Category Archives: cancer screening

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
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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.

 

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

Cancer What is it?

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. Modeled after my book of the same name available on th web site and Amazon

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, FIRST OFF WE DID NOT GET TO THE QUESTIONS OF LAST WEEK ALTHOUGH THE TALK DID COVER THEM ALL LET’S JUST QUICKLY TAKE A LOOK WITH MY APOLOGIES

First answer questions J

just how do you know if there is a depressive state in things? Covered this

Can you see the depression in your self or others? Perhaps not little insight

What does depression look like? See list of symptoms

How does depression feel to people? Never and forever lie See list

How can you work with the depressive state? Very difficult

Should you have guilt being depressed? No no no guilt is part of the fisease in many see list especially inelderly

So its all in what you eat? No no no I was just being fair to unfounded claims The blood sugar and binging and starving that may occur ae bad however

Where do the good studies come from? There are none for food there are for depression in general ,meds, the integrative modalities and therapy

. Recently, Mehnert and colleagues reported a 31% prevalence rate for any psychiatric disorder in cancer patients. Rates for depression vary from 11% to 37%,. The rate for depression in the general population is 7%—and thus HIGHER among cancer patients—THE RATE OF SUICIDE IS TWICE THE NORMAL POPULATION

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

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

 

Since most cancer occur is the elderly and cancer is proportional with age and depression may look different than just those simple 7 symptoms Diagnosing Depression IN THE ELDERLY is somewhat different

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 identifying these symptoms is not necessarily useful in older adults.

“The gateway questions come off the table as less than useful diagnostic criteria when we combine cancer and aging. “

Major and Minor Themes

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. These are big and also seen somewhat in younger patients

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

Another central issue was loneliness, depressed patients tended to have limited meaningful relationships and were socially isolated and withdrawn.

 

Loss of meaning and purpose in life was STRONGLY PRESENT and they display an inability to adjust to their new limitations. “rumination THIS IS CRITICAL AND PATIENTS GO BACK TO IT (WHAT THEY DID IN THE PAST) OVER AND OVER AGAIN Lack of usefulness and sense of being a burden is also displayed in all depressed.

There was no difference between depressed and non depressed participants in terms of their willingness to engage in treatment, but attitude toward treatment different“

 

The non depressed are much more proactive regarding their treatment, whereas the depressed are resentful, angry, and upset about their treatment,”

Both depressed and non depressed look back at their lives and experience some level of regret, but the amount of guilt experienced the differentiating factor between the non depressed and the depressed. “The depressed patients seemed to ruminate on their regrets, whereas the non depressed are able to put their regrets in a tolerable perspective,”

 

No actual difference in physical limitations is observed between the two groups, but a difference is noted in how they cope with those limitations. Depressed do not adapt.

 

LECTURE 6 PART 1  BLOG IT AND SUBMIT IHEART FORM

 

BUT WE MUST KNOW THAT WHICH WE ARE AFRAID OF WE MUST KNOW THE ERSONALITY OF THE BEAST TO BE BETTER ABLE TO FIGHT IT , WE MUST KNOW THE ENEMY AND THAT IS WHAT WE ARE GOING TO TALK ABOUT TODAY AND  NEXT WEEK

THE ENEMY

 

 

THE ENEMY

 

First, a Parable

 

 

Winter was coming early to the western Cordillera range of the Sierra Nevada and the mountain man knew it was time to head down to safer ground. Packing his mule, he heard from behind a cold craggy granite precipice the unmistakable hissing and eerie rattle of the deadly western diamond back. Then, as strange as it seems, the snake spoke and began pleading with the rugged frontiersman. “Pleasssse, oh Pleassse.”, it begged while hissing, “Winter has come early and I will ssssurely freesssse if you do not put me in your pack and take me down to ssssafer warmer ground

Hard won experience had told the mountain man to be wary. He declined, stating firmly, “You will surely bite me before the trail is through”. The snake assured him he would never do such a thing if the man would save him. Thus, reckoning back to lessons from his ma and pa long since dead after hard laboring the rocky western Kentucky soil, the cautious but kindly outdoorsman took pity on one of God’s creatures. Carefully, against his gut instincts, he placed the viper in his pack and headed to lower, warmer ground.

At the end of the journey, as promised, he reached into the pack to release the viper. Of course the snake struck, injecting the outdoorsman with blindingly painful venom and the near certainty of an ugly and lonely demise. The Good Samaritan of the frontier was enraged and while still lucid reminded the snake of his promise.

The snake replied, slowly and sincerely, “but you knew I wassss a sssnake when you helped me, I just did what sssnakes do”

 

…. and so it is with the enemy, cancer.

 

“They’re toast”. That is not a rare expression uttered by some physicians in private when hearing of a severely threatening diagnosis. I have heard this common irreverent comment and similar ones uttered by my colleagues and young residents when referring to those newly diagnosed with cancer. Curiously, these flippant declarations do not always follow a diagnosis of advanced or terminal disease. These insensitive quips have even popped out at the mere confirmation of the mere diagnosis before any determination of stage or degree of severity. Why? It is because cancer is the ultimate terrorist, the perfect enemy.

Cancer, the anathema, the incubus; nothing evokes more fear. There is no greater pariah to caretaker, clinician or patient. Indeed the very origin of the word “cancer,” from “crab” speaks legions regarding the dread with which we regard the word. Why is this?

Perhaps we fear cancers’ amazing talent for infernal mimicry of the norm. Cancer cells imitate normal cells, but perversely. Perhaps we detest the macabre brilliance by which cancer cells systematically unravel the elegant mysteries of normal cells. Cancer cells, regarded by some scientists intellectually as little medical miracles, take their cue from normalcy but with a deviant twist. They grow; constantly, irrepressibly.

Their mere presence conjures up visions of evil humors reminiscent of those alluded to by Galen, the ancient Greek founding father of medicine, as they swarm over the unsuspecting patient. They are admirably ingenious rogues with innumerable deceptions cloaking them from our immune systems’ elegant surveillance and intelligence network. They have amazing techniques that protect them from detection and eradication.

Cancer cells will also not stay put. They marshal innocent patients’ wondrous blood vessel factories and command those factories to build an evil network of canals and thoroughfares of new vessels which bring the malignant little monsters nourishment and usher them on journeys to distant organs to wreak havoc. These princes of parasitism suck essential nutrients from us, decimating our defenses. Some cause local mayhem, blocking critical passageways, bowel and bladder alike. Some make us weep blood. Some sneak off to the otherwise pristine recesses of the brain confounding movement and sensation while causing neurological crises. Malignant and malevolent, it is no wonder we hate cancer with unbridled passion.

It is so poignant that in our battle against cancer we employ potent poisons in a sort of chemical and biological warfare. These therapies frequently count on the “good guys”, our normal tissues, to hang in there despite the sometimes enormous toll therapy exacts on the body. The quest is rather daunting; to kill a cancer cell and still leave normal cells and tissues largely undisturbed and surviving normally. For some, successful surgical removal of the cancer holds a pivotal place in the armamentarium. For others, blasting away with radiation is the treatment. Others receive chemical, biological or combined assaults.

Cancer can be and is often killed. However,  biologically resistant and insolent to the last, this enemy will not die without a fight and without a fight, the patient often will

Some CANCER BASICS

 

PONDER THIS

HOW DO LIVER CELLS KNOW WHEN IT IS TIME TO STOP GROWING BECAUSE THEY HAVE REACHED LIVER NESS

 

And so it goes for every other organ

in cancer the cells do not stop , they escape or impair immune detection or fool it , They simplY do not stop having children. They do not stop growing .

they have ways of turning off natural timing of cells death or making vascular highways for themselves to feed themselves as well as have highways to travel on and spread either by direct extension or through the blood

What Is Cancer?

Cancer can start any place in the body. It starts when cells grow out of control and crowd out normal cells. This makes it hard for the body to work the way it should.

Cancer can be treated very well for many people. In fact, more people than ever before lead full lives after cancer treatment. 65% The numbers used to be opposite

Here we will explain what cancer is and how it’s treated. You’ll find a list of words about cancer and what they mean at the end of this booklet.

Cancer basics

Causes

 

How cancer begins

Cells are the basic units that make up the human body. Cells grow and divide to make new cells as the body needs them. Usually, when cells get too old or damaged, they die. Then new cells take their place. AT A NORMAL HEALTHY PACE

Cancer begins when genetic changes impair this orderly process. Cells start to grow uncontrollably. These cells may form a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor means the tumor can grow but will not spread.

 

Some types of cancer do not form a tumor. These include leukemias, most types of lymphoma, and myeloma.

Cancer is caused by changes (mutations) to the DNA within cancer cells. The DNA inside a cell is packaged into a large number of individual genes, each of which contains a set of instructions telling the cell what functions to perform, as well as how to grow and divide. Errors in the instructions can cause the cell to stop its normal function and may allow a cell to become cancerous.

What do gene mutations do?

A gene mutation can instruct a healthy cell to:

  • Allow rapid growth. A gene mutation can tell a cell to grow and divide more rapidly. This creates many new cells that all have that same mutation.
  • Fail to stop uncontrolled cell growth. Normal cells know when to stop growing so that you have just the right number of each type of cell. Cancer cells lose the controls (tumor suppressor genes) that tell them when to stop growing. A mutation in a tumor suppressor gene allows cancer cells to continue growing and accumulating.
  • Gene mutations can cause normal cells to Make mistakes when repairing DNA errors. DNA repair genes look for errors in a cell’s DNA and make corrections. A mutation in a DNA repair gene may mean that other errors aren’t corrected, leading cells to become cancerous.

Those mutations are the most common ones found in cancer. But many other gene mutations can contribute to causing cancer.

What causes gene mutations?

Gene mutations can occur for several reasons, for instance:

  • Gene mutations you’re born with. You may be born with a genetic mutation that you inherited from your parents. This type of mutation accounts for a small percentage of cancers. Perhaps 5-8%
  • Gene mutations that occur after birth. Most gene mutations occur after you’re born and aren’t inherited. A number of forces can cause gene mutations, such as smoking, radiation, viruses, cancer-causing chemicals (carcinogens), obesity, hormones, chronic inflammation and a lack of exercise.

Gene mutations occur frequently during normal cell growth. However, cells and especially those in our immune system when it works correctly contain a mechanism that recognizes when a mistake occurs and repairs the mistake. Occasionally, a mistake is missed. This could cause a cell to become cancerous.

How do gene mutations interact with each other?

The gene mutations you’re born with and those that you acquire throughout your life work together to cause cancer.

For instance, if you’ve inherited a genetic mutation that predisposes you to cancer, that doesn’t mean you’re certain to get cancer. Instead, you may need one or more other gene mutations to cause cancer. Your inherited gene mutation could make you more likely than other people to develop cancer when exposed to a certain cancer-causing substance.

It’s not clear just how many mutations must accumulate for cancer to form. It’s likely that this varies among cancer types

 

While doctors have an idea of what may increase your risk of cancer, MANY of cancers occur in people who don’t have any known risk factors. Factors known to increase your risk of cancer include:

Your age

A big factor Cancer can take decades to develop. That’s why most people diagnosed with cancer are 65 or older. While it’s more common in older adults, cancer isn’t exclusively an adult disease — cancer can be diagnosed at any age.

 

Your habits

Certain lifestyle choices are known to increase your risk of cancer. Smoking, drinking more than one alcoholic drink a day (for women of all ages and men older than age 65) or two drinks a day (for men age 65 and younger), excessive exposure to the sun or frequent blistering sunburns, being obese, and having unsafe sex can contribute to cancer.

You can change these habits to lower your risk of cancer — though some habits are easier to change than others.

 

Your family history

Only a small portion of cancers are due to an inherited condition. If cancer is common in your family, it’s possible that mutations are being passed from one generation to the next. You might be a candidate for genetic testing to see whether you have inherited mutations that might increase your risk of certain cancers. Keep in mind that having an inherited genetic mutation doesn’t necessarily mean you’ll get cancer.

 

Your health conditions

Some chronic health conditions, such as ulcerative colitis, can markedly increase your risk of developing certain cancers. Talk to your doctor about your risk. Chronic inflammatory states

 

Your environment

The environment around you may contain harmful chemicals that can increase your risk of cancer. Even if you don’t smoke, you might inhale secondhand smoke if you go where people are smoking or if you live with someone who smokes. Chemicals in your home or workplace, such as asbestos and benzene, also are associated with an increased risk of cancer

 

Cancer is a scary and complex disease. Even when it’s caught early and with good odds for surviving and living a long, healthy life, there are a lot of people who develop cancer each year—and, sadly, not everyone survives it. Most cancers develop depending on several factors, but research has identified many contributing causes of cancer. Some are obvious and preventable, while others are the simple yet unfortunate result of genetics. And although many cancers have a high probability of being beat, the lack of proper or available medical care in certain areas, and even whole countries, can greatly impact the survival rate.

 

 

Taking into account the complexity of the disease and recognizing that many factors usually contribute to developing it, here’s again the wide range of what causes cancer— a little more in depth and some tips to change what you can to prevent the disease…

 

1. The Sun

The damage caused by ultraviolet (UV) rays from the sun have been studied immensely over the years. According to the Skin Cancer Foundation, UV is a proven carcinogen that in excess, can lead to skin cancer as a result of gene mutations from exposure to these harmful rays. There are various types of skin cancer that UV rays can cause or contribute to the risk of, with melanoma being the most serious and often deadly type. There’s a reason many health experts don’t approve of the use of tanning beds, and at least one developed country has completely banned the use of them (hint: it’s Australia).

 

Although people frequently flock to warm, sunny, vacation destinations to soak up the rays, it doesn’t need to be hot outside to damage your skin and potentially increase your risk of skin cancer. A cooler, cloudy day can still be risky, so you shouldn’t only wear sunscreen when you’re somewhere hot and sunny. You often see parents lathering their children in sunscreen, and while kids have sensitive skin and would be in a lot of pain if they were seriously burned from the sun, adults need protection too.

 

Genes

As we stated People can be at a higher risk of developing cancer from their genetic makeup, or DNA. More specifically, certain mutated genes can be passed onto children from generation to generation, something you can’t prevent or control the effect of. The American Cancer Society explains that cancer is believed to be formed from more than one gene mutation, so you aren’t likely to develop cancer just from one mutated gene inherited through DNA. However, people who inherit these faulty genes are then at a disadvantage because they’re automatically starting off with one mutated gene.

 

Breast cancer is a prime example of this—there are two genes that can be inherited, which can greatly increase the risk of breast cancer within families or lineages. There’s testing that can be done to find out if you have one of these risky genes, and it’s believed that around 5- to 10-percent of breast cancer cases are caused by them. Although many women and some men are diagnosed with breast cancer each year, it’s something that is often caught early enough to treat and overcome.

 

. Smoking

No list of factors that cause cancer would be complete without smoking. Cigarettes kill a staggering amount of people each year because of various types of cancer, many of which develop in the lung, esophagus, mouth, throat, and stomach. More and more cities are banning the use of cigarettes inside public establishments, on patios, and in vehicles as research has shown that second hand smoke is harmful and even deadly for those who don’t smoke. It seriously increases the risk of developing several types of cancer, as well as harmful diseases in other organs.

 

 

With all the advertisements about how dangerous smoking is to your health and its ability to greatly increase your risk of cancer, you might wonder how and why it’s legal. The good news is, the U.S. Centers for Disease Control (CDC) has tracked smoking trends since 1965, and the amount of adult smokers has decreased by over 20-percent in that time frame. If you need help quitting smoking, take advantage of the many helpful online tools available, join a support group, and talk to your doctor about kicking the habit for good.

Eating Habits and (Lack of) Physical Activity

There are many things that increase the risk of or cause cancer that can’t be prevented. But there are some lifestyle choices that contribute to the risk of developing it, and poor eating habits and little physical activity are two of them. The research relating to diet and cancer is still ongoing, but what we currently know is that a poor diet could increase the risk of cancer. More recent research has shown that the food we eat can not only influence developing the disease, but certain healthy foods may decrease or even help prevent cancer from developing. SUCH AS LEAN MEATS VEGGIES

 

How we treat our bodies is a major factor in being healthy—including limiting and reducing the risk of diseases like cancer, obesity, heart disease, diabetes, and others that vary in severity. Exercising and getting regular physical activity play a role in this too. Being active not only reduces the risk of cardiovascular disease, but also lowers the chance of obesity, hormone fluctuations, and immune system function. These factors have all been connected to cancer, so taking care of your body in every way is important. Being overweight TRIPLES your risk of UTERINE cancer: HWEW IA AOMW MOEW ABOUT IT

Fatty tissue produces the hormone oestrogen, which regulates a woman’s reproduction and is linked to the cancer when levels in the body are excessive

  • Obesity increases a woman’s chance of the disease by a massive six times
  • Other risk factors are diabetes, being postmenopause and not having children
  • Women should look out for abnormal vaginal bleeding, as well as pain during sex
  • If detected early, a sufferer’s survival chances beyond one year are 95 per cent

 

AGE Age

It’s a common fact that as you grow older, your chance of developing cancer increases. This isn’t surprising because many types of cancer are more common amongst older age groups. According to the Mayo Clinic, since cancer can take decades to develop it’s most common for people 65 and older to develop cancer. Cells don’t mutate into cancerous cells overnight, so slow changes can happen over a healthy person’s lifetime without them knowing. Sometimes it happens naturally,IS DETECTED AND DEALT WUTH BECAUSE OF EARLY SCREENING OR A HEALTHY IMMUNE SYSTEM while in some cases the cell mutates from the person being exposed to carcinogens, like cigarettes or environmental hazards.

No one can prevent cancer completely but there are steps that can be taken to help lower the risk of developing cancer. You can’t stop the aging process, but eating healthy, exercising, limiting exposure to carcinogens, and seeing your doctor for regular physicals, GETTING SCREENS are all important for your future—what you do now and how you treat your body as you grow older can have a long-term impact, and being as healthy as possible is the best way to avoid certain preventable diseases, including contributing to your risk of certain cancers.

 

Asbestos

Asbestos exposure, and mesothelioma as a result of this exposure, might be rare these days, but you’d be surprised by the amount of people suffering from cancer and other complications associated with asbestos. Over the years, the use of asbestos in buildings and materials has dramatically decreased, but it’s still possible to be exposed to these deadly minerals, especially in older buildings. And it’s still used frequently in some countries, so the dangers are still there.

Asbestos comes in the form of tiny fibers that are inhaled and cause damage to the lungs. It can also be ingested through water that gets contaminated from the pipes it runs through. In addition to lung cancer and mesothelioma, asbestos has shown to increase the risk of cancer in the larynx and ovaries. It’s also been linked to other forms of cancer, making asbestos exposure a very real and serious threat to the health of anyone exposed to it. People working in construction are most at risk because of the materials used and potential for mishandling and other ways of exposure

Excessive Alcohol Consumption

The impact of alcohol consumption on our health has been widely studied. Many experts believe a drink a day, or specifically a glass of wine a day, could be good for your health. Others believe there are too many potential harmful effects and that alcohol should be completely avoided. Regardless of these two sides, it’s agreed that excessive alcohol consumption can lead to numerous serious medical conditions, including cancer, cardiovascular disease, and mental health problems. Then there’s the effect on your personal and professional life, which can cause serious problems.

 

Some of the most common cancers linked to drinking too much over a long period of time are liver, colon, throat and breast cancer. In the case of breast cancer, it could increase your risk by around 10-percent. It’s important to note that drinking excessively doesn’t equate to being addicted to alcohol. There are many people who binge drink or regularly have 10 or more drinks per week but aren’t considered alcoholics or have a risky dependence on alcohol. But there is both short and long-term damage associated with drinking, so most experts agree that moderation is key.

 

Sex HPV

Conditions Affecting the Immune System

The immune system is your body’s way to defend and prevent infections and diseases. Weakened immune systems or those that don’t function properly are at risk of allowing harmful cells to hurt the body. An unfortunate cause of cancer stems from immune systems that are already affected by another medical condition or syndrome. This makes it especially difficult on the person with the existing condition, as oftentimes the problems they currently face cause them to struggle even more and cause additional complications once cancer has also been diagnosed.

 

Since viruses weaken the immune system, there are certain types of viruses that could cause cancer or put the person at a higher risk of developing it in their lifetime. According to the American Cancer Society, some of these viruses include hepatitis B and C, human immunodeficiency virus (HIV), human papilloma viruses (HPVs), and human herpes virus 8 (HHV-8). Several other viruses have been linked to causing cancer but there isn’t enough evidence yet to prove the connection

 

AGENT ORANGE OTHER TOXINS

 

Types of cancer

Doctors divide cancer into types based on where it began. Four main types of cancer are:

 

There are many other types of cancer. These are the main groups

 

 

How cancer spreads

As a cancerous tumor grows, the bloodstream or lymphatic system may carry cancer cells to other parts of the body. During this process, known as metastasis, the cancer cells grow and may develop into new tumors.

One of the first places a cancer often spreads is to regional lymph nodes draining the area. Lymph nodes are tiny, bean-shaped organs that help fight infection. They are located in clusters in different parts of the body, such as the neck, groin area, and under the arms.

Cancer may also spread through the bloodstream to distant parts of the body. These parts may include the bones, liver, lungs, or brain. Even if the cancer spreads, it is still named for the area where it began. For example, if breast cancer spreads to the lungs, it is called metastatic breast cancer, not lung cancer.a very very common mistake and not just grammar

.

Diagnosing cancer

Often, a diagnosis begins when a person visits a doctor about an unusual symptom. The doctor will talk with the person about his or her medical history and symptoms. Then the doctor will perform various tests to find out the cause of these symptoms. Many people with cancer have no symptoms, though. For these people, cancer is diagnosed during a medical test for another issue or condition.

Sometimes a doctor diagnoses cancer after a cancer screening test in an otherwise healthy person. Examples of screening tests include colonoscopy, mammography, and a Pap test. A person may need additional tests to confirm or disprove the result of the screening test.

 

For most cancers, a biopsy is the only way to make a definite diagnosis. A biopsy is the removal of a small amount of tissue for further study.

 

Cancer and its treatment can cause several complications, including:

  • Pain. Pain can be caused by cancer or by cancer treatment, though not all cancer is painful. Medications and other approaches can effectively treat cancer-related pain
  • .
  • Fatigue. Fatigue in people with cancer has many causes, but it can often be managed. Fatigue associated with chemotherapy or radiation therapy treatments is common, but it’s usually temporary.
  • Difficulty breathing. Cancer or cancer treatment may cause a feeling of being short of breath. Treatments may bring relief.
  • Nausea. Certain cancers and cancer treatments can cause nausea. Your doctor can sometimes predict if your treatment is likely to cause nausea. Medications and other treatments may help you prevent or decrease nausea.
  • Diarrhea or constipation. Cancer and cancer treatment can affect your bowels and cause diarrhea or constipation.
  • Weight loss. Cancer and cancer treatment may cause weight loss. Cancer steals food from normal cells and deprives them of nutrients. This is often not affected by how many calories or what kind of food is eaten; it’s difficult to treat. In most cases, using artificial nutrition through tubes into the stomach or vein does not help change the weight loss.
  • Chemical changes in your body. Cancer can upset the normal chemical balance in your body and increase your risk of serious complications. Signs and symptoms of chemical imbalances might include excessive thirst, frequent urination, constipation and confusion.
  • Brain and nervous system problems. Cancer can press on nearby nerves and cause pain and loss of function of one part of your body. Cancer that involves the brain can cause headaches and stroke-like signs and symptoms, such as weakness on one side of your body.
  • Unusual immune system reactions to cancer. In some cases the body’s immune system may react to the presence of cancer by attacking healthy cells. Called paraneoplastic syndrome, these very rare reactions can lead to a variety of signs and symptoms, such as difficulty walking and seizures.
  • Cancer that spreads. As cancer advances, it may spread (metastasize) to other parts of the body. Where cancer spreads depends on the type of cancer.
  • Cancer that returns. Cancer survivors have a risk of cancer recurrence. Some cancers are more likely to recur than others. Ask your doctor about what you can do to reduce your risk of cancer recurrence. Your doctor may devise a follow-up care plan for you after treatment. This plan may include periodic scans and exams in the months and years after your treatment, to look for cancer recurrence.
  • We will do more next weekLet’s see if there are any questions See you Next Tuesday at noon PST when we will look at PART 2 OF WHAT IS CANCER WITH A LOT OF REINFORCEMENT AND NEEDED REPEPTITION AND SOME NEW INFORMATION    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, BUT WE MUST KNOW THAT WHICH WE ARE AFRAID OF WE MUST KNOW THE ERSONALITY OF THE BEAST TO BE BETTER ABLE TO FIGHT IT , WE MUST KNOW THE ENEMY AND THAT IS WHAT WE ARE GOING TO TALK ABOUT TODAY
  • 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. Modeled after my book of the same name available on th web site and Amazon
  • WHAT IS CANCER WITH A LOT OF REINFORCEMENT FROM LAST WEEK AND SOME NEW NEEDED INFORMATION
  • PART 2
  •  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 available on the website of the same name and Amazon signing off radio www.w4cs.com the cancer support radio program   and ARCHIVED AUDIO FILES ON iheart RADIO
  • ANY QUESTION S

Remember Cancer is not just one disease.

There are many types of cancer. It’s not just one disease. Cancer can start in the lungs, the breast, the colon, or even in the blood. Cancers are alike in some ways, but they are different in the ways they grow and spread.

 

How are cancers alike?

The cells in our bodies all have certain jobs to do. Normal cells divide in an orderly way. They die when they are worn out or damaged, and new cells take their place. Cancer is when the cells start to grow out of control. The cancer cells keep on growing and making new cells. They crowd out normal cells. This causes problems in the part of the body where the cancer started.

 

Cancer cells can also spread to other parts of the body. For instance, cancer cells in the lung can travel to the bones and grow there. When cancer cells spread, it’s called metastasis (meh-TAS-tuh-sis). When lung cancer spreads to the bones, it’s still called lung cancer. And folks often confuse this The distinction is not academic as the original cancer behaves like the behavior of the orginal cancer not like the place is spread to. To doctors, the cancer cells in the bones look just like the ones from the lung. It’s not called bone cancer unless it started in the bones.

 

How are cancers different?

Some cancers grow and spread fast. Others grow more slowly. They also respond to treatment in different ways. Some types of cancer are best treated with surgery; others respond better to drugs called chemotherapy (key-mo-THER-uh-pee). Often 2 or more treatments are used to get the best results.

When someone has cancer, the doctor will want to find out what kind of cancer it is. People with cancer need treatment that works for their type of cancer.

 

What are tumors?

Most cancers form a lump called a tumor or a growth. But not all lumps are cancer. Doctors take out a piece of the lump and look at it to find out if it’s cancer. Lumps that are not cancer are called benign (be-NINE). Lumps that are cancer are called malignant (muh-LIG-nunt).

There are some cancers, like leukemia (cancer of the blood), that don’t form tumors. They grow in the blood cells or other cells of the body such as the bone marrow and or lymphnodes.

What stage is the cancer? We will talk more about that later

The doctor also needs to know if and how far the cancer has spread from where it started. This is called the cancer stage. You may have heard other people say that their cancer was stage 1 or stage 2. Knowing the stage of the cancer helps the doctor decide what type of treatment is best.

For each type of cancer there are tests that can be done to figure out the stage of the cancer. As a rule, a lower stage (such as a stage 1 or 2) means that the cancer has not spread very much. A higher number (such as a stage 3 or 4) means it has spread more. Stage 4 is the highest stage.

Ask your doctor to explain the stage of your cancer and what it means for you.

 

How is cancer treated?

The most common treatments for cancer are surgery, chemotherapy, and radiation (ray-dee-A- shun). Although immuno therapy and a number of precision and targeted medicines  and techniques are exciting , on the rise in treatment , early detection, screening finding early relapse  with some in previously hopeless situations. We are on the edge of a brave new world and much later we will cover future treatments

Surgery can be used to take out the cancer. The doctor might also take out some or all of the body part the cancer affects. For breast cancer, part (or all) of the breast might be removed. For prostate cancer, the prostate gland might be taken out. Surgery is not used for all types of cancer. For example, blood cancers like leukemia are best treated with drugs.

 

Chemo (short for chemotherapy) is the use of drugs to kill cancer cells or slow their growth. Some chemo can be given by IV (into a vein through a needle), and others are a pill you swallow. Because chemo drugs travel to nearly all parts of the body, they are useful for cancer that has spread.

 

Radiation is also used to kill or slow the growth of cancer cells. It can be used alone or with surgery or chemo. Radiation treatment is like getting an x-ray. Sometimes it’s given by putting a “seed” inside the cancer to give off the radiation.

 

What treatment is best for me?

Your cancer treatment will depend on what’s best for you. Some cancers respond better to surgery; others respond better to chemo or radiation. Knowing the type of cancer you have is the first step toward knowing which treatments will work best for you.

The stage of your cancer will also help the doctor decide on the best treatment for you. A stage 3 or 4 cancer is likely to respond better to treatments that treat the whole body, like chemo.

Your health and the treatment you prefer will also play a part in deciding about cancer treatment. Not all types of treatment will work for your cancer, so ask what options you have. And treatments do have side effects, so ask about what to expect with each treatment.

Don’t be afraid to ask questions. It’s your right to know what treatments are most likely to help and what their side effects may be.

 

Why did this happen to me?

People with cancer often ask, “What did I do wrong?” or “Why me?” Doctors don’t know for sure what causes cancer. But we covered a lot of reasons When doctors can’t give a cause, people may come up with their own ideas about why it happened and many are wrong and suffer from guilt Nonetheless lifestyle choices have a major role.

Some people think they’re being punished for something they did or didn’t do in the past. Most people wonder if they did something to cause the cancer. In many cases they did but the guilt has no role and stopping the behavior and starting healthy ones even after diagnosis can actually be beneficial but in terms of the cancer, quality of life and psycho emotional status and sense of control and fighting back

If you’re having these feelings, you’re not alone. Thoughts and beliefs like this are common for people with cancer. You need to know that cancer is not a punishment for your past actions..It may be a consequence though. Try to not blame yourself or focus on looking for ways you might have prevented cancer. It does no good other than what I said

 

How to talk to your loved ones about cancer I cover this in the section called But What Do I say and we will repeat them then but here are some tips..

It can be hard to talk about cancer, even with the people you love. Learning you have cancer can stir many feelings, such as sadness, anger, and fear. Sometimes it’s hard to know how you’re feeling, much less talk to others about it.

Your loved ones may also have a hard time talking about cancer. It’s not easy for them to know what to say to help you or make you feel better.

Here are some tips to help you and your loved ones deal with cancer:

  • Tell your family and friends about your cancer as soon as you feel up to it. Sooner or later, they’ll all know you have cancer. They might feel hurt or left out if they haven’t heard about it from you.
  • When you talk to them, explain what kind of cancer you have and how it will be treated. Let them know that no one can catch it from you.
  • Allow friends and family to help you, and tell them what kind of help you need. If you need a ride to the doctor’s office or hospital, let them know. If you need help around the house, let them know that, too. There may be times when you’re not sure what you need. That’s OK. Just let them know you aren’t sure, but you’ll let them know when you are.
  • Tell the people who are closest to you how you feel. This may not be easy, but it can be a very important way to get the support you need when you need it most. If you have trouble talking about your feelings, you might find a support group or a mental health counselor to help you.
  • If you have friends or family who tell you to “cheer up” when you’re not feeling good, it’s OK to ask them to just listen, and not tell you what to do. Sometimes you need to talk about what’s going on without getting advice in return.
  • If some people are not OK with talking about your feelings, don’t be upset. Try talking to others who might listen.
  • You may not be able to do things you were doing before you got cancer. If that’s true, let your family and friends know.
  • It’s best for your family and friends to keep doing the things they did before you had cancer. They should not feel guilty about doing this.
  • If you’re feeling sad or depressed, talk to your doctor, nurse, or religious leader. You can also call the American Cancer Society at 1-800-227-2345.

Cancer words you may hear A new vocabulary

These are words that you may hear your cancer care team use.

Benign (be-NINE): a tumor that’s not cancer

Biopsy (BY-op-see): taking out a piece of tissue to see if cancer cells are in it

Cancer (CAN-sur): a word used to describe more than 100 diseases in which cells grow out of control; or a tumor with cancer in it

Chemotherapy (key-mo-THER-uh-pee): the use of drugs to treat disease. The word most often refers to drugs used to treat cancer. Sometimes it’s just called “chemo.”

Malignant (muh-LIG-nunt): having cancer in it

Metastasis/Metastasized (meh-TAS-tuh-sis/meh-TAS-tuh-sized): the spread of cancer cells to distant parts of the body through the lymph system or bloodstream

Oncologist (on-KAHL-uh-jist): a doctor who treats people who have cancer

Radiation therapy (ray-dee-A-shun THER-uh-pee): the use of high-energy rays, like x-rays, to treat cancer

Remission (re-MISH-un): when signs or symptoms of cancer are all or partly gone

Stage: a word that tells whether a cancer has spread, and if so, how far

How can I learn more about my cancer?

If you have questions about cancer or need help finding resources in your area, please call the American Cancer Society at 1-800-227-2345. We’re there when you need us – 24 hours a day, 7 days a week.

PART 2 A REVIEW

Cancer is the uncontrolled growth of abnormal cells in the body. Cancer develops when the body’s normal control mechanism stops working. Old cells do not die and instead grow out of control, forming new, abnormal cells. These extra cells may form a mass of tissue, called a tumor. Some cancers, such as leukemia, do not form tumors.

What are the most common forms of cancer?

Cancer may occur anywhere in the body. In women, breast cancer is one of the most common. In men, it’s prostate cancer. Lung cancer and colorectal cancer affect both men and women in high numbers.

There are five main categories of cancer:

  • Carcinomas begin in the skin or tissues that line the internal organs.
  • Sarcomas develop in the bone, cartilage, fat, muscle or other connective tissues.
  • Leukemia begins in the blood and bone marrow.
  • Lymphomas start in the immune system.
  • Central nervous system cancers develop in the brain and spinal cord.Treatment options depend on the type of cancer, its stage, if the cancer has spread and your general health. The goal of treatment is to kill as many cancerous cells while reducing damage to normal cells nearby. Advances in technology make this possible.
  • The three main treatments are:
  • How is cancer treated?
  • Surgery: directly removing the tumor
  • Chemotherapy: using chemicals to kill cancer cells
  • Radiation therapy: using X-rays to kill cancer cells
  • AND NOW TARGETED PRECISION AND MOELCULAR
  • gentic THERAPY AND IMUNO AND BIOLOGIGAL THERAPYWhat can you do to manage the side effects of cancer treatment? AND I COVER THAT LATER WHEN WE DEAL WITH SIDE EFFECTS
  • Supportive care services describe a broad range of therapies designed to combat side effects and maintain well-being. Treating cancer requires focusing on more than the disease alone; it must also address the pain, fatigue, depression and other side effects that come with it.
  • The same cancer type in one individual is very different from that cancer in another individual. Within a single type of cancer, such as breast cancer, researchers are discovering subtypes that each requires a different treatment approach.
  •  The future of cancer treatment lies in providing patients with an even greater level of personalization. Doctors are beginning to offer treatment options based on the genetic changes occurring in a specific tumor.
  • An innovative new diagnostic tool, the genomic tumor assessment, examines a patient’s tumor genetically to identify the mechanism that caused the cancer. Genomic tumor assessment may result in a more personalized approach to cancer treatment
  • What does the future hold for cancer treatment?

THUS CANCER IS A Collection of Related Diseases

Cancer is the name given to a collection of related diseases. In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues.

 

Cancer can start almost anywhere in the human body, which is made up of trillions of cells. Normally, human cells grow and divide to form new cells as the body needs them. When cells grow old or become damaged, they die, and new cells take their place.

 

When cancer develops, however, this orderly process breaks down. As cells become more and more abnormal, old or damaged cells survive when they should die, and new cells form when they are not needed. These extra cells can divide without stopping and may form growths called tumors.

 

Many cancers form solid tumors, which are masses of tissue. Cancers of the blood, such as leukemias, generally do not form solid tumors.

 

Cancerous tumors are malignant, which means they can spread into, or invade, nearby tissues. In addition, as these tumors grow, some cancer cells can break off and travel to distant places in the body through the blood or the lymph system

 

Unlike malignant tumors, benign tumors do not spread into, or invade, nearby tissues. Benign tumors can sometimes be quite large, however. When removed, they usually don’t grow back, whereas malignant tumors sometimes do. Unlike most benign tumors elsewhere in the body, benign brain tumors can be life threatening.

 

Differences between Cancer Cells and Normal Cells

Cancer cells differ from normal cells in many ways that allow them to grow out of control and become invasive. One important difference is that cancer cells are less specialized than normal cells. That is, whereas normal cells mature into very distinct cell types with specific functions, cancer cells do not. This is one reason that, unlike normal cells, cancer cells continue to divide without stopping.

 

In addition, cancer cells are able to ignore signals that normally tell cells to stop dividing or that begin a process known as programmed cell death, or apoptosis, which the body uses to get rid of unneeded cells.

 

Cancer cells may be able to influence the normal cells, molecules, and blood vessels that surround and feed a tumor—an area known as the microenvironment. For instance, cancer cells can induce nearby normal cells to form blood vessels that supply tumors with oxygen and nutrients, which they need to grow. These blood vessels also remove waste products from tumors.

 

Cancer cells are also often able to evade the immune system, a network of organs, tissues, and specialized cells that protects the body from infections and other conditions. Although the immune system normally removes damaged or abnormal cells from the body, some cancer cells are able to “hide” from the immune system.

Tumors can also use the immune system to stay alive and grow. For example, with the help of certain immune system cells that normally prevent a runaway immune response, cancer cells can actually keep the immune system from killing cancer cells.

How Cancer Arises

Cancer is a genetic disease—that is, it is caused by changes to genes that control the way our cells function, especially how they grow and divide.

Genetic changes that cause cancer can be inherited from our parents. They can also arise during a person’s lifetime as a result of errors that occur as cells divide or because of damage to DNA caused by certain environmental exposures. Cancer-causing environmental exposures include substances, such as the chemicals in tobacco smoke, and radiation, such as ultraviolet rays from the sun. Each person’s cancer has a unique combination of genetic changes. As the cancer continues to grow, additional changes will occur. Even within the same tumor, different cells may have different genetic changes.

In general, cancer cells have more genetic changes, such as mutations in DNA, than normal cells. Some of these changes may have nothing to do with the cancer; they may be the result of the cancer, rather than its cause.

“Drivers” of Cancer

The genetic changes that contribute to cancer tend to affect three main types of genes—proto-oncogenes, tumor suppressor genes, and DNA repair genes. These changes are sometimes called “drivers” of cancer.

Proto-oncogenes are involved in normal cell growth and division. However, when these genes are altered in certain ways or are more active than normal, they may become cancer-causing genes (or oncogenes), allowing cells to grow and survive when they should not.

Tumor suppressor genes are also involved in controlling cell growth and division. Cells with certain alterations in tumor suppressor genes may divide in an uncontrolled manner.

DNA repair genes are involved in fixing damaged DNA. Cells with mutations in these genes tend to develop additional mutations in other genes. Together, these mutations may cause the cells to become cancerous.

As scientists have learned more about the molecular changes that lead to cancer, they have found that certain mutations commonly occur in many types of cancer. Because of this, cancers are sometimes characterized by the types of genetic alterations that are believed to be driving them, not just by where they develop in the body and how the cancer cells look under the microscope.

DNA IS LIKE A LADDER WITH TWO IDENTICAL LONG LEGS AND RUNGS THAT ALWAYS MATCH IN A CERTAIN WAY THE LADDER AND RUNGS ARE MADE OF BUILDUBG BKICJS CAKKED NUCKEITIDES

The fidelity of the human genome is maintained by multiple pathways of DNA repair that respond to DNA damage or errors in replication.1 Mismatch repair (MMR) proteins proofread newly replicated DNA strands for mistakes. When an error is found, the MMR protein complex excises the incorrect building block in the DNA and the resulting gap is repaired.4 It is estimated that MMR proteins improve the accuracy of DNA replication by several orders of magnitude.5

Mutations of a principal MMR protein can result in the accumulation of DNA errors, which are compounded by subsequent cycles of DNA replication.6 Repetitive elements within the DNA are especially sensitive to MMR protein dysfunction and the gain or loss of nucleotide repeats within these repetitive elements is termed microsatellite instability (MSI).7 As the burden of pointS OF mutations and MSI increases, DNA stability is lost and cells accumulate malignant properties.8 The consequences of this cellular dysregulation are most clearly observed in patients with Lynch syndrome who carry germline mutations in one of the MMR proteins.9 Most commonly, these patients develop colorectal cancer and women who carry these mutations are also at significant risk for endometrial and ovarian cancer.10 Patients with Lynch syndrome are also at increased risk for gastric, pancreatic, small bowel, urothelial cancers, and gliomas in the brain.10

When Cancer Spreads

 

In metastasis, cancer cells break away from where they first formed (primary cancer), travel through the blood or lymph system, and form new tumors (metastatic tumors) in other parts of the body. The metastatic tumor is the same type of cancer as the primary tumor.

A cancer that has spread from the place where it first started to another place in the body is called metastatic cancer. The process by which cancer cells spread to other parts of the body is called metastasis.

Metastatic cancer has the same name and the same type of cancer cells as the original, or primary, cancer. For example, breast cancer that spreads to and forms a metastatic tumor in the lung is metastatic breast cancer, not lung cancer.

Under a microscope, metastatic cancer cells generally look the same as cells of the original cancer. Moreover, metastatic cancer cells and cells of the original cancer usually have some molecular features in common, such as the presence of specific chromosome changes.

Treatment may help prolong the lives of some people with metastatic cancer. In general, though, the primary goal of treatments for metastatic cancer is to control the growth of the cancer or to relieve symptoms caused by it. Metastatic tumors can cause severe damage to how the body functions, and most people who die of cancer die of metastatic disease.

Tissue Changes that Are Not Cancer

Not every change in the body’s tissues is cancer. Some tissue changes may develop into cancer if they are not treated, however. Here are some examples of tissue changes that are not cancer but, in some cases, are monitored:

Hyperplasia occurs when cells within a tissue divide faster than normal and extra cells build up, or proliferate. However, the cells and the way the tissue is organized look normal under a microscope. Hyperplasia can be caused by several factors or conditions, including chronic irritation.

Dysplasia is a more serious condition than hyperplasia. In dysplasia, there is also a buildup of extra cells. But the cells look abnormal and there are changes in how the tissue is organized. In general, the more abnormal the cells and tissue look, the greater the chance that cancer will form.

Some types of dysplasia may need to be monitored or treated. An example of dysplasia is an abnormal mole (called a dysplastic nevus) that forms on the skin. A dysplastic nevus can turn into melanoma, although most do not.

An even more serious condition is carcinoma in situ. Although it is sometimes called cancer, carcinoma in situ is not cancer because the abnormal cells do not spread beyond the original tissue. That is, they do not invade nearby tissue the way that cancer cells do. But, because some carcinomas in situ may become cancer, they are usually treated.

 

Normal cells may become cancer cells. Before cancer cells form in tissues of the body, the cells go through HYPERPASIA AND DYSPLASIA

Types of Cancer

There are more than 100 types of cancer. Types of cancer are usually named for the organs or tissues where the cancers form. For example, lung cancer starts in cells of the lung, and brain cancer starts in cells of the brain. Cancers also may be described by the type of cell that formed them, such as an epithelial cell or a squamous cell.

You can search NCI’s website for information on specific types of cancer based on the cancer’s location in the body or by using THEIR A to Z List of Cancers. THEY also have collections of information on childhood cancers and cancers in adolescents and young adults.

Here are some categories of cancers that begin in specific types of cells:

Carcinoma

Carcinomas are the most common type of cancer. They are formed by epithelial cells, which are the cells that cover the inside and outside surfaces of the body. There are many types of epithelial cells, which often have a column-like shape when viewed under a microscope.

Carcinomas that begin in different epithelial cell types have specific names:

Adenocarcinoma is a cancer that forms in epithelial cells that produce fluids or mucus. Tissues with this type of epithelial cell are sometimes called glandular tissues. Most cancers of the breast, colon, and prostate are adenocarcinomas.

Basal cell carcinoma is a cancer that begins in the lower or basal (base) layer of the epidermis, which is a person’s outer layer of skin.

Squamous cell carcinoma is a cancer that forms in squamous cells, which are epithelial cells that lie just beneath the outer surface of the skin. Squamous cells also line many other organs, including the stomach, intestines, lungs, bladder, and kidneys. Squamous cells look flat, like fish scales, when viewed under a microscope. Squamous cell carcinomas are sometimes called epidermoid carcinomas.

 

Transitional cell carcinoma is a cancer that forms in a type of epithelial tissue called transitional epithelium, or urothelium. This tissue, which is made up of many layers of epithelial cells that can get bigger and smaller, is found in the linings of the bladder, ureters, and part of the kidneys (renal pelvis), and a few other organs. Some cancers of the bladder, ureters, and kidneys are transitional cell carcinomas.

Sarcoma

Soft tissue sarcoma forms in soft tissues of the body, including muscle, tendons, fat, blood vessels, lymph vessels, nerves, and tissue around joints.

Sarcomas are cancers that form in bone and soft tissues, including muscle, fat, blood vessels, lymph vessels, and fibrous tissue (such as tendons and ligaments).

Osteosarcoma is the most common cancer of bone. The most common types of soft tissue sarcoma are leiomyosarcoma, Kaposi sarcoma, malignant fibrous histiocytoma, liposarcoma, and dermatofibrosarcoma protuberans.

FINALLY.

Blood Cancers

Blood cancers such as multiple myeloma affect the function and production of blood cells. In most MYELOMA blood cancers, normal blood cell development is interrupted by uncontrolled growth of abnormal blood cells called plasma cells which make anribodies. The abnormal blood cells can prevent blood from fighting off infection or preventing uncontrolled bleeding. In rare cases myeloma is found in one place in the body, and is called solitary myeloma. Myeloma blood cancer treatment may include chemotherapy, radiation and stem cell transplant.

 

There are three main blood cancer types:

HUGE PROGRESS IN MULTIPLE RELAPSES

Leukemia

 

And lymphoma

Multiple Myeloma

Leukemia is a blood cancer in both the bone marrow and in blood itself. Both types of leukemia involve an over-production of white blood cells. Lymphocytic leukemia involves over-production of lymphocytes, and myelogenous leukemia involves over-production of white blood cells called granulocytes. Over time, leukemia cells crowd out normal blood cells leading to serious bleeding and infection.

Lymphoma

Lymphoma is a blood cancer that develops in the lymphatic system. The lymphatic system is made up of groups of lymph nodes which keep body fluids free from infection. The blood cancer may spread from one group of lymph nodes to another in order (Hodgkin lymphoma) or spread randomly (non-Hodgkin lymphoma).

Lymphoma is cancer that begins in lymphocytes (T cells or B cells). These are disease-fighting white blood cells that are part of the immune system. In lymphoma, abnormal lymphocytes build up in lymph nodes and lymph vessels, as well as in other organs of the body.

There are two main types of lymphoma:

Hodgkin lymphoma – People with this disease have abnormal lymphocytes that are called Reed-Sternberg cells. These cells usually form from B cells.

Non-Hodgkin lymphoma – This is a large group of cancers that start in lymphocytes. The cancers can grow quickly or slowly and can form from B cells or T cells.

 

Leukemia

Cancers that begin in the blood-forming tissue of the bone marrow are called leukemias. These cancers do not form solid tumors. Instead, large numbers of abnormal white blood cells (leukemia cells and leukemic blast cells) build up in the blood and bone marrow, crowding out normal blood cells. The low level of normal blood cells can make it harder for the body to get oxygen to its tissues, control bleeding, or fight infections.

There are four common types of leukemia, which are grouped based on how quickly the disease gets worse (acute or chronic) and on the type of blood cell the cancer starts in (lymphoblastic or myeloid).

.

Multiple Myeloma

AS WE DISCUSSED Multiple myeloma is cancer that begins in plasma cells, another type of immune cell. The abnormal plasma cells, called myeloma cells, build up in the bone marrow and form tumors in bones all through the body. Multiple myeloma is also called plasma cell myeloma.

.

Melanoma

Melanoma is cancer that begins in cells that become melanocytes, which are specialized cells that make melanin (the pigment that gives skin its color). Most melanomas form on the skin, but melanomas can also form in other pigmented tissues, such as the eye.

.

Brain and Spinal Cord Tumors

There are different types of brain and spinal cord tumors. These tumors are named based on the type of cell in which they formed and where the tumor first formed in the central nervous system. For example, an astrocytic tumor begins in star-shaped brain cells called astrocytes, which help keep nerve cells healthy. Brain tumors can be benign (not cancer) or malignant (cancer).

Other Types of Tumors

Germ Cell Tumors

Germ cell tumors are a type of tumor that begins in the cells that give rise to sperm or eggs. These tumors can occur almost anywhere in the body and can be either benign or malignant.

.

Neuroendocrine Tumors

Neuroendocrine tumors form from cells that release hormones into the blood in response to a signal from the nervous system. These tumors, which may make higher-than-normal amounts of hormones, can cause many different symptoms. Neuroendocrine tumors may be benign or malignant.

.

Carcinoid Tumors

Carcinoid tumors are a type of neuroendocrine tumor. They are slow-growing tumors that are usually found in the gastrointestinal system (most often in the rectum and small intestine). Carcinoid tumors may spread to the liver or other sites in the body, and they may secrete substances such as serotonin or prostaglandins, causing carcinoid syndrome.

Let’s see if there are any questions

 

 

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 available on the website of the same name and Amazon signing off radio www.w4cs.com the cancer support radio program   and ARCHIVED AUDIO FILES ON iheart RADIO 

See you Next Tuesday at noon PST when we will look MORE OF THE NUTS AND BOLTS OF THE OVERVIEW OF CANCER

 

 

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

Should Physicians Help Terminal Patients Die?

Should Physicians Help Terminal Patients Die?

hospitals

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

This is a increasingly common question from the bedside to the jurists bench and beyond. Listen in on some of our best thinkers dissect the topic

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age. Continue Reading We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

| Disclosures | August 25, 2016

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

 

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds.

Dr Caplan: Just to emphasize, it is the reversibility of their psychological state.

Dr Markman: That is correct. Again, this is an example and certainly an example in the cancer domain, which is my experience. A patient could have been taking a tremendous amount of pain medications. They are not working and they say that nothing is working. I accept that. However, it could be that there is a single anatomical lesion that has not been appreciated or has not been approached. An interventional radiology approach or a surgical approach might be able to relieve that pain. If that pain were relieved, that could change the patient’s psychological despair that led them to say, “I want to end my life.”

Dr Caplan: What do you say to the advocates of physician-assisted dying? What do you say to the patient who says, “I understand that you can manipulate this and manipulate that, but I am dying and I do not want to go through all of that. I would rather be in control of how I die. I know that you could do this or sedate me or block this. I do not want to go through all of that.”

Dr Markman: It is their right. It is as simple as that. Again, as a physician, I would see my role as an advisor, no more than that. If someone were to say that to me, I would say, “I accept that. Did you consider this? Did you consider that?” But of course, I am not a psychologist or a psychiatrist. It is also not for me to decide right or wrong. As a physician, I can voice an opinion. I can advise. I can even go to a family member if I think that there may be some element that just doesn’t make sense to me, based on objective data. In your example, the patients want to be in control, but it may be a potentially curable cancer, let’s say. There may be a concern that we are not getting through to them. My role in that is not to tell patients that they are wrong; my role might be to ask whether there is another way of approaching this that they’re not hearing. If the answer is that this is their decision, it is their decision.

Making Death the Goal ‘Is the Antithesis of Medicine’

Dr Caplan: Dr Markman has brought up some very thoughtful and provoking points. Now we will speak with Dr Farr Curlin, a physician and an expert in palliative care at Duke University. He is the Trent Professor of Medical Humanities and also works in the Center for Bioethics, Humanities, and History of Medicine at Duke. He is certainly one of the nation’s leading experts on end-of-life care, and he has done pioneering work in integrating theology and healthcare. Welcome, Farr.

Farr A. Curlin, MD: Thank you.

Dr Caplan: Let me begin by asking you a straightforward question. You-

 

 

  •  Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds.

Dr Caplan: Just to emphasize, it is the reversibility of their psychological state.

Dr Markman: That is correct. Again, this is an example and certainly an example in the cancer domain, which is my experience. A patient could have been taking a tremendous amount of pain medications. They are not working and they say that nothing is working. I accept that. However, it could be that there is a single anatomical lesion that has not been appreciated or has not been approached. An interventional radiology approach or a surgical approach might be able to relieve that pain. If that pain were relieved, that could change the patient’s psychological despair that led them to say, “I want to end my life.”

Dr Caplan: What do you say to the advocates of physician-assisted dying? What do you say to the patient who says, “I understand that you can manipulate this and manipulate that, but I am dying and I do not want to go through all of that. I would rather be in control of how I die. I know that you could do this or sedate me or block this. I do not want to go through all of that.”

Dr Markman: It is their right. It is as simple as that. Again, as a physician, I would see my role as an advisor, no more than that. If someone were to say that to me, I would say, “I accept that. Did you consider this? Did you consider that?” But of course, I am not a psychologist or a psychiatrist. It is also not for me to decide right or wrong. As a physician, I can voice an opinion. I can advise. I can even go to a family member if I think that there may be some element that just doesn’t make sense to me, based on objective data. In your example, the patients want to be in control, but it may be a potentially curable cancer, let’s say. There may be a concern that we are not getting through to them. My role in that is not to tell patients that they are wrong; my role might be to ask whether there is another way of approaching this that they’re not hearing. If the answer is that this is their decision, it is their decision.

Making Death the Goal ‘Is the Antithesis of Medicine’

Dr Caplan: Dr Markman has brought up some very thoughtful and provoking points. Now we will speak with Dr Farr Curlin, a physician and an expert in palliative care at Duke University. He is the Trent Professor of Medical Humanities and also works in the Center for Bioethics, Humanities, and History of Medicine at Duke. He is certainly one of the nation’s leading experts on end-of-life care, and he has done pioneering work in integrating theology and healthcare. Welcome, Farr.

Farr A. Curlin, MD: Thank you.

Dr Caplan: Let me begin by asking you a straightforward question. You have a lot of experience in palliative care. What do you think is the key reason to oppose physician-assisted dying or physician-assisted suicide?

Dr Curlin: The main reason physicians should oppose physician-assisted suicide is that assisted suicide directly contradicts the purpose of medicine. It directly contradicts physicians’ long-standing profession to maintain solidarity with those who are sick and debilitated. It is not just about medicine. I think it is the antithesis of medicine. Continue Reading

Dr Caplan: How do you respond to those who say that part of their mission as a physician is to relieve suffering and that part of their mission is to listen to their terminally ill patients— that if they want assistance in dying, it is consistent with a physician’s ethical obligation both to relieve suffering and to honor their wishes?

Dr Curlin: Relieving suffering is obviously an essential aspect of physicians’ work, but if we have no other objective criteria to decide what suffering we are obligated to relieve and what suffering we are not, then there is literally no boundary on our use of medical technology to achieve things that people want. For any conditions that people suffer from, they can ask that we take them away.

Dr Caplan: We have doctors contacting us with this kind of question. They say that, certainly, we don’t want to be involved with children or psychiatric patients, but for those who are at the far end of dying, in the final throes of death with their MS overcoming them or their parkinsonism overcoming them, those who are in a stage of dying that is imminent, not even 6 months away but days—is there no relief, no mercy to be offered by hastening their death even at that point?

We do not make the death a part of our plan. We make relief of those health-diminishing and health-crushing symptoms our goal.

Dr Curlin: Patients in that situation are taken care of. Scores are in that situation. Without ever making their death our goal, we can treat those symptoms with powerful medications—as much as they need to get the symptoms relieved, whether it is choking on their secretions or gasping for breath or being in pain. If, as a side effect, the medication hastens their death, then of course physicians can still do that, and they have done that for centuries under what has been called the rule of double effect. It has been an important heuristic for guiding us. We do not make the death a part of our plan. We make relief of those health-diminishing and health-crushing symptoms our goal. We work toward it as hard as we need to get it done.

The Key Points

Dr Caplan: So, where is all of this headed and what does it mean for physician-assisted dying? Here are the key points that we have heard in today’s program:

On the pro side, assistance in dying relieves suffering in terminal patients who are in pain. It enables ill patients to have some control over their life and death. Many consider this merciful and a part of what compassionate care is for patients. Patients with little time to live may want their suffering to end on their terms.

On the con side, physicians are enjoined against doing harm. Many believe that assisting in dying is harm. Some worry that there is a slippery slope, that it is going to become too easy for patients to commit suicide, not because they are terminally ill but because of depression or other reasons. Some conditions may actually turn out to be treatable. Death is not reversible, and some religions consider suicide in any manner a sin.

Here is my take. The issue of physician-assisted death is clearly going to remain a divisive topic for the foreseeable future, but I think we are going to see more states move to legalize it. The momentum is there. I think the practice is going to spread around the United States.

I hope that this program has given you some further insight and information so that you can make up your own mind about the subject. I am Art Caplan from the NYU Langone Medical Center on behalf of Medscape. I hope to see you next time on Both Sides Now.

 

 

Lung Cancer Screening: Beneficial for Certain Populations but Not Without Controversy

BE ADVISED THIS IS STILL CONTROVERSIAL DESPITE VERY ENCOURAAGING DSTS THAT OF USE LOW DOE  CAT SCAN TO SCREEN AT RICK POPULATION SOCIEY MAY SAVE LIVES AND HEARTACHE AND MONEY. IT IS NOT YET THE STANDARD OF CARE BUT I DID WHEN IT WAS MY TURN IIN SLECTED PATIENTS

WHAT FOLLOWS IS LONG BUT WELL WORTH THE LESSON IN HOW TO READ CONTROVERSIAL STUDIES INTELLIGENTLY AND ACCURATELY AND KNOW WHAT THEY SAY AS WELL DO NOT SAY  The required counseling and shared decision-making visit must include the benefits and harms of screening, follow-up testing, overdiagnosis, false-positive rate, and total radiation exposure. The patient must also be told about the importance of annual screening and the effect of comorbidities as well as be willing to undergo diagnosis and treatment. Smoking cessation also should be part of counseling.

Furthermore, under the Affordable Care Act, all privately insured patients who meet USPSTF eligibility have coverage for low-dose CT screening for lung cancer as a preventive health benefit (ie, without a copay). The same is true for Medicare beneficiaries; there is no co-pay for patients eligible for lung cancer screening.

Primary Care Perspective

If we apply risk calculators to identify nodules most likely to be malignant [appearance and size of the nodule, patient age, gender, and family history], we could have much better discrimination.

— Richard Hoffman, MD, MPH

How can primary care physicians convince their patients to be screened—and should they? Richard Hoffman, MD, MPH, Professor of Internal Medicine and Epidemiology, University of Iowa Carver College of Medicine, is not so positive. “Not only is the absolute benefit from lung cancer screening very small, there is a high rate of false-positives, as well as significant concerns about being able to safely and effectively translate the NLST results into community practice.”

Are primary care practitioners even aware of the NLST results? Not so much. Dr. Hoffman reported there was only limited awareness in New Mexico, and physicians there believed the absolute mortality benefit was small. In South Carolina, 41% believed that low-dose CT reduced lung cancer mortality, and 76% thought the benefits outweighed the risks. In North Carolina, 42% of physicians rated screening as effective in reducing lung cancer mortality (but erroneously thought it is less effective than screening for breast and colorectal cancers).

Dr. Hoffman reported that 49% to 86% of primary physicians are aware of the USPSTF guidelines. Those with the highest awareness recognized that guidelines targeted heavy current or former smokers and not those with just exposure to second-hand smoke. Those with the lowest awareness knew little about the criteria, and some believed that chest x-ray, not low-dose CT, was the way to go.

Dr. Hoffman said that although the false-positive rate is high, applying Lung-RADS could reduce the rate by 50% to 75%. “If we apply risk calculators to identify nodules most likely to be malignant [appearance and size of the nodule, patient age, gender, and family history], we could further reduce the risks of unnecessary diagnostic procedures.”

Lung-RADS Categories

There is a great deal of concern about testing, radiation exposure, patient anxiety, follow-up invasive procedures, and cost. Lung-RADS can provide standardized reporting and management, and it can facilitate outcomes tracking.

— Ella Kazerooni, MD

Why Lung-RADS? asked Ella Kazerooni, MD, Professor of Radiology, University of Michigan. Because of the lack of clarity about how to manage positive screens, she said. “There is a great deal of concern about testing, radiation exposure, patient anxiety, follow-up invasive procedures, and cost. Lung-RADS can provide standardized reporting and management, and it can facilitate outcomes tracking.” Use of LungRADS has been shown in two published studies, including a reclassification of the NLST data, to reduce the positive screen rate from approximately 1 in 4 to approximately 1 in 10. This is accomplished by increasing the size of nodules used to define a “positive” screen and reducing the need for interim testing between annual screens for nodules that have a very low likelihood of becoming a clinically active or significant cancer. This gets at a common concern in screening, which is overdiagnosis. These cancers a person has but can live with and don’t manifest themselves clinically while a person is alive. This reduces the downstream noninvasive and invasive testing that follows a positive screen and should make lung cancer CT screening even more cost-effective than has already been demonstrated.

The system consists of the following five categories:

  • Incomplete (0): The CT cannot be interpreted and must be repeated.
  • Negative (1): No nodules or definitely benign nodules. This category and category 2 include 90% of people screened and carry a less than 1% probability of malignancy. The recommendation is to continue annual screening with low-dose CT.
  • Benign appearance or behavior (2): These nodules have a very low likelihood of becoming a clinically active cancer due to their size or lack of growth.
  • Probably benign (3): These nodules have a low likelihood of becoming clinically active cancer. Six percent of people screened fall into this category, which carries a 1% to 2% probability of malignancy. Patients here should have another low-dose CT in 6 months to re-evaluate the abnormalities for interval growth that may prompt further evaluation; if the nodules are unchanged or have resolved, patients should return to their annual screening calendar with their next screening CT in 6 months.
  • Suspicious (4A, 4B): For these findings, additional diagnostic testing and/or tissue sampling is recommended. Two percent of people screened fall into each of these two categories, respectively. Category 4A has a 5% to 15% chance of malignancy, and category 4B has a greater than 15% probability. Patients in category 4A should have another low-dose CT in 3 months; a PET-CT may be considered if the solid component of the nodule is greater than 8 mm. Patients in category 4B have a greater than 15% chance of having malignancy, with further workup predicated on their individual risk of cancer, as can be evaluated using a lung cancer risk assessment tool. The subsequent testing may be a chest CT with intravenous contrast, PET-CT, and/or tissue sampling with multidisciplinary collaboration and/or referral to an appropriate specialist familiar with lung cancer diagnosis strongly encouraged.When thinking about recommending lung cancer screening, physicians need to consider whether the harms outweigh the benefits and whether patients can understand all the ramifications and are likely to follow up, said Dr. Hoffman. Even when all these factors are taken into consideration, he added, screening discussions often fail to inform and engage. “Perhaps the presentation is unbalanced, maybe the patients have limited knowledge, and maybe their preferences are not elicited.”Dr. Hoffman noted that there are variations in the use of CT screening for lung cancer. In New Mexico, for example, some physicians ordered baseline chest x-rays for smokers but not low-dose CT. In South Carolina, 73% reported discussing low-dose CT, but only 59% referred even a single patient in the past year. Many recommended x-ray, however. In North Carolina, 21% offered chest x-ray, and only 12% offered low-dose CT. In Texas, 56% said they planned to offer screening, but only 10% had a program in their practice.Racial, Ethnic, Socioeconomic DisparitiesNot everyone thinks about lung cancer screening in the same way, said Christopher S. Lathan, MD, MPH, Assistant Professor of Medicine, Harvard Medical School, and Director, Cancer Care Equity, Dana-Farber Cancer Institute. Nor does everyone experience the disease in the same way. He said that according to the American Cancer Society, between 2007 and 2011, the incidence rate for black American men was 95.4/100,000 and 81.3/100,000 for white men. The death rate was 77.5 and 63.9, respectively.Income plays a role as important as race, continued Dr. Lathan. “Poor people face a double jeopardy. They are at increased risk because they smoke more, and poverty increases their risk of dying. Income is directly related to the stage of disease at diagnosis, and stage drives mortality.”The second report, from May 2016, associated financial strain with symptom burden and quality of life.6 Among patients with lung cancer, 40% reported limited financial reserves (less than 2 months). They suffered significantly more pain than patients who had financial reserves of 12 months, had greater symptom burden, and poorer quality of life.Disclosure: Drs. Massetti, Kramer, LeFevre, Wood, Hoffman, Kazerooni, and Lathan reported no potential conflicts of interest.1. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al: Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365:395-409, 2011.3. Patient and Physician Guide: National Lung Screening Trial (NLST). Available at http://www.cancer.gov/types/lung/research/NLSTstudyGuidePatientsPhysicians.pdf. Accessed July 7, 2016.5. Walker GV, Grant SR, Guadagnolo BA, et al: Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol 32:3118-3125, 2014.Editor’s Note: For more on the issue of lung cancer screening with low-dose CT, be sure to see As Low-Dose CT Screening Moves Into the Clinic, Implementation Issues Move Up on the Agenda for a report from the Prevent Cancer Foundation’s 18th Annual Quantitative Imaging Workshop.As Low-Dose CT Screening Moves Into the Clinic, Implementation Issues Move Up on the AgendaAdvertisement
  • Low-dose computed tomography (CT) screening for lung cancer in high-risk groups is moving into the clinic in the wake of its approval by the U.S. Centers for Medicaid & Medicare Services. That does not mean, however, the discussion is over. As low-dose CT moves from research to everyday…
  • Related Articles
  • 6. Lathan CS, Cronin A, Tucker-Seeley R, et al: Association of financial strain with symptom burden and quality of life for patients with lung or colorectal cancer. J Clin Oncol 34:1732-1740, 2016.
  • 4. Wood DE: The importance of lung cancer screening with low-dose computed tomography for Medicare beneficiaries. JAMA Intern Med 174:2016-2018, 2014.
  • 2. Pinsky PF, Church TR, Izmirlian G, et al: The National Lung Screening Trial: Results stratified by demographics, smoking history, and lung cancer histology. Cancer 119:3976-3983, 2013.
  • References
  • The Health Information Trends Survey (HINTS) is a public database started in 2002 that examines changing patterns in health information and access. It reports that overall knowledge about lung cancer among all races is limited, but black individuals appear to expect more symptoms, be reluctant to seek care for fear of disease, and be confused about prevention. ■
  • Money matters in other ways, too. Dr. Lathan discussed two reports in the Journal of Clinical Oncology. The first, from October 2014, was about insurance status and patients with the 10 most deadly cancers.5 Those with non-Medicaid insurance (ie, Medicare or a private carrier) were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or with no insurance (34.7%). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery and/or radiation (79.6%) than those on Medicaid (67.9%) or those who were uninsured (62.1%). Patients covered by Medicaid (or who had no insurance) were more likely to die than those with other coverage.
  • Dr. Lathan noted that, of all racial and ethnic groups in the United States, the incidence and mortality rates of lung cancer are highest among black men. The good news is that over the past 40 years, there has been a decrease in all races, although black men are still at the top of the heap when smoking habits are adjusted for. Other good news, said Dr. Lathan, is that low-dose CT decreased mortality to a greater extent for black individuals than for all other groups, even though they were younger, had more comorbidities, and were less educated.
  • Christopher S. Lathan, MD, MPH
  • In essence, it appears that a majority of primary care doctors do not know about lung cancer screening, order inappropriate tests in an effort to screen, and have not yet incorporated guidelines for lung cancer screening into their practice. All cancer guidelines groups in the United States, Canada, and Europe have endorsed low-dose CT for lung cancer screening in the high-risk patient population.
  • When screening is not offered at all, it may be because the patient doesn’t fit the criteria; he or she is not healthy enough; or the physician isn’t convinced the benefits outweigh the harms, doesn’t know whether the patient smokes, or thinks it’s more appropriate to allocate resources to younger patients.
  • Considerations for and Against Screening