with the advent of sophisticated chemotherapy regimens. A “quarterback” for cancer care was needed. Patients are usually referred to us after the diagnosis.. Our role has largely evolved to being deeply involved behind the scenes when the diagnosis is suspected but not made.

Pediatric oncology.

Gynecologic oncology

Urology involves the primary surgical approach, but not the chemotherapy, if any, of bladder, kidney, and prostate cancer..

Otolaryngology, also known as (ENT) involves primarily surgery only on cancers of the head and neck and may parent with radiation and chemotherapy.

Surgical oncology largely concentrates on breast, colon, melanoma, and other solid tumors: some have training sufficient to credential them to give chemotherapy.

Neurosurgeons deal largely with the removal and or biopsy of tumors of the brain or spinal cord tumors.

Thoracic surgery concentrates on early stage lung cancers and occasional open biopsies of the lining of the heart or other chest structures.

Orthopedic surgery deals with the primary surgery of bone cancers or metastases, surgical removal and stabilization of bones (rods/ pins) weakened by cancers.

Radiation Oncology they give radiation to different types of cancer as primary treatment such as brain tumors, lung cancers, some lymphomas (cancer of lymphocytes) or treatment after surgery (breast after removal of breast cancer) or treatment along with chemotherapy (synergism)-head and neck, rectal, anal, and lung, or treatment of local painful boney areas of tumor spread.

The Scope Of The Problem

Age is the greatest single factor worldwide for developing malignancy.

Globally, over 13 million people are diagnosed with some form of cancer yearly with 8 million deaths. This represents a global cancer burden doubling in the last 30 years of the 20th century, with doubling again between 2000 and 2020 and nearly tripling by 2030. By 2030, over 25 million people a year may be diagnosed with cancer, with two thirds dying from it..

The most recent figures show that for the first time since records have been kept, less than 20 percent of adults were smokers in 2007. However, cigarette companies are finding new customers in developing countries. About 40 percent of the world’s smokers live in just two nations — China and India.

Cancer treatment facilities are out of reach for many and life-saving treatments are less available. .

Cancer is uncommon in adolescents and children (with only about 150 cases per million in the U.S.), with leukemia the most common. If we put all ages and both sexes together the odds of getting cancer are about 460 per 100,000. This is not rare

Cancer in the first year of life has an incidence of about 230 per million in the U.S. with the most common cancer being nueroblastoma.

In the U.K., cancer is in the lead over cardiovascular disease yet it appears much lower in third world countries most likely owing to much higher deaths from infectious diseases such as malaria and TB and accidents. Nonetheless, cancer remains a major public health problem worldwide with skin, lung, prostate, and breast, lung, colorectal and urinary bladder representing the majority of types

EARLY NUTS AND BOLTS OF ONCOLOGY

Hi DR Ryan here, medical oncologist, PROFESSOR, RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer.
This is largely FROM A BOOK OF THE SAME NAME AS WELL AS ITS WEB SITE www.whentumoristherumorandcanceristheanswer.com WHICH are both  THERAPEUTIC
The goal is not to sell books as much as it is to get out the authentic words about cancer as 2 million people and more, as we age, will have it and 80% of us knew know or will know someone with it .
In terms of family and friends that is more than 20 million people and that too is growing. Visit the web site. The book is available on Amazon as well as the web site but again this is a NON PROFIT endeavor which is all paid for by me so I could control the content and stay away from untruths and sensationalisms which editors often in this field want
THIS is the real deal and take from it what you need when you need it .
After this, our 9th time of meeting. Next week we will do a summary of all we have said. In this section I will try to answer questions as we go along as possible
THIS IS A BROAD OVERVIEW OF NUTS AND BOLTS OF ONCOLOGY
        In this section, I present an overview of the structure of the field of oncology and some critical terms and aspects all patients will encounter. Also as I said since this is a short section I encourage questions on both it and anything regarding cancer and I’ll do my best to answer them as long as a good answer is not too lengthy. This sets the stage by being less in depth than an individual might find in some textbooks for professionals on the matter and covers some material that will appear again in different format later on.
You will also see the tone change just a bit when we get to the direct and dry science. The material is going to be in-depth, for many of you of interest and for others not so and be a bit dry but it is ok and a necessary part of  the big picture and needs to be covered.
We will later. not in this section, discuss some chemotherapy agents somewhat. Nonetheless, I urge you take a good look at it all, even if you only understand it notionally. The reason is this; cancer is damn frightening and profoundly complex. The more you understand, even notionally, of the tools we use to describe it and classify it and its treatments as well as its origin, the more you can control the experience. The more you comprehend its ‘mindset’ physiologically on a cellular level and the tools we have to image it and eradicate it, the more you can engage in outside reading that is focused and appropriate. Facts are your fodder and fuel to go from a leap of faith in your treatment to informed conviction, and I suspect the material is not so dry as to not be worth a run though.
The more you understand putting all the pieces together the more peace you will have. If only it serves as reference for loved ones or perhaps not at all, you still have the comfort of knowing it is there for you to understand more. It is not essential that you know all of this but the more you master the more you will master the anxiety that seeks to direct you rather than you be in the director’s chair.
Thus, the book can serve readily as a reference taking you wherever you need to go to learn more about the journey you are on or are about to undertake. Take advantage of that structure and peruse the table of contents selecting easily what you need and jump right in.
In this section, you will have enough to be familiar with the road and major signposts starting from your first rumor of tumor until you actually begin therapy because cancer was the answer.

 

Overview of Specialty

 

Let us first look at what is required to become a medical oncologist.

 

 

Training requirements:

 

 

 

University (BS or BA)      4 years

Medical school (MD)      4 years*

Internship                1 year

Internal medicine residency      2 years

Oncology fellowship            or  2 years

Hematology fellowship   or     2 years

Hematology/Oncology            3 years (combined)

 

*Osteopathy degree is also acceptable in place of MD

 

The above is needed to sit for the exam for board certification in Hematology or Oncology (separate boards).

Training falls under the auspices of the American Board of Internal Medicine. You must be board certified in Internal Medicine and complete the training of the above fellowships to be eligible to sit for oncology or hematology written exams. Essentially all those completing the fellowships sit for the Medical Oncology exam and about 50% sit for the hematology board. My advice is never be treated by a non-board certified (in medical oncology or only hematology) physicians with few exceptions.( leukemia and lymphoma are often treated expertly by both. The board pass rate is 58-65% with board certification only good for 10 years, as you must re-pass a new exam. As mentioned, many do not sit for the hematology board and remain “board eligible” until first request to sit for the exam, then eligibility is good for six years. This system is under review.

 

Specific and related fields

 

Medical oncology involves the management of most cancers in adults and is one of the younger Internal Medicine sub-specialties. The need for a “cancer specialist” did not arise until early 1970’s with the advent of sophisticated chemotherapy regimens. This required specific training for delivery of drugs and follow-up of unique, life-threatening side effects as well as much more in depth understanding of the natural history of a disease promulgating the need for a “quarterback” for cancer care. Patients are usually referred to us after the diagnosis. There is significant overlap with hematological cancers of the blood system such as leukemia and lymphoma as mentioned above. Our role has largely evolved to being deeply involved behind the scenes when the diagnosis is suspected but not made.

Pediatric oncology involves cancers of children and young adults (up to 18 years old). The above training is similar with a pediatric residency instead of internal medicine.

Gynecologic oncology treats ovarian, cervical, and uterine cancers. An obstetrics and gynecology residency, followed by a 2-year fellowship is required with formalized board certification.

Urology involves the primary surgical approach, but not the chemotherapy, if any, of bladder, kidney, and prostate cancer. There is some significant degree of chemotherapy treatment by the urologist directly into the bladder for the more superficial bladder cancers. There is some extent of treatment of recurrent or even preoperative and immediately postoperative hormonal manipulation of prostate cancer being increasingly done by this field. Training is four years after a one-year surgical internship.

Otolaryngology, also known as (ENT) involves primarily surgery only on cancers of the head and neck. There is a 4-year residency after internship.

Surgical oncology largely concentrates on breast, colon, melanoma, and other solid tumors: some have training sufficient to credential them to give chemotherapy. This entails a 5-year residency followed by 1-2 year fellowship.

Neurosurgeons deal largely with the removal and or biopsy of tumors of the brain or spinal cord tumors. This entails a 7-year residency.

Thoracic surgery concentrates on early stage lung cancers and occasional open biopsies of the lining of the heart or other chest structures. This entails a five-year residency followed by fellowship.

Orthopedic surgery deals with the primary surgery of bone cancers or metastases, surgical removal and stabilization of bones (rods/ pins) weakened by cancers.

Radiation Oncology entails a 1-year general internship. After a 3-4 year residency, they give radiation to different types of cancer as primary treatment such as brain tumors, lung cancers, some lymphomas (cancer of lymphocytes) or treatment after surgery (breast after removal of breast cancer) or treatment along with chemotherapy (synergism)-head and neck, rectal, anal, and lung, or treatment of local painful boney areas of tumor spread.

The Scope Of The Problem

 

Perhaps not obvious to some and certainly not meant to be clever, age is the greatest single factor worldwide for developing malignancy. Think of it. Assaults of whatever nature from the outside are constant (to varying degrees) and continuous. Our own aging argues for how our major mechanisms to fend off the various external causes of cancer are not what they used to be in our youth. Think of sun caused skin changes and cancers.

Cancer may one day replace heart disease as the No. 1 cause of death worldwide with a growing burden in poor countries thanks to more cigarette smoking and other factors. Globally, over 13 million people are diagnosed with some form of cancer yearly with 8 million deaths. This represents a global cancer burden doubling in the last 30 years of the 20th century, with doubling again between 2000 and 2020 and nearly tripling by 2030. By 2030, over 25 million people a year may be diagnosed with cancer, with two thirds dying from it.

In men, lung cancer is the most common form in terms of new cases and deaths, while breast cancer is the most common type among women in new cases and deaths. More men than women get cancer and die from it with cancer currently accounting for about one in eight deaths worldwide.

Trends that will contribute to rising cancer cases and deaths include the aging of populations in many countries, as cancer is more common in the elderly and cigarette smoking rates are increasing in poor countries.  Some countries have made progress in cutting cigarette smoking, which causes most cases of lung cancer as well as many other illnesses. In the United States, the most recent figures show that for the first time since records have been kept, less than 20 percent of adults were smokers in 2007. However, cigarette companies are finding new customers in developing countries. About 40 percent of the world’s smokers live in just two nations — China and India.

Decades ago, cancer was considered largely a problem of westernized, rich, industrialized countries. However, much of the global burden now rests in poor and medium-income countries. Many of these countries have limited health budgets and high rates of communicable diseases, while cancer treatment facilities are out of reach for many and life-saving treatments are less available.

At the same time, progress against cancer is occurring in such places as the United States and Europe. For example, health authorities in the United States report that cancer diagnosis rates are now dropping for the first time in both men and women and previous declines in cancer death rates are accelerating. They attributed the progress to factors such as regular screening for breast and colorectal cancer, declining smoking rates and improved treatments.

Let’s look a little more specifically at the numbers in the United States. Cancer is about 25% of all deaths and appears on track to replace cardiovascular disease as number one. One cancer alone, lung, is 30 % of all deaths. Prostate is second in men responsible for 25% of deaths. Prostate is also the most commonly occurring cancer in men with breast cancer just ahead of lung cancer, in women.

Cancer is uncommon in adolescents and children (with only about 150 cases per million in the U.S.), with leukemia the most common. If we put all ages and both sexes together the odds of getting cancer are about 460 per 100,000. This is not rare

Cancer in the first year of life has an incidence of about 230 per million in the U.S. with the most common cancer being nueroblastoma.

In the U.K. cancer is in the lead over cardiovascular disease yet it appears much lower in third world countries most likely owing to much higher deaths from infectious diseases such as malaria and TB and accidents.

Nonetheless, cancer remains a major public health problem worldwide with skin, lung, prostate, and breast, lung, colorectal and urinary bladder representing the majority of types

 

 

THIS HAS BEEN the first of a series on the nuts and bolts on oncology kept intentionally short to encourage questions. Next week , our 9th week together, will be a summary of all we have covered so this is the first  week on the nuts and bolts of oncology and intentionally kept more mellow

 

Any more questions?????

 

This has ben DR kevin Ryanmd mba facp and hematologist oncologist here, medical oncologist PROFESSOR AND RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer. Modeled after my book of the same name available on thE web site OF THE SAME NAME you can find it on the web site and a lot more, interviews, films excerpts on the site and it is also available on Amazon   IN ALL FORMATS I AM Signing off radio www.w4cs.com the cancer support radio program REMIND YOU THE PROGRAM IS ARCHIVED HERE AND THE iheart RADIO AS WELL AS THE WWW.W4CS BLOG AND MYBLOG ACCESSED EASILY FROM THE WEB SITE

DEPRESSION AND CANCER

Hi DR Ryan here, medical oncologist AND PROFESSOR AND RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer.

I am sure you are familiar with our opening song   from chariots  of fire. A man has a plan and in a day it is crushed…… so it is when you have been told you have cancer ,thoughts of loss of control, soul sucking anxiety, what about your family and the list goes on as it hits  you like a ton of bricks.

He rose above it in the film  and so you to will be a hero ………I have seen no exception no matter how afraid you are, and that is what we are going to talk about today …your attitude when first diagnosed and through your course of therapy.. What about Depression

 

. We will take our time so feel free to write in your questions or comments at www.w4cs.com and i will try to get to them

Depression and Anxiety Disorders in Patients With Cancer

 

OVERVIEW

Over 15.5 million cancer survivors are alive today in the US, which is similar to the populations of New York City, Los Angeles, and Chicago combined.

 

The number of survivors continues to grow, not just because of earlier detection and treatment AND AGING OF THE POPULATION , but because of revolutionary new therapies that have been emerging over the past decade.

Now, patients with poor-prognosis metastatic cancers such as lung cancer and melanoma can live many years with good quality of life while on active treatment. For many individuals, this changes the landscape from a terminal illness to more of a chronic illness.

 

Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. In 2008, the Institute of Medicine published Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which documented under-detection and failure to optimally manage psychiatric disorders and psychosocial needs in patients with cancer and their families.

 

Unmet needs can have negative consequences for quality of life, treatment adherence, and survival. Subsequently, the American College of Surgeons Commission on Cancer started requiring cancer centers to screen patients for psychosocial distress as part of accreditation, and the American Society of Clinical Oncology developed practice guidelines for managing depression and anxiety.

 

THEY ARE NOT ALWAYS FOLLOWED OR SCREENING DONE SORRY BUT THAT IS REALITY AND RESEARCH SUPPORTS THAT

 

 

Although most cancer centers provide some psychosocial services, increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals . Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management.

 

Studies have documented that a cancer diagnosis results in high levels of emotional distress. Patients go through an adjustment period for about 4 to 6 weeks after diagnosis. SOME LONGER AND EXPECT THAT Cancer for many patients is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions—all while continuing to manage family, work, and other responsibilities.

 

However, for the majority of patients, once they receive a plan of action and begin treatment, their emotions tend to level out. Yet, cancer should not be considered as one discrete crisis, but rather as a series of crises that may occur at any time in the disease trajectory from diagnosis, treatment, cycles of recurrences and remissions, post-treatment, and sometimes palliative care.

 

In terms of psychiatric disorders among cancer patients, there is significant variability in the prevalence rates reported due to different assessment methods (clinical interview versus standardized measures), diagnostic criteria, type of cancer, and stage of disease among other variables. Recently, Mehnert and colleagues reported a 31% prevalence rate for any psychiatric disorder in cancer patients. Adjustment disorders tend to be the most commonly diagnosed, with the rates ranging from 11% to 35%. Rates for depression vary from 11% to 37%, and anxiety disorders show rates from 2.6% to 19.4%. The rate for depression in the general population is 7%—and thus lower than among cancer patients—but the rates for overall anxiety disorders seem to be comparable WHICH I DO NOT BELIEVE IT IS UNDER REPORTED.

 

 

Assessment and treatment

The Case Vignette presents specific issues important for psychiatrists to consider when treating patients with cancer.

CASE VIGNETTE

Mrs. T is a 53-year-old postmenopausal married woman with 2 teenage daughters who recently received a diagnosis of stage IV breast cancer metastatic to pelvic bone. Up until 2 months ago, she had been working full-time as an attorney but had to stop because of severe pain that progressively worsened. A medical workup showed an HIGHLY TREATABLE BUT INCURABLE LONG TEERM POSSIBLE SURVIVAL CANCER.

She does not have a psychiatric history or comorbid illnesses. Soon after starting THERAPY, she began to feel very sad, anxious, irritable, and fatigued; cried easily; and had trouble sleeping because of hot flashes. She ruminates on dying and leaving her daughters. She denies hopelessness and suicidal ideation, and quite the contrary she very much wants to live.

 

Depression and Anxiety Disorders in Patients With Cancer: Page 2 of 3

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

 

Coordinating with the oncology team. With the patient’s permission, consulting and informing the oncology team of your involvement is critical. As mentioned earlier, psychiatrists need to understand the patient’s cancer diagnosis, staging, treatments, adverse effects of treatment, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life. Medical concerns can cause or exacerbate depression and anxiety.

 

For example, in this case, knowing that survival with metastatic breast cancer can be years is critical in providing psychiatric care for the patient. Remaining silent as the patient expresses fear of death within the next few months can be taken by the patient as agreement and can exacerbate anxiety. Psychiatrists contribute to oncology care by providing information to the oncology team regarding the patient’s emotional status and potential barriers to care and treatment adherence.

 

 

Pharmacotherapy. While there may be overlap between symptoms of depression and anxiety and cancer- and treatment-related adverse effects (fatigue, changes in sleep and appetite), treatment of the psychiatric disorder is primary rather than a focus on differentiating the causes of the symptoms. The most prescribed antide­pressants in cancer patients are SSRIs, At times the choice of an antidepressant is made based on the antidepressant adverse-effect profile.

 

.

Some psychiatric medications may adversely affect the efficacy of commonly used systemic cancer therapies.

.

Be aware that some systemic cancer treatments are associated with psychiatric adverse effects. DRUGS TO TREAT leukemia and some lymphomas, may cause depression. Interferon at high doses can cause depression and even suicidal ideation. SOME CAN CAUSE can cause lethargy, depression, mania, confusion, and hallucinations. THEY can potentiate the effects of alcohol, opioids, and tricyclic antidepressants.

 

Glucocorticosteroids such as prednisone and dexamethasone are widely used in cancer care. They can cause a range of psychiatric symptoms, from emotional lability, depression, anxiety, restlessness, irritability, and insomnia to paranoia, delusions, and hallucinations. Symptoms may develop within a couple of days of the start of treatment and are also common if the dose is rapidly tapered off. But psychiatric symptoms can develop even on a stable dose.

Mindfulness Practice Reduces Cortisol Blunting During Chemo

×

You must be a member to content.

Already Have An Account? Log in Now

Join PracticeUpdate Now

×

You’ve saved your first item

You can find your saved items on your dashboard, in the “saved” tab.

Ok

×

You’ve recommended your first item

Your recommendations help us improve our content suggestions for you and other PracticeUpdate members.

Ok

×

You’ve subscribed to your first topic alert

What does that mean?

1.Each day, we’ll check to see if new items have been published to the topics you’re subscribed to, and we’ll send you one email with all of the new items from that day.

2.We’ll keep all topic alert notifications available on your dashboard for 30 days, to make sure you don’t miss anything.

3.Lastly, whenever you have unread items in the topics you’ve subscribed to, the “Alerts” icon will light up in the main menu. Just click on the bell to see your five most-recent, unread notifications.

Ok

Mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published online April 7 in Cancer.

) — Mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published online April 7 in Cancer.

David S. Black, Ph.D., M.P.H., from University of Southern California in Los Angeles, and colleagues assigned 57 English- or Spanish-speaking colorectal cancer patients to either mindfulness, attention-control, or resting exposure at the start of chemotherapy. Four saliva samples were collected at the start of chemotherapy and at 20-minute intervals during the first 60 minutes of chemotherapy. Self-reported biobehavioral assessments after chemotherapy included distress, fatigue, and mindfulness

An area-under-the-curve analysis showed a relative increase in cortisol reactivity in the mindfulness group, after adjustments for biological and clinical measures (P = 0.03). From baseline to 20 minutes, more than twice as many patients in the mindfulness group displayed a cortisol rise, compared to controls (69 versus 34 percent; P = 0.02). Mindfulness scores were inversely correlated with fatigue and DEPRESSION (P < 0.01) and distress scores (P < 0.01).

 

 

 

 

Pain management. Suffering from uncontrollable pain is one of the most common fears of cancer patients. Unfortunately, pain is under-recognized and undertreated in patients with cancer. Bone pain experienced by cancer patients can be excruciating, and explaining to the patient that at times she may need to use opioids under the care of her oncologist without fearing addiction can prevent the patient from suffering unnecessarily. Poorly managed pain can lead to depression and anxiety. Once pain is appropriately managed, depressive and anxiety symptoms often diminish or resolve.

While some psychiatrists and oncologists have expertise in pain management, others may not and are reluctant to prescribe the necessary medications at the appropriate doses. AND SOME OVERPRESCRIBE Speaking with the oncology team and helping to get appropriate referral to a cancer pain specialist or palliative care team is crucial to the quality of life of cancer patients, especially those with advanced disease.

 

 

Before the patient’s visit with the pain specialist, it is helpful for the psychiatrist to provide education and correct some common misconceptions. The following 3 key issues should be considered regarding referral for pain management:

1) A majority of cancer patients do not have a history of addiction and actually fear becoming addicted to pain medications

2) Patients view the taking of pain medications as associated with death and dying: “Only a patient who is dying takes morphine”

3) Patients may need education on the difference between addiction and tolerance, in order to comply with prescribed pain medications

 

Psychiatry appointments

The traditional paradigm for psychiatric treatment may require a more flexible approach to scheduling to adjust to the reality of the patient’s needs during treatment. Patients may initially need more frequent appointments as they are adjusting to the diagnosis. New patients may be unsure when to make follow-up appointments because they have many upcoming oncology visits. Letting the patient know that scheduling psychiatry visits shortly after the oncology visits provides an opportunity to review the new medical information during the session.

 

 

During treatment, patients may need to cancel or reschedule appointments because of the adverse effects of treatment. Depending on the specific patient’s clinical situation, exceptions may need to be made to policies about late cancellations and no-shows. As the disease advances, patients may become hospitalized and are too weak to make office visits. Accommodating shorter inpatient visits may be indicated for continuity of care.

 

Patients often include their family in oncology visits, and some assume that this practice also occurs in psychiatric visits. Psychiatrists in cancer centers frequently see patients with their family members in the room. It would not have been out of the ordinary for Mrs. T to have her husband or another family member join her for her psychiatric evaluation. Providing effective support and treatment of patients with cancer will often entail providing support and education to their spouses, children, and significant others. Family members may need support in coping with their own concerns and often need education in how best to support the cancer patient.

 

 

Concluding OVERVIEW thoughts

 

Cancer care will continue to change over the next several years, sometimes rapidly. While psychiatrists cannot be expected to stay up to date with all of the emerging cancer treatments, they do need to learn about the ones that their patients might be receiving. Many resources are available for learning more about the psychiatric care of individuals with cancer. The American Psychosocial Oncology Society (www.apos-society.org) has published quick reference handbooks on psychosocial care for adults, children, and elderly adults with cancer and produces webinars on particular topics, such as sexual health and cancer.

 

7 Physical Clues You Could Have Depression

 

Many people who suffer from chronic illnesses also suffer from depression. Depression isn’t something that should be overlooked; it should be brought to your doctor’s attention so that it can be treated. But how do you spot depression?  With help from prevention.com, we’ve put together a list of some of the most common physical signs that someone is suffering from depression.

 

Aches and Pains

Although many chronic illnesses have their share of aches and pains, depression can also make muscles and joints feel sore or exacerbate the problem. People who are happy or content generally feel pain less than those who have depression.

 

Difficulty Sleeping or Waking Through the Night

Not being able to relax enough to fall asleep or frequently waking up during the night and finding it difficult to go back to sleep could both be signs of depression. Lack of sleep or disturbed sleep can have a profound effect on mood and the ability to concentrate.

 

Changes in Weight

Loss of appetite or comfort eating are both associated with depression, but you may not realize you have either until you step on the scale and notice a difference. In addition, if you’re not sleeping well because you’re anxious or depressed, this can also mess with your appetite leading to weight loss or gain.

 

Skin Complaints

Because depression affects hormones, this often becomes apparent in our skin. Depression can lead to skin complaints like acne, psoriasis, and eczema and treating the depression can help with the skin complaint.

 

Stomach Problems

Mood definitely affects the gut, and people with depression may suffer from symptoms like nausea, constipation, diarrhea, heartburn and indigestion.

 

Headaches and Migraines

People with depression are more likely to experience frequent headaches or migraines. Although this could also be a side effect of medication or treatments you take for your chronic illness.

 

Oral Problems

Dentists in Australia have found people with depression are more likely to need dental work such as tooth extractions and cavities than those who don’t. The thought behind this is that if you’re depressed, you’re less likely to be as diligent about oral health.

 

Depression questionqaire IS KEY

 

Suicide

 

 

LONDON, England, AND I MENTIONED THIS BEFORE – British researchers have found that people who are frequently depressed or anxious may run a higher risk of dying from certain types of cancer. THERE ARE SEVERE PROBLEMS WITHIS STUDY AND IT HAS NOT BEEN REPLICATED LOOK AT COMLIANCE, SYMTOM COMPLAINING, ALCOHOL, QUALITY OF LIFE ISSUES, AND SUCH

In THIS study published in the BMJ medical journal, the scientists were cautious in their conclusions, pointing out that a statistical link does not necessarily signify a cause-and-effect relationship between mood and cancer.

Their findings nevertheless added to the growing body of evidence that mental and physical health do not function on separate planes, and that one can influence the other.

While earlier research had shown that chronic depression and anxiety could help trigger heart disease and stroke, attempts to forge similar links between states of mind and cancer have yielded mixed results.

 

It has already been established that depression can disrupt hormonal balance to the extent of boosting natural cortisone concentrations and inhibiting DNA repair mechanisms – both of which weaken defences to cancer.

 

It is also well known that emotionally distressed people are more likely to smoke, drink and become obese – all of which are associated with a higher cancer risk.

 

.

The scientists could not discount the possibility that depression could be a result, rather than the cause of cancer, however.

 

“Distress might be a consequence of the early stages of the malignancy rather than a potential predictor,” they said.

 

THE AUTHORS noted that further research was needed to confirm the link and tease out the causal connections.

 

 

 

Seeing Cancer Through a Sibling’s Eyes: What We Don’t Know Can Hurt Them

SO LETS DRILL DOWN TO WHAT WE HAVE LEARNED

 

Depression and Anxiety Disorders in Patients With Cancer

AGAIN

7 Physical Clues You Could Have Depression

 

Many people who suffer from chronic illnesses also suffer from depression. Depression isn’t something that should be overlooked; it should be brought to your doctor’s attention so that it can be treated. But how do you spot depression?  With help from prevention.com, we’ve put together a list of some of the most common physical signs that someone is suffering from depression.

 

Aches and Pains

Although many chronic illnesses have their share of aches and pains, depression can also make muscles and joints feel sore or exacerbate the problem. People who are happy or content generally feel pain less than those who have depression.

 

Difficulty Sleeping or Waking Through the Night

Not being able to relax enough to fall asleep or frequently waking up during the night and finding it difficult to go back to sleep could both be signs of depression. Lack of sleep or disturbed sleep can have a profound effect on mood and the ability to concentrate.

 

Changes in Weight

Loss of appetite or comfort eating are both associated with depression, but you may not realize you have either until you step on the scale and notice a difference. In addition, if you’re not sleeping well because you’re anxious or depressed, this can also mess with your appetite leading to weight loss or gain.

 

Skin Complaints

Because depression affects hormones, this often becomes apparent in our skin. Depression can lead to skin complaints like acne, psoriasis, and eczema and treating the depression can help with the skin complaint.

 

Stomach Problems

Mood definitely affects the gut, and people with depression may suffer from symptoms like nausea, constipation, diarrhea, heartburn and indigestion.

 

Headaches and Migraines

People with depression are more likely to experience frequent headaches or migraines. Although this could also be a side effect of medication or treatments you take for your chronic illness.

 

Oral Problems

Dentists in Australia have found people with depression are more likely to need dental work such as tooth extractions and cavities than those who don’t. The thought behind this is that if you’re depressed, you’re less likely to be as diligent about oral health.

 

Depression questionqaire IS CRUCIAL

 

Suicide TWICE THE RATE

Elderly patients with cancer

 

are far less likely to be diagnosed with depression than patients in any other age group for two primary reasons: There is an overlap between cancer symptoms/treatment side effects and the diagnostic criteria for depression, and older adults are more likely to present with anhedonic “depression without sadness,” according to Chris Nelson, PhD, Associate Attending Psychologist at Memorial Sloan Kettering Cancer Center in New York.

 

 

According to Dr. Nelson, self-report instruments tend to underestimate the severity of depressive symptoms, and many depressed older patients with cancer are completely overlooked. “There is clearly a need to better understand, quantify, and treat depression in older cancer patients,” he said at the 2017 American Psychosocial Oncology Society (APOS) Annual Conference in Orlando, Florida.1 “This represents a significant public health concern that will grow in importance as the U.S. population continues to age.”

 

Diagnosing Depression

Common symptoms of depression—fatigue, diminished concentration, thoughts of death/suicide, weight loss/gain—are confounded with side effects from cancer treatments or, potentially, the cancer itself.

 

The literature suggests that two gateway symptoms—depressed mood and loss of interest—are most valuable in diagnosing depression in cancer, but according to Dr. Nelson, identifying these symptoms is not necessarily useful in older adults.

“The gateway questions come off the table as less than usefull useful diagnostic criteria when we combine cancer and aging,” he said. “So we’ve been trying to identify additional symptoms that are useful for diagnosing depression in older adults with cancer.”

 

He and his colleagues conducted a study aimed at identifying the phenomenology of depression in older cancer patients and developing a set of indicators to identify, assess, and treat depression in this population. They performed a literature review and interviewed eight experts in the fields of oncology, social work, psychiatry, and psychology to assist in identifying important constructs.

 

Based on input from the experts and findings from the literature review, the researchers conducted qualitative interviews with 12 depressed and 12 nondepressed cancer patients older than age 70. Depressed patients were identified by referral and subsequently interviewed by the panel of experts to confirm their depression.

 

Major and Minor Themes

The researchers identified four major themes in distinguishing depression in older cancer patients: anhedonia depressed mood without sadness , reduction in social relationships/loneliness, loss of meaning and purpose, and lack of usefulness and sense of being a burden.

 

Four minor themes also emerged: attitude toward treatment, mood, regret and guilt, and physical symptoms and limitations.

 

 

In the patient interviews, the experience of anhedonia was nuanced and involved a lack of initiation of new activities in addition to difficulty maintaining existing activities, he reported.

 

Another central issue was, reduction in social relationships and loneliness, varied based on the range and depth of patients’ social engagement, but depressed patients tended to have limited meaningful relationships and were socially isolated and withdrawn.

 

Loss of meaning and purpose in life was salient in the depressed group, and they displayed an inability to adjust to their new limitations. “Patients in the nondepressed group didn’t need to be engaging in anything particularly purposeful, but what they did in the past carried over and was still important to them,” he noted. THIS IS CRITICAL AND THEY GO BACK TO IT OVER AND OBVER AGAIN Lack of usefulness and sense of being a burden was also displayed in all depressed participants.

There was no difference between depressed and nondepressed participants in terms of their willingness to engage in treatment, but their attitude toward treatment was the nuanced difference. “

 

The nondepressed were much more proactive regarding their treatment, whereas the depressed were resentful, angry, and upset about their treatment,” he said. Mood also varied more in the depressed group, with some patients citing worse mood in the morning, when the demands of the day were in front of them.

 

Both groups looked back at their lives and experienced some level of regret, but the amount of guilt experienced was the differentiating factor between the nondepressed and the depressed. “The depressed patients seemed to ruminate on their regrets, whereas the nondepressed were able to put their regrets in a tolerable perspective,” he said.

 

No actual difference in physical limitations was observed between the two groups, but a difference was noted in how they coped with those limitations. Two aspects of coping were deemed to be specifically useful to older cancer patients: acceptance of the limitations associated with aging; and adaptation—changing and modifying one’s lifestyle and activities—to adjust to those limitations.

 

Of the four major and four minor themes recognized by the researchers, only two—the major theme of anhedonia DEPRESSION WITHOUT SADNESS and the minor theme of mood—are identified in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for depression. Based on their findings, the researchers conclude that the DSM-5 criteria might not apply in identification of depression in older patients with cancer. We missed the boat perhaps According to Dr. Nelson, a new patient-reported outcome based on these symptoms we have talked about may be beneficial in identifying depression. ■

 

Cancer survivors show patients how to overcome the ordeal WITH COMPEMATRY AND ALTERNATIVE MEDICINE FOR WHICH THERE IS SCANT TO NO PROOF REMEMBER ANECDOTE DOES NOT MEAN ANTIDOTE

THESE ARE CLAIMED HEAD FOODS

Diet may a huge role in Depression. There are a number of lifestyle factors that contribute to Depression but one cannot overlook what you put in your mouth. The following foods are THOUGHT to lift the mood by working at the cellular level:

Chamomile Tea: One of the most recommended bedtime soothers. Pennsylvania university tested chamomile supplements on 57 participants suffering from Depression for eight weeks and found that it led to a significant drop in symptoms. Pour a cup of boiling water over 2 to 3 heaping tablespoons of the dried flowers (you can buy chamomile either loose or in tea bags at health food stores) and steep for 10 minutes. Try having a cup every night: Turn off the TV, computer, and phone and settle down for a peaceful end to the day. It’s nice iced, too.THIS WAS POOORLY DONE STUDY AND NOT CORROBORATED

 

Chocolate: Therapy for Depression, especially if it is dark chocolate. The antioxidants boost up not just the heart health but PERHAPS the mood. Dark chocolate is known to lower blood pressure, adding calmness. It contains MORE polyphenols and flavonols than some fruit juices. WHAT THAT MEANS IS UNCLEAR

 

Garlic: Surprised?. But garlic is packed with antioxidants which neutralise free radicals (particles that damage cells). It has allicin, said to fend off heart disease, cancer and common cold.AGAIN NOT PROVEN Depression weakens our immune system, but garlic IS CLAIMED TO mend it back. Have raw in the morning, saute it in broth, or add to all the meals, it is an enemy of depression.

Green Tea: Yes there’s caffeine but green tea also has theanine, an important amino acid IS THOUGHT TO fights Depression. in addition to ALLEGEDLY protecting against cancer, this slimming food is a brain booster as well, enhancing mental performance. Have two cups a day.

 

Oatmeal: The humble oat is actually a complex carbohydrate which compels the brain to produce serotonin, a feel-good chemical. Children on oatmeal breakfast stay sharper through the morning. AGAIN NOT FULLY CORROBORATED IN CONTROLLED STUDIES Beta-glucan, a soluble fibre in oatmeal, promotes satiety. THAT IS TRUE The whole grains release the glucose slowly in the blood stream hence keeping the blood sugars levels optimum. Stabilised blood sugar help the person to have a stable mood too PERHAPS BUT NO [ROVEN ROLE IN DEPRESSION.

 

Tomatoes: Contain folic acid and alpha-lipoic acid, both of which are good for fighting Depression. AGAIN SAME ANSWER NOT PROVEN

According to a paper in the Journal of Psychiatry and Neuroscience, an elevated incidence of folate deficiency is shown in patients suffering from Depression. About one-third Depression patients are deficient in folate. AGAIN NOT PROVEN TO HAVE ANY CAUSE AND AFFECT

 

Fatty Fish: When it comes to omega-3 fatty acids, no food source is better than fatty fish like mackerel, bluefish, wild salmon and tuna. The fatty acids found in these fish not only have ALLEGED UN PROVEN specific brain-boosting properties AND WHAT DOES THAT MEAN to fight depression, but also are good for overall health TRUE. They REDUCErisk of heart disease. For those who cannot or do not consume fish should have dietary supplements of fatty fish of high quality.

Berries: All the berries like strawberries, raspberries and blackberries BUT ESPECIALLY DARK BERRIES are the high antioxidants sources. These antioxidants are also called as DNA repairmen AGAIN UNPROVEN. They ward off the free radicals which are toxic and affect our mood UNPROVEN and the sense of well-being THEY TASTE GOOD AS WELL. These food products go around fixing your cells and prevent them from getting illnesses. AGAIN NOT REALLY PROVEN BEYOND GENERAL HEALTH

Mushrooms & Onions: ARE ALLEGED AND AGAIN UNSTUDIED REPOSIBLY AND UNPROVEN TO promote healthy gut bacterium. Nerve cells in our gut manufacture 80-90% of our body’s serotonin the neurotransmitter NOT REALLY which keeps us sane & happy.A WHOE BUNCH OF INTERACTIONS AND TRANSMITTERS ARE U INVOLVED AND SEROTONIN ALONE IS NOT ENOUGH

Dark Green leafy vegetables ARE HEA;THY FOR YOU Spinach and kale are THOUGHT TO FIGHT DEPRESSION Depression and cancer. GBOMBS stands for greens, berries, onion, mushroom, beans & seeds.

Apple: Is a rich source of antioxidants NOT THAT RICH and helps prevent and repair oxidation damage NOT PROVEN and cellular inflammation WHAT DOES THAT MEAN

 

THE KEY IS DO NOT BELIEVE ALL YOU HEAR. YES DIET HAS VARIOUS ROLES BUT DO NOT DO NOT DO NOT DEPEND ON THEM FOR TREATMENT OF SEVERE DEPRESSION IT CAN END WITH SUICIDE IT MAY NEED COUNSELING AND MANY OTHER PROVEN MODALITIES [PEOPLE WANT THIS TO WORK BUT STUDIES TO PROVE THEY HELP IGNORE THE 13& PPLACEBO EFFECT AND TREATING MILD TRANSIENT MOOD DEPRESSION NOT CLINICAL DEPRESSION. CALIMS ABOUT MEDICAL SPECIFIC MECHANISMS OF ACTION ARE ALMOST ALWAYS CA CA AND UNPROVEN CRITICALLY

 

I promised you stories and this one is filled with depression, hope and my only miracle—believing in miracles is miraculous enough for me

The Gift

 

 

It was as if her soul was branded cruelly at birth, “Kick Here”. It was not that she was dealt bad cards so much as she never had much of a prayer to be in the game of life. Alcoholic and abusive parents spawned this only child almost three decades ago and rendered havoc on her congenitally frail spirit and teetering health. Not surprisingly, she was cursed from the beginning as a severe diabetic. This had withered away her adolescence in angry diabetic comas  and multiple illnesses  as her family rambled helter-skelter across the country lashed to the whims of a drunken, oft-unemployed father.

Now a mother herself, Maria was at most a trembling waif of a young woman. She was murderously robbed of childhood innocence, weaned on despair, suckled on disappointment. Against the odds for severe diabetics she had amazingly survived pregnancy with very healthy twins.

She had escaped her hell of a family only to find herself in a ramshackle marriage to a pestilence, not a man. Wife beater and child abuser, her enlisted military husband was a belligerent brooding hulk for which fatherhood was a grave inconvenience and blot on his life.

I have come to believe that it was not by chance that one of our sage senior physicians happened to pull E.R. duty the day she walked the miles to our hospital carrying her precious cargo shivering in her arms. Both of her babies had fevers and to the discerning eye, it was clear that evil had pitched its tent in their home. Incessant apologies from a terrified tearful mother, scarred blistered skin from burning cigarettes pressed into innocent skin and classic fractures wailed as a wounded plaintiff cry for a savior, for justice.  Clearly both she and her children had been abused. She collapsed out of catharsis and  at least a momentary reprieve from fear and overwhelming grief when the emergency room team were marshaled to gather them all into our protective bosom. Simultaneously the search was set for her stain of a husband.

In short order, it was painfully clear that the tragedy had no bounds. It was soon obvious that Maria was ill. Evaluation in the emergency room showed that she had rapidly worsening kidney failure from what was soon learned to be malignant masses in her abdomen choking off her kidneys and eating voraciously through her pelvis.

I was drawn to this wounded pup. The ache of seeing such unfairness from a world which offers no guarantee of freedom from suffering  was a constant companion for many of us tending to her care. Our clinical bond and trust falteringly evolved. Leveraging the lifeboat of her children, I painstakingly strained to encourage in her a glimmer of hope and perhaps flame the fading flicker of fighting for her life, for her children.

We all have bucket lists of dreams unfulfilled and longed for. Her dream was common enough. She longed to have simply played with her children, to frolic with fantasy, unburdened by dread. Now she was resigned to a painful death; it was all she expected. Only the irrepressible devotion to her babies and the possibility of their future being so uncertain carried her on. However, it quickly became clear that the cancer would agonizingly strain the last beats of life from her.

We had raced through the diagnostic evaluation and the hurried dash to save her kidneys and numb what had to be blinding pain. There was never the slightest whimper, the faintest flinch from her. Through wounded eyes she watched disaffected, rallying only when her babies were safe and near. It was for them she allowed the tubes into her kidneys, for them she tolerated the invasion of her belly to knit together her perforated strangulated bowels, for them she bloodlessly whispered a vacant “yes” to chemotherapy. If only she could have just a moments peace.

A few years ago, I suffered through the disaster of a rental condominium in Orlando while visiting the magical mouse that only Irma Bombeck could rightly do justice. It was absolute architectural anarchy. If water should have passed through it, it did not, if designed to support weight, it would not, if it controlled the environment, it could not. It was simply a massive disappoint and grand inconvenience.

Therefore, one day the stuff of fairy tales landed in my mind. I fashioned a story and made the calls. Perhaps I was serving my need to somehow save her, perhaps not. By the time the smoke cleared, it was all arranged, clearly by the hand of a force far greater than mine; Airfare, a rental car, lodging and Disney World admission was waiting, free of charge for Maria and her babes.

Yet she was  giving up and dying. I eagerly told her of the scheme to whisk her away to fantasyland. I was stupefied by her visceral response. Life beamed in her eyes and for the first time of what was to become an adorable habit, Maria smiled. I could almost hear her soul snap into action barking orders to finally fight the beast eating her body. Her husband safely spirited away, a battered and bruised young, very alive mommy made it home for a long weekend for the first time. Irrespective of my personal faith, I was ill prepared for what lay ahead for Maria and her children.

A few Mondays later my nurse hovered in my doorway, seemingly buoyed by joy, wet eyed and spiritually transfigured. Stammering, she parsed out “It is Maria, Maria, she, ah, she is so alive “. I am sure I fumbled out something only to have my nurse return, “No, it’s Maria, You don’t understand what’s happened.” In an instant, she was gone and I was confused.

Then I saw the glow of life as never I have seen before. Guided by grace this beautiful woman glided into my office and settled into the chair. I was steeped in the warmth issuing from this vision. It looked like the Maria God would have fashioned were he to meddle mercifully in her miseries. She spoke serenely, “I stopped taking the narcotics, they made me sleepy and I have no more pain. I am eating everything in sight and my sugars seem okay. Dr.? Dr.? Are you okay?” Aghast and afraid that I might burst the bubble I beckoned her in to the exam room. It was normal, unbelievably normal.

A lump was growing in my throat and my voice grew strangely hushed. I vaguely remember calling the chief of radiology for the urgent CAT scan but I do remember his return call after it was done He was incredulous, questioning me. “I do not know what you pulled, but the scan I have here, well its normal – no tumor, and healing bone”. Gone too was the bowel obstruction, the blocked kidneys, all of it gone. The physical exams, CAT scan, blood tests; all were normal. Softly, before I could gather myself, she spoke as if the hand of God was gently stroking my disbelief, “I know”, and then silence. I was in the presence of grace.

I had no problem getting through on the phone to make all the arrangements final and in moments, it was done. She would leave for Orlando that weekend. The sweat of my soul slid down my face to  as my nurse handed me a tissue and floated out with our miracle.

On a Monday, some weeks after the joy of a lifetime with her children in Orlando, she appeared in my office. She was gaunt, wasted and desperately pleading “Tell me my babies will be OK; tell me what will happen to them. Tell me.” We spoke until the ache lifted from her spirit and she reached some manner of closure with the cancer that had so quickly returned to ravage her body. Abruptly she stopped, rose to face me  and gently put her arms around my neck without a word. I saw that she knew it was over and her children would be safe.

There was no sorrow that Friday in the hospital. Her babies lay besides her in her arms, sleeping, as God called his angel home.

 

This is Dr Kevin Ryan author of the book when tumor is the rumor and cancer is the answer, a comprehensive text for newly diagnosed patients and their families signing off radio www.w4cs.com and iheart  the cancer support radio program

See you Next Tuesday at noon PST when we will look at depression and cancer

 

Now for any questions

Cancer Anxiety

Anxiety ( blog) and iheart)

Hi DR Ryan here, medical oncologist AND PROFESSOR AND RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer.

I am sure you are familiar with our opening song   from chariots  of fire. A man has a plan and in a day it is crushed…… so it is when you have been told you have cancer ,thoughts of loss of control, soul sucking anxiety, what about your family and the list goes on as it hits  you like a ton of bricks.

He rose above it in the film  and so you to will be a hero ………I have seen no exception no matter how afraid you are, and that is what we are going to talk about today …your attitude when first diagnosed and through your course of therapy.. What about ANXIETY

. We will take our time so feel free to write in your questions or comments at www.w4cs.com and i will try to get to them

Anxiety and fear

it is anxiety that is the killer, NOT FEAR. We humans suffer most when not knowing all that needs known, especially when there is so much to fear. I choose, as do many dictionaries and as have countless great religious leaders and philosophers, to define anxiety as fear of the unknown.

I frequently relate a parable to my patients on this crucial subject. Let us travel back in time to the clan of the proverbial cave man. In one cave, somewhat safe from the elements and huddled about a fire, is a family fraught with anxiety towards the savage carnivores outside. These beasts only know this clan as prey. The clan shrinks under the weight of this knowledge, convinced that the predators will most assuredly find and devour them. The clan huddles all the closer, shaken by every foreign sound and every dimming of the fire. They dare not move. They are not ready to battle for their next meal or to survive. That is the primordial example of paralysis by analysis– as old as man is. That is anxiety.

in the hillside just to the east, another clan of warriors huddle. They know well the dangers that lurk and are ready to pounce as the fire dims and the sounds draw near. Fearful of what they know, and armed, they set forth into what will now be the known. History has shown us that this clan survives. That is the liberating power of fear inciting action.

Both anxiety and fear evoke the same visceral and pressing emotional urgings. However, for the first clan, the unknown fuels their feelings. That is anxiety and that is the end of that clan. However, the second clan knows that the bigger enemy is anxiety, fear of the unknown. It is fear of anxiety that drives them to action. Anxiety is the road to paralysis. Fear can ignite action without guarantee of success, but action nevertheless.

anxiety disorders in patients and their relationship to the quality of life have been the subject of legions of studies in the medical literature. Their conclusion is universal. Anxiety is as much a killer as is living in constant bodily pain. What is life worth, one wonders, when the icy soul sucking grip of the never and forever lie holds you tight to its bosom. This lie screams into your psyche saying, “it will never change and it will forever be the same”.

anxiety is not abnormal and may in fact be an emotion that leads to a positive outcome. Nonetheless, it is almost the kiss of death when it too easily evolves into the loosely defined term morbid anxiety causing panic, irrationality and paralysis. There is little doubt that morbid anxiety has negative consequences in many regards for the cancer patient as well as their family.

Granted, some malignancies with a less ominous prognosis will not elicit as much morbid anxiety. Once again, the key is that the patient knows that the prognosis is less ominous. It is knowledge that is the oncologists’ first and most precious gift to the patient. It is knowledge that the patient and family must demand. Knowledge delivered through teaching that must be thorough, comprehensible, and empathetic. The flow of information must never stop. Physicians must teach patients how to deal with family, friends, sources on the internet, the staging procedures and their meaning, the treatment and the value of second opinions. Patients must learn well that they will not be alone, that thousands have handled this and that others were no less anxious and no braver.

physicians must speak to their patients of the odds of cure, remission and durability of remission. They must not shy away from discussing spirituality, life’s goals, and the effects of treatment on normal bodily function. Common anxiety-laden patient questions, as “what functions or abilities will I lose” as well as “what will I keep” are essential front burner issues. Discussions must be frank regarding the specter that pain, nausea and vomiting often represent to patients. Moreover, physicians will find the more empathetic time spent the greater the patient’s trust and quality of life.

Patients need to know if research studies hold out a realistic promise. Oncologists must explain the amazing armamentarium of medications they have, the psychological assistance patients will be given and potentially, the beautiful role which hospice may play. Most of all, patients must be put in charge by being given repeated slow but thorough helpings of knowledge. That is the key to killing anxiety. Caretakers must indeed take great care to embrace the god given, hero-making emotion of fear, break the paralyzing bonds of anxiety and guide patients and families onward to face the future.

Remember it’s ok to tell someone you are not ok

Lets summarize the overview of anxiety

First page

 

Second page

For example , mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published in cancer.

Other issues are what some have called scanziety and also the issue of telephone messages.

Scanxiety refers to the fear and worry associated with imaging, both before and after a test is performed, and lasts until the test results are communicated to the patient. As described by cancer survivor Bruce Feiler in a time magazine column, “scans are like revolving doors, emotional roulette wheels that spin us around for a few days and spit us out the other side. Land on red, we’re in for another trip to cancerland; land on black, we have a few more months of freedom.”  The root of this anxiety is  related to the uncertainty of the test results and the amount of time that elapses between when the test is performed and the results known. Not surprisingly, most patients report an escalation of anxiety that correlates with longer wait times.

In an ideal world, scanxiety could be alleviated by immediate test results. However, test results also need someone qualified to interpret them and explain their implications. When scans show no evidence of disease, or a blood test is within normal limits, the phone calls are easy to make. It’s a different story when the scans or tests are abnormal or indicate disease progression. In these cases, face-to-face conversations about treatment options are usually best.

“phone tag” frustration

So, what can healthcare providers do to reduce scanxiety? Some oncology practices schedule patients for a clinic visit on the same day a scan or test is performed or results known. Of course, this approach only works when there is collaboration between the imaging or laboratory department and oncology providers. “the test results are not back yet” are words no patient wants to hear on a follow-up visit.

Patients who have scans and tests performed in their hometowns need to be informed that test results may or may not be available on the same day. These patients should be instructed to call their oncology providers to obtain results rather than wait for a call with the results.

Every oncology facility should have procedures that reduce the likelihood that patients will “fall through the cracks” and not be followed up. This can happen when return calls to patients go unanswered. The resulting “phone tag” is frustrating for patients and healthcare providers alike.

After-hours calls are particularly challenging, as they are often placed or received via personal cell phones. One option is to block or hide personal cell phone numbers; however, patients may ignore or decline these calls since the callers are not identified. Another option is the doximity dialer, an app that allows healthcare providers to call patients without revealing their personal cell phone numbers. Patients see an office or clinic number instead. The app allows healthcare providers to call patients at any US number, choose the caller id that appears, and send return calls to an office or clinic.

The app can be downloaded for iphone at the app store and for android devices at google play.

What else can be done to reduce scanxiety? Cognitive-behavioral therapy may be helpful in dealing with the thoughts that are at the root of the anxiety. This helps by examining possible outcomes. This leads to a reduction in all or nothing, and catastrophic thinking, which in turn reduces anxiety. The bottom line is that there are a number of strategies to help patients reduce scanxiety and cope with its effects . Being diagnosed with cancer is hard enough; we need to do all we can do to make the journey less stressful. –

The physical changes regarding patient;s anxiety are measurable David s. Black, phd, mph, from university of southern California in los Angeles, and colleagues assigned 57 English- or Spanish-speaking colorectal cancer patients to either mindfulness, attention-control, or resting exposure at the start of chemotherapy. Four saliva samples were collected at the start of chemotherapy and at 20-minute intervals during the first 60 minutes of chemotherapy. Self-reported biobehavioral assessments after chemotherapy included distress, fatigue, and mindfulness

Analysis showed a relative increase in cortisol reactivity in the mindfulness group, more than twice as many patients in the mindfulness group displayed a cortisol rise, compared to controls (69 versus 34 percent; Mindfulness scores were inversely correlated with fatigue and distress scores “implications include support for the use of mindfulness practice in integrative oncology,” the authors wrote.

 

Let’s go back to Yoga

Researchers have put yoga to the scientific test for years, and the results so far have been impressive. The practice has been shown to lower risk for heart disease, type 2 diabetes, depression and hypertension and anxiety.

But yoga can also help those who are already ill feel better. A new study suggests that doing yoga twice a week may improve quality of life for men being treated for prostate cancer and may help reduce the side effects of radiation, which include fatigue, sexual dysfunction and urinary incontinence.

So again if you have any of these tell your doctor, there is help

  • Difficulty concentrating and making decisions
  • Heart palpitations, sweating, shaking
  • Shortness of breath, feeling faint
  • Numbness or tingling in the hands or feet
  • Heightened sense of alertness
  • Anticipating feeling anxious or a persistent worry
  • Feelings of guilt, worthlessness, and/or helplessness
  • Feeling of unreality or detachment from oneself
  • Fear of dying or losing control
  • Irritability, restlessness
  • Dry mouth
  • Muscle tension
  • Nausea
  • Sleep difficulties
  • Cold or sweaty hands
  • Loss of interest in activities or hobbies once pleasurable
  • Withdrawal from normal activities and friends (avoidance)
  • Appetite change or weight change (usually loss)
  • Persistent aches or pains, headaches, cramps, or digestive problems

Lets also give a non scholarly but becoming so, nod to smoked cannabis, the psychoactive form in alleviating anxiety- there are some early trials in the 80’s mostly about control of nauseas and vomiting where it was no better than what was then the standard and inferior to what we have now with exceptions existing on a case by case basis. It being a class 1 drug highly controlled by the FDA has made scholarly work hard but there is a growing body of evidence that supports a possible role in alleviating anxiety, besides improving mood , appetite and pain as well as anticipatory nauseas Mostly we are left with it being no better than standard of care but there are some powerful small studies and of course individual anecdotes. Remember ,anecdote does not equal antidote

None of the above is true for any other herbal substance despite what you think or may have heard

Remember anecdote does not equal antidote

Seeing cancer through a sibling’s eyes: what we don’t know can hurt them an article summarized from the ONS

Family-centered care is crucial to the care of children with cancer, whose disease and treatment are both life-threatening and often prolonged over the course of several years, through survivorship or until death. Family-centered care recognizes the stark reality that cancer is disruptive to the family system. And can cause great anxiety in many family members with children being no exception While acknowledging the value of family-centered care to the ill child and parents in clinical practice, we may overlook other family members who would also benefit from family-centered care, most notably the healthy siblings of the child with cancer.

Indeed, healthy siblings have described wanting more information about their ill brother or sister and the illness; parents have described wanting guidance on how to best meet the needs of the siblings when one child has advanced cancer and to do so across the spectrum of life-threatening illness.
Challenges associated with a cancer diagnosis, treatment, and adaptation impact the entire family. Recent research has demonstrated that families experience altered family function and may face an accumulation of risk for mental health and severe emotional problems including anxiety over the course of illness,

other research reports that the experience of cancer increases family cohesion and family resilience. So it can bond as well as break- it is a case by case , family member by family member SITUATION even within the same family

Through the sibling’s eyes

Perceptions of the impact of cancer on the family often come from the parental perspective. BUT NOT ALWAYS. Each member of a family will assess the impact of the illness differently

Some experience feelings of jealousy, neglect, and bitterness. But almost all experience anxiety. Parents may spend less time emotionally and literally with the healthy child

When a child is diagnosed with cancer, the whole family is disrupted and anxiety initially runs rampant and delayed anxiety after a siblings death is all too common.

The nurse’s role

It starts with awareness. Nurses can promote a broadened scope of family-centered care and recognition of sibling needs in advanced disease and other times of turmoil. In doing so, they may mitigate some negative effects of strained or limited communication. Oncology nurses directly impact families through communication and can model open, compassionate, developmentally appropriate communication with siblings. Moreover, coaching and teaching are inherent to nursing care of families. Thus, oncology nurses role can be 2-fold: communicating with siblings across settings to increase their comfort or to provide education and

coaching to parents in discussing sensitive, emotional topics related to the illness.

Teaching parents to keep lines of communication open across the various fronts on which they parent all their children can diminish anxiety.

Although there are many methodological flaws in the following report it stresses the mind body connection which is never to be ignored.

However we are not saying the diagnosis of anxiety or for that matter, depression causes cancer in all , most or a significant minority nor does it mean you will get cancer if you have those diagnoses . Nonetheless, anxiety does have measurable effects on the immune system and that weaves a complex web

So what did they find in England in a study which I remind you has many limitations.

A BMJ article addressed how depression and psychological distress can increase the chances of dying from cancer. The study revealed a 32 percent cancer risk due to anxiety and depression. Of course something called multivariant analysis biases this dramatically as stated… just having anxiety  of unrevealed duration and severity does not cause cancer in 30 percent of people…. but this is interesting. The authors are clear to point out that Cause and effect are not established clearly.

The study stresses that the correlation between anxiety, depression, and cancer cannot be treated as evidence. In some cases, people with undiagnosed cancer can get anxious and stressed due to the changes happening in their body despite being aware of their sickness.

An expansion of part of this observation must follow

Up to one in ten people will battle anxiety or depression at some point, and this makes people more likely to smoke and drink, and less likely to take exercise and maintain a good diet. But even accounting for this, anxious and depressed people seem to die in greater numbers from cancer

PERHAPS THIS SHOWS that their unhappiness damages the body’s defense systems against the disease. The chicken and egg argument is self apparent however

Some suggest damages in DNA repair in the severely stressed patient but little good data supports this. What we do know is stress can also put people off from attending screenings which could spot cancer early, or prevent them seeking proper treatment when they do fall ill.

.

People who are anxious often stop looking after themselves and this could lead to poor diet and lack of exercise both proven to have a role in cancer cause

AGAIN THE LEAD AUTHOR STATES THE flaws are too deep in the English study to walk away thinking if you are depressed or anxious you will get cancer

Finally what about the internet in all this. Rather than recite every nuance and nonsense ( not all is nonsense) that DR Google spouts….. All the following key phrases will take you to links that are self explanatory and say pretty much the same thing as what we have covered  here

fear of getting cancer

anxiety about having cancer

constant fear of getting cancer

fear of cancer diagnosis

fear of cancer

cancer and anxiety attacks

cancer anxiety symptoms

anxiety after cancer

So, anxiety is soul sucking, it has many forms and presentations, it is harmful and it is treatable in cancer patients and families by MANY approaches

This show will be posted both in script form on www.w4cs.com blog and the book blog reachable through the book web site www.whentumoristherumorandcanceristheanswer.com and the audio will be here as well as on iheart radio in a few days

I urge you to reread and listen critically to what has been said and note what has NOT been said regarding the connection between cancer and anxiety, especially regarding cause and complementary and alternative medicine

Now, as I promised in the first show I would, along the way, read stories I have published independently as well as in the book of actual patients with names changed , to at times illustrate a point. The past few shows have been about attitude- both up and down and what works, Here is a tale of my first and only encounter with a leprechaun…I think you will all get the point

A Leprechauns’ Laser Light Of Life

As I made rounds, lilting laughter punctuated a rag tag vocal ensemble’s singing of “Danny Boy”. It ebbed and flowed from the oncology ward lounge, warmly filling a sterile hallway; but not my heart. It was the twentieth St. Patrick’s Day since small cell lung cancer riddled and devoured my son of Hell’s Kitchen, World War II veteran, tough Irish dad. Although he died during the dreary wet frozen rains of a New England fall, he was etched into my heart’s memory owing to one very magical St. Patrick’s Day.

As I did every St Patrick’s since his death, I was reminiscing a time when I, a newly minted, wet behind everything medical student and a 2nd Lt in the USAF in the Health Professions Scholarship Program, visited my dad at work as  General Electric’s chief labor relations negotiator in Manhattan. The day ended at a midtown Irish bar with me accompanying him on the tavern’s beer soaked upright as he crooned “Danny Boy”. You could feel the century old pub wood weep as a sonorous tenor voice I never knew he had lifted hearts, minds and glasses. Mutually uninhibited but not inebriated, father and son were in tune.

So here I was decades later on another St Patrick’s Day rounding on the Oncology ward, tired and tied to a bittersweet memory. Regaining focus for the duties of the day, I began to thumb through the chart rack. Suddenly, intruding through the funk was the unmistakable sound of a Buck Rogers’s ray gun. It was right behind my left ear, magically mixing with leprechaun like chortling and giggles.

I spun on my heels and was bowled over by the impish grin and theatrical posturing of my toy toting assailant. Hopping and toe dancing as light as a shamrock blown by faerie breath and half naked in hospital regalia with toy cosmic carbine in hand, retired USAF Chief Master Sergeant “O’Reilly” squealed, “Ah-eee, Gotcha Doc”!

O’Reilly had whistled and skipped to an easy truce with his sleepy follicular Non Hodgkin’s lymphoma for sixteen years prior to this admission. His blarney charmed the beast called anxiety. His acceptance of the capriciousness of a life filled with the Damocles Sword of a strong probability of an aggressive transformation of his disease was like a therapeutic balm of Gilead for not only himself, but so many patients he befriended and bolstered.

His checkups were always a happy routine rife with fabulous tale spinning, unabashed limerick singing and other sound medical practices. Clinic visits from the sage retired chief leprechaun of the USAF always ended with a pat on my head, a wink at the nurses and his trademark squeezing off of a couple  laser beams of magic from the now infamous toy gun at whomever he thought needed it most.  It never hurt, it often helped and more than once, it seemed more powerful than my prescription pad. An emeritus professor of mirth and mentorship, O’Reilly was one of the wisest men I knew.

Shortly before this final admission, the limber leprechaun interrupted plans to visit family in Ireland because, as he said, “Me shillelagh’s telling me something ain’t right”.  A thorough history and physical revealed nothing. The complete blood count showed a slight drop in his usually robust hemoglobin and his platelet count had fallen considerably. So did my heart when review of the peripheral blood smear suggested what an immediate bone marrow examination confirmed; myelopthisis. His lymphoma had transformed aggressively and was exploding into banshee like furor. It was replacing his bone marrow. Further staging showed broad lymph node, boney, spleen and meningeal dissemination.  An incredibly bright man, he fully understood the limits of therapy and the grave prognosis.  Typically unafraid and more concerned for his family, he was annoyed at the change in travel plans. He sprightly assured me, “I have a few things yet to do, so let’s have a go at it.”

We did. After a rocky course consisting of intensive systemic and intrathecal brain chemotherapy, massive transfusions and considerable assistance from colony stimulating factors to support his white blood cell count and fight infection and erythropoietin to help him make blood, this knobby kneed leprechaun of a man was zapping my dour spirits. Bald and beaming and headed towards a major clinical response,   he was working his magic on this very special St Patrick’s Day.

That was his family in the lounge warming the ward with lilts of laughter. Spying my doleful drudge as I began ward rounds, he left the comfort of family and friends to fire a laser beam of life my way. Clearly unfazed by the enormous odds of a rapid and refractory to treatment recurrence of his cancer, he often grandly showcased his plastic phaser quipping something to the effect of, “If it comes back, we’ll zap me cancer with this thing; it’s better than those poisons, eh?”

O’Reilly was one of the gifts clinical oncologists can garner in decades of clinical practice, if they are open to receive them. He was one of those wonderful “doctor-patients” put in our path to minister magical wisdoms just when we oncologists need those most. Being touched by such patients’ special zest, zeal and wisdoms is one of those easy medicines to swallow. Souls such as these are precious jewels in the growing treasure chest of a clinicians experience and the luster of the clinical pearls they impart are often both illuminating and transformative. So it was with O’Reilly

Unbeknownst to me, he had more things than fighting his cancer on his agenda. He had taken particular notice of one of my young clinic nurses. She was a seemingly emotionally cold and somewhat intense Second Lieutenant nurse that was “too young to act such a tough nut and too talented not to try and crack”, according to O’Reilly. She had requested transfer to the inpatient Oncology service. This coincidentally put her on the ward and in O’Reilly’s service and sights when the aggressive transformation of his lymphoma occurred. Both I and the senior nursing staff were concerned for her, believing her far more fragile than her implacable demeanor might suggest, but our “tough nut” showed no signs of trouble and sadly, few signs of warmth even when O’Reilly’s improbable  clinical remission occurred.

Shortly after that St Patrick’s Day, the probable occurred. O’Reilly was readmitted with signs and symptoms of a rapid recurrence. He was quick to grasp his situation, calmly and confidently summarizing my lengthy delivering of sad news to a family unwilling to believe the unacceptable, saying gently to all, “It’s been a great run, so now, soon, I’ll be with sod and saints”. In his final days of a rapidly progressing malignancy that would not be denied, he had three simple requests; some intimate uninterrupted time with the Mrs., a steady supply of Guinness Stout and “one last shot at some unfinished business”. Curiously, and without any explanation offered, he decreed that the “tough nut” young nurse be assigned to his care and furthermore she was to be the only medical staff he wanted in his room; no one else, no exceptions.  Somewhat bewildered but always admiring of his wisdom, the charge nurse and I warily agreed. On hearing his request, the young lieutenant almost condescendingly agreed seemingly fashioning it as some sort of dramatic last wish. After all, she thoughtlessly quipped, it was “probably (her) turn anyway”. She would be in his service having no idea how true that would prove.

I was shaken upon news of his passing the next morning. However, deeply appreciative of O’Reilly’s gifts, I was both concerned and curious as to the impact, if any, his passing had on the young “ tough nut” nurse. No worries. I no sooner strode onto the ward than she ran up to me glowing, seemingly transformed and weightless, her eyes brimming with tears of joy. Reaching into her pocket she produced our leprechauns’ little laser gun. Smiling, she told how he called her to his room, eschewing all others. She bubbled joyously of how they chatted for hours about secret things, special things about love and the rich life. She was bursting with the pride and surprise as one who had been picked above all others as something special and lovable. Tugging at my white coat like the impatient exuberant child she then was, she announced triumphantly that she was the last target he leveled a final salvo of saving love at. He then bequeathed his other worldly potion in a pistol to her, assuring her that, “I can go now. You’ll know when to use it and when it’s time to pass it on.”

Death is not always so kind, so graceful in its gifts. When we healers and helpers are absorbed in our sorrows, perhaps lost in the fog of sadness over the limits of our skills or other concerns, we may also be most vulnerable to the laser beams of life from those who by all rights should be sorrowful, yet are not.

This is Dr Kevin Ryan author of the book when tumor is the rumor and cancer is the answer, a comprehensive text for newly diagnosed patients and their families signing off radio www.w4cs.com the cancer support radio program

See you Next Tuesday at noon PST when we will look at depression and cancer

Now for any questions