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Cancer Information

Breast Cancer    
Uterine Cancer    
Cervical Cancer    
Ovarian Cancer   

Breast Cancer 

anatomy of breastEach breast has 15 to 20 sections called lobes. Within each lobe are many smaller lobules. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat surrounds the lobules and ducts. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.

Each breast also contains blood vessels and lymph vessels. The lymph vessels carry colorless fluid called lymph, and lead to small bean-shaped organs called lymph nodes. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest. Lymph nodes are also found in many other parts of the body. 

Who's at Risk?

The exact causes of breast cancer are not known. However, studies show that the risk of breast cancer increases as a woman gets older. This disease is very uncommon in women under the age of 35. Most breast cancers occur in women over the age of 50, and the risk is especially high for women over age 60. Also, breast cancer occurs more often in white women than African American or Asian women.

Research has shown that the following conditions increase a woman's chances of getting breast cancer:

  • Personal history of breast cancer - Women who have had breast cancer face an increased risk of getting breast cancer in their other breast.
  • Family history - Woman's risk for developing breast cancer increases if her mother, sister, or daughter had breast cancer, especially at a young age.
  • Certain breast changes - Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) may increase a woman's risk for developing cancer.
  • Genetic alterations - Changes in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, gene testing can sometimes show the presence of specific genetic changes that increase the risk of breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or to improve the detection of this disease in women who have these changes in their genes. For more information about gene testing, read the "Causes and Prevention" section under "The Promise of Cancer Research."
  • Certain breast changes - Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) may increase a woman's risk for developing cancer.
  • Genetic alterations - Changes in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, gene testing can sometimes show the presence of specific genetic changes that increase the risk of breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or to improve the detection of this disease in women who have these changes in their genes. For more information about gene testing, read the "Causes and Prevention" section under "The Promise of Cancer Research."
Certain breast changes - Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) may increase a woman's risk for developing cancer.

 

Genetic alterations - Changes in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, gene testing can sometimes show the presence of specific genetic changes that increase the risk of breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or to improve the detection of this disease in women who have these changes in their genes. For more information about gene testing, read the "Causes and Prevention" section under "The Promise of Cancer Research."

  • Other factors associated with an increased risk for breast cancer include:

    • Estrogen - Evidence suggests that the longer a woman is exposed to estrogen (estrogen made by the body, taken as a drug, or delivered by a patch), the more likely she is to develop breast cancer. For example, the risk is somewhat increased among women who began menstruation at an early age (before age 12), experienced menopause late (after age 55), never had children, or took hormone replacement therapy for long periods of time. Each of these factors increases the amount of time a woman's body is exposed to estrogen.

      DES (diethylstilbestrol) is a synthetic form of estrogen that was used between the early 1940s and 1971. Women who took DES during pregnancy to prevent certain complications are at a slightly higher risk for breast cancer. This does not appear to be the case for their daughters who were exposed to DES before birth. However, more studies are needed as these daughters enter the age range when breast cancer is more common.
    • Late childbearing - Women who have their first child late (after about age 30) have a greater chance of developing breast cancer than women who have a child at a younger age.
    • Breast density - Breasts that have a high proportion of lobular and ductal tissue appear dense on mammograms. Breast cancers nearly always develop in lobular or ductal tissue (not fatty tissue). That's why cancer is more likely to occur in breasts that have a lot of lobular and ductal tissue (that is, dense tissue) than in breasts with a lot of fatty tissue. In addition, when breasts are dense, it is more difficult for doctors to see abnormal areas on a mammogram.
    • Radiation therapy - Women whose breasts were exposed to radiation during radiation therapy before age 30, especially those who were treated with radiation for Hodgkin's disease, are at an increased risk for developing breast cancer. Studies show that the younger a woman was when she received her treatment, the higher her risk for developing breast cancer later in life.
    • Alcohol - Some studies suggest a slightly higher risk of breast cancer among women who drink alcohol.

    Most women who develop breast cancer have none of the risk factors listed above, other than the risk that comes with growing older. Scientists are conducting research into the causes of breast cancer to learn more about risk factors and ways of preventing this disease.

    Detecting Breast Cancer

    Women should talk with their doctor about factors that can increase their chance of getting breast cancer. Women of any age who are at higher risk for developing this disease should ask their doctor when to start and how often to be checked for breast cancer. Breast cancer screening has been shown to decrease the risk of dying from breast cancer.

    Women can take an active part in the early detection of breast cancer by having regularly scheduled screening mammograms and clinical breast exams (breast exams performed by health professionals). Some women also perform breast self-exams.

    A screening mammogram is the best tool available for finding breast cancer early, before symptoms appear. A mammogram is a special kind of x-ray. Screening mammograms are used to look for breast changes in women who have no signs of breast cancer.

    Mammograms can often detect a breast lump before it can be felt. Also, a mammogram can show small deposits of calcium in the breast. Although most calcium deposits are benign, a cluster of very tiny specks of calcium (called microcalcifications) may be an early sign of cancer.

    If an area of the breast looks suspicious on the screening mammogram, additional (diagnostic) mammograms may be needed. Depending on the results, the doctor may advise the woman to have a biopsy.

    Although mammograms are the best way to find breast abnormalities early, they do have some limitations. A mammogram may miss some cancers that are present (false negative) or may find things that turn out not to be cancer (false positive). And detecting a tumor early does not guarantee that a woman's life will be saved. Some fast-growing breast cancers may already have spread to other parts of the body before being detected.

    Nevertheless, studies show that mammograms reduce the risk of dying from breast cancer. Most doctors recommend that women in their forties and older have mammograms regularly, every 1 to 2 years.

    Some women perform monthly breast self-exams to check for any changes in their breasts. When doing a breast self-exam, it's important to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period. Women in their forties and older should be aware that a monthly breast self-exam is not a substitute for regularly scheduled screening mammograms and clinical breast exams by a health professional.

    Recognizing Symptoms

    Early breast cancer usually does not cause pain. In fact, when breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause changes that women should watch for:

    • A lump or thickening in or near the breast or in the underarm area
    • A change in the size or shape of the breast
    • Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast
    • Ridges or pitting of the breast (the skin looks like the skin of an orange)
    • A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly)

    A woman should see her doctor about any symptoms like these. Most often, they are not cancer, but it's important to check with the doctor so that any problems can be diagnosed and treated as early as possible.

    Diagnosing Breast Cancer

    To help find the cause of any sign or symptom, a doctor does a careful physical exam and asks about personal and family medical history. In addition, the doctor may do one or more breast exams:

    • Clinical breast exam - The doctor can tell a lot about a lump by carefully feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The doctor can examine the size and texture of the lump and determine whether the lump moves easily.
    • Mammography - X-rays of the breast can give the doctor important information about a breast lump.
    • Ultrasonography - Using high-frequency sound waves, ultrasonography can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). This exam may be used along with mammography.

    Based on these exams, the doctor may decide that no further tests are needed and no treatment is necessary. In such cases, the doctor may need to check the woman regularly to watch for any changes.

    • Biopsy - Often, fluid or tissue must be removed from the breast so the doctor can make a diagnosis. A woman's doctor may refer her for further evaluation to a surgeon or other health care professional who has experience with breast diseases. These doctors may perform:
    • Fine-needle aspiration - A thin needle is used to remove fluid and/or cells from a breast lump. If the fluid is clear, it may not need to be checked by a lab.
    • Needle biopsy - Using special techniques, tissue can be removed with a needle from an area that looks suspicious on a mammogram but cannot be felt. Tissue removed in a needle biopsy goes to a lab to be checked by a pathologist for cancer cells.
    • Surgical biopsy - In an incisional biopsy, the surgeon cuts out a sample of a lump or suspicious area. In an excisional biopsy, the surgeon removes all of a lump or suspicious area and an area of healthy tissue around the edges. A pathologist then examines the tissue under a microscope to check for cancer cells.

    When Cancer Is Found

    The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called lobular carcinoma, arises in the lobules. When cancer is found, the pathologist can tell what kind of cancer it is (whether it began in a duct or a lobule) and whether it is invasive (has invaded nearby tissues in the breast).

    Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help determine whether hormones help the cancer to grow. If test results show that hormones do affect the cancer's growth (a positive test result), the cancer is likely to respond to hormonal therapy. This therapy deprives the cancer cells of estrogen. More information about hormonal therapy can be found in the "Planning Treatment" section.

    Other tests are sometimes done to help the doctor predict whether the cancer is likely to progress. For example, the doctor may order x-rays and lab tests. Sometimes a sample of breast tissue is checked for a gene (the human epidermal growth factor receptor-2 or HER-2 gene) that is associated with a higher risk that the breast cancer will come back. The doctor may also order special exams of the bones, liver, or lungs because breast cancer may spread to these areas.

    Planning Treatment

    Many women with breast cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it is helpful to prepare a list of questions in advance. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

    The patient's doctor may refer her to doctors who specialize in treating cancer, or she may ask for a referral. Treatment generally begins within a few weeks after the diagnosis. There will be time for the woman to talk with the doctor about her treatment choices, to get a second opinion, and to prepare herself and her loved ones.

    Second Opinion

    Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the woman requests it. It may take a little while to arrange to see another doctor. In most cases, a brief delay (up to 3 or 4 weeks) between biopsy and treatment does not make breast cancer treatment less effective. There are a number of ways to find a doctor for a second opinion:

    The patient's doctor may refer her to one or more specialists. Specialists who treat women with breast cancer include surgeons, medical oncologists, plastic surgeons, and radiation oncologists. At cancer centers or special centers for breast diseases, these doctors often work together as a team.

    Patients can get the names of specialists from their local medical society, a nearby hospital, or a medical school.
    Methods of Treating Breast Cancer
    Breast cancer may be treated with local or systemic therapy. Some patients have both kinds of treatment.

    Local therapy is used to remove or destroy breast cancer in a specific area. Surgery and radiation therapy are local treatments. They are used to treat the disease in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control cancer in those specific areas, such as in the lung or bone.

    Systemic treatments are used to destroy or control cancer throughout the body. Chemotherapy, hormonal therapy, and biological therapy are systemic treatments. Some patients have systemic therapy to shrink the tumor before local therapy. Others have systemic therapy to prevent the cancer from coming back, or to treat cancer that has spread.

    Surgery is the most common treatment for breast cancer, and there are several types of surgery. The doctor can explain each type, discuss and compare their benefits and risks, and describe how each will affect the patient's appearance.

    An operation to remove the cancer but not the breast is called breast-sparing surgery or breast-conserving surgery. Lumpectomy and segmental mastectomy (also called partial mastectomy) are types of breast-sparing surgery. After breast-sparing surgery, most women receive radiation therapy to destroy cancer cells that remain in the area.

    An operation to remove the breast (or as much of the breast as possible) is a mastectomy. Breast reconstruction is often an option at the same time as the mastectomy, or later on.

    In most cases, the surgeon also removes lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system. This is called an axillary lymph node dissection.

    In lumpectomy, the surgeon removes the breast cancer and some normal tissue around it. (Sometimes an excisional biopsy serves as a lumpectomy.) Often, some of the lymph nodes under the arm are removed.

    In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some lymph nodes under the arm may also be removed.

     

    In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.

    In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm, and, often, the lining over the chest muscles. The smaller of the two chest muscles also may be taken out to help in removing the lymph nodes.

    In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, both chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered the standard one for women with breast cancer, but it is almost never used today. In rare cases, radical mastectomy may be suggested if the cancer has spread to the chest muscles.

    Breast reconstruction (surgery to rebuild the shape of a breast) is often an option after mastectomy. Women considering reconstruction should discuss this with a plastic surgeon before having a mastectomy.

    Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. The radiation may be directed at the breast by a machine (external radiation). The radiation can also come from radioactive material placed in thin plastic tubes that are placed directly in the breast (implant radiation). Some women have both kinds of radiation therapy.

    For external radiation therapy, the patient goes to the hospital or clinic, generally 5 days a week for several weeks. For implant radiation, a patient stays in the hospital. The implants remain in place for several days. They are removed before the woman goes home.

    Sometimes, depending on the size of the tumor and other factors, radiation therapy is used after surgery, especially after breast-sparing surgery. The radiation destroys any breast cancer cells that may remain in the area.

    Before surgery, radiation therapy, alone or with chemotherapy or hormonal therapy, is sometimes used to destroy cancer cells and shrink tumors. This approach is most often used in cases in which the breast tumor is large or not easily removed by surgery.

    Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given in a pill or by injection. Either way, the drugs enter the bloodstream and travel throughout the body.

    Most patients have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Depending on which drugs are given and her general health, however, a woman may need to stay in the hospital during her treatment.

    Hormonal therapy keeps cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work, or surgery to remove the ovaries, which make female hormones. Like chemotherapy, hormonal therapy can affect cancer cells throughout the body.

    Biological therapy is a treatment designed to enhance the body's natural defenses against cancer. For example, Herceptin® (trastuzumab) is a monoclonal antibody that targets breast cancer cells that have too much of a protein known as human epidermal growth factor receptor-2 (HER-2). By blocking HER-2, Herceptin slows or stops the growth of these cells. Herceptin may be given by itself or along with chemotherapy.

    Treatment Choices

    Women with breast cancer now have many treatment options. Many women want to learn all they can about the disease and their treatment choices so that they can take an active part in decisions about their medical care. They are likely to have many questions and concerns about their treatment options.

    The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are and how successful her treatment is expected to be. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. A woman should not feel that she needs to ask all her questions or understand all the answers at once. She will have many chances to ask the doctor to explain things that are not clear and to ask for more information.

    A woman may want to talk with her doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for women with all stages of breast cancer. The "Research on Staging and Treatment" part of "The Promise of Cancer Research" section has more information.

    A woman's treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size and location of the tumor and the stage of the cancer; the results of lab tests; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered. In most cases, the most important factor is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread. The following are brief descriptions of the stages of breast cancer and the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

    Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ.

    Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may take a drug called tamoxifen, which can reduce the risk of developing breast cancer. Others may take part in studies of other promising new preventive treatments. Some women may choose not to have treatment, but to return to the doctor regularly for checkups. And, occasionally, women with LCIS may decide to have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)

    Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct to invade the surrounding breast tissue. However, women with DCIS are at an increased risk of getting invasive breast cancer. Some women with DCIS have breast-sparing surgery followed by radiation therapy. Or they may choose to have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Underarm lymph nodes are not usually removed. Also, women with DCIS may want to talk with their doctor about tamoxifen to reduce the risk of developing invasive breast cancer.

    Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct and invaded nearby tissue. Stage I means that the tumor is no more than about an inch across and cancer cells have not spread beyond the breast. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; or the tumor is between 1 and 2 inches (with or without spread to the lymph nodes under the arm); or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.

    Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy to the breast, or they may have a mastectomy, with or without breast reconstruction to rebuild the breast. These approaches are equally effective in treating early stage breast cancer. (Sometimes radiation therapy is also given after mastectomy.)

    The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.

    Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy after primary treatment with surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. If the systemic therapy is given to shrink the tumor before surgery, this is called neoadjuvant therapy. Systemic treatment is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back, in the breast or elsewhere.

    Stage III is also called locally advanced cancer. In this stage, the tumor in the breast is large (more than 2 inches across) and the cancer has spread to the underarm lymph nodes; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.

    Inflammatory breast cancer is a type of locally advanced breast cancer. In this type of cancer the breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

    Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both. Systemic therapy may be given before local therapy to shrink the tumor or afterward to prevent the disease from recurring in the breast or elsewhere.

    Stage IV is metastatic cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the body.

    Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.

    Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

    Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.

    Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, the distant recurrence is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments for recurrent cancer.

    Side Effects of Treatment

    It is hard to protect healthy cells from the harmful effects of breast cancer treatment. Because treatment does damage healthy cells and tissues, it causes side effects. The side effects of cancer treatment depend mainly on the type and extent of the treatment. Also, the effects may not be the same for each person, and they may be different from one treatment to the next. An important part of the treatment plan is the management of side effects.

    A patient's reaction to treatment is closely monitored by physical exams, blood tests, and other tests. Doctors and nurses will explain the possible side effects of treatment, and they can suggest ways to deal with problems that may occur during and after treatment. The NCI provides helpful, informative booklets about cancer treatments and coping with side effects. Patients may want to read Understanding Breast Cancer Treatment: A Guide for Patients, as well as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients.

    • Surgery

      Surgery causes short-term pain and tenderness in the area of the operation, so women may need to talk with their doctor about pain management. Any kind of surgery also carries a risk of infection, poor wound healing, bleeding, or a reaction to the anesthesia used during surgery. Women who experience any of these problems should tell their doctor or nurse right away.

      Removal of a breast can cause a woman's weight to be out of balance -- especially if she has large breasts. This imbalance can cause discomfort in her neck and back. Also, the skin in the area where the breast was removed may be tight, and the muscles of the arm and shoulder may feel stiff. After a mastectomy, some women have some permanent loss of strength in these muscles, but for most women, reduced strength and limited movement are temporary. The doctor, nurse, or physical therapist can recommend exercises to help a woman regain movement and strength in her arm and shoulder.

      Because nerves may be injured or cut during surgery, a woman may have numbness and tingling in the chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months, but some women have permanent numbness.

      Removing the lymph nodes under the arm slows the flow of lymph. In some women, this fluid builds up in the arm and hand and causes swelling (lymphedema). Women need to protect the arm and hand on the treated side from injury or pressure, even long after surgery. They should ask the doctor how to handle any cuts, scratches, insect bites, or other injuries to the arm or hand. Also, they should contact the doctor if an infection develops in that arm or hand.
    • Radiation Therapy

      During radiation therapy, patients may become extremely tired, especially after several treatments. This feeling may continue for a while after treatment is over. Resting is important, but doctors usually advise their patients to try to stay reasonably active, matching their activities to their energy level. It is also common for the skin in the treated area to become red, dry, tender, and itchy. The breast may feel heavy and hard, but these conditions will clear up with time. Toward the end of treatment, the skin may become moist and "weepy." Exposing this area to air as much as possible will help the skin heal. Because bras and some types of clothing may rub the skin and cause irritation, patients may want to wear loose-fitting cotton clothes. Gentle skin care is important at this time, and patients should check with their doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin are temporary, and the area gradually heals once treatment is over. However, there may be a permanent change in the color of the skin.
    • Chemotherapy

      As with radiation, chemotherapy affects normal as well as cancer cells. The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected, patients are more likely to get infections, may bruise or bleed easily, and may feel unusually weak and very tired. Rapidly dividing cells in hair roots and cells that line the digestive tract may also be affected. As a result, side effects may include loss of hair, poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can now be controlled, thanks to new or improved drugs. Side effects generally are short-term and gradually go away. Hair grows back, but it may be different in color and texture.

      Some anticancer drugs can damage the ovaries. If the ovaries fail to produce hormones, the woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her periods may become irregular or may stop, and she may not be able to become pregnant. Other long-term side effects are quite rare, but there have been cases in which the heart is weakened, and second cancers such as leukemia (cancer of the blood cells) have occurred.

      Women who are still menstruating may still be able to get pregnant during treatment. Because the effects of chemotherapy on an unborn child are not known, it is important for a woman to talk with her doctor about birth control before treatment begins. After treatment, some women regain their ability to become pregnant, but in women over the age of 35, infertility is likely to be permanent.
    • Hormonal Therapy

      The side effects of hormonal therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormonal treatment. This drug blocks the cancer cells' use of estrogen but does not stop estrogen production. Tamoxifen may cause hot flashes, vaginal discharge or irritation, nausea, and irregular periods. Women who are still menstruating and having irregular periods may become pregnant more easily when taking tamoxifen. They should discuss birth control methods with their doctor.

      Serious side effects of tamoxifen are rare. It can cause blood clots in the veins, especially in the legs and in the lungs, and in a small number of women, it can slightly increase the risk of stroke. Also, tamoxifen can cause cancer of the lining of the uterus. Any unusual vaginal bleeding should be reported to the doctor. The doctor may do a pelvic exam, as well as a biopsy of the lining of the uterus, or other tests. (This does not apply to women who have had a hysterectomy, surgery to remove the uterus.)

      Young women whose ovaries are removed to deprive the cancer cells of estrogen experience menopause immediately. Their symptoms are likely to be more severe than symptoms associated with natural menopause.
    • Biological Therapy

      The side effects of biological therapy differ with the types of substances used, and from patient to patient. Rashes or swelling where the biological therapy is injected are common. Flu-like symptoms also may occur.

      Herceptin may cause these and other side effects, but these effects generally become less severe after the first treatment. Less commonly, Herceptin can also cause damage to the heart that can lead to heart failure. It can also affect the lungs, causing breathing problems that require immediate medical attention. For these reasons, women are checked carefully for heart and lung problems before taking Herceptin. Patients who do take it are watched carefully during treatment.
    • Breast Reconstruction

      After a mastectomy, some women decide to wear a breast form (prosthesis). Others prefer to have breast reconstruction, either at the same time as the mastectomy or later on. Each option has its pros and cons, and what is right for one woman may not be right for another. What is important is that nearly every woman treated for breast cancer has choices. It is best to consult with a plastic surgeon before the mastectomy, even if reconstruction will be considered later on.
    • Rehabilitation

      Rehabilitation is a very important part of breast cancer treatment. The health care team makes every effort to help women return to their normal activities as soon as possible. Recovery will be different for each woman, depending on the extent of the disease, the type of treatment, and other factors.

      Exercising the arm and shoulder after surgery can help a woman regain motion and strength in these areas. It can also reduce pain and stiffness in her neck and back. Carefully planned exercises should be started as soon as the doctor says the woman is ready, often within a day or so after surgery. Exercising begins slowly and gently and can even be done in bed. Gradually, exercising can be more active, and regular exercise becomes part of a woman's normal routine. (Women who have a mastectomy and immediate breast reconstruction need special exercises, which the doctor or nurse will explain.)

      Often, lymphedema after surgery can be prevented or reduced with certain exercises and by resting with the arm propped up on a pillow. If lymphedema occurs, the doctor may suggest exercises and other ways to deal with this problem. For example, some women with lymphedema wear an elastic sleeve or use an elastic cuff to improve lymph circulation. The doctor also may suggest other approaches, such as medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm. The woman may be referred to a physical therapist or another specialist.

    Follow up Care

    Regular followup exams are important after breast cancer treatment. Regular checkups ensure that changes in health are noticed. Followup exams usually include examination of the breasts, chest, neck, and underarm areas, as well as periodic mammograms. If a woman has a breast implant, special mammogram techniques can be used. Sometimes the doctor may order other imaging procedures or lab tests.

    A woman who has had cancer in one breast should report any changes in the treated area or in the other breast to her doctor right away. Because a woman who has had breast cancer is at risk of getting cancer in the other breast, mammograms are an important part of followup care.

    Also, a woman who has had breast cancer should tell her doctor about other physical problems, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. She should also report headaches, dizziness, shortness of breath, coughing or hoarseness, backaches, or digestive problems that seem unusual or that don't go away. These symptoms may be a sign that the cancer has returned, but they can also be signs of various other problems. It's important to share these concerns with a doctor.

    Support for Women with Breast Cancer

    The diagnosis of breast cancer can change a woman's life and the lives of those close to her. These changes can be hard to handle. It is common for the woman and her family and friends to have many different and sometimes confusing emotions. Having helpful information and support services can make it easier to cope with these problems.

    People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to people who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for help with rehabilitation, emotional support, financial aid, transportation, or home care.

    Friends and relatives can be very supportive. Also, it helps many patients to discuss their concerns with others who have cancer. Women with breast cancer often get together in support groups, where they can share what they have learned about coping with their disease and the effects of their treatment. It is important to keep in mind, however, that each person is different. Treatments and ways of dealing with cancer that work for one person may not be right for another -- even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

    Several organizations offer special programs for patients with breast cancer. Trained volunteers, who have had breast cancer themselves, may talk with or visit patients, provide information, and lend emotional support before and after treatment. They often share their experiences with breast cancer treatment, rehabilitation, and breast reconstruction.

    Sometimes women who have had breast cancer are afraid that changes to their body will affect not only how they look but how other people feel about them. They may be concerned that breast cancer and its treatment will affect their sexual relationships. Many couples find that talking about these concerns helps them find ways to express their love during and after treatment. Some seek counseling or a couples' support group.

    The Promise of Cancer Research

    Doctors all over the country are conducting many types of clinical trials (research studies in which people take part voluntarily). These include studies of ways to prevent, detect, diagnose, and treat breast cancer; studies of the psychological effects of the disease; and studies of ways to improve comfort and quality of life. Research already has led to significant advances in these areas, and researchers continue to search for more effective approaches.

    People who take part in clinical trials have the first chance to benefit from new approaches. They also make important contributions to medical science. Although clinical trials may pose some risks, researchers take very careful steps to protect people who take part.

    Causes and Prevention

    Doctors can seldom explain why one woman gets breast cancer and another doesn't. It is clear, however, that breast cancer is not caused by bumping, bruising, or touching the breast. And this disease is not contagious; no one can "catch" breast cancer from another person.

    Scientists are trying to learn more about factors that increase the risk of developing this disease. For example, they are looking at whether the risk of breast cancer might be affected by environmental factors. So far, scientists do not have enough information to know whether any factors in the environment increase the risk of this disease. (The main known risk factors are listed in the "Breast Cancer: Who's at Risk?" section.)

    Some aspects of a woman's lifestyle may affect her chances of developing breast cancer. For example, recent studies suggest that regular exercise may decrease the risk in younger women. Also, some evidence suggests a link between diet and breast cancer. Ongoing studies are looking at ways to prevent breast cancer through changes in diet or with dietary supplements. However, it is not yet known whether specific dietary changes will actually prevent breast cancer. These are active areas of research.

    Scientists are trying to learn whether having a miscarriage or an abortion increases the risk of breast cancer. Thus far, studies have produced conflicting results, and this question is still unresolved.

    Research has led to the identification of changes (mutations) in certain genes that increase the risk of developing breast cancer. Women with a strong family history of breast cancer may choose to have a blood test to see if they have inherited a change in the BRCA1 or BRCA2 gene. Women who are concerned about an inherited risk for breast cancer should talk to their doctor. The doctor may suggest seeing a health professional trained in genetics. Genetic counseling can help a woman decide whether testing would be appropriate for her. Also, counseling before and after testing helps women understand and deal with the possible results of a genetic test. Counseling can also help with concerns about employment or about health, life, and disability insurance. The Cancer Information Service can supply additional material on genetic testing.

    Detection and Diagnosis

    At present, mammograms are the most effective tool we have to detect breast cancer. Researchers are looking for ways to make mammography more accurate, such as using computers to read mammograms (digital mammography). They are also exploring other techniques, such as magnetic resonance imaging (MRI), breast ultrasonography, and positron emission tomography (PET), to produce detailed pictures of the tissues in the breast.

    In addition, researchers are studying tumor markers. These are substances that may be present in abnormal amounts in people with cancer. Tumor markers may be found in blood or urine, or in fluid from the breast (nipple aspirate). Some of these markers may be used to check women who have already been diagnosed with breast cancer. At this time, however, no tumor marker test is reliable enough to be used routinely to detect breast cancer.

    Treatment

    Through research, doctors try to find new, more effective ways to treat cancer. Many studies of new approaches for patients with breast cancer are under way. When laboratory research shows that a new treatment method has promise, cancer patients receive the new approach in treatment clinical trials. These studies are designed to answer important questions and to find out whether the new approach is safe and effective. Often, clinical trials compare a new treatment with a standard approach.

    Researchers are testing new anticancer drugs, doses, and treatment schedules. They are working with various drugs and drug combinations, as well as with several types of hormonal therapy. They also are looking at the effectiveness of using chemotherapy before surgery (called neoadjuvant chemotherapy) and at new ways of combining treatments, such as adding hormonal therapy or radiation therapy to chemotherapy.

    New biological approaches also are under study. For example, several cancer vaccines have been designed to stimulate the immune system to mount a response against breast cancer cells. Combinations of biological treatments with other agents are also undergoing clinical study.

    Researchers are exploring ways to reduce the side effects of treatment (such as lymphedema from surgery), improve the quality of patients' lives, and reduce pain. One procedure under study is called sentinel lymph node biopsy. Researchers are trying to learn whether this procedure may reduce the number of lymph nodes that must be removed during breast cancer surgery. Before surgery, the doctor injects a radioactive substance near the tumor. The substance flows through the lymphatic system to the first lymph node or nodes where cancer cells are likely to have spread (the "sentinel" node or nodes). The doctor uses a scanner to locate the radioactive substance in the sentinel nodes. Sometimes the doctor also injects a blue dye near the tumor. The dye travels through the lymphatic system to collect in the sentinel nodes. The surgeon makes a small incision and removes only the nodes with radioactive substance or blue dye. A pathologist checks the sentinel lymph nodes for cancer cells. If no cancer cells are detected, it may not be necessary to remove additional nodes. If sentinel lymph node biopsy proves to be as effective as the standard axillary lymph node dissection, the new procedure could prevent lymphedema.

    Chemotherapy can reduce the ability of bone marrow to make blood cells. That is why researchers are studying ways to help the blood cells recover so that high doses of chemotherapy can be given. These studies use biological therapies (known as colony-stimulating factors), autologous bone marrow transplants, or peripheral stem cell transplants.

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    Cervical Cancer

    The cervix is the lower, narrow part of the uterus (womb). The uterus, a hollow, pear-shaped organ, is located in a woman's lower abdomen, between the bladder and the rectum. The cervix forms a canal that opens into the vagina, which leads to the outside of the body.

    Precancerous Conditions and Cancer of the Cervix

    Cells on the surface of the cervix sometimes appear abnormal but not cancerous. Scientists believe that some abnormal changes in cells on the cervix are the first step in a series of slow changes that can lead to cancer years later. That is, some abnormal changes are precancerous; they may become cancerous with time.

    Over the years, doctors have used different terms to refer to abnormal changes in the cells on the surface of the cervix. One term now used is squamous intraepithelial lesion (SIL). (The word lesion refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells.) Changes in these cells can be divided into two categories:

    Low-grade SIL refers to early changes in the size, shape, and number of cells that form the surface of the cervix. Some low-grade lesions go away on their own. However, with time, others may grow larger or become more abnormal, forming a high-grade lesion. Precancerous low-grade lesions also may be called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Such early changes in the cervix most often occur in women between the ages of 25 and 35 but can appear in other age groups as well.

    High-grade SIL means there are a large number of precancerous cells; they look very different from normal cells. Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix. The cells will not become cancerous and invade deeper layers of the cervix for many months, perhaps years. High-grade lesions also may be called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ. They develop most often in women between the ages of 30 and 40 but can occur at other ages as well.

    Cause and Prevention

    If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. It occurs most often in women over the age of 40.

    By studying large numbers of women all over the world, researchers have identified certain risk factors that increase the chance that cells in the cervix will become abnormal or cancerous. They believe that, in many cases, cervical cancer develops when two or more risk factors act together.

    Research has shown that women who began having sexual intercourse before age 18 and women who have had many sexual partners have an increased risk of developing cervical cancer. Women also are at increased risk if their partners began having sexual intercourse at a young age, have had many sexual partners, or were previously married to women who had cervical cancer.

    Scientists do not know exactly why the sexual practices of women and their partners affect the risk of developing cervical cancer. However, research suggests that some sexually transmitted viruses can cause cells in the cervix to begin the series of changes that can lead to cancer. Women who have had many sexual partners or whose partners have had many sexual partners may have an increased risk for cervical cancer at least in part because they are more likely to get a sexually transmitted virus.

    Scientists are studying the effects of sexually transmitted human papillomaviruses (HPVs). Some sexually transmitted HPVs cause genital warts (condylomata acuminata). In addition, scientists believe that some of these viruses may cause the growth of abnormal cells in the cervix and may play a role in cancer development. They have found that women who have HPV or whose partners have HPV have a higher-than-average risk of developing cervical cancer. However, most women who are infected with HPV do not develop cervical cancer, and the virus is not present in all women who have this disease. For these reasons, scientists believe that other factors act together with HPVs. For example, the genital herpes virus also may play a role. Further research is needed to learn the exact role of these viruses and how they act together with other factors in the development of cervical cancer.

    Smoking also increases the risk of cancer of the cervix, although it is not clear exactly how or why. The risk appears to increase with the number of cigarettes a woman smokes each day and with the number of years she has smoked.

    Women whose mothers were given the drug diethylstilbestrol (DES) during pregnancy to prevent miscarriage also are at increased risk. (This drug was used for this purpose from about 1940 to 1970.) A rare type of vaginal and cervical cancer has been found in a small number of women whose mothers used DES.

    Several reports suggest that women whose immune systems are weakened are more likely than others to develop cervical cancer. For example, women who have the human immunodeficiency virus (HIV), which causes AIDS, are at increased risk. Also, organ transplant patients, who receive drugs that suppress the immune system to prevent rejection of the new organ, are more likely than others to develop precancerous lesions.

    Some researchers believe that there is an increased risk of cervical cancer in women who use oral contraceptives (the pill). However, scientists have not found that the pill directly causes cancer of the cervix. This relationship is hard to prove because the two main risk factors for cervical cancer -- intercourse at an early age and multiple sex partners -- may be more common among women who use the pill than among those who do not. Still, oral contraceptive labels warn of this possible risk and advise women who use them to have yearly Pap tests.

    Some research has shown that vitamin A may play a role in stopping or preventing cancerous changes in cells like those on the surface of the cervix. Further research with forms of vitamin A may help scientists learn more about preventing cancer of the cervix.

    At present, early detection and treatment of precancerous tissue remain the most effective ways of preventing cervical cancer. Information about early detection appears in the Early Detection section. Women should talk with their doctors about an appropriate schedule of checkups. The doctor's advice will be based on such factors as the women's age, medical history, and risk factors.

    Early Detection

    If all women had pelvic exams and Pap tests regularly, most precancerous conditions would be detected and treated before cancer develops. That way, most invasive cancers could be prevented. Any invasive cancer that does occur would likely be found at an early, curable stage.

    In a pelvic exam, the doctor checks the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum. The doctor feels these organs for any abnormality in their shape or size. A speculum is used to widen the vagina so that the doctor can see the upper part of the vagina and the cervix.

    The Pap test is a simple, painless test to detect abnormal cells in and around the cervix. A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of her menstrual period. For about 2 days before a Pap test, she should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician), which may wash away or hide any abnormal cells.

    A Pap test can be done in a doctor's office or a health clinic. A wooden scraper (spatula) and/or a small brush is used to collect a sample of cells from the cervix and upper vagina. The cells are placed on a glass slide and sent to a medical laboratory to be checked for abnormal changes.

    The way of describing Pap test results is changing. The newest method is the Bethesda System. Changes are described as low-grade or high-grade SIL. Many doctors believe that the Bethesda System provides more useful information than an older system, which uses numbers ranging from class 1 to class 5. (In class 1, the cells in the sample are normal, while class 5 refers to invasive cancer.) Women should ask their doctor to explain the system used for their Pap test.

    Women should have regular checkups, including a pelvic exam and a Pap test, if they are or have been sexually active or if they are age 18 or older. Those who are at increased risk of developing cancer of the cervix should be especially careful to follow their doctor's advice about checkups. (For a discussion of risk factors for cervical cancer see the Cause and Prevention section.) Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) should ask their doctor's advice about having pelvic exams and Pap tests.

    Symptoms

    Precancerous changes of the cervix usually do not cause pain. In fact, they generally do not cause any symptoms and are not detected unless a woman has a pelvic exam and a Pap test.

    Symptoms usually do not appear until abnormal cervical cells become cancerous and invade nearby tissue. When this happens, the most common symptom is abnormal bleeding. Bleeding may start and stop between regular menstrual periods, or it may occur after sexual intercourse, douching, or a pelvic exam. Menstrual bleeding may last longer and be heavier than usual. Bleeding after menopause also may be a symptom of cervical cancer. Increased vaginal discharge is another symptom of cervical cancer.

    These symptoms may be caused by cancer or by other health problems. Only a doctor can tell for sure. It is important for a woman to see her doctor if she is having any of these symptoms.

    Diagnosis

    The pelvic exam and Pap test allow the doctor to detect abnormal changes in the cervix. If these exams show that an infection is present, the doctor treats the infection and then repeats the Pap test at a later time. If the exam or Pap test suggests something other than an infection, the doctor may repeat the Pap test and do other tests to find out what the problem is.

    Colposcopy is a widely used method to check the cervix for abnormal areas. The doctor applies a vinegar-like solution to the cervix and then uses an instrument much like a microscope (called a colposcope) to look closely at the cervix. The doctor may then coat the cervix with an iodine solution (a procedure called the Schiller test). Healthy cells turn brown; abnormal cells turn white or yellow. These procedures may be done in the doctor's office.

    The doctor may remove a small amount of cervical tissue for examination by a pathologist. This procedure is called a biopsy. In one type of biopsy, the doctor uses an instrument to pinch off small pieces of cervical tissue. Another method used to do a biopsy is called loop electrosurgical excision procedure (LEEP). In this procedure, the doctor uses an electric wire loop to slice off a thin, round piece of tissue. These types of biopsies may be done in the doctor's office using local anesthesia.

    The doctor also may want to check inside the opening of the cervix, an area that cannot be seen during colposcopy. In a procedure called endocervical curettage (ECC), the doctor uses a curette (a small, spoon-shaped instrument) to scrape tissue from inside the cervical opening.

    These procedures for removing tissue may cause some bleeding or other discharge. However, healing usually occurs quickly. Women also often experience some pain similar to menstrual cramping, which can be relieved with medicine.

    These tests may not show for sure whether the abnormal cells are present only on the surface of the cervix. In that case, the doctor will then remove a larger, cone-shaped sample of tissue. This procedure, called conization or cone biopsy, allows the pathologist to see whether the abnormal cells have invaded tissue beneath the surface of the cervix. Conization also may be used as treatment for a precancerous lesion if the entire abnormal area can be removed. This procedure requires either local or general anesthesia and may be done in the doctor's office or in the hospital.

    In a few cases, it may not be clear whether an abnormal Pap test or a woman's symptoms are caused by problems in the cervix or in the endometrium (the lining of the uterus). In this situation, the doctor may do dilation and curettage (D and C). The doctor stretches the cervical opening and uses a curette to scrape tissue from the lining of the uterus as well as from the cervical canal. Like conization, this procedure requires local or general anesthesia and may be done in the doctor's office or in the hospital.

    Treating Precancerous Conditions

    Treatment for a precancerous lesion of the cervix depends on a number of factors. These factors include whether the lesion is low or high grade, whether the woman wants to have children in the future, the woman's age and general health, and the preference of the woman and her doctor. A woman with a low-grade lesion may not need further treatment, especially if the abnormal area was completely removed during biopsy, but she should have a Pap test and pelvic exam regularly. When a precancerous lesion requires treatment, the doctor may use cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery to destroy the abnormal area without harming nearby healthy tissue. The doctor also can remove the abnormal tissue by LEEP or conization. Treatment for precancerous lesions may cause cramping or other pain, bleeding, or a watery discharge.

    In some cases, a woman may have a hysterectomy, particularly if abnormal cells are found inside the opening of the cervix. This surgery is more likely to be done when the woman does not want to have children in the future.

    Treating Cancer of the Cervix

    Staging

    The choice of treatment for cervical cancer depends on the location and size of the tumor, the stage (extent) of the disease, the woman's age and general health, and other factors.

    Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Blood and urine tests usually are done. The doctor also may do a thorough pelvic exam in the operating room with the patient under anesthesia. During this exam, the doctor may do procedures called cystoscopy and proctosigmoidoscopy. In cystoscopy, the doctor looks inside the bladder with a thin, lighted instrument. Proctosigmoidoscopy is a procedure in which a lighted instrument is used to check the rectum and the lower part of the large intestine. Because cervical cancer may spread to the bladder, rectum, lymph nodes, or lungs, the doctor also may order x-rays or tests to check these areas. For example, the woman may have a series of x-rays of the kidneys and bladder, called an intravenous pyelogram. The doctor also may check the intestines and rectum using a barium enema. To look for lymph nodes that may be enlarged because they contain cancer cells, the doctor may order a CT or CAT scan, a series of x-rays put together by a computer to make detailed pictures of areas inside the body. Other procedures that may be used to check organs inside the body are ultrasonography and MRI.

    Getting a Second Opinion

    Before starting treatment, the patient may want a second pathologist to review the diagnosis and another specialist to review the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. It may take a week or two to arrange for a second opinion. This short delay will not reduce the chance that treatment will be successful. There are a number of ways to find a doctor who can give a second opinion:

    The woman's doctor may be able to suggest pathologists and specialists to consult.

    Women can get the names of specialists from their local medical society, a nearby hospital, or a medical school.
    Preparing for Treatment
    Most women with cervical cancer want to learn all they can about their disease and treatment choices so they can take an active part in decisions about their medical care. Doctors and others on the medical team can help women learn what they need to know.

    When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often it helps to make a list of questions. Also, to help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

    Patients should not feel they need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

    Here are some questions a woman with cervical cancer may want to ask the doctor before her treatment begins:

    • What is the stage (extent) of my disease?
    • What are my treatment choices? Which do you recommend for me? Why?
    • What are the chances that the treatment will be successful?
    • Would a clinical trial be appropriate for me?
    • What are the risks and possible side effects of each treatment?
    • How long will treatment last?
    • Will it affect my normal activities?
    • What is the treatment likely to cost?
    • What is likely to happen without treatment?
    • How often will I need to have checkups?

    Methods of Treatment

    Most often, treatment for cervical cancer involves surgery and radiation therapy. Sometimes, chemotherapy or biological therapy is used. Patients are often treated by a team of specialists. The team may include gynecologic oncologists and radiation oncologists. The doctors may decide to use one treatment method or a combination of methods. Some patients take part in a clinical trial (research study) using new treatment methods. Such studies are designed to improve cancer treatment. More information about clinical trials is in the Clinical Trials section.

    Surgery is local therapy to remove abnormal tissue in or near the cervix. If the cancer is only on the surface of the cervix, the doctor may destroy the cancerous cells in ways similar to the methods used to treat precancerous lesions. If the disease has invaded deeper layers of the cervix but has not spread beyond the cervix, the doctor may perform an operation to remove the tumor but leave the uterus and the ovaries. In other cases, however, a woman may need to have a hysterectomy or may choose to have this surgery, especially if she is not planning to have children in the future. In this procedure, the doctor removes the entire uterus, including the cervix; sometimes the ovaries and fallopian tubes also are removed. In addition, the doctor may remove lymph nodes near the uterus to learn whether the cancer has spread to these organs.

    Here are some questions a woman may want to ask the doctor before surgery:

    • What kind of operation will it be?
    • How will I feel after the operation?
    • If I have pain, how will you help me?
    • When can I return to my normal activities?
    • How will this treatment affect my sex life?

    Radiation therapy (also called radiotherapy) uses high-energy rays to damage cancer cells and stop them from growing. Like surgery, radiation therapy is local therapy; the radiation can affect cancer cells only in the treated area. The radiation may come from a large machine (external radiation) or from radioactive materials placed directly into the cervix (implant radiation). Some patients receive both types of radiation therapy.

    A woman receiving external radiation therapy goes to the hospital or clinic each day for treatment. Usually treatments are given 5 days a week for 5 to 6 weeks. At the end of that time, the tumor site very often gets an extra "boost" of radiation.

    For internal or implant radiation, a capsule containing radioactive material is placed directly in the cervix. The implant puts cancer-killing rays close to the tumor while sparing most of the healthy tissue around it. It is usually left in place for 1 to 3 days, and the treatment may be repeated several times over the course of 1 to 2 weeks. The patient stays in the hospital while the implants are in place.

    The National Cancer Institute booklet Radiation Therapy and You, contains more information about this form of treatment.

    Here are some questions a woman may want to ask the doctor before radiation therapy:

    • What is the goal of this treatment?
    • How will the radiation be given?
    • How long will treatment last?
    • How will I feel during therapy?
    • What can I do to take care of myself during therapy?
    • Can I continue my normal activities?
    • How will this treatment affect my sex life?

    Chemotherapy is the use of drugs to kill cancer cells. It is most often used when cervical cancer has spread to other parts of the body. The doctor may use just one drug or a combination of drugs.

    Anticancer drugs used to treat cervical cancer may be given by injection into a vein or by mouth. Either way, chemotherapy is systemic treatment, meaning that the drugs flow through the body in the bloodstream.

    Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients have chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). Depending on which drugs are given and the woman's general health, however, she may need to stay in the hospital during her treatment.

    Here are some questions a woman may want to ask the doctor before chemotherapy begins:

    • What is the goal of this treatment?
    • What drugs will I be taking?
    • Do the drugs have side effects? What can I do about them?
    • How long will I need to take this treatment?

    Biological therapy is treatment using substances to improve the way the body's immune system fights disease. It may be used to treat cancer that has spread from the cervix to other parts of the body. Interferon is the most common form of biological therapy for this disease; it may be used in combination with chemotherapy. Most patients who receive interferon are treated as outpatients.

    Clinical Trials

    Some women with cervical cancer are treated in clinical trials. Doctors conduct clinical trials to find out whether a new treatment is both safe and effective and to answer scientific questions. Patients who take part in these studies may be the first to receive treatments that have shown promise in laboratory research. Some patients may receive the new treatment while others receive the standard approach. In this way, doctors can compare different therapies. Patients who take part in a trial make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.

    Clinical trials of new treatments for cervical cancer are under way. Doctors are studying new types and schedules of radiation therapy. They also are looking for new drugs, drug combinations, and ways to combine various types of treatment.

    Women with cervical cancer may want to read the National Cancer Institute booklet called Taking Part in Clinical Trials: What Cancer Patients Need To Know, which explains the possible benefits and risks of treatment studies. Those who are interested in taking part in a trial should talk with their doctor.

    Side Effects of Treatment

    It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes unpleasant side effects.
    The side effects of cancer treatment depend mainly on the type and extent of the treatment. Also, each patient reacts differently. Doctors and nurses can explain the possible side effects of treatment, and they can help relieve symptoms that may occur during and after treatment. It is important to let the doctor know if any side effects occur. The booklets Radiation Therapy and You and Chemotherapy and You also have helpful information about cancer treatment and coping with side effects.

    Surgery

    Methods for removing or destroying small cancers on the surface of the cervix are similar to those used to treat precancerous lesions. Treatment may cause cramping or other pain, bleeding, or a watery discharge.

    Hysterectomy is major surgery. For a few days after the operation, the woman may have pain in her lower abdomen. The doctor can order medicine to control the pain. A woman may have difficulty emptying her bladder and may need to have a catheter inserted into the bladder to drain the urine for a few days after surgery. She also may have trouble having normal bowel movements. For a period of time after the surgery, the woman's activities should be limited to allow healing to take place. Normal activities, including sexual intercourse, usually can be resumed in 4 to 8 weeks.

    Women who have had their uterus removed no longer have menstrual periods. However, sexual desire and the ability to have intercourse usually are not affected by hysterectomy. On the other hand, many women have an emotionally difficult time after this surgery. A woman's view of her own sexuality may change, and she may feel an emotional loss because she is no longer able to have children. An understanding partner is important at this time. Women may want to discuss these issues with their doctor, nurse, medical social worker, or member of the clergy. They also may find it helpful to read the National Cancer Institute booklet called Taking Time.

    Radiation Therapy

    Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

    With external radiation, it is common to lose hair in the treated area and for the skin to become red, dry, tender, and itchy. There may be permanent darkening or "bronzing" of the skin in the treated area. This area should be exposed to the air when possible but protected from the sun, and patients should avoid wearing clothes that rub the treated area. Patients will be shown how to keep the area clean. They should not use any lotion or cream on their skin without the doctor's advice.

    Usually, women are told not to have intercourse during radiation therapy or while an implant is in place. However, most women can have sexual relations within a few weeks after treatment ends. Sometimes, after radiation treatment, the vagina becomes narrower and less flexible, and intercourse may be painful. Patients may be taught how to use a dilator as well as a water-based lubricant to help minimize these problems.

    Patients who receive external or internal radiation therapy also may have diarrhea and frequent, uncomfortable urination. The doctor can make suggestions or order medicines to control these problems.

    Chemotherapy

    The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives. In addition, as with other types of treatment, side effects vary from person to person. Generally, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. When chemotherapy affects these cells, patients may lose their hair and may have other side effects, such as poor appetite, nausea, vomiting, or mouth sores. The doctor may be able to give medicine to help with side effects. Side effects gradually go away during the recovery periods between treatments or after treatment is over.

    Biological Therapy

    The side effects caused by biological therapies vary with the type of treatment the patient receives. These treatments may cause flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Sometimes patients get a rash, and they may bleed or bruise easily. These problems can be severe, but they gradually go away after the treatment stops.

    Nutrition for Cancer Patients

    Some patients find it hard to eat well during cancer treatment. They may lose their appetite. In addition to loss of appetite, the common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. For some patients, foods taste different. Also, people may not feel like eating when they are uncomfortable or tired.

    Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and regain strength. Patients who eat well often feel better and have more energy. In addition, they may be better able to handle the side effects of treatment.

    Doctors, nurses, and dietitians can offer advice for healthy eating during cancer treatment. Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

    Follow-up Care

    Regular follow-up exams -- including a pelvic exam, a Pap test, and other laboratory tests -- are very important for any woman who has been treated for precancerous changes or for cancer of the cervix. The doctor will do these tests and exams frequently for several years to check for any sign that the condition has returned.

    Cancer treatment may cause side effects many years later. For this reason, patients should continue to have regular checkups and should report any health problems that appear.

    Support for Cancer Patients

    Living with a serious disease is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services. Several useful booklets, including the National Cancer Institute booklet Taking Time, are available from the Cancer Information Service.

    Cancer patients may worry about holding their job, caring for their family, keeping up with daily activities, or starting a new relationship. Worries about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Also, meeting with a social worker, counselor, or member of the clergy can be helpful to patients who want to talk about their feelings or discuss their concerns.

    Friends and relatives can be very supportive. Also, it helps many patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another -- even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

    Often, a social worker at the hospital or clinic can suggest groups that can help with rehabilitation, emotional support, financial aid, transportation, or home care. For example, the American Cancer Society has many services for patients and their families. They also offer many free booklets, including one on sexuality and cancer. Local offices of the American Cancer Society are listed in the white pages of the telephone directory.

    What the Future Holds

    The outlook for women with precancerous changes of the cervix or very early cancer of the cervix is excellent; nearly all patients with these conditions can be cured. Researchers continue to look for new and better ways to treat invasive cervical cancer.

    Patients and their families are naturally concerned about what the future holds. Sometimes patients use statistics to try to figure out their chances of being cured. It is important to remember, however, that statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to a particular woman because no two patients are alike; treatments and responses vary greatly. The doctor who takes care of the patient and knows her medical history is in the best position to talk with her about her chance of recovery (prognosis).

    Doctors often talk about surviving cancer, or they may use the term remission rather than cure. Although many women with cervical cancer recover completely, doctors use these terms because the disease can recur. (The return of cancer is called a recurrence.)

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    Ovarian Cancer

    ovariesThe ovaries are a pair of organs in the female reproductive system. They are located in the pelvis, one on each side of the uterus (the hollow, pear-shaped organ where a baby grows). Each ovary is about the size and shape of an almond. The ovaries have two functions:  they produce eggs and female hormones (chemicals that control the way certain cells or organs function).

    Every month, during the menstrual cycle, an egg is released from one ovary in a process called ovulation. The egg travels from the ovary through the fallopian tube to the uterus.

    The ovaries are also the main source of the female hormones estrogen and progesterone. These hormones influence the development of a woman's breasts, body shape, and body hair. They also regulate the menstrual cycle and pregnancy. 

    Ovarian cancer cells can break away from the ovary and spread to other tissues and organs in a process called shedding. When ovarian cancer sheds, it tends to seed (form new tumors) on the peritoneum (the large membrane that lines the abdomen) and on the diaphragm (the thin muscle that separates the chest from the abdomen). Fluid may collect in the abdomen. This condition is known as ascites. It may make a woman feel bloated, or her abdomen may look swollen.

    Ovarian cancer cells can also enter the bloodstream or lymphatic system (the tissues and organs that produce and store cells that fight infection and disease). Once in the bloodstream or lymphatic system, the cancer cells can travel and form new tumors in other parts of the body.

    Who's at Risk?

    The exact causes of ovarian cancer are not known. However, studies show that the following factors may increase the chance of developing this disease:

    • Family history - First-degree relatives (mother, daughter, sister) of a woman who has had ovarian cancer are at increased risk of developing this type of cancer themselves. The likelihood is especially high if two or more first-degree relatives have had the disease. The risk is somewhat less, but still above average, if other relatives (grandmother, aunt, cousin) have had ovarian cancer. A family history of breast or colon cancer is also associated with an increased risk of developing ovarian cancer.
    • Age - The likelihood of developing ovarian cancer increases as a woman gets older. Most ovarian cancers occur in women over the age of 50, with the highest risk in women over 60.
    • Childbearing - Women who have never had children are more likely to develop ovarian cancer than women who have had children. In fact, the more children a woman has had, the less likely she is to develop ovarian cancer.
    • Personal history - Women who have had breast or colon cancer may have a greater chance of developing ovarian cancer than women who have not had breast or colon cancer.
    • Fertility drugs - Drugs that cause a woman to ovulate may slightly increase a woman's chance of developing ovarian cancer. Researchers are studying this possible association.
    • Talc - Some studies suggest that women who have used talc in the genital area for many years may be at increased risk of developing ovarian cancer.
    • Hormone replacement therapy (HRT) - Some evidence suggests that women who use HRT after menopause may have a slightly increased risk of developing ovarian cancer.

    As we learn more about what causes ovarian cancer, we may also learn how to reduce the chance of getting this disease. Some studies have shown that breast feeding and taking birth control pills (oral contraceptives) may decrease a woman's likelihood of developing ovarian cancer. These factors decrease the number of times a woman ovulates, and studies suggest that reducing the number of ovulations during a woman's lifetime may lower the risk of ovarian cancer.

    Women who have had an operation that prevents pregnancy (tubal ligation) or have had their uterus and cervix removed (hysterectomy) also have a lower risk of developing ovarian cancer. In addition, some evidence suggests that reducing the amount of fat in the diet may lower the risk of developing ovarian cancer.

    Women who are at high risk for ovarian cancer due to a family history of the disease may consider having their ovaries removed before cancer develops (prophylactic oophorectomy). This procedure usually, but not always, protects women from developing ovarian cancer. The risks associated with this surgery and its side effects should be carefully considered. A woman should discuss the possible benefits and risks with her doctor based on her unique situation.

    Having one or more of the risk factors mentioned here does not mean that a woman is sure to develop ovarian cancer, but the chance may be higher than average. Women who are concerned about ovarian cancer may want to talk with a doctor who specializes in treating women with cancer: a gynecologist, a gynecologic oncologist, or a medical oncologist. The doctor may be able to suggest ways to reduce the likelihood of developing ovarian cancer and can plan an appropriate schedule for checkups.

    Recognizing Symptoms

    Ovarian cancer often shows no obvious signs or symptoms until late in its development. Signs and symptoms of ovarian cancer may include:

    • General abdominal discomfort and/or pain (gas, indigestion, pressure, swelling, bloating, cramps)
    • Nausea, diarrhea, constipation, or frequent urination
    • Loss of appetite
    • Feeling of fullness even after a light meal
    • Weight gain or loss with no known reason
    • Abnormal bleeding from the vagina

    These symptoms may be caused by ovarian cancer or by other, less serious conditions. It is important to check with a doctor about any of these symptoms.

    To help find the cause of symptoms, a doctor evaluates a woman's medical history. The doctor also performs a physical exam and orders diagnostic tests. Some exams and tests that may be useful are described below:

    • Pelvic exam - includes feeling the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to find any abnormality in their shape or size. (A Pap test, a good test for cancer of the cervix, is often done along with the pelvic exam, but it is not a reliable way to find or diagnose ovarian cancer.)
    • Ultrasound - refers to the use of high-frequency sound waves. These waves, which cannot be heard by humans, are aimed at the ovaries. The pattern of the echoes they produce creates a picture called a sonogram. Healthy tissues, fluid-filled cysts, and tumors look different on this picture.
    • CA-125 assay - a blood test used to measure the level of CA-125, a tumor marker that is often found in higher-than-normal amounts in the blood of women with ovarian cancer.
    • Lower GI series, or barium enema - a series of x-rays of the colon and rectum. The pictures are taken after the patient is given an enema with a white, chalky solution containing barium. The barium outlines the colon and rectum on the x-ray, making tumors or other abnormal areas easier to see.
    • CT (or CAT) scan - a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine.
    • Biopsy - the removal of tissue for examination under a microscope. A pathologist studies the tissue to make a diagnosis. To obtain the tissue, the surgeon performs a laparotomy (an operation to open the abdomen). If cancer is suspected, the surgeon performs an oophorectomy (removal of the entire ovary). This is important because, if cancer is present, removing just a sample of tissue by cutting through the outer layer of the ovary could allow cancer cells to escape and cause the disease to spread.

    If the diagnosis is ovarian cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. Staging may involve surgery, x-rays and other imaging procedures, and lab tests. Knowing the stage of the disease helps the doctor plan treatment.

    Detecting Ovarian Cancer

    The sooner ovarian cancer is found and treated, the better a woman's chance for recovery. But ovarian cancer is hard to detect early. Many times, women with ovarian cancer have no symptoms or just mild symptoms until the disease is in an advanced stage. Scientists are studying ways to detect ovarian cancer before symptoms develop. They are exploring the usefulness of measuring the level of CA 125, a substance called a tumor marker, which is often found in higher-than-normal amounts in the blood of women with ovarian cancer. They also are evaluating transvaginal ultrasound, a test that may help detect the disease early. The Cancer Information Service can provide information about this research.

    Treatment for Ovarian Cancer

    Treatment depends on a number of factors, including the stage of the disease and the general health of the patient. Patients are often treated by a team of specialists. The team may include a gynecologist, a gynecologic oncologist, a medical oncologist, and/or a radiation oncologist. Many different treatments and combinations of treatments are used to treat ovarian cancer.

    • Surgery is the usual initial treatment for women diagnosed with ovarian cancer. The ovaries, the fallopian tubes, the uterus, and the cervix are usually removed. This operation is called a hysterectomy with bilateral salpingo-oophorectomy. Often, the surgeon also removes the omentum (the thin tissue covering the stomach and large intestine) and lymph nodes (small organs located along the channels of the lymphatic system) in the abdomen.

      Staging during surgery (to find out whether the cancer has spread) generally involves removing lymph nodes, samples of tissue from the diaphragm and other organs in the abdomen, and fluid from the abdomen. If the cancer has spread, the surgeon usually removes as much of the cancer as possible in a procedure called tumor debulking. Tumor debulking reduces the amount of cancer that will have to be treated later with chemotherapy or radiation therapy.
    • Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be given to destroy any cancerous cells that may remain in the body after surgery, to control tumor growth, or to relieve symptoms of the disease.

      Most drugs used to treat ovarian cancer are given by injection into a vein (intravenously, or IV). The drugs can be injected directly into a vein or given through a catheter, a thin tube. The catheter is placed into a large vein and remains there as long as it is needed. Some anticancer drugs are taken by mouth. Whether they are given intravenously or by mouth, the drugs enter the bloodstream and circulate throughout the body.

      Another way to give chemotherapy is to put the drug directly into the abdomen through a catheter. With this method, called intraperitoneal chemotherapy, most of the drug remains in the abdomen.

      After chemotherapy is completed, second-look surgery may be performed to examine the abdomen directly. The surgeon may remove fluid and tissue samples to see whether the anticancer drugs have been successful.
    • Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation). Some women receive a treatment called intraperitoneal radiation therapy in which radioactive liquid is put directly into the abdomen through a catheter.

    Possible Side Effects of Treatment

    The side effects of cancer treatment depend on the type of treatment and may be different for each woman. Doctors and nurses will explain the possible side effects of treatment, and they can suggest ways to help relieve problems that may occur during and after treatment.

    Surgery causes short-term pain and tenderness in the area of the operation. Discomfort or pain after surgery can be controlled with medicine. Patients should feel free to discuss pain relief with their doctor. For several days after surgery, the patient may have difficulty emptying her bladder and having bowel movements.

    When both ovaries are removed, a woman loses her ability to become pregnant. Some women may experience feelings of loss that may make intimacy difficult. Counseling or support for both the patient and her partner may be helpful.

    Also, removing the ovaries means that the body's natural source of estrogen and progesterone is lost, and menopause occurs. Symptoms of menopause, such as hot flashes and vaginal dryness, are likely to appear soon after the surgery. Some form of hormone replacement therapy may be used to ease such symptoms. Deciding whether to use it is a personal choice; women with ovarian cancer should discuss with their doctors the possible risks and benefits of using hormone replacement therapy.

    Chemotherapy affects normal as well as cancerous cells. Side effects depend largely on the specific drugs and the dose (amount of drug given). Common side effects of chemotherapy include nausea and vomiting, loss of appetite, diarrhea, fatigue, numbness and tingling in hands or feet, headaches, hair loss, and darkening of the skin and fingernails. Certain drugs used in the treatment of ovarian cancer can cause some hearing loss or kidney damage. To help protect the kidneys while taking these drugs, patients may receive extra fluid intravenously.

    Radiation therapy, like chemotherapy, affects normal as well as cancerous cells. Side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Common side effects of radiation therapy to the abdomen are fatigue, loss of appetite, nausea, vomiting, urinary discomfort, diarrhea, and skin changes on the abdomen. Intraperitoneal radiation therapy may cause abdominal pain and bowel obstruction (a blockage of the intestine).

    The Importance of Follow up Care

    Follow up care after treatment for ovarian cancer is important. Regular checkups generally include a physical exam, as well as a pelvic exam and Pap test. The doctor also may perform additional tests such as a chest x-ray, CT scan, urinalysis, complete blood count, and CA-125 assay.

    In addition to having follow up exams to check for the return of ovarian cancer, patients may also want to ask their doctor about checking them for other types of cancer. Women who have had ovarian cancer may be at increased risk of developing breast or colon cancer. In addition, treatment with certain anticancer drugs may increase the risk of second cancers, such as leukemia.

    Emotional Support

    Living with a serious disease is challenging. Apart from having to cope with the physical and medical challenges, people with cancer face many worries, feelings, and concerns that can make life difficult. They may need help coping with the emotional aspects of their disease.

    In fact, attention to the emotional burden of having cancer is often a part of a patient's treatment plan. The support of the health care team (doctors, nurses, social workers), support groups, and patient-to-patient networks can help people feel less isolated and distressed and can improve the quality of their lives. Cancer support groups provide an environment where cancer patients can talk about living with cancer with others who may be having similar experiences. Patients may want to speak with their health care team about finding a support group.

    Questions for Your Doctor

    This booklet is designed to help you work with your doctor to get the information you need to make informed decisions about your health care. In addition, asking your doctor the following questions will help you further understand your condition. To help you remember what the doctor says, you may take notes or ask whether you may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

    Diagnosis

    • What tests can diagnose ovarian cancer?
    • Are they painful? Do they carry any other risks to my health?
    • How soon after the tests will I learn the results?
    • What type of ovarian cancer do I have?

    Treatment

    • What treatments are recommended for me?
    • What clinical trials are appropriate for my type of cancer?
    • Will I need to be in the hospital to receive my treatment? For how long?
    • How might my normal activities change during my treatment?

    Side Effects

    • What side effects should I expect? How long will they last?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?
    • Whom should I call if I am concerned about a side effect?

    Follow up

    • After treatment, how often do I need to be checked? What type of follow up care should I have?
    • Will I eventually be able to resume my normal activities?

    The Health Care Team

    • Who will be involved with my treatment and follow up care? What is the role of each member of the health care team in my care?
    • What has been your experience in caring for patients with ovarian cancer?

    Resources

    • Are there support groups in the area with people I can talk to?
    • Are there organizations where I can get more information about ovarian cancer?

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    Uterine Cancer

     

    uterusThe uterus is part of a woman's reproductive system. It is the hollow, pear-shaped organ where a baby grows. The uterus is in the pelvis between the bladder and the rectum.

    The narrow, lower portion of the uterus is the cervix. The broad, middle part of the uterus is the body, or corpus. The dome-shaped top of the uterus is the fundus. The fallopian tubes extend from either side of the top of the uterus to the ovaries.

    The wall of the uterus has two layers of tissue. The inner layer, or lining, is the endometrium. The outer layer is muscle tissue called the myometrium.

    In women of childbearing age, the lining of the uterus grows and thickens each month to prepare for pregnancy. If a woman does not become pregnant, the thick, bloody lining flows out of the body through the vagina. This flow is called menstruation.

    Who's at Risk?

    No one knows the exact causes of uterine cancer. However, it is clear that this disease is not contagious. No one can "catch" cancer from another person.

    Women who get this disease are more likely than other women to have certain risk factors. A risk factor is something that increases a person's chance of developing the disease.

    Most women who have known risk factors do not get uterine cancer. On the other hand, many who do get this disease have none of these factors. Doctors can seldom explain why one woman gets uterine cancer and another does not.

    Studies have found the following risk factors:

    • Age - Cancer of the uterus occurs mostly in women over age 50.
      Endometrial hyperplasia - The risk of uterine cancer is higher if a woman has endometrial hyperplasia. This condition and its treatment are described above.
    • Hormone replacement therapy (HRT) - HRT is used to control the symptoms of menopause, to prevent osteoporosis (thinning of the bones), and to reduce the risk of heart disease or stroke.

      Women who use estrogen without progesterone have an increased risk of uterine cancer. Long-term use and large doses of estrogen seem to increase this risk. Women who use a combination of estrogen and progesterone have a lower risk of uterine cancer than women who use estrogen alone. The progesterone protects the uterus.

      Women should discuss the benefits and risks of HRT with their doctor. Also, having regular checkups while taking HRT may improve the chance that the doctor will find uterine cancer at an early stage, if it does develop.
    • Obesity and related conditions - The body makes some of its estrogen in fatty tissue. That's why obese women are more likely than thin women to have higher levels of estrogen in their bodies. High levels of estrogen may be the reason that obese women have an increased risk of developing uterine cancer. The risk of this disease is also higher in women with diabetes or high blood pressure (conditions that occur in many obese women).
    • Tamoxifen - Women taking the drug tamoxifen to prevent or treat breast cancer have an increased risk of uterine cancer. This risk appears to be related to the estrogen-like effect of this drug on the uterus. Doctors monitor women taking tamoxifen for possible signs or symptoms of uterine cancer.

      The benefits of tamoxifen to treat breast cancer outweigh the risk of developing other cancers. Still, each woman is different. Any woman considering taking tamoxifen should discuss with the doctor her personal and family medical history and her concerns.
    • Race - White women are more likely than African-American women to get uterine cancer.
    • Colorectal cancer - Women who have had an inherited form of colorectal cancer have a higher risk of developing uterine cancer than other women.
      Other risk factors are related to how long a woman's body is exposed to estrogen. Women who have no children, begin menstruation at a very young age, or enter menopause late in life are exposed to estrogen longer and have a higher risk.

    Women with known risk factors and those who are concerned about uterine cancer should ask their doctor about the symptoms to watch for and how often to have checkups. The doctor's advice will be based on the woman's age, medical history, and other factors.
    Symptoms

    Uterine cancer usually occurs after menopause. But it may also occur around the time that menopause begins. Abnormal vaginal bleeding is the most common symptom of uterine cancer. Bleeding may start as a watery, blood-streaked flow that gradually contains more blood. Women should not assume that abnormal vaginal bleeding is part of menopause.

    A woman should see her doctor if she has any of the following symptoms:

    • Unusual vaginal bleeding or discharge
    • Difficult or painful urination
    • Pain during intercourse
    • Pain in the pelvic area
    • These symptoms can be caused by cancer or other less serious conditions. Most often they are not cancer, but only a doctor can tell for sure.

    Diagnosis

    If a woman has symptoms that suggest uterine cancer, her doctor may check general signs of health and may order blood and urine tests. The doctor also may perform one or more of the exams or tests described on the next pages.

    • Pelvic exam -- A woman has a pelvic exam to check the vagina, uterus, bladder, and rectum. The doctor feels these organs for any lumps or changes in their shape or size. To see the upper part of the vagina and the cervix, the doctor inserts an instrument called a speculum into the vagina.
    • Pap test -- The doctor collects cells from the cervix and upper vagina. A medical laboratory checks for abnormal cells. Although the Pap test can detect cancer of the cervix, cells from inside the uterus usually do not show up on a Pap test. This is why the doctor collects samples of cells from inside the uterus in a procedure called a biopsy.
    • Transvaginal ultrasound -- The doctor inserts an instrument into the vagina. The instrument aims high-frequency sound waves at the uterus. The pattern of the echoes they produce creates a picture. If the endometrium looks too thick, the doctor can do a biopsy.
    • Biopsy -- The doctor removes a sample of tissue from the uterine lining. This usually can be done in the doctor's office. In some cases, however, a woman may need to have a dilation and curettage (D&C). A D&C is usually done as same-day surgery with anesthesia in a hospital. A pathologist examines the tissue to check for cancer cells, hyperplasia, and other conditions. For a short time after the biopsy, some women have cramps and vaginal bleeding.
      Staging
      If uterine cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has spread, and if so, to what parts of the body.

    The doctor may order blood and urine tests and chest x-rays. The woman also may have other x-rays, CT scans, an ultrasound test, magnetic resonance imaging (MRI), sigmoidoscopy, or colonoscopy.

    In most cases, the most reliable way to stage this disease is to remove the uterus (hysterectomy). (The description of surgery in the "Methods of Treatment" section has more information.) After the uterus has been removed, the surgeon can look for obvious signs that the cancer has invaded the muscle of the uterus. The surgeon also can check the lymph nodes and other organs in the pelvic area for signs of cancer. A pathologist uses a microscope to examine the uterus and other tissues removed by the surgeon.

    These are the main features of each stage of the disease:

    Stage I -- The cancer is only in the body of the uterus. It is not in the cervix.
    Stage II -- The cancer has spread from the body of the uterus to the cervix.
    Stage III -- The cancer has spread outside the uterus, but not outside the pelvis (and not to the bladder or rectum). Lymph nodes in the pelvis may contain cancer cells.
    Stage IV -- The cancer has spread into the bladder or rectum. Or it has spread beyond the pelvis to other body parts.
    Treatment

    Many women want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some women also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

    The patient's doctor may refer her to doctors who specialize in treating cancer, or she may ask for a referral. Treatment generally begins within a few weeks after the diagnosis. There will be time for the woman to talk with the doctor about her treatment choices, get a second opinion, and learn more about uterine cancer.

    Getting a Second Opinion

    Before starting treatment, a woman might want a second opinion about the diagnosis, the stage of cancer, and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the woman requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay does not make treatment less effective.

    There are a number of ways to find a doctor for a second opinion:

    The patient's doctor may refer her to one or more specialists. Specialists who treat women with uterine cancer include surgeons, gynecologic oncologists, medical oncologists, and radiation oncologists. At cancer centers, these doctors often work together as a team.

    People can get the names of specialists from their local medical society, a nearby hospital, or a medical school.

    Preparing for Treatment

    The choice of treatment depends on the size of the tumor, the stage of the disease, whether female hormones affect tumor growth, and the tumor grade. (The grade tells how closely the cancer cells resemble normal cells and suggests how fast the cancer is likely to grow. Low-grade cancers are likely to grow and spread more slowly than high-grade cancers.) The doctor also considers other factors, including the woman's age and general health.

    Women do not need to ask all their questions or understand all the answers at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

    Methods of Treatment

    Women with uterine cancer have many treatment options. Most women with uterine cancer are treated with surgery. Some have radiation therapy. A smaller number of women may be treated with hormonal therapy. Some patients receive a combination of therapies.

    The doctor is the best person to describe the treatment choices and discuss the expected results of treatment.

    A woman may want to talk with her doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for women with all stages of uterine cancer. The section on "The Promise of Cancer Research" has more information about clinical trials.

    Most women with uterine cancer have surgery to remove the uterus (hysterectomy) through an incision in the abdomen. The doctor also removes both fallopian tubes and both ovaries. (This procedure is called a bilateral salpingo-oophorectomy.)

    The doctor may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it may mean that the disease has spread to other parts of the body. If cancer cells have not spread beyond the endometrium, the woman may not need to have any other treatment. The length of the hospital stay may vary from several days to a week.

    In radiation therapy, high-energy rays are used to kill cancer cells. Like surgery, radiation therapy is a local therapy. It affects cancer cells only in the treated area.

    Some women with Stage I, II, or III uterine cancer need both radiation therapy and surgery. They may have radiation before surgery to shrink the tumor or after surgery to destroy any cancer cells that remain in the area. Also, the doctor may suggest radiation treatments for the small number of women who cannot have surgery.

    Doctors use two types of radiation therapy to treat uterine cancer:

    • External radiation: In external radiation therapy, a large machine outside the body is used to aim radiation at the tumor area. The woman is usually an outpatient in a hospital or clinic and receives external radiation 5 days a week for several weeks. This schedule helps protect healthy cells and tissue by spreading out the total dose of radiation. No radioactive materials are put into the body for external radiation therapy.
    • Internal radiation: In internal radiation therapy, tiny tubes containing a radioactive substance are inserted through the vagina and left in place for a few days. The woman stays in the hospital during this treatment. To protect others from radiation exposure, the patient may not be able to have visitors or may have visitors only for a short period of time while the implant is in place. Once the implant is removed, the woman has no radioactivity in her body.
      Some patients need both external and internal radiation therapies.
      Hormonal therapy involves substances that prevent cancer cells from getting or using the hormones they may need to grow. Hormones can attach to hormone receptors, causing changes in uterine tissue. Before therapy begins, the doctor may request a hormone receptor test. This special lab test of uterine tissue helps the doctor learn if estrogen and progesterone receptors are present. If the tissue has receptors, the woman is more likely to respond to hormonal therapy.

    Hormonal therapy is called a systemic therapy because it can affect cancer cells throughout the body. Usually, hormonal therapy is a type of progesterone taken as a pill.

    The doctor may use hormonal therapy for women with uterine cancer who are unable to have surgery or radiation therapy. Also, the doctor may give hormonal therapy to women with uterine cancer that has spread to the lungs or other distant sites. It is also given to women with uterine cancer that has come back.

    Side Effects of Cancer Treatment

    Because cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, doctors and nurses will explain the possible side effects and how they will help you manage them.

    Surgery

    After a hysterectomy, women usually have some pain and feel extremely tired. Most women return to their normal activities within 4 to 8 weeks after surgery. Some may need more time than that.

    Some women may have problems with nausea and vomiting after surgery, and some may have bladder and bowel problems. The doctor may restrict the woman's diet to liquids at first, with a gradual return to solid food.

    Women who have had a hysterectomy no longer have menstrual periods and can no longer get pregnant. When the ovaries are removed, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. Hormone replacement therapy (HRT) is often given to women who have not had uterine cancer to relieve these problems. However, doctors usually do not give the hormone estrogen to women who have had uterine cancer. Because estrogen is a risk factor for this disease (see "Uterine Cancer: Who's at Risk?"), many doctors are concerned that estrogen may cause uterine cancer to return. Other doctors point out that there is no scientific evidence that estrogen increases the risk that cancer will come back. NCI is sponsoring a large research study to learn whether women who have had early stage uterine cancer can take estrogen safely.

    For some women, a hysterectomy can affect sexual intimacy. A woman may have feelings of loss that may make intimacy difficult. Sharing these feelings with her partner may be helpful.

    Radiation Therapy

    The side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Common side effects of radiation include dry, reddened skin and hair loss in the treated area, loss of appetite, and extreme tiredness. Some women may have dryness, itching, tightening, and burning in the vagina. Radiation also may cause diarrhea or frequent and uncomfortable urination. It may reduce the number of white blood cells, which help protect the body against infection.

    Doctors may advise their patients not to have intercourse during radiation therapy. However, most can resume sexual activity within a few weeks after treatment ends. The doctor or nurse may suggest ways to relieve any vaginal discomfort related to treatment.

    Hormonal Therapy

    Hormonal therapy can cause a number of side effects. Women taking progesterone may retain fluid, have an increased appetite, and gain weight. Women who are still menstruating may have changes in their periods.
    Nutrition

    People need to eat well during cancer therapy. They need enough calories and protein to promote healing, maintain strength, and keep a healthy weight. Eating well often helps people with cancer feel better and have more energy.

    Patients may not feel like eating if they are uncomfortable or tired. Also, the side effects of treatment such as poor appetite, nausea, or vomiting can make eating difficult. Foods may taste different.

    Follow up Care

    Followup care after treatment for uterine cancer is important. Women should not hesitate to discuss followup with their doctor. Regular checkups ensure that any changes in health are noticed. Any problem that develops can be found and treated as soon as possible. Checkups may include a physical exam, a pelvic exam, x-rays, and laboratory tests.

    Support for Women with Uterine Cancer

    Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group.

    It is natural for a woman to be worried about the effects of uterine cancer and its treatment on her sexuality. She may want to talk with the doctor about possible side effects and whether these effects are likely to be temporary or permanent. Whatever the outlook, it may be helpful for women and their partners to talk about their feelings and help one another find ways to share intimacy during and after treatment.

    People living with cancer may worry about caring for their families, holding on to their jobs, or keeping up with daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team will answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

    The Promise of Cancer Research

    Doctors all over the country are conducting many types of clinical trials, research studies in which people take part voluntarily. Many treatment studies for women with uterine cancer are under way. Research has already led to advances, and researchers continue to search for more effective approaches.

    Patients who take part in clinical trials have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take many very careful steps to protect people who take part.

    In a large trial with hundreds of women, doctors are studying a less extensive method of surgery to remove the uterus. Normally, the doctor makes an incision in the abdomen to remove the uterus. In this study, doctors use a laparoscope (a lighted tube) to help remove the uterus through the vagina. Also, the doctor can use the laparoscope to help remove the ovaries and lymph nodes and to look into the abdomen for signs of cancer.

    Other researchers are looking at the effectiveness of radiation therapy after surgery, as well as at the combination of surgery, radiation, and chemotherapy. Other trials are studying new drugs, new drug combinations, and biological therapies. Some of these studies are designed to find ways to reduce the side effects of treatment and to improve the quality of women's lives.

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