Download Cancer Survivorship - David Geffen School of Medicine at UCLA

Cancer Survivorship
Endometrial Cancer Module
Part 2
©2007. David Geffen School of Medicine, UCLA
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Case
Goal of this Module
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This is an interactive and self-directed learning module
intended to build a foundation of knowledge around the
epidemiology and late effects of cancer survival. This is
one of several educational modules you will complete
during your core clinical clerkships. Themes
emphasized in this, and other modules, are:
Epidemiology of survival
Late effects
Psychosocial concerns
Secondary prevention
Strategies for behavior change
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Part 2
Case Summary
Ms. Johnson, an obese (BMI =37), 64 yearold, Caucasian woman, gravida 1, para 1,
came to see you because she was having post
menopausal bleeding over the past month. She
had no other symptoms. She did not receive
hormone replacement therapy with estrogen
or progesterone. Endometrial biopsy revealed
endometrial cancer.
Next
Summary Continued
Ms. Johnson was treated with an exploratory
laparotomy, total abdominal hysterectomy and
bilateral salpingo-oophorectomy (TAH & BSO)
pelvic and para-aortic lymphadenectomy and
adjuvant chemotherapy (paclitaxel,
doxorubicin and cisplatin (CAP)
chemotherapy). She was staged as endometrial
cancer stage 2A.
Next
Paclitaxel
 Licensed to University of California ©2006 UpToDate ®
 U.S. BRAND NAMES — Abraxane®
 PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Antimicrotubular
Antineoplastic Agent, Natural Source (Plant) Derivative
 USE — Treatment of relapsed or refractory breast cancer
 Adverse reactions
Back to
Case
Paclitaxel
(Adverse Reactions)
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case
>10%:
Cardiovascular: EKG abnormal (60%)
Dermatologic: Alopecia (90%)
Gastrointestinal: Nausea (30%; grades 3/4: 3%), diarrhea (27%; grades 3/4: <1%), vomiting (18%; grades 3/4: 4%)
Hematologic: Neutropenia (80%; grade 4: 9%), anemia (33%; grades 3/4: 1%)
Hepatic: AST increased (39%), alkaline phosphatase increased (36%), GGT increased (grades 3/4: 14%)
Neuromuscular & skeletal: Sensory neuropathy (71%; grades 3/4: 10%; dose dependent; may be cumulative), weakness
(47%), myalgia/arthralgia (44%)
Ocular: Vision disturbance (13%; severe [keratitis, blurred vision]: 1%)
Respiratory: Dyspnea (12%)
Miscellaneous: Infection (24%; primarily included oral candidiasis, respiratory tract infection, and pneumonia)
1% to 10%:
Cardiovascular: Edema (10%), hypotension (5%), cardiovascular events (grades 3/4: 3%; included chest pain, cardiac arrest,
supraventricular tachycardia, edema, thrombosis, pulmonary thromboembolism, pulmonary emboli, and hypertension)
Gastrointestinal: Mucositis (7%; grades 3/4: <1%)
Hematologic: Bleeding (2%), neutropenic fever (2%), thrombocytopenia (2%; grades 3/4: 1%)
Hepatic: Bilirubin increased (7%)
Neuromuscular and skeletal: Peripheral neuropathy (grade 3: 10%)
Renal: Creatinine increased (11%; severe 1%)
Respiratory: Cough (7%)
Miscellaneous: Hypersensitivity reaction (4%)
<1% (Limited to important or life-threatening): Bradycardia, cardiac ischemia, cerebrovascular attack, cranial nerve palsies,
embolism, erythema, hand-foot syndrome (in patients previously exposed to capecitabine), injection site reaction,
maculopapular rash, MI, motor neuropathy, nail discoloration, nail pigmentation changes, photosensitivity reaction,
pneumothorax, pruritus, radiation recall, stroke, thrombosis, transient ischemic attack
Adverse reactions reported with paclitaxel, which may occur with paclitaxel (protein bound): Autonomic neuropathy, cellulitis,
conjunctivitis, extravasation recall, fibrosis, hepatic necrosis, hepatic encephalopathy, induration, intestinal obstruction,
intestinal perforation, interstitial pneumonia, ischemic colitis, lacrimation increased, lung fibrosis, necrosis, neutropenic
enterocolitis (typhlitis), optic nerve damage (persistent), pancreatitis, paralytic ileus, phlebitis, radiation pneumonitis with
concurrent radiation therapy, skin exfoliation, Stevens-Johnson syndrome, toxic epidermal necrolysis
Doxorubicin
 Licensed to University of California ©2006 UpToDate ®
 U.S. BRAND NAMES — Adriamycin PFS®; Adriamycin
RDF®; Rubex®
 PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Anthracycline
 USE — Treatment of leukemias, lymphomas, multiple
myeloma, osseous and nonosseous sarcomas,
mesotheliomas, germ cell tumors of the ovary or testis, and
carcinomas of the head and neck, thyroid, lung, breast,
stomach, pancreas, liver, ovary, bladder, prostate, uterus, and
neuroblastoma
 Adverse reactions
Back to
Case
Doxorubicin
(Adverse Reactions)
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
Back to
case
>10%:
Cardiovascular: Transient ECG abnormalities (supraventricular tachycardia, S-T wave changes, atrial or ventricular
extrasystoles); generally asymptomatic and self-limiting. CHF, dose related, may be delayed for 7-8 years after treatment.
Cumulative dose, mediastinal/pericardial radiation therapy, cardiovascular disease, age, and use of cyclophosphamide (or other
cardiotoxic agents) all increase the risk.
Recommended maximum cumulative doses:
No risk factors: 550 mg/m2
Concurrent radiation: 450 mg/m2
Note: Regardless of cumulative dose, if the left ventricular ejection fraction is <30% to 40%, the drug is usually not given.
Dermatologic: Alopecia
Gastrointestinal: Acute nausea and vomiting (21% to 55%), mucositis, ulceration, and necrosis of the colon, anorexia, and
diarrhea, stomatitis, esophagitis
Genitourinary: Discoloration of urine (red)
Hematologic: Myelosuppression, leukopenia (75%), dose-limiting toxicity
WBC: Moderate
Platelets: Moderate
Onset (days): 7
Nadir (days): 10-14
Recovery (days): 21-28
Local: Vesicant chemotherapy
1% to 10%:
Cardiovascular: Acute: Arrhythmias, heart block, pericarditis-myocarditis, facial flushing; Delayed: CHF (related to cumulative
dose; usually a maximum total lifetime dose of 450-550 mg/m2; possibly higher if given by continuous infusion)
Dermatologic: Hyperpigmentation of nail beds, erythematous streaking along the vein if administered rapidly
Endocrine & metabolic: Hyperuricemia
<1% (Limited to important or life-threatening):
Pediatric patients may be at increased risk of later neoplastic disease, particularly acute myeloid leukemia (pediatric patients).
Prepubertal growth failure may result from intensive chemotherapy regimens.
Radiation recall: Noticed in patients who have had prior irradiation; reactions include redness, warmth, erythema, and
dermatitis in the radiation port. Can progress to severe desquamation and ulceration. Occurs 5-7 days after doxorubicin
administration; local therapy with topical corticosteroids and cooling have given the best relief.
Cisplatin
 Licensed to University of California ©2006 UpToDate ®
 U.S. BRAND NAMES — Platinol®-AQ [DSC]
 PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Alkylating Agent
 USE — Treatment of bladder, testicular, and ovarian cancer
 USE - UNLABELED / INVESTIGATIONAL —
Treatment of head and neck, breast, gastric, lung,
esophageal, cervical, prostate and small cell lung cancer;
Hodgkin's and non-Hodgkin's lymphoma; neuroblastoma;
sarcomas, myeloma, melanoma, mesothelioma, and
osteosarcoma
 Adverse reactions
Back to
Case
Cisplatin
(Adverse Reactions)
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case
>10%:
Central nervous system: Neurotoxicity: Peripheral neuropathy is dose- and durationdependent.
Dermatologic: Mild alopecia
Gastrointestinal: Nausea and vomiting (76% to 100%)
Hematologic: Myelosuppression (25% to 30%; mild with moderate doses, mild to moderate
with high-dose therapy)
WBC: Mild
Platelets: Mild
Onset: 10 days
Nadir: 14-23 days
Recovery: 21-39 days
Hepatic: Liver enzymes increased
Renal: Nephrotoxicity (acute renal failure and chronic renal insufficiency)
Otic: Ototoxicity (10% to 30%; manifested as high frequency hearing loss; ototoxicity is
especially pronounced in children)
1% to 10%:
Gastrointestinal: Diarrhea
Local: Tissue irritation
<1% (Limited to important or life-threatening): Anaphylactic reaction, arrhythmias, blurred
vision, bradycardia, cerebral blindness, hemolytic anemia, liver enzymes increased, mild
alopecia, mouth sores, optic neuritis, papilledema
Central nervous system: Peripheral and autonomic neuropathy, ototoxicity
Endocrine & metabolic: Hypokalemia, hypomagnesemia
Gastrointestinal: Highly emetogenic
Hematologic: Myelosuppression
Renal: Acute renal failure, increased serum creatinine, azotemia
Miscellaneous: Transient pain at tumor, transient autoimmune disorders
Presenting Complaint
Four weeks into her treatment and 8 weeks
after her diagnosis, Ms Johnson notices her
bed is full of hair when she wakes up. She
also loses a lot of hair when she brushes.
She is very agitated because she is very
proud of her wavy curly blonde hair.
Next
Question #1
A.
B.
C.
D.
E.
She comes to your office seeking an
explanation about her hair loss. What is the
most likely diagnosis?
Alopecia areata
Telogen effluvium
Cicatricial alopecia
Traumatic alopecia
Drug induced alopecia
Incorrect. Question #1
B. Alopecia areata
 Alopecia areata causes one or more patches of scalp hair loss.
 Tends to affect younger individuals, both male and female.
 It is an autoimmune disorder, in which the immune system
attacks hair follicles.
 The condition resolves without treatment within a year, but
hair loss is sometimes permanent.
 Treatments may be steroid injections and cream (such as
clobetasol or fluocinonide), minoxidil, irritants (anthralin or
topical coal tar), and topical immunotherapy (cyclosporine).
Back to
Question 1
Incorrect. Question #1
B. Alopecia
areata
 Alopecia areata causes one or more patches of scalp hair loss.
 Tends to affect younger individuals, both male and female.
 It is an autoimmune disorder, in which the immune system
attacks hair follicles.
 The condition resolves without treatment within a year, but hair
loss is sometimes permanent.
 Treatments may be steroid injections and cream (such as
clobetasol or fluocinonide), minoxidil, irritants (anthralin or
topical coal tar), and topical immunotherapy (cyclosporine).
Teaching Points for
Incorrect Answers
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Case
Minoxidil
 BRAND NAME: Rogaine
 DRUG CLASS AND MECHANISM: Oral minoxidil, a medication that originally
was used to treat high blood pressure, has been found to increase hair growth. This
lead to the development of topical (solution applied to the skin) minoxidil. Topical
minoxidil (Rogaine) has been shown to stimulate hair growth on the bald spot of the
back of the head in men. In women, Rogaine can increase hair growth in the forehead
areas. Minoxidil is in a class of drugs called hair growth stimulants.
 DRUG INTERACTIONS: Oral minoxidil can cause a fall in blood pressure, an
increase in the heart rate, and weight gain (fluid retention). An increase in the
absorption of minoxidil from the scalp can occur in patients with inflamed or
abnormal scalps, leading to side effects mentioned above. Patients with heart failure
or significant coronary heart disease should avoid Rogaine because of these side
effects. Rogaine's alcohol base can irritate the eyes. Rogaine should not be used with
other topical medications because they may increase its absorption and side effects.
Rogaine should be used with caution in those with high blood pressure.
 PREGNANCY: Rogaine should not be used in pregnancy.
 NURSING MOTHERS: Rogaine should not be used by nursing women.
 SIDE EFFECTS: Skin side effects are seen at times with Rogaine, including
irritation, itch, contact dermatitis, hives, swelling, and sensitivity.
Back to
Case
Minoxidil
 BRAND NAME: Rogaine
 DRUG CLASS AND MECHANISM: Oral minoxidil, a medication that originally
was used to treat high blood pressure, has been found to increase hair growth. This
lead to the development of topical (solution applied to the skin) minoxidil. Topical
minoxidil (Rogaine) has been shown to stimulate hair growth on the bald spot of the
back of the head in men. In women, Rogaine can increase hair growth in the forehead
areas. Minoxidil is in a class of drugs called hair growth stimulants.
 DRUG INTERACTIONS: Oral minoxidil can cause a fall in blood pressure, an
increase in the heart rate, and weight gain (fluid retention). An increase in the
absorption of minoxidil from the scalp can occur in patients with inflamed or
abnormal scalps, leading to side effects mentioned above. Patients with heart failure
or significant coronary heart disease should avoid Rogaine because of these side
effects. Rogaine's alcohol base can irritate the eyes. Rogaine should not be used with
other topical medications because they may increase its absorption and side effects.
Rogaine should be used with caution in those with high blood pressure.
 PREGNANCY: Rogaine should not be used in pregnancy.
 NURSING MOTHERS: Rogaine should not be used by nursing women.
 SIDE EFFECTS: Skin side effects are seen at times with Rogaine, including
irritation, itch, contact dermatitis, hives, swelling, and sensitivity.
Back to
Incorrect
Answers
Incorrect. Question #1
C. Telogen effluvium
 Telogen effluvium is nonscarring alopecia with diffuse hair
shedding.
 A reactive process caused by a metabolic, hormonal stress or
medications that shifts follicles in anagen to a telogenpredominant distribution.
 Generally, recovery is spontaneous and occurs by 6 months.
 Acute telogen effluvium is hair shedding lasting < 6 months.
 Usually initiated by metabolic or physiologic stressors.
 Papulosquamous diseases of the scalp, such as psoriasis and
seborrheic dermatitis, can produce telogen effluvium.
 Chronic telogen effluvium is hair shedding lasting > 6 months.
Back to
Question 1
Incorrect. Question #1
C. Telogen effluvium
 Telogen effluvium is nonscarring alopecia with diffuse hair
shedding.
 A reactive process caused by a metabolic, hormonal stress or
medications that shifts follicles in anagen to a telogenpredominant distribution.
 Generally, recovery is spontaneous and occurs by 6 months.
 Acute telogen effluvium is hair shedding lasting < 6 months.
 Usually initiated by metabolic or physiologic stressors.
 Papulosquamous diseases of the scalp, such as psoriasis and
seborrheic dermatitis, can produce telogen effluvium.
 Chronic telogen effluvium is hair shedding lasting > 6 months.
Teaching Points for
Incorrect Answers
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Case
Incorrect. Question #1
D. Cicatricial alopecia
 Cicatricial alopecia is hair loss from scalp and hair
follicle damage.
 The scalp usually has an abnormal appearance.
 Plaques of erythema, scaling or pustules occur.
 Associations include infections (e.g., syphilis,
tuberculosis, acquired immunodeficiency syndrome,
herpes zoster), autoimmune disease (discoid lupus
erythematosus), sarcoidosis, scalp trauma (e.g.,
injuries, burns), and radiation therapy.
Back to
Question 1
Incorrect. Question #1
D. Cicatricial alopecia
 Cicatricial alopecia is hair loss from scalp and hair
follicle damage.
 The scalp usually has an abnormal appearance.
 Plaques of erythema, scaling or pustules occur.
 Associations include infections (e.g., syphilis,
tuberculosis, acquired immunodeficiency syndrome,
herpes zoster), autoimmune disease (discoid lupus
erythematosus), sarcoidosis, scalp trauma (e.g., injuries,
burns), and radiation therapy.
Teaching Points for
Incorrect Answers
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Case
Incorrect. Question #1
E. Traumatic alopecia
 Traumatic alopecia is caused by cosmetic
practices that damage hair follicles over time.
 Cosmetic alopecia has been linked to the use of
brush rollers, curling irons, hair brushes with
square or angular tips, and tight braiding of the
hair.
Back to
Question 1
Incorrect. Question #1
E. Traumatic alopecia
 Traumatic alopecia is caused by cosmetic
practices that damage hair follicles over time.
 Cosmetic alopecia has been linked to the use of
brush rollers, curling irons, hair brushes with
square or angular tips, and tight braiding of the
hair.
Teaching Points for
Incorrect Answers
Continue
Case
Correct. Question #1
F. Drug induced alopecia
 Anagen effluvium occurs after insult to hair follicle that impairs mitotic or
metabolic activity.
 Due to exposure to chemotherapeutic agents
 Inhibition of cell division in the hair matrix leads to thin, weakened hair
shaft likely to fracture with minimal trauma
 May cause complete failure of hair formation.
 Worse with combination chemotherapy and higher doses.
 Hair loss usually begins 7-14 days after exposure and is clinically most
apparent after 1-2 months.
 Reversible; hair growth resumes few weeks after treatment cessation;
regrows in 3-5 months; color or texture of new hair may differ from
original hair.
Continue
Teaching Points
for Incorrect Answers
Case
Question #1 Incorrect Answers




Alopecia areata
Telogen effluvium
Cicatricial alopecia
Traumatic alopecia
Continue
Case
Case Continued
After discussing her options Ms Johnson is fitted
with a wig.
Four months after her treatment and 5 months after
diagnosis. Mrs. Johnson comes to see you and
states: “ I have noticed that over the last 2 months
my shoes don’t fit and I can only wear bathroom
slippers. Both my legs feel tight and appear very
swollen but I don’t feel much pain. What is
happening to me?”
Next
Question #2
What is the most likely diagnosis?
A.
B.
C.
D.
E.
Deep venous thrombosis
Lymphedema
Compartment syndrome
Femoral artery ligation
Necrotizing fascitis
Incorrect. Question #2
A.






Deep venous thrombosis
Cancer results in a hypercoagulable state.
Deep venous thrombosis occurs in up to 11% of
cancer patients and is an important cause of death
Usually unilateral and about half are asymptomatic.
Symptoms of include swelling, pain, and
discoloration.
Physical examination may reveal a palpable cord
(reflecting a thrombosed vein), ipsilateral edema,
warmth, and/or superficial venous dilation.
Diagnosed by: venography of the legs, Doppler
ultrasound, plethysmography, D-dimer blood test
Back to
Question 2
Incorrect. Question #2
A.






Deep venous thrombosis
Cancer results in a hypercoagulable state.
Deep venous thrombosis occurs in up to 11% of cancer
patients and is an important cause of death
Usually unilateral and about half are asymptomatic.
Symptoms of include swelling, pain, and discoloration.
Physical examination may reveal a palpable cord
(reflecting a thrombosed vein), ipsilateral edema,
warmth, and/or superficial venous dilation.
Diagnosed by: venography of the legs, Doppler
ultrasound, plethysmography, D-dimer blood test
Teaching Points for
Incorrect Answers
Continue
Case
Correct. Question #2
B. Lymphedema




Stage 3
Lymphedema is nonpitting swelling of an extremity,
usually bilateral.
In cancer is due to lymphatic obstruction from node
dissection, radiation or malignant obstruction.
Treated by exercise, gradient pressure garments,
massage or external pneumatic compression.
Patients undergoing dissection or radiation of lymph
nodes should be counseled on preventing
lymphedema; which are: elevating limb, avoiding
constricting garments that cause a tourniquet effect,
meticulous skin hygiene and nail care.
Teaching Points for
Incorrect Answers
Continue
Module
Incorrect. Question #2
C. Compartment syndrome
 Compartment syndrome is increased tissue
pressure in a closed muscle compartment
compromising local circulation and neuromuscular
function.
 Requires 1:constricting envelope (fascia or cast) 2:
increase in volume (blood, edema).
 Fascia of leg muscles do not allow muscle
expansion when significant edema occurs.
 Due to a direct blow, usually to an unpadded softtissue area. Causes pain that is more severe than
physical findings.
 Treatment is fasciotomy: longitudinal incisions in
affected compartments.
Back to
Question 2
Incorrect. Question #2
C. Compartment syndrome
 Compartment syndrome is increased tissue
pressure in a closed muscle compartment
compromising local circulation and neuromuscular
function.
 Requires 1:constricting envelope (fascia or cast) 2:
increase in volume (blood, edema).
 Fascia of leg muscles do not allow muscle
expansion when significant edema occurs.
 Due to a direct blow, usually to an unpadded softtissue area. Causes pain that is more severe than
physical findings.
 Treatment is fasciotomy: longitudinal incisions in
affected compartments.
Teaching Points for
Incorrect Answers
Continue
Case
Incorrect. Question #2
D. Femoral artery ligation
 Femoral artery ligation will result in
pulselessness and lower extremity ischemia.
 If not corrected, will result in lower limb
ischemia and necrosis necessitating
amputation.
 It may occurs as an inadvertent injury
following extensive and difficult surgery for
extensive cancer.
Back to
Question 2
Incorrect. Question #2
D. Femoral artery ligation
 Femoral artery ligation will result in
pulselessness and lower extremity ischemia.
 If not corrected, will result in lower limb
ischemia and necrosis necessitating
amputation.
 It may occurs as an inadvertent injury
following extensive and difficult surgery for
extensive cancer.
Teaching Points for
Incorrect Answers
Continue
Case
Incorrect. Question #2
E. Necrotizing fascitis
 Necrotizing fasciitis is an insidiously advancing soft
tissue infection with widespread fascial necrosis.
 Mixed infection after surgery with diabetes or
peripheral vascular disease.
 Systemic toxicity and high mortality.
 Extensive tissue destruction, thrombosis of blood
vessels, bacteria spread along fascial planes.
 Unexplained pain. Erythema darken to a reddishpurple color, with blisters and bullae.
 Treatment is early and aggressive surgical exploration
and debridement of necrotic tissue, antibiotics, and
hemodynamic support.
Back to
Question 2
Incorrect. Question #2
E. Necrotizing fascitis
 Necrotizing fasciitis is an insidiously advancing soft
tissue infection with widespread fascial necrosis.
 Mixed infection after surgery with diabetes or
peripheral vascular disease.
 Systemic toxicity and high mortality.
 Extensive tissue destruction, thrombosis of blood
vessels, bacteria spread along fascial planes.
 Unexplained pain. Erythema darken to a reddishpurple color, with blisters and bullae.
 Treatment is early and aggressive surgical exploration
and debridement of necrotic tissue, antibiotics, and
hemodynamic support.
Teaching Points for
Incorrect Answers
Continue
Case
Question #2 Incorrect Answers
A. Deep venous thrombosis
C. Compartment syndrome
D. Femoral artery ligation
E. Necrotizing fascitis
Continue
Case
Case Continued
She is started on an exercise program, fitted with
gradient pressure garments and diuretics were
prescribed.
Three months later and seven months after diagnosis
she comes to see you. She is very distraught and
agitated. She tells you “I cry a lot and have lost
interest in almost everything. I don’t sleep well and I
don’t want to eat. I’ve lost weight. I think the cancer
has come back.”
Next
Question #3
Of the following, what is the most likely
explanation?
A.
B.
C.
D.
Insomnia
Nutritional imbalance
Depression
Recurrence of the cancer
Incorrect. Question #3
A.
Work-up for insomnia is helpful but does not explain all the other
symptoms that she has.
Sedatives should be used with caution since tolerance or dependence
can develop. Time and effort should be spent in finding the cause of
insomnia.
Causes of insomnia include:
Medical disease cont.
Psychiatric disease:
Schizophrenia
Anxiety
Depression
Medical disease:
Alcoholism
Degenerative Neurological Disorders
Alzheimer’s disease
Parkinson’s disease
Fatal Familial Insomnia (FFI)
Headaches
Chronic Obstructive Pulmonary Disease
(COPD)
Sleep apnea
Asthma
Gastroesophageal Reflux
Fibromyalgia
Hypothyriodism
Medications
Back to
Question 3
Incorrect. Question #3
A.
Work-up for insomnia is helpful but does not explain all the other
symptoms that she has.
Sedatives should be used with caution since tolerance or dependence
can develop. Time and effort should be spent in finding the cause of
insomnia.
Causes of insomnia include:
Medical disease cont.
Psychiatric disease:
Schizophrenia
Anxiety
Depression
Medical disease:
Alcoholism
Degenerative Neurological Disorders
Alzheimer’s disease
Parkinson’s Disease
Fatal Familial Insomnia (FFI)
Headaches
Chronic Obstructive Pulmonary Disease
(COPD)
Sleep apnea
Asthma
Gastroesophageal Reflux
Fibromyalgia
Hypothyriodism
Medications
Teaching Points for
Incorrect Answers
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Case
Alcoholism
 Alcoholism
Alcohol may induce sleep for up to four
hours, but after that it can lead to frequent
awakenings and sleep fragmentation.
Insomnia is a common symptom of
alcoholism.
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Case
Alcoholism
 Alcoholism
Alcohol may induce sleep for up to four
hours, but after that it can lead to frequent
awakenings and sleep fragmentation.
Insomnia is a common symptom of
alcoholism.
Back to
Insomnia
Back to
Incorrect
Answers
Degenerative Neurological
Disorders
 Insomnia is often associated with
degenerative neurological disorders, such as
Alzheimer's disease, Pick's disease, and
hydrocephalus. People with dementia who
require institutionalization typically have
insomnia.
Back to
Case
Degenerative Neurological
Disorders
 Insomnia is often associated with
degenerative neurological disorders, such as
Alzheimer's disease, Pick's disease, and
hydrocephalus. People with dementia who
require institutionalization typically have
insomnia.
Back to
Insomnia
Back to
Incorrect
Answers
Alzheimer’s disease
 Alzheimer's disease (AD) is an irreversible,
progressive disorder in which brain cells (neurons)
deteriorate, resulting in the loss of cognitive
functions, primarily memory, judgment and
reasoning, movement coordination, and pattern
recognition. In advanced stages of the disease, all
memory and mental functioning may be lost.
 The condition predominantly affects the cerebral
cortex and hippocampus, which lose mass and
shrink (atrophy) as the disease advances.
Back to
Case
Alzheimer’s disease
 Alzheimer's disease (AD) is an irreversible,
progressive disorder in which brain cells (neurons)
deteriorate, resulting in the loss of cognitive
functions, primarily memory, judgment and
reasoning, movement coordination, and pattern
recognition. In advanced stages of the disease, all
memory and mental functioning may be lost.
 The condition predominantly affects the cerebral
cortex and hippocampus, which lose mass and
shrink (atrophy) as the disease advances.
Back to
Insomnia
Back to
Incorrect
Answers
Parkinson's Disease
 Insomnia is a common complication of Parkinson's
disease and of the medications used to treat it.
Other causes of insomnia in people with
Parkinson's disease include periodic limb
movements and sleep-related breathing disorders.
Parkinson's patients also don't move much in bed
and experience pain from agitated pressure-point
arousal. Rapid eye movement disorder is thought to
precede Parkinson's disease.
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Case
Parkinson's Disease
 Insomnia is a common complication of Parkinson's
disease and of the medications used to treat it.
Other causes of insomnia in people with
Parkinson's disease include periodic limb
movements and sleep-related breathing disorders.
Parkinson's patients also don't move much in bed
and experience pain from agitated pressure-point
arousal. Rapid eye movement disorder is thought to
precede Parkinson's disease.
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Insomnia
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Incorrect
Answers
Fatal Familial Insomnia
 Fatal familial insomnia is an extremely rare,
infectious prion disease. It involves proteinaceous
cells, probably of the thalamus, that lack the ability
to produce nucleic acid. It is a progressive disorder
that begins with difficulty initiating sleep and leads
to total lack of sleep within a few months. It can be
fatal within 7 to 13 months after symptoms begin
but may last longer.
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Case
Prion
 A microscopic protein particle similar to a
virus but lacking nucleic acid, responsible for
certain degenerative diseases of the nervous
system.
Back to FFI
Fatal Familial Insomnia
 Fatal familial insomnia is an extremely rare,
infectious prion disease. It involves proteinaceous
cells, probably of the thalamus, that lack the ability
to produce nucleic acid. It is a progressive disorder
that begins with difficulty initiating sleep and leads
to total lack of sleep within a few months. It can be
fatal within 7 to 13 months after symptoms begin
but may last longer.
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Insomnia
Back to
Incorrect
Answers
Prion
 A microscopic protein particle similar to a
virus but lacking nucleic acid, responsible for
certain degenerative diseases of the nervous
system.
Back to FFI
Headaches
 Any type of headache that occurs during sleep may
wake a person up. For example, hypnic (sleepinducing) headaches are characterized by
generalized pulsating pain and may occur three
times a night for 30 minutes for several consecutive
nights. They are benign and usually affect people
over the age of 60. They sometimes respond to
lithium treatment
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Case
Headaches
 Any type of headache that occurs during sleep may
wake a person up. For example, hypnic (sleepinducing) headaches are characterized by
generalized pulsating pain and may occur three
times a night for 30 minutes for several consecutive
nights. They are benign and usually affect people
over the age of 60. They sometimes respond to
lithium treatment
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Insomnia
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Incorrect
Answers
Chronic Obstructive Pulmonary Disease
(COPD)
 Many aspects of COPD can disturb one's
sleep. Low blood oxygen levels, coughing to
clear secretions from the lungs,
bronchospasm (narrowing and obstruction of
airways), and the side effects of the
medications used to treat the condition can
create a night of broken sleep.
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Case
Chronic Obstructive Pulmonary Disease
(COPD)
 Many aspects of COPD can disturb one's
sleep. Low blood oxygen levels, coughing to
clear secretions from the lungs,
bronchospasm (narrowing and obstruction of
airways), and the side effects of the
medications used to treat the condition can
create a night of broken sleep.
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Insomnia
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Incorrect
Answers
Asthma
 Asthma-related bronchospasm and
subsequent airway obstruction is often worse
during the night. This may lead to shortness
of breath that causes a person to wake up. As
with COPD, many asthma medications can
cause insomnia, including theophylline, beta
agonists (used as inhalants), and
corticosteroids.
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Case
Asthma
 Asthma-related bronchospasm and
subsequent airway obstruction is often worse
during the night. This may lead to shortness
of breath that causes a person to wake up. As
with COPD, many asthma medications can
cause insomnia, including theophylline, beta
agonists (used as inhalants), and
corticosteroids.
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Insomnia
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Incorrect
Answers
Gastroesophageal Reflux and Heartburn
 Nocturnal acid reflux and its characteristic chronic
burning sensation in the lower esophagus can
arouse one from sleep. If the symptoms are
pronounced before going to sleep, they may cause
sleep-onset difficulties. Heartburn often wakes
people up and makes it difficult to go back to sleep.
Avoiding fatty foods before sleep may help reduce
heartburn and sleep disturbance.
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Case
Gastroesophageal Reflux and Heartburn
 Nocturnal acid reflux and its characteristic chronic
burning sensation in the lower esophagus can
arouse one from sleep. If the symptoms are
pronounced before going to sleep, they may cause
sleep-onset difficulties. Heartburn often wakes
people up and makes it difficult to go back to sleep.
Avoiding fatty foods before sleep may help reduce
heartburn and sleep disturbance.
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Insomnia
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Incorrect
Answers
Fibromyalgia
 People with fibromyalgia often complain of
light sleep and nonrestorative sleep.
Fibromyalgia causes chronic pain in muscles
and joint tissue, which can significantly
disrupt or prevent sleep.
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Case
Fibromyalgia
 People with fibromyalgia often complain of
light sleep and nonrestorative sleep.
Fibromyalgia causes chronic pain in muscles
and joint tissue, which can significantly
disrupt or prevent sleep.
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Insomnia
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Incorrect
Answers
Medications
 There are numerous medications for which insomnia is a predictable side
effect. The most common ones are listed below:











Decongestants (pseudoephedrine)
Bronchodilators (beta-2 agonists, theophylline)
Antihypertensives (hydrochlorothiazide, nifedipine, methyldopa, propranolol)
Antidepressants (fluoxetine, bupropion, sertraline)
Antidepressants that may cause daytime drowsiness (desipramine, imipramine,
nortriptyline)
Diuretics (furosemide)
Antiepileptics (phenytoin)
Antiarrhythmic agents (quinidine, propranolol, verapamil)
Histamine H2 inhibitors (cimetidine -for gastrointestinal conditions)
Thyroid medications
Alcohol, caffeine, nicotine
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Case
Medications
 There are numerous medications for which insomnia is a predictable side
effect. The most common ones are listed below:











Decongestants (pseudoephedrine)
Bronchodilators (beta-2 agonists, theophylline)
Antihypertensives (hydrochlorothiazide, nifedipine, methyldopa, propranolol)
Antidepressants (fluoxetine, bupropion, sertraline)
Antidepressants that may cause daytime drowsiness (desipramine, imipramine,
nortriptyline)
Diuretics (furosemide)
Antiepileptics (phenytoin)
Antiarrhythmic agents (quinidine, propranolol, verapamil)
Histamine H2 inhibitors (cimetidine -for gastrointestinal conditions)
Thyroid medications
Alcohol, caffeine, nicotine
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Insomnia
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Incorrect
Answers
Incorrect. Question #3
B. Nutritional Imbalance
Nutrition evaluation is always important but
must not prevent physicians from making a
diagnosis that maybe potentially lifethreatening and treatable.
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Question 3
Incorrect. Question #3
B. Nutritional Imbalance
Nutrition evaluation is always important but
must not prevent physicians from making a
diagnosis that maybe potentially lifethreatening and treatable.
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Case
Correct. Question #3
C. Depression
 Clinical depression occurs in about 25% with
cancer, causing distress, impaired functioning, and
less ability to follow treatment and is treatable.
Symptoms of clinical depression that our patient
has are:

Sad or "empty" mood

Loss of interest or pleasure

Significant weight changes

“Slowed down" or restless and agitated

Sleeping disorders
Continue
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Case
Incorrect. Question #3
D. Recurrence of the cancer
Cancer recurrence is always a concern. A
thorough physical examination would be the
first step, including an MRI. However the
patient has other symptoms that need to be
evaluated.
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Question 3
Incorrect. Question #3
D. Recurrence of the cancer
Cancer recurrence is always a concern. A
thorough physical examination would be the
first step, including an MRI. However the
patient has other symptoms that need to be
evaluated.
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Case
Question #3 Incorrect Answers
A. Insomnia
B. Nutritional imbalance
D. Recurrence of the cancer
Continue
Case
Case Continued
She is started on an SSRI, psychotherapy sessions
are initiated and she joins a cancer support group.
A year after her diagnosis, Ms. Johnson, comes for
her check-up with her oncologist. Clinical
evaluation and follow-up MRI shows that she has a
suspicious enlarged para-aortic lymph node. Further
therapy is suggested.
Next
Question #4
Of the following, which is the best management?
A.
B.
C.
D.
E.
Surgical removal of lymph node
Combined chemotherapy
Brachytherapy
External pelvic and abdominal radiation
Tamoxifen
Incorrect. Question #4
A. Surgical removal of lymph node
Surgical removal of the lymph node will
increase the risk of disseminating cancerous
tissue. It is not curative since the exact extent
of local spread cannot be determined.
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Question 4
Incorrect. Question #4
A. Surgical removal of lymph node
Surgical removal of the lymph node will
increase the risk of disseminating cancerous
tissue. It is not curative since the exact extent
of local spread cannot be determined.
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Case
Incorrect. Question #4
B. Combined chemotherapy
Patient has previously been treated with
chemotherapy. Repeat chemotherapy is not felt to
be effective and will increase morbidity with little
or no benefit.
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Question 4
Incorrect. Question #4
B. Combined chemotherapy
Patient has previously been treated with
chemotherapy. Repeat chemotherapy is not felt to
be effective and will increase morbidity with little
or no benefit.
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Case 4
Question
Incorrect. Question #4
C.
Brachytherapy

Brachyterapy is, giving a high radiation dose to the
tumor while reducing the radiation exposure in the
surrounding healthy tissues by using radioactive seeds or
applicators placed in or near the tumor itself. It allows
use of a higher total dose of radiation to treat a smaller
area and in a shorter time than is possible with external
radiation treatment. It is given at a short distance:
internally, localized, precise, and high-tech. This is not
possible with lymph nodes. Some of the tumors treated
with: Breast , Lung, Esophageal, cervical, Anal/Rectal,
head and neck cancers and Sarcomas
Back to
Question 4
Incorrect. Question #4
C.
Brachytherapy

Brachyterapy is, giving a high radiation dose to the
tumor while reducing the radiation exposure in the
surrounding healthy tissues by using radioactive seeds or
applicators placed in or near the tumor itself. It allows
use of a higher total dose of radiation to treat a smaller
area and in a shorter time than is possible with external
radiation treatment. It is given at a short distance:
internally, localized, precise, and high-tech. This is not
possible with lymph nodes. Some of the tumors treated
with: Breast , Lung, Esophageal, Cervical, Anal/Rectal,
head and neck cancers and Sarcomas
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Case 4
Question
Correct. Question #4
D. External pelvic and abdominal radiation




Radiation therapy may be used in combination with other forms
of cancer treatment, or when surgery is not an option.
Radiotherapy uses high-energy rays to destroy or impede tumor
growth. External Beam Radiation Therapy, or EBRT involves
focusing a “beam” of radiation from an external source on the
cancerous internal organ and/or tissue.
Radiotherapy should be considered for women with endometrial
cancer who suffer a localized relapse following surgery. It can be
curative in a select group of previously non-irradiated women.
In the literature, long-term survival rates in women who undergo
irradiation after relapse range from 25 to 71 percent, with most
reporting five-year survival rates between 40 and 55 percent.
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Case
Incorrect. Question #4
E. Tamoxifen
 Tamoxifen, a selective estrogen receptor modulator
(SERM), appears to have some efficacy in women
with advanced endometrial cancer as a single
agent, with response rates of 10 to 22 percent .
 It is inactive in women who are resistant to
progestins or chemotherapy.
 Low-grade endometrial cancers are far more likely
to respond to tamoxifen than are high-grade
tumors. There is a more effective therapy for this
patient
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Question 4
Incorrect. Question #4
E. Tamoxifen
 Tamoxifen, a selective estrogen receptor modulator
(SERM), appears to have some efficacy in women
with advanced endometrial cancer as a single
agent, with response rates of 10 to 22 percent .
 It is inactive in women who are resistant to
progestins or chemotherapy.
 Low-grade endometrial cancers are far more likely
to respond to tamoxifen than are high-grade
tumors. There is a more effective therapy for this
patient
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Question
Case 4
Tamoxifen
 Licensed to University of California ©2006 UpToDate ®
 U.S. BRAND NAMES — Nolvadex®; Soltamox™
 PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Estrogen Receptor Antagonist
 USE — Palliative or adjunctive treatment of advanced
breast cancer; reduce the incidence of breast cancer in
women at high risk; reduce risk of invasive breast cancer in
women with ductal carcinoma in situ (DCIS); metastatic
female and male breast cancer
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Case
Tamoxifen
 Licensed to University of California ©2006 UpToDate ®
 U.S. BRAND NAMES — Nolvadex®; Soltamox™
 PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Estrogen Receptor Antagonist
 USE — Palliative or adjunctive treatment of advanced
breast cancer; reduce the incidence of breast cancer in
women at high risk; reduce risk of invasive breast cancer in
women with ductal carcinoma in situ (DCIS); metastatic
female and male breast cancer
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Incorrect Answers
Question #4 Incorrect Answers
A.
B.
C.
E.
Surgical removal of lymph node
Combined chemotherapy
Brachytherapy
Tamoxifen
Continue
Case
Case Continued
Six months later and 18 months after her diagnosis, Ms
Johnson receives external pelvic and abdominal
radiation.
A repeat MRI shows resolution of the enlarged lymph
node.
Mrs Johnson returns to your office and states; “ My
bladder is very painful, I have strong urgency with
frequent urination and sometimes lose my urine
before I get to the bathroom. Also my urine is very
bloody. Is it happening again?
Next
Question #5
What is the most likely diagnosis?
A.
B.
C.
D.
E.
Urinary tract infection
Estrogen loss cystitis
Irradiation cystitis
Recurrence of endometrial cancer
Detrusor instability
Incorrect. Question #5
A. Urinary tract infection
Because of a short urethra, urinary tract infection is
common in women but is usually not associated with
hematuria.
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Question 5
Incorrect. Question #5
A. Urinary tract infection
Because of a short urethra, urinary tract infection is
common in women but is usually not associated with
hematuria
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Case
Incorrect. Question #5
B. Estrogen loss cystitis


Estrogen deficiency may lead to vaginal atrophy
resulting in vaginal dryness and dyspareunia.
The mucosal lining of the vagina and urethra are
very sensitive to estrogen, and thinning of the
vaginal epithelium occurs after the menopause.
Estrogen deprivation is unlikely to cause bladder
inflammation.
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Question 5
Incorrect. Question #5
B. Estrogen loss cystitis


Estrogen deficiency may lead to vaginal atrophy
resulting in vaginal dryness and dyspareunia.
The mucosal lining of the vagina and urethra are
very sensitive to estrogen, and thinning of the
vaginal epithelium occurs after the menopause.
Estrogen deprivation is unlikely to cause bladder
inflammation.
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Case
Correct. Question #5
C. Irradiation cystitis
Radiation results in cell death, vasculitis, fibrosis and neuritis.
Early findings (<12 mo) are submucosal inflammation and fibrosis,
perineural inflammation, surface ulceration, and epithelial atypia
Late findings (>12 mo) include luminal occlusion, vascular ectasia,
and necrosis of vessel walls.
Acute symptoms consist of urgency, frequency, dysuria, and
hematuria.
Chronic symptoms are due to ischemia and fibrosis resulting in
contracted bladders, ulcer formation, fistulas, and bladder
dysfunction; therefore, clinical presentation can include frequency,
urgency, dysuria, hematuria, incontinence, hydronephrosis,
pneumaturia, and fecaluria.
Continue
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Case
Incorrect. Question #5
D. Recurrence of endometrial cancer
Since the lymph node has resolved, recurrence of the
endometrial cancer is less likely. Also endometrial
cancer does not commonly present as heamturia.
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Question 5
Incorrect. Question #5
D. Recurrence of endometrial cancer
Since the lymph node has resolved, recurrence of the
endometrial cancer is less likely. Also endometrial
cancer does not commonly present as heamturia.
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Case
Incorrect. Question # 5
E. Detrusor instability
Detrusor instability is due to uninhibited bladder
contractions of detrusor overactivity resulting in
urgency, frequency, and nocturia, and urge
incontinence but does not cause heamturia.
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Question 5
Incorrect. Question # 5
E. Detrusor instability
Detrusor instability is due to uninhibited bladder
contractions of detrusor overactivity resulting in
urgency, frequency, and nocturia, and urge
incontinence but does not cause heamturia.
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Case
Question #5 Incorrect Answers
A.
B.
D.
E.
Urinary tract infection
Estrogen loss cystitis
Recurrence of endometrial cancer
Detrusor instability
Continue
Case
Case Continued
She is treated with hyperbaric oxygen and alum
irrigation with good results.
Six months, later and 20 months after her diagnosis,
Ms Johnson calls your office. “I am really mad. My
daughter, who takes care of me, is being threatened
with termination from her job because of all the time
she has taken off work to help me during my
treatment.”
Next
Question #6
Which federal law best protects her caregiver?
A.
B.
C.
D.
E.
F.
American with disabilities act of 1990(ADA), P.L. 101-336
Family medical Leave Act of 1993 (FMLA), P.L. 103-3
Federal Rehabilitation Act of 1973, P.L. 93-112(amended
1998)
Employee Retirement Income Security Act of 1974
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA), P.L. 99-272
Health Insurance Portability and Accountability Act of
1996
Incorrect. Question #6
A. American with disabilities act of
1990(ADA), P.L. 101-336
The ADA prohibits employers with 15 or more
employees from treating a cancer survivor or the
family of a cancer survivor differently from other
employees. The ADA requires employees to make
reasonable accommodations to the survivor’s work
schedule, work environment or duties if needed.
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Question 6
Incorrect. Question #6
A. American with disabilities act of
1990(ADA), P.L. 101-336
The ADA prohibits employers with 15 or more
employees from treating a cancer survivor or the
family of a cancer survivor differently from other
employees. The ADA requires employees to make
reasonable accommodations to the survivor’s work
schedule, work environment or duties if needed.
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Case
Correct. Question #6
B.
Family medical Leave Act of 1993 (FMLA), P.L. 103-3

FMLA states: Subject to section 103, an eligible employee shall be entitled
to a total of 12 work weeks of leave during any 12-month period for any of
the following:
A) Birth of a son or daughter of the employee and in order to care for such
son or daughter.
(B) Placement of a son or daughter with the employee for adoption or foster
care.
(C) In order to care for the spouse, or a son, daughter, or parent, of the
employee, if such spouse, son, daughter, or parent has a serious health
condition.
(D) Serious health condition that makes the employee unable to perform the
functions of the position of such employee.
Employers with at least 50 employees are required to provide up to 12
weeks of unpaid leave to care for a spouse, child or oneself with a serious
medical condition. The leave need not be taken at once. The person is
entitled to health benefits and must be allowed to return to his or her job or
an equivalent position.
Continue
Teaching Points for
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Case





Incorrect. Question #6
C. Federal Rehabilitation Act of 1973, P.L. 93112(amended 1998)
This legislation bans discrimination of employees that are
not covered under the ADA. These include the Federal
Government, Federal contract receivers who have less
than 15 employees and Federal assistance receivers who
have less than 15 employees.
Back to
Question 6
Incorrect. Question #6
C. Federal Rehabilitation Act of 1973, P.L. 93112(amended 1998)
This legislation bans discrimination of employees that are
not covered under the ADA. These include the Federal
Government, Federal contract receivers who have less
than 15 employees and Federal assistance receivers who
have less than 15 employees.
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Case
Incorrect. Question #6
D. Employee Retirement Income Security Act of
1974
ERISA sets minimum standards for established pensions
and health plans in private industry and protects the
individuals in these plans. It stipulates that a person
cannot be fired because the employer thinks the
individual’s health care will cost too much.
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Question 6
Incorrect. Question #6
D. Employee Retirement Income Security Act of
1974
ERISA sets minimum standards for established pensions
and health plans in private industry and protects the
individuals in these plans. It stipulates that a person
cannot be fired because the employer thinks the
individual’s health care will cost too much.
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Case
Incorrect. Question #6
E. Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA),
P.L. 99-272
Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA), P.L. 99-272 is the legislation that
enables a worker at a company of more than 20
employees who must leave his/her job for health
reasons to continue to participate in the employer’s
group health plan. The employee must pay the full
monthly premium plus an administrative fee.
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Question 6
Incorrect. Question #6
E. Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA),
P.L. 99-272
Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA), P.L. 99-272 is the legislation that
enables a worker at a company of more than 20
employees who must leave his/her job for health
reasons to continue to participate in the employer’s
group health plan. The employee must pay the full
monthly premium plus an administrative fee.
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Case
Incorrect. Question # 6
F. Health Insurance Portability and Accountability
Act of 1996
Employees must be allowed to join a group health plan
without an exclusion or waiting period for coverage of
pre-existing conditions as long as they have had
continuous “credible” coverage without a break for 63
days.
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Question 6
Incorrect. Question # 6
F. Health Insurance Portability and Accountability
Act of 1996
Employees must be allowed to join a group health plan
without an exclusion or waiting period for coverage of
pre-existing conditions as long as they have had
continuous “credible” coverage without a break for 63
days.
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Case
Question #6 Incorrect Answers
A. American with disabilities act of 1990(ADA),
P.L. 101-336
C. Federal Rehabilitation Act of 1973, P.L. 93112(amended 1998)
D. Employee Retirement Income Security Act of
1974
E. Consolidated Omnibus Budget Reconciliation
Act of 1985 (COBRA), P.L. 99-272
F. Health Insurance Portability and Accountability
Act of 1996
Continue
Case
Case Continued
With the assistance of an employment attorney, her
daughter is able to retain her job.
You have a counseling session with Mrs. Johnson.
At the end of the visit she responds; “I was
concerned about the status of my cancer. My
diagnosis of cancer was made about 3 years ago. I
am relieved that you state that I am in remission. I
am now ready to face the fact that I am a cancer
survivor.”
Next
Question #7
How can her current status be best categorized?
A.
B.
C.
D.
Acute survivor
Extended survivor
Permanent survivor
End of life survivor
Incorrect. Question #7
A. Acute survivor
Begins at diagnosis and continues till end of
treatment. This “season of life” is dominated by
cancer treatment including medical, surgical and
radiological. Fear and anxiety are important elements
of this phase. Pain is common and the person for the
first time may have to deal with the fact that they
may die.
Back to
Question 7
Incorrect. Question #7
A. Acute survivor
Begins at diagnosis and continues till end of
treatment. This “season of life” is dominated by
cancer treatment including medical, surgical and
radiological. Fear and anxiety are important elements
of this phase. Pain is common and the person for the
first time may have to deal with the fact that they
may die.
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Correct. Question #7
B. Extended Survivor


Begins at the conclusion of treatment and lasts until the
risk of recurrence has decreased. This is the period of
watchful waiting, periodic examinations and
intermittent therapy. This phase is dominated by the
fear of recurrence.
The 5 year survival for endometrial cancer stage 2A is
about 78%. There is probably an increased of risk till 5
years after diagnosis, thus this patient is most likely an
extended survivor.
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Incorrect. Question #7
C. Permanent Survivor


The period when the activity of the disease or the
likelihood of its recurrence is sufficiently small that
the cancer can now be considered permanently
arrested.
This encompasses the duration of survivor’s life.
This is the period that the individual deals with
employment; insurance and discrimination issues.
Secondary effects such as sterility, secondary tumors,
and radiation effects are a concern.
Back to
Question 7
Incorrect. Question #7
C. Permanent Survivor


The period when the activity of the disease or the
likelihood of its recurrence is sufficiently small that
the cancer can now be considered permanently
arrested.
This encompasses the duration of survivor’s life.
This is the period that the individual deals with
employment; insurance and discrimination issues.
Secondary effects such as sterility, secondary tumors,
and radiation effects are a concern.
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Incorrect. Question #7
D. End of Life Survivor
Weeks or months at the end of life associated with
palliative care.
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Question 7
Incorrect. Question #7
D. End of Life Survivor
Weeks or months at the end of life associated with
palliative care.
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Question #7 Incorrect Answers
A. Acute Survivor
C. Permanent Survivor
D. End of Life Survivor
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