A new diagnosis of cancer can be a shock, making you feel out of control and overwhelmed. Getting informed can help alleviate these feelings. Remember, very few cancers require emergency treatment; you have time to learn about your diagnosis and treatment options, ask questions, and get a second opinion. This section is designed to help you address your initial questions before you move forward with your treatment.
What is Cancer?Cancer is not one disease, but many diseases that occur in different areas of the body. Each type of cancer is characterized by the uncontrolled growth of cells. Under normal conditions, cell reproduction is carefully controlled by the body. However, these controls can malfunction, resulting in abnormal cell growth and the development of a lump, mass, or tumor. Some cancers involving the blood and blood-forming organs do not form tumors but circulate through other tissues where they grow.
A tumor may be benign (non-cancerous) or malignant (cancerous). Cells from cancerous tumors can spread throughout the body. This process, called metastasis, occurs when cancer cells break away from the original tumor and travel in the circulatory or lymphatic systems until they are lodged in a small capillary network in another area of the body. Common locations of metastasis are the bones, lungs, liver, and central nervous system.
The type of cancer refers to the organ or area of the body where the cancer first occurred. Cancer that has metastasized to other areas of the body is named for the part of the body where it originated. For example, if breast cancer has spread to the bones, it is called “metastatic breast cancer” not bone cancer.
How did I get cancer?
Although every patient and family member wants to know the answer to this question, the reason people develop cancer is not well understood. There are some known carcinogens (materials that can cause cancer), but many are still undiscovered. We do not know why some people who are exposed to carcinogens get cancer and others do not. The length and amount of exposure are believed to affect the chances of developing a disease. For example, as exposure to cigarette smoking increases, the chance of developing lung cancer also increases. Genetics also plays an important role in whether an individual develops cancer. For example, certain types of breast cancer have a genetic component.
Following your diagnosis of cancer, your reaction may be one of shock and disbelief. If you have been told that chemotherapy or radiation therapy are an important part of your treatment, many unpleasant images may come to mind. But as you move beyond that initial shock to begin the journey of surviving your cancer, you have many good reasons to be optimistic. Medicine has made—and continues to make—great strides in treating cancer and in making cancer treatment more tolerable, both physically and emotionally. The greatest recent advances are in Precision Medicine.
Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. By defining the consequences of these genetic abnormalities doctors can identify specific treatments directed against each genetic abnormality for each individual patient’s unique DNA profile.
Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of cells. Standard chemotherapy typically destroys both normal and cancerous rapidly dividing cells in a wide range of tissues, often causing side effects by damaging normal cells. Precision cancer medicine uses targeted therapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed.
No one would call cancer a normal experience, but by proactively managing aspects of your treatment, you can maintain a sense of normalcy in your life. Fighting cancer is not a challenge you face alone. It’s a team effort that involves family, friends, and your healthcare team. Don’t overlook the strength that can come from having your support network by your side.
What is a cancer diagnosis?
Diagnosis is not the same as detection. Cancer may be detected when symptoms or abnormalities, such as a lump or growth, are recognized by a patient or doctor. After a cancer is detected, it still must be carefully diagnosed.
A diagnosis is an identification of a particular type of cancer. When making a diagnosis, the initial signs and symptoms are investigated through a variety of tests in order to identify whether cancer is causing them and, if so, what type of cancer it is. For example, breast cancer may be detected when a patient notices a lump, but it must be carefully evaluated with a number of tests in order to determine an accurate diagnosis. The diagnosis describes what type of breast cancer it is (i.e. “ductal” if it started in the ducts of the breast or “lobular” if it started in the lobes) and how advanced it is.
What is a cancer stage?
Following a diagnosis of cancer, the most important step is to accurately determine the stage of cancer. Stage describes how far the cancer has spread. (Some cancers, such as leukemia, may not be staged.) Each stage of cancer may be treated differently. In order for you to begin evaluating and discussing treatment options with your healthcare team, you need to know the correct stage of your cancer.
There are many staging systems, but TNM is the most common. “T” refers to the size of the tumor, “N” to the number of lymph nodes involved, and “M” to metastasis. TNM staging measures the extent of the disease by evaluating these three aspects and assigning a stage, which is usually between 0-4. Generally, the lower the stage, the better the treatment prognosis (outcome).
- Stage 0 – precancer
- Stage 1 – small cancer found only in the organ where it started
- Stage 2 – larger cancer that may or may not have spread to the lymph nodes
- Stage 3 – larger cancer that is also in the lymph nodes
- Stage 4 – cancer in a different organ from where it started
How is prognosis determined?
The probable course and/or outcome of the cancer is called the prognosis. Identifying factors that indicate a better or worse prognosis may help you and your doctor plan your treatment. There are many factors that help determine your prognosis. Some of these include:
- Your age
- Your level of physical fitness
- Size of your cancer
- Stage of your cancer
- Aggressiveness of your cancer (cancer cells that are growing and dividing rapidly are considered more aggressive)
Your doctor will evaluate all possible factors to determine your prognosis.
Recently, the genetic make-up of cancer is being increasingly recognized as an important prognostic factor. For example, some genes have been associated with an aggressive course or tendency to recur. Identification of these in an early stage cancer may indicate a poor prognosis. Some research suggests that the genetic make-up of the cancer may be even more important for determining prognosis than the stage of the cancer.
How is cancer diagnosed?
Diagnosing cancer involves the use of a variety of tests that provide details about abnormal cells, which may have been detected through routine medical examinations, self-examination, or reported symptoms. More information about these cells must be gathered in order to identify them as malignant (cancerous) or non-malignant (non-cancerous), and if they are malignant, to determine how serious (aggressive) the particular cancer cells are. Aggressive cancers grow and spread more quickly than less-aggressive or “indolent” cancers. There are many types of tests specifically designed to evaluate cancer:
- A pathology report is based on observation of abnormal cells under a microscope.
- Diagnostic imaging involves visualization of abnormal masses using high tech machines that create images, such as x-rays, computed tomography (CT), positron emission test (PET), magnetic resonance imaging (MRI), and combined PET/CT.
- Blood tests measure substances in the blood that may indicate how advanced the cancer is or other problems related to the cancer.
- Tumor marker tests detect substances in blood, urine, or other tissues that occur in higher than normal levels with certain cancers.
- Special laboratory evaluation of DNA involves the identification of the genetic make-up—the DNA—of the abnormal cells.
How does diagnosis determine treatment?
Historically, a combination of pathological assessment (laboratory evaluation using a microscope) and diagnostic imaging has been used to identify the type of cancer and its stage, and then the treatment. Stage indicates how extensive the cancer is and how much it has spread. Staging usually involves determining the size of the primary tumor and evaluating whether it has remained in the tissue in which it started, whether it has invaded other nearby organs or tissues, and whether cancer cells have spread to distant locations in the body. The cancer is then assigned a stage on a predetermined scale of numbers and letters, for example stage I, II, IIIa, IIIb, IV, etc. The higher number and letter combination indicates more extensive spread, and therefore a more serious condition. Treatment is often selected based on the stage of disease. Higher stage cancers typically receive very aggressive treatments and lower stage disease less aggressive treatment.
However, research has indicated that identifying the stage of disease may not be the most accurate technique for determining how aggressive it is. For example, some early stage diseases may recur or progress even after treatment, while some late stage cancers may stay in remission. These findings suggest that there may be factors other than how the cancer looks under a microscope and how far it has spread at the time of diagnosis that may better indicate the likelihood that a given cancer will recur and/or progress.
Human genomics, which is the study of the entire genetic material of humans, has provided invaluable tools for identifying the genetic components of cancers. The mapping of the human genome, which consists of 30,000 to 70,000 genes, has laid the ground work for understanding the role those genes play in human health and disease. Cancer is many different diseases; however, one aspect of all cancers that is similar is damage to the DNA resulting in uncontrolled cell growth. Identifying the genes for each cancer type that are involved in the capacity grow and spread may provide valuable prognostic information.
As improvements are made in the special laboratory techniques used to identify the genetic make-up of cancers, this genetic information may become a better predictor of cancer aggressiveness and outcome than stage, which has been the diagnostic indicator of choice in the past. Additionally, this genetic information will likely play an increasing role in directing treatment. Specifically, the genes involved in each cancer may indicate more aggressive treatment for some cancers and less aggressive treatment for others.
Introduction to Cancer Treatment
Choice of cancer treatment is influenced by several factors, including the specific characteristics of your cancer; your overall condition; and whether the goal of treatment is to cure your cancer, keep your cancer from spreading, or to relieve the symptoms caused by cancer. Depending on these factors, you may receive one or more of the following:
- Radiation therapy
- Hormonal therapy
- Targeted therapy
- Biological therapy
One or more treatment modalities may be used to provide you with the most effective treatment. Increasingly, it is common to use several treatment modalities together (concurrently) or in sequence with the goal of preventing recurrence. This is referred to as multi-modality treatment of the cancer.
Surgery is used to diagnose cancer, determine its stage, and to treat cancer. One common type of surgery that may be used to help with diagnosing cancer is a biopsy. A biopsy involves taking a tissue sample from the suspected cancer for examination by a specialist in a laboratory. A biopsy is often performed in the physician’s office or in an outpatient surgery center. A positive biopsy indicates the presence of cancer; a negative biopsy may indicate that no cancer is present in the sample.
When surgery is used for treatment, the cancer and some tissue adjacent to the cancer are typically removed. In addition to providing local treatment of the cancer, information gained during surgery is useful in predicting the likelihood of cancer recurrence and whether other treatment modalities will be necessary.
Learn more about surgery.
Chemotherapy is any treatment involving the use of drugs to kill cancer cells. Cancer chemotherapy may consist of single drugs or combinations of drugs, and can be administered through a vein, injected into a body cavity, or delivered orally in the form of a pill. Chemotherapy is different from surgery or radiation therapy in that the cancer-fighting drugs circulate in the blood to parts of the body where the cancer may have spread and can kill or eliminate cancers cells at sites great distances from the original cancer. As a result, chemotherapy is considered a systemic treatment.
More than half of all people diagnosed with cancer receive chemotherapy. For millions of people who have cancers that respond well to chemotherapy, this approach helps treat their cancer effectively, enabling them to enjoy full, productive lives. Furthermore, many side effects once associated with chemotherapy are now easily prevented or controlled, allowing many people to work, travel, and participate in many of their other normal activities while receiving chemotherapy.
Radiation therapy, or radiotherapy, uses high-energy rays to damage or kill cancer cells by preventing them from growing and dividing. Similar to surgery, radiation therapy is a local treatment used to eliminate or eradicate visible tumors. Radiation therapy is not typically useful in eradicating cancer cells that have already spread to other parts of the body. Radiation therapy may be externally or internally delivered. External radiation delivers high-energy rays directly to the tumor site from a machine outside the body. Internal radiation, or brachytherapy, involves the implantation of a small amount of radioactive material in or near the cancer. Radiation may be used to cure or control cancer, or to ease some of the symptoms caused by cancer. Sometimes radiation is used with other types of cancer treatment, such as chemotherapy and surgery, and sometimes it is used alone.
For more information, go to Radiation Therapy.
Hormones are naturally occurring substances in the body that stimulate the growth of hormone sensitive tissues, such as the breast or prostate gland. When cancer arises in breast or prostate tissue, its growth and spread may be caused by the body’s own hormones. Therefore, drugs that block hormone production or change the way hormones work, and/or removal of organs that secrete hormones, such as the ovaries or testicles, are ways of fighting cancer. Hormone therapy, similar to chemotherapy, is a systemic treatment in that it may affect cancer cells throughout the body.
A targeted therapy is one that is designed to treat only the cancer cells and minimize damage to normal, healthy cells. Cancer treatments that “target” cancer cells may offer the advantage of reduced treatment-related side effects and improved outcomes.
Conventional cancer treatments, such as chemotherapy and radiation therapy, cannot distinguish between cancer cells and healthy cells. Consequently, healthy cells are commonly damaged in the process of treating the cancer, which results in side effects. Chemotherapy damages rapidly dividing cells, a hallmark trait of cancer cells. In the process, healthy cells that are also rapidly dividing, such as blood cells and the cells lining the mouth and GI tract are also damaged. Radiation therapy kills some healthy cells that are in the path of the radiation or near the cancer being treated. Newer radiation therapy techniques can reduce, but not eliminate this damage. Treatment-related damage to healthy cells leads to complications of treatment, or side effects. These side effects may be severe, reducing a patient’s quality of life, compromising their ability to receive their full, prescribed treatment, and sometimes, limiting their chance for an optimal outcome from treatment.
Biological therapy is referred to by many terms, including immunologic therapy, immunotherapy, or biotherapy. Biological therapy is a type of treatment that uses the body’s immune system to facilitate the killing of cancer cells. Types of biological therapy include interferon, interleukin, monoclonal antibodies, colony stimulating factors (cytokines), and vaccines.
Personalized Cancer Care
There is no longer a “one-size-fits-all” approach to cancer treatment. Even among patients with the same type of cancer, the behavior of the cancer and its response to treatment can vary widely. By exploring the reasons for this variation, researchers have begun to pave the way for more personalized cancer treatment. It is becoming increasingly clear that specific characteristics of cancer cells and cancer patients can have a profound impact on prognosis and treatment outcome. Although factoring these characteristics into treatment decisions makes cancer care more complex, it also offers the promise of improved outcomes.
The idea of matching a particular treatment to a particular patient is not a new one. It has long been recognized, for example, that hormonal therapy for breast cancer is most likely to be effective when the breast cancer contains receptors for estrogen and/or progesterone. Testing for these receptors is part of the standard clinical work-up of breast cancer. What is new, however, is the pace at which researchers are identifying new tumor markers, new tests, and new and more targeted drugs that individualize cancer treatment. Tests now exist that can assess the likelihood of cancer recurrence, the likelihood of response to particular drugs, and the presence of specific cancer targets that can be attacked by new anti-cancer drugs that directly target individual cancer cells.
To learn more about personalized cancer care for two common types of cancer, visit the following:
By proactively understanding and managing aspects of your treatment, you can help ensure the best possible outcome from treatment and maintain some degree of control in your life. Things you can do to optimize treatment of cancer are:
- Get informed
- Stay organized
- Discuss the effectiveness of treatment
- Work with your physician to select the best treatment for you
Don’t forget that fighting cancer is not a challenge you should face alone. It is a team effort that involves family, friends, and your healthcare team. Don’t overlook the strength that can come from having your support network by your side. In order to ensure optimal treatment, consider the following:
Get informed: A new diagnosis of cancer can be a shock, making you feel out of control and overwhelmed. Getting informed can help alleviate these feelings. Seek out many resources to investigate your treatment options for your type and stage of cancer. Resources should include your healthcare team, second opinions, books, the internet, and other patients with your disease. As you learn, identify the specific questions that only your doctor can answer.
Most importantly, work toward understanding your diagnosis and stage of disease, goals of therapy, treatment plan, benefits of treatment, and possible side effects. Following a diagnosis of cancer, the most important step is to accurately define the stage of your disease. Staging is a system that describes how far the cancer has spread. (Keep in mind that some cancers, such as leukemia, may not be staged.) Each stage of cancer may be treated differently. In order for you to begin evaluating and discussing treatment options with your healthcare team, you need to find out from your doctor the correct stage of your cancer.
Stay organized: Develop a system for keeping all the information that you gather organized, such as laboratory and test results, admissions and consultation information, and additional instructions. Keep a folder or three-ring binder with all your information in one location.
Discussing the effectiveness of treatment: It is important that you and your caregivers are able to evaluate treatment options and to understand how cancer treatments are compared so that you can work with your healthcare team to make informed treatment choices. Understanding the goals of a specific therapy, as well as the risk and benefits it poses, will help you decide which treatment is most appropriate for your situation. Patients typically receive cancer treatment in order to cure the cancer, prolong the duration of their life or alleviate symptoms caused by the cancer and improve their quality of life. These potential benefits of treatment must be balanced against the risks of treatment. Some risks posed by various cancer treatments may include time away from family and friends, uncomfortable side effects of therapy and/or long-term complications or death.
The most common term used to describe the effectiveness of cancer treatment is remission. Remission means that the cancer has disappeared and can no longer be measured using existing technology. Oncologists use the terms partial and complete remission to describe partial or complete disappearance of cancer after treatment. A cancer cannot be cured if a remission is not obtained; however, a remission does not always ensure that a cancer is cured. The best ways to evaluate the benefits of treatment are to examine the duration of remission, survival, and disease-free survival (cure). Since it often takes many years to determine whether a new treatment is better than a previous treatment, remission rates may be useful for comparing therapies when patients have not been evaluated long enough to know whether the chance of cure or survival is improved.
Treatment of cancer is associated with risks. It is important that you evaluate the risks and benefits of treatment within the context of the overall goal of receiving cancer therapy.
Cancer treatment may be inconvenient, prolonged, or unavailable close to home. These are important considerations when evaluating treatment options, but not typically mentioned in medical journals reporting the results and benefits of new treatments.
Select your optimal treatment: Cancer treatment varies depending upon your type of cancer, stage of cancer, and overall condition. Additionally, treatment options may vary depending on whether or not the goal of treatment is to cure the cancer, keep the cancer from spreading, or to relieve the symptoms caused by cancer. You and your physician will consider all of these factors as you work on selecting your optimal treatment.
Questions to Ask
Being educated and informed will help you make the best decisions about your cancer treatment. Get all the information you can as early as possible concerning your evaluation, treatment, and possible side effects. The sooner you know about side effects and possible treatments, the more likely you are to protect yourself against them, or manage them more effectively.
Your doctor and nurse are your best sources of information, but you must remember to ask questions. There is no such thing as a dumb question. Don’t be afraid to ask anything that is on your mind. To make the most of your opportunities to learn from your health care providers, read as much as you can and make a list of questions before each appointment. Also, ask family, friends, and your support team to help you remember the questions. These approaches will help you talk more effectively with your doctor or nurse. Finally, you or your caregiver should consider taking notes during your visit to ensure you remember what you learned.
The following are some questions, grouped by topic, which you may wish to ask your nurse or physician:
- Do you typically treat patients with my diagnosis?
- What stage is my cancer?
- Is there anything unique about my cancer that makes my prognosis better or worse?
- Should I get a second opinion?
- What is the goal of treatment?
- To cure my cancer or stop it from growing?
- What are my treatment options?
- How can each treatment option help me achieve my goal of therapy?
- What risks or potential side effects are associated with each treatment?
- What research studies (“clinical trials”) are available?
- Are there any clinical trials that are right for me?
- How long will I receive treatment, how often, and where?
- How will it be given?
- How will I know if the treatment is working?
- How might a disruption in my chemotherapy dose or timing affect my results?
- How and when will I be able to tell whether the treatment is working?
- What are the names of all the drugs I will be taking?
- Can I talk with another of your patients who has received this treatment?
- Are there any resources or Web sites you recommend for more information?
- What types of lab tests will I need?
- Will I need x-rays and scans?
- Can you explain the results of my complete blood count (CBC)?
- Are there tests for the genetic make-up of my cancer?
- Will I benefit from having my cancer evaluated for its genetic make-up?
- How frequently will I get the tests?
Side Effects of Treatment
- What possible side effects should I prepare for?
- When might they start?
- Will they get better or worse as my treatment goes along?
- How can I prepare for them or lessen their impact?
- Are there treatments that can help relieve the side effects? What are they? Do you usually recommend or prescribe them?
- Which risks are most serious?
- Will I require blood transfusions? Why?
- How can I best monitor myself for complications related to either my disease or my treatment?
Protecting Against Infection
- Will my type of chemotherapy put me at risk for a low white blood cell count and infection?
- Can I help protect myself against infection right from the start of chemotherapy, instead of waiting until problems develop?
- Am I at special risk for infection?
- What are the signs of infection?
- How serious is an infection?
- How long will I be at risk for infection?
- What should I do if I have a fever?
- How are infections treated?
- How will my cancer treatment affect my usual activities?
- Will I be able to work?
- Will I need to stay in the hospital?
- Will I need someone to help me at home?
- Will I need help taking care of my kids?
- Are there any activities I should avoid during my chemotherapy?
What to Expect After Treatment
- What happens after I complete my treatment?
- How can I best continue to monitor myself for complications related to either my disease or my treatment?
- What kind of lab tests will I need?
- How frequently should I get those lab tests?
- What types of x-rays and scans will I need?
- How often do I need to come in for checkups?
- When will you know if I am cured?
- What happens if my disease comes back?
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