Download Cancer Guide - William S. Rosenberg, MD

ISSN 2152-0577
F
Ta R
ke E
on E
e
A Tr e a t m e n t a n d F a c i l i t i e s G u i d e f o r P a t i e n t s a n d T h e i r F a m i l i e s
PAT I ENT
RESOURCE
Cancer Guide
Interviews with cancer survivors
KAREEM ABDUL-JABBAR & JACLYN SMITH
Content reviewed by a distinguished medical advisory board
Seventh Edition, Vol. 2
November 2013 – April 2014
PRP PATIENT RESOURCE PUBLISHING ®
Helping to make access
to the therapies you need easier
Novartis Oncology is committed to helping patients living with cancer
receive the medicines they need. Patient Assistance NOW Oncology offers
quick and easy access to information about the broad array of support and
reimbursement programs available.
You can get information about our Patient Assistance NOW Oncology
support programs in 2 ways:
r
Call 1-800-282-7630 to speak with a member of our knowledgeable staff
dedicated to making access to our programs as simple and convenient
as possible; or
r
Visit our website at: www.OncologyAssistanceNow.com
Support for Patients Includes:
r Insurance verification
r Assistance with denials/appeals
r Coding/billing questions
r Patient assistance for low-income and
uninsured patients
r Medicare education
r Therapy-specific support programs for
out-of-pocket costs
r Alternative assistance searches and referrals
to federal or state assistance programs
r Referrals to independent charitable
foundations for assistance with co-pay costs
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936-1080
r Patients prequalified via phone screening
for the Patient Assistance Program (PAP)
will be sent a 30-day supply of their needed
medication while completing the application
r Convenient provider portal to access
program services or check the status
of patients enrolled
© 2012 Novartis
10/12
T-PAN-1052066
PA T I E N T R E S O U R C E
CANCER GUIDE
Seventh Edition, Vol. 2
Advisory Boards
Editor-in-Chief
Charles M. Balch, MD, FACS
Professor of Surgery, University of Texas
Southwestern Medical Center
Medical Advisory Board
Chief Executive Officer
Publisher
Editor-in-Chief
Senior Vice President
Vice President Operations
Managing Editor
Contributing Writers
Graphic Designer
Production Manager
Senior Director of Sales
Advertising Sales Director
Account Executives
Office Address
For Additional Information
Advisory Board
Mark A. Uhlig
Linette Atwood
Charles M. Balch, MD, FACS
Debby Easum
Leann Sandifar
Matt Smithmier
Lori Alexander, MTPW, ELS
Anna Braunsdorf
Kelli Schmidt
Jennifer Hiltunen
Stephanie Kenney
Amy Galey
Kathy Hungerford
Jessica Morrow
8455 Lenexa Drive
Overland Park, KS 66214
[email protected]
Visit our website at
PatientResource.com to
read bios of our medical
and patient advisory
board members.
For Additional Copies: To order additional copies of Patient Resource
Cancer Guide, visit www.patientresource.com, call 913-725-1600 or
email [email protected].
Editorial Submissions: Editorial submissions should be sent to
[email protected].
Disclaimer: Information presented in Patient Resource Cancer Guide
is not intended as a substitute for the advice given by your health care
provider. The opinions expressed in Patient Resource Cancer Guide are
those of the authors and do not necessarily reflect the views of the
publisher. Although Patient Resource Cancer Guide strives to present
only accurate information, readers should not consider it as professional
advice, which can only be given by a health care provider. Patient
Resource, its authors, and its agents shall not be responsible or in any
way liable for the continued currency of the information or for any errors,
omissions or inaccuracies in this publication, whether arising from
negligence or otherwise or for any consequences arising therefrom.
Patient Resource, its authors, and its agents make no representations
or warranties, whether express or implied, as to the accuracy,
completeness or timeliness of the information contained herein or
the results to be obtained from using the information. The publisher is
not engaged in rendering medical or other professional services. The
publication of advertisements, whether paid or not, and survivor stories
is not an endorsement. If medical or other expert assistance is required,
the services of a competent professional person should be sought.
© 2013 Patient Resource LLC. All rights reserved.
PRP PATIENT RESOURCE PUBLISHING®
For reprint information, email [email protected].
Pa t ie n tResource.com
James O. Armitage, MD
Professor, Internal Medicine, Section of
Hematology & Oncology, The Nebraska Medical
Center University Hospital
J. Max Austin Jr., MD
Professor of Gynecologic Oncology,
Department of Obstetrics and Gynecology,
U.A.B. Medical Center
Al B. Benson III, MD, FACP
Professor of Medicine, Associate Director
for Clinical Investigations, Robert H. Lurie
Comprehensive Cancer Center of
Northwestern University
Thomas A. Buchholz, MD, FACR
Professor and Chair, Department of
Radiation, The University of Texas MD
Anderson Cancer Center
Paul A. Bunn, MD
Executive Director, International Association
for the Study of Lung Cancer
James Dudley Endowed Professor of Lung
Cancer Research, University of Colorado School
of Medicine
Frederick L. Greene, MD
Clinical Professor of Surgery, University of
North Carolina School of Medicine
Jay R. Harris, MD
Professor and Chair, Department of Radiation
Oncology, Dana-Farber Cancer Institute,
Brigham and Women’s Hospital at Harvard
Medical School
Jimmie C. Holland, MD
Chairperson, Department of Psychiatry and
Behavioral Sciences, Memorial Sloan-Kettering
Cancer Center
Waun Ki Hong, MD
Chair of Medical Oncology, The University of
Texas MD Anderson Cancer Center
Gabriel N. Hortobagyi, MD, FACP
Professor of Medicine, Department of Breast
Medical Oncology, The University of Texas MD
Anderson Cancer Center
Mario E. Lacouture, MD
Dermatology Service, Department of Medicine,
Memorial Sloan-Kettering Cancer Center
LaSalle D. Leffall Jr., MD, FACS
Charles R. Drew Professor of Surgery,
Howard University
Martin A. Makary, MD, MPH, FACS
Minimally Invasive Cancer Surgeon,
Associate Professor of Surgery and Public
Health, Johns Hopkins University
John E. Niederhuber, MD
Executive Vice President and CEO,
Inova Translational Medicine Institute
CEO, Director, Inova Cancer Institute
Nicholas J. Petrelli, MD
Medical Director, Helen F. Graham Cancer Center
Raphael E. Pollock, MD
Chair of Surgery, The University of Texas MD
Anderson Cancer Center
Richard B. Reiling, MD
Medical Director, Presbyterian Cancer Center,
Charlotte, N.C.
William S. Rosenberg, MD
Neurosurgeon, Founder, Center for the Relief of
Pain, Kansas City, Mo.
President and Founder, Cancer Pain Research
Consortium
Thomas R. Russell, MD, FACS
Chairman of the Board of Directors,
American College of Surgeons Foundation
Peter T. Scardino, MD
Chair of Surgery, Chief of Urologic Oncology,
Head of the Prostate Cancer Research Program,
Memorial Sloan-Kettering Cancer Center
Donald L. Trump, MD, FACP
President and CEO, Roswell Park Cancer Institute
Terry T. Tsue, MD, FACS
Physician-in-Chief, University of Kansas
Cancer Center
David P. Winchester, MD
Director of Cancer Department,
American College of Surgeons
Chair Emeritus, Department of Surgery,
Evanston Northwestern Medical Center
Global Medical Advisory Board
Antonio Carlos Buzaid, MD
Chairman, Oncology Center of the Hospital São
José da Beneficencia
Portuguesa de São Paulo, Brazil
Eduardo Cazap, MD, PhD
President, Union for International Cancer
Control (UICC-Geneva)
Founder, First President, Latin American
& Caribbean Society of Medical Oncology
(SLACOM)
Alexander M.M. Eggermont, MD, PhD
General Director, Cancer Institute Gustave
Roussy, Villejuif-Paris
Jaime G. de la Garza, MD
Clinical Research Investigator,
Instituto Nacional de Cancerología, Mexico
Yuko Kitagawa, MD, PhD, FACS
Professor and Chairman, Department of Surgery,
Director of Keio Cancer Center,
Vice President of Keio University Hospital (Tokyo)
John F. Thompson, MD, FRACS, FACS
Professor of Melanoma and Surgical Oncology,
The University of Sydney, Australia
Umberto Veronesi, MD
Founder, European School of Oncology and
European Society of Surgical Oncology
Yi-Long Wu, MD
Vice-President, Guangdong General Hospital &
Guangdong Academy of Medical Sciences
Director, Guangdong Lung Cancer Institute
Patient Advisory Board
Alan J. Balch, PhD
CEO, National Patient Advocate Foundation
and Patient Advocate Foundation
Diane S. Blum, MSW
Past CEO, Lymphoma Research Foundation
Rosalie Canosa, MSW, LCSW-R, MPA
Program Division Director, CancerCare
Peggy Conlon
President and CEO, Ad Council
Nancy Davenport-Ennis
Founder and Chairman, Board of Directors,
National Patient Advocate Foundation and
Patient Advocate Foundation
Sam Donaldson
ABC Newscaster
Brian Garofalo
President, Patient Alliances, LLC
Lisa Greaves
Director, Integrated Media and Technology,
American Society of Clinical Oncology
Linda House, RN, BSN, MSM
Executive Vice President, External Affairs,
Cancer Support Community
Lillie D. Shockney, RN, BS, MAS
University Distinguished Service Associate
Professor of Breast Cancer
Director, Johns Hopkins Avon Foundation
Breast Center
Director, Johns Hopkins Survivorship Programs
Doug Ulman
President, LIVESTRONG Foundation
Louise Villejo
Executive Director for Patient Education, The
University of Texas MD Anderson Cancer Center
Armin D. Weinberg, PhD
CEO, Life Beyond Cancer Foundation
Professor of Medicine, Baylor College of Medicine
Co-Founder, Intercultural Cancer Council
1
Education Leads
to Empowerment
Table of Contents
What You Should Know to Understand Cancer ........................3
It’s OK to Seek a Second Opinion.................................................3
Dear Reader,
Cate Edwards: A Caregiver’s Perspective ....................................4
If you’ve recently been told you have cancer, you
might be wondering, “Now what?” You want to
educate yourself about your diagnosis, but the
amount of information available – both printed
and online – can be overwhelming.
Of the many emotions a cancer diagnosis can
elicit, at Patient Resource, we believe that confusion and isolation don’t have to be among
them. This guide and our companion website,
PatientResource.com, will point you toward reliable resources that will help you understand,
confront and take control of your disease. This is
not your battle to fight alone. An enormous and active cancer community stands ready to help you meet the challenges ahead.
Should You Participate In a Clinical Trial? ...............................10
Types of Treatments: Learn About Your Options ....................12
A Personalized Approach to Cancer Treatment .......................16
Finding Relief from Cancer Pain................................................18
Prevent or Control Side Effects...................................................22
Jaclyn Smith: Breast Cancer Patient Story.................................26
Types of Cancer
Lung Cancer Overview and Staging ..........................................28
Lung Cancer Treatment Options................................................30
Elizabeth Lacasia: Lung Cancer Patient Story ..........................31
Breast Cancer Overview and Staging.........................................32
In addition to support, self-education is also important. Education
leads to empowerment, and empowerment leads to self-advocacy.
By learning about your options, you will enable yourself to make
informed decisions about your care and treatment at every step of
your cancer journey. And your cancer team becomes immeasurably
stronger and more effective when you assume the role of an educated, active partner.
Breast Cancer Treatment Options ..............................................34
You can rely on the information in this Cancer Guide to be current,
medically accurate and understandable. You will not only find practical suggestions for finding a medical team, a second opinion and
the best treatment facilities for your needs, but you also will read inspiring stories from survivors who have been in your shoes. In addition, this guide includes an extensive directory of trusted resources
for medical, psychological and financial information.
Colorectal Cancer Treatment Options ......................................43
At Patient Resource, we are grateful and fortunate to benefit from
the remarkable breadth of knowledge and expertise of the distinguished Medical Advisory Board and Patient Advisory Board. You
can learn more about their accomplishments on our website. We
also thank our industry partners and advertisers, without whom
Cancer Guide would not be possible, and a special thanks to TEVA
Oncology, the exclusive distribution partner for this edition. Finally, we extend our sincere gratitude to you for reading and learning
as you embark on your cancer journey.
Melanoma Overview and Treatment Options ..........................53
We know that your best outcome depends on education, empowerment and advocacy throughout your cancer treatment. Knowledge
leads to sound choices, which in turn bring comfort and hope.
Misty Smith: Breast Cancer Patient Story .................................36
Prostate Cancer Overview and Staging .....................................37
Prostate Cancer Treatment Options ..........................................38
Len Dawson: Prostate Cancer Patient Story .............................40
Colorectal Cancer Overview and Staging .................................42
Mary Ellen Fleming-Jones: Colon Cancer Patient Story.........44
Leukemias and Multiple Myeloma .............................................45
Kareem Abdul-Jabbar: CML Patient Story ...............................46
Gynecologic Cancers Overview and Treatment Options........51
Anissa Norris: Cervical Cancer Patient Story...........................52
LeAnn Hankel: Melanoma Patient Story...................................54
Patient Resources
Financial Help for Patients & Families ......................................56
Advocacy & Assistance Resource Groups .................................61
Cancer Treatment Facilities
NCI-Designated Cancer Centers................................................72
Treatment Facilities by State .......................................................73
All the best,
Linette Atwood
Publisher
2
Charles M. Balch, MD, FACS
Editor-in-Chief
See page 112 to order additional guides.
Pa t i e n t Re s o u r ce .co m
understanding cancer | general information
What You Should Know
W
to Understand Cancer
While learning about cancer can seem like
a daunting task, it’s best to start with the basics. And with this disease, it all begins with
cells. Normal human cells, which are the basic units of the body, grow, divide and die in
a predictable and orderly way. As our bodies develop in childhood and adolescence,
our cells divide rapidly, but once we become
adults, most cells divide only to replace dying cells or repair injuries. Cancer cells, however, are abnormal cells of the human body
that grow and divide out of control quickly.
When cells continue to multiply even
when our body does not need new cells, they
can form a disorganized mass composed of
billions of cells called a tumor. A tumor can
be harmful (malignant) or harmless (benign) to your body. Cancer cells become
malignant because of changes or damage to
the genetic material (DNA) in the cell that
affects normal cell growth. A malignant tumor is called cancer.
Benign tumors, such as warts, polyps
and cysts, can usually be removed from the
body and ordinarily do not return. Cancer
cells, however, can penetrate and damage adjacent organs and tissues, a process
known as invasion. Cancer cells may also
break away from a malignant tumor and
spread to other parts of the body through
the bloodstream or lymphatic system, a
process known as metastasis.
Types of cancers
• Carcinomas are the most common cancers and include breast, lung and colon
cancers. Carcinomas grow from cells
that cover the outside of the body, such
as cells in the skin, as well as cells that
cover the internal body surfaces, such
as cells lining the lungs. These cancers
can invade surroundTypes of cancers
ing tissues and organs
and spread to the
lymph nodes.
• Melanomas are serious
forms of skin cancer.
They initially appear
on the surface of the
skin as a change in the
shape, size, color or feel
of a mole. Most malignant melanomas have
an area that is black
or blue-black in color.
If detected when they
first appear, they are
easy to treat. However,
if left untreated, they
can grow down into
the skin, reach blood
©Patient Resource LLC
vessels and lymphatic
vessels and spread through the body.
• Sarcomas grow from cells in connective
• Leukemias are immature cells arising in
or supportive tissue in the body, such
bone marrow that should have become
as bone, cartilage, joints, muscle, fat,
functioning white blood cells. If you
nerves, deep skin tissues and blood veshave leukemia, your bone marrow
sels. These are relatively rare, accounting
produces abnormally large numbers of
for about 1 percent of all cancers. They
white blood cells that block the producinclude bone tumors called osteosarcotion of the normal white blood cells,
mas, fat-tissue tumors called liposarcowhich help you fight infections, as well
mas and smooth-muscle tumors called
as red blood cells, which carry oxygen
leiomyosarcomas.
to tissues throughout your body.
• Lymphomas arise in lymph nodes and
other tissues of your immune system,
ADDITIONAL RESOURCES
which is the body’s defense against infecAmerican Society of Clinical Oncology
tions and some cancers. Immune system
(patient website): www.cancer.net
tissues, or lymphoid tissues, include your
National Cancer Institute: www.cancer.gov
tonsils and adenoids, spleen, thymus and
National Comprehensive Cancer Network:
bone marrow. The two major types of
www.nccn.org
lymphomas include Hodgkin lymphomas
OncoLink: www.oncolink.org
and non-Hodgkin lymphomas.
It’s OK to Seek a Second Opinion
A cancer treatment plan can be difficult
to understand, so you may decide you’d
like to consult with another doctor before
or even after you begin treatment. Hearing a new perspective can be helpful,
even if you have complete confidence in
your doctor’s judgment.
A second opinion involves asking another cancer specialist to review your
medical records, confirm your doctor’s
diagnosis and treatment plan, verify your
pathology report and stage of cancer,
and suggest alternatives to the proposed
Pa t ie n tResource.com
treatment plan. Another doctor might
suggest a different treatment approach
that your first doctor was not aware of,
and a new outlook may even change your
diagnosis. It’s important to hear arguments for all of your treatment options.
Many people feel worried to tell their
doctor they’re seeking a second opinion, but second opinions are a normal
part of cancer care, and some insurance
companies even require one. Most doctors are comfortable with such requests,
and yours may even help you find other
specialists to see. After you decide which
specialist you want to trust with your second opinion, ask your doctor to share the
results of any previous tests so you can
avoid repeating them.
New treatment information is continuously discovered, so it’s OK to look at
all of your options and speak to several
specialists before choosing the treatment that’s best for you. It’s a very important decision, and a second opinion
could better protect your quality of life
or even save it.
3
general information
caregiver
story
| subject
A Caregiver’s Perspective
Cate Edwards helped her mom, Elizabeth Edwards,
through two battles with breast cancer
ate Edwards is the daughter of former U.S. Senator and
vice presidential candidate John Edwards and author
and health care activist Elizabeth Edwards. She graduated with honors with a degree in political economics
from Princeton University and later graduated with a law
degree from Harvard Law School. Cate is currently practicing law as
well as serving as president of the Elizabeth Edwards Foundation,
which she started in her mother’s honor.
Cate Edwards was just 22 years old when her mother, Elizabeth,
was first diagnosed with breast cancer in November 2004. After getting over the initial shock, Cate, who had just graduated
from Princeton, returned home to help her mom figure out the
next steps.
“We decided to gear up and fight this thing,” Cate said. “We
figured it was going to be a short-term experience that would
hopefully end with her being cured.”
After undergoing treatment, Elizabeth’s cancer went into remission in 2006, but a follow-up scan a year later revealed that
the cancer had returned. The official diagnosis was Stage IV
metastatic breast cancer.
“The mentality in terms of her life and living was very different
because it wasn’t like we were going to stop everything to deal
with this cancer, which it was in the initial diagnosis period,” Cate
said. “Instead it was like we’re going to continue to live and live
life actually to its fullest. It was her goal to make every single day
count, so that was a different mentality in a lot of ways.”
Cate was one of her mom’s primary caregivers while she was
undergoing treatment
with chemotherapy,
hormone therapy and
radiation therapy—as
well as fighting side
effects such as fatigue and back pain.
“There were days
where she had trouble
moving around a lot,
and that just meant
I had to be a support
for her in a different
way,” Cate said. “So
I’d crawl into bed with
her and watch HGTV
C at e
How to Offer Your Help to a Loved One
As a patient’s loved one, you undoubtedly have wonderful intentions when you ask, “How can I help?” And you truly mean it
when you say, “Call me if you need anything.” However, patients
often have a hard time figuring out exactly what they need help
with while undergoing treatment. Then, if they do decide, they
have difficulty deciding how to delegate.
The solution? Be direct about what you would like to do and
Photo: David Plakke
when you’re available to do it. The more specific you are, the
more likely your loved one will accept your offer of assistance.
When deciding what help to offer, think about how much time
you have and what you are good at doing. The following chart
can help you generate some possibilities. Both big and small
gestures will be appreciated, so make sure you only commit to
tasks with which you’re sure you can follow through.
Ideas for offering help
Talent:
Task:
If you’re good at… Volunteer to…
How to ask/offer
Communicating
Be the
spokesperson
This can alleviate the patient’s burden of telling the same story
multiple times to different family members and friends.
“Would you like me to set up a blog or email group and send
out daily/weekly updates to your family and friends?”
Cooking
Cook meals (using
Healthy eating is important during treatment; in addition,
cooking takes time and energy, which patients often don’t have.
“I’m going to swing by with a few frozen meals that you
can easily reheat. Do you have any preferences or food
allergies?”
disposable containers
if possible)
4
Why it is helpful
Organizing
Help with
paperwork
Disease comes with a lot of paperwork, which can quickly
become overwhelming. Help your loved one fill out forms, get
bills ready to mail, track insurance claims and more, and/or
assist with setting up an organizational filing system.
“I swung by the store on my way over and picked up some
organizational supplies for you. Do you want any other help
staying on top of all your medical paperwork?”
Driving
Drive the patient
Patients often have numerous doctors’ appointments and
sometimes can’t drive themselves.
“I’m home all day anyway, so if you give me your
appointment schedule, I’ll be happy to drive you.”
Drive the
patient’s family
Patients may not have the time or energy to drive themselves
places, let alone their families.
“Because our children are in the same activities, don’t worry
about driving. I’ll just plan to drop off and pick up both of
them unless you tell me differently!”
Pa t i e n t Re s o u r ce .co m
subject | general information
or a ‘House’ marathon—that was one of her favorite shows. We
did a lot of just cozying up and being lazy together, and that was
really meaningful in its own way.”
Elizabeth also suffered from extreme skin dryness and flaking
on her hands and feet.
“She used to do this thing where she would rub her feet with
Udder Cream, and then wrap them in Saran Wrap and put on
socks to help moisturize them,” Cate said. “So we did that together a few times. And my husband actually came to stay with
her, and she made him do it, too. I walked in one day and saw
him with his Udder Cream and his socks on the couch with my
mom. So sometimes it was little things that made a difference
and sort of made her feel more normal.”
While Cate’s focus was solely on taking care of her mom, she
later realized it was just as important to take care of herself.
“It’s difficult when your loved one is going through cancer to
say, ‘What about me?’” Cate said. “But the reality is that’s not
the right mentality. It’s also hard on us as family members and
loved ones, and that’s okay. To be there the best I could for her, I
think it would have been smarter of me to try to take better care
of myself.”
Fortunately, Cate did receive a lot of support from her husband,
family and friends even when she didn’t ask for it. But now, as
part of the Count Us, Know Us, Join Us advanced breast cancer
community, Cate encourages caregivers to actively seek support.
“Looking for a support system is one thing that’s really important, and I’m not sure caregivers recognize that,” Cate said.
“Our website (www.advancedbreastcancercommunity.org) provides resources and support that are really useful for everyone
in this community, including caregivers and family members. So
Talent
Task
If you’re good at… Volunteer to…
Cate and her mom Elizabeth enjoy spending time together.
I would encourage people to go there to find out more about
what they can do.”
As for knowing what to expect as a caregiver, Cate says it’s
hard to predict.
“Every patient is different. Their needs are different. So keeping the line of communication open and being willing to talk about
the disease, how the patient is feeling on a day-to-day basis and
what their needs are is vital,” Cate said. “Even if it’s something
like mowing the lawn; even if it’s making a grocery store run;
even if it’s picking up prescriptions. Those things make a big
difference. But every patient is different, so talking to them
about their needs I think is a really important aspect of being a
good caregiver.”
Why it is helpful
How to ask/offer
Cleaning
Take on some
household chores
Household chores often take a backseat to everything else that
comes with a serious illness.
“I just finished washing my windows and I’m in the zone.
Can I come over and do yours, too?”
Caring for
children
Babysit
Children have a lot of energy and crave fun and attention.
Patients who are parents sometimes can’t provide that and/or
simply need a break.
“I’ve really been wanting to see that new animated movie.
Do you think your children would want to come along?”
Loving on animals Help with the
family pets
Pets can be affected by the stress of the situation, too, so a
little love and attention can go a long way.
“I usually have some extra time during my lunch breaks.
Could I borrow your dog for a walk around noon on
weekdays?”
Educating or
advocating
Tag along
to doctor’s
appointments
Doctor’s appointments can be extremely overwhelming and
anxiety-inducing for patients. Four ears are better than two for
listening and remembering. In addition, your loved one may
want or need some help advocating for his or her wishes.
“I can never remember anything my doctor says. Do you
want me to tag along to your next appointment and take
some notes?”
Crafting
Teach and/or
share a hobby
Patients often get restless when they’re stuck at home. If you
“I never knew how relaxing knitting could be! I have some
know how to knit, sew, paint, bead, quilt or something else,
extra needles and would be happy to teach you. How does
teach your loved one. You will not only create a reason to spend Tuesday night sound?”
time together, you will also alleviate boredom.
Working outdoors
Mow the lawn
Yard work is physically exhausting, and many patients don’t
have the stamina for it.
“The weather is beautiful and I’m looking for an excuse to
be outside. Does your lawn need mowing?”
Shovel snow from
the sidewalk and
driveway
During the winter, shoveling is a necessary task, but it can be
an impossible one for patients.
Something like this is sometimes better done
without asking.
Shopping
Grocery shop
The need to eat never goes away, but it is sometimes too
difficult for patients to get to the store.
“I’m heading to the grocery store and only have a few things
on my list. Can I pick up anything for you while I’m there?”
Fixing things
Repair broken
items around the
house
Serious illness can quickly strain a patient’s budget, leaving
little room to pay a handyman.
“I just fixed my garbage disposal. Who knew I was so
handy? Does anything at your house need to be repaired?”
Pa t ie n tResource.com
5
Persons shown are not actual patients.
Currently available data have not shown an
increase in overall survival. Additional data
will be available in the future.
I think of AFINITOR as hormone therapy PLUS—
combined with exemestane, it gives me MORE.
MORE out of my hormone treatment.
MORE time before progression.
MORE in the moment.
AFINITOR® (everolimus) Tablets is a prescription
medicine used to treat advanced hormone
receptor-positive, HER2-negative breast cancer, along
with the medicine exemestane, in postmenopausal
women who have already received certain other
medicines for their cancer.
If you’re a postmenopausal woman with advanced hormone
receptor-positive, HER2-negative breast cancer, you now have a
treatment choice that offers you MORE than hormone therapy alone:
AFINITOR combined with exemestane tablets. AFINITOR is the first
treatment in 10 years to be specifically approved for HR+, HER2metastatic breast cancer patients. Adding AFINITOR to the hormone
therapy exemestane is proven to extend the hormone therapy’s
benefits, more than doubling the time before cancer progression
compared to exemestane alone.
The median progression-free period was 7.8 months with AFINITOR
plus exemestane vs 3.2 months with exemestane alone. AFINITOR is
offered in a once-daily dose.
Learn MORE. Ask your doctor about AFINITOR.
Important Safety Information
Patients should not take AFINITOR if they are allergic to AFINITOR
or to any of its ingredients. Patients should tell their healthcare
provider before taking AFINITOR if they are allergic to sirolimus
(Rapamune®) or temsirolimus (Torisel®).
Learn more at PLUS-AFINITOR.com.
Hormone therapy
Exemestane is available in the US under the brand name Aromasin® from Pfizer. It is also available in generic form.
PLUS.
IMPORTANT SAFETY INFORMATION
Patients should not take AFINITOR if they are allergic to AFINITOR
or to any of its ingredients. Patients should tell their healthcare
provider before taking AFINITOR if they are allergic to sirolimus
(Rapamune®) or temsirolimus (Torisel®).
AFINITOR can cause serious side effects, which can even lead to
death. If patients experience these side effects, they may need
to stop taking AFINITOR for a while or use a lower dose. Patients
should follow their healthcare provider’s instructions. Serious side
effects include:
Lung or Breathing Problems: In some patients, lung or breathing
problems may be severe and can even lead to death. Patients
should tell their healthcare provider right away if they have any of
these symptoms: new or worsening cough, shortness of breath,
chest pain, difficulty breathing, or wheezing.
Infections: AFINITOR may make patients more likely to develop
an infection, such as pneumonia, or a bacterial, fungal, or viral
infection. Viral infections may include reactivation of hepatitis B in
people who have had hepatitis B in the past. In some people these
infections may be severe and can even lead to death. Patients
may need to be treated as soon as possible. Patients should tell
their healthcare provider right away if they have a temperature of
100.5˚F or above, chills, or do not feel well. Symptoms of hepatitis
B or infection may include the following: fever, chills, skin rash,
joint pain and inflammation, tiredness, loss of appetite, nausea,
pale stools or dark urine, yellowing of the skin, or pain in the
upper right side of the stomach.
Kidney Failure: Patients taking AFINITOR may develop kidney
failure. In some people this may be severe and can even lead to
death. Patients should have tests to check their kidney function
before and during their treatment with AFINITOR.
Before taking AFINITOR, tell your healthcare provider about all
your medical conditions, including if you:
Have or have had kidney problems
Have or have had liver problems
Have diabetes or high blood sugar
Have high blood cholesterol levels
Have any infections
Previously had hepatitis B
Are scheduled to receive any vaccinations. You should not
receive a live vaccine or be around people who have recently
received a live vaccine during your treatment with AFINITOR. If
you are not sure about the type of vaccine, ask your healthcare
provider
ƒ Have other medical conditions
ƒ Are pregnant or could become pregnant. AFINITOR can cause
harm to your unborn baby. You should use effective birth control
while using AFINITOR and for 8 weeks after stopping treatment
ƒ Are breastfeeding or plan to breastfeed. You and your healthcare
provider should decide if you will take AFINITOR or breastfeed.
You should not do both
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Tell your healthcare provider about all of the medicines you take,
including prescription and nonprescription medicines, vitamins,
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936-1080
and herbal supplements. Using AFINITOR with certain other
medicines can cause serious side effects. Keep a list of medicines
you take and show it to your healthcare provider when you get a
new medicine. Especially tell your healthcare provider if you take
St. John’s wort (Hypericum perforatum), medicines that weaken
your immune system (your body’s ability to fight infections and
other problems), or medicines for:
ƒ Seizures
ƒ Fungal infections
ƒ HIV-AIDS
ƒ Bacterial infections
ƒ Heart conditions or high
ƒ Tuberculosis
blood pressure
If you are taking any medicines for the conditions previously
listed, your healthcare provider might need to prescribe a
different medicine or your dose of AFINITOR may need to be
changed. Tell your healthcare provider before you start taking
any new medicine.
Common Side Effects: Common side effects include mouth
ulcers. AFINITOR can cause mouth ulcers and sores. Tell your
healthcare provider if you have pain, discomfort, or open sores in
your mouth. Your healthcare provider may tell you to use a special
mouthwash or gel that does not contain alcohol, peroxide, iodine,
or thyme.
Other common side effects include:
Infections
Feeling weak or tired
Cough, shortness of breath
Diarrhea and constipation
Rash, dry skin, and itching
Nausea and vomiting
Fever
Loss of appetite,
weight loss
ƒ Swelling of arms, hands,
feet, ankles, face, or other
parts of the body
ƒ Abnormal taste
ƒ Dry mouth
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ Inflammation of the lining
of the digestive system
ƒ Headache
ƒ Nose bleeds
ƒ Pain in arms and legs,
mouth and throat, back
or joints
ƒ High blood glucose
ƒ High blood pressure
ƒ Difficulty sleeping
ƒ Hair loss
ƒ Muscle spasms
ƒ Feeling dizzy
ƒ Nail disorders
Tell your healthcare provider if you have any side effect that
bothers you or does not go away.
These are not all the possible side effects of AFINITOR.
For more information, ask your healthcare provider or pharmacist.
Call your doctor for medical advice about side effects.
You are encouraged to report negative side effects of
prescription drugs to the FDA. Visit www.fda.gov/medwatch
or call 1-800-FDA-1088.
Please see Brief Summary of Prescribing Information
on adjacent pages.
The brands listed are the trademarks or registered trademarks
of their respective owners and are not trademarks or register
marks of Novartis.
© 2013 Novartis
3/13
AFB-1052568
Brief Summary of Important Risk Information. This information does not take the place of talking with your
doctor about your medical condition or treatment.
AFINITOR® (everolimus) Tablets
What is AFINITOR?
AFINITOR® (everolimus) Tablets is a prescription medicine used to treat advanced hormone receptor-positive, HER2-negative breast cancer, along with the medicine
exemestane, in postmenopausal women who have already received certain other medicines for their cancer.
What is the most important information I should know about AFINITOR?
AFINITOR can cause serious side effects. These serious side effects include:
1. You may develop lung or breathing problems.
In some people lung or breathing problems may
be severe and can even lead to death. Tell your
healthcare provider right away if you have any of
these symptoms:
s.EWORWORSENINGCOUGH
s3HORTNESSOFBREATH
s#HESTPAIN
s$IFFICULTYBREATHING
s7HEEZING
2. You may be more likely to develop an infection,
such as pneumonia, or a bacterial, fungal, or viral
infection.
Viral infections may include active hepatitis B
in people who have had hepatitis B in the past
(reactivation). In some people these infections may
be severe and can even lead to death. You may
need to be treated as soon as possible. Tell your
healthcare provider right away if you have a
temperature of 100.5°F or above, chills, or do not
feel well.
3. You may develop kidney failure.
In some people this may be severe and can even
lead to death. Your healthcare provider should do
tests to check your kidney function before and
during your treatment with AFINITOR.
3YMPTOMSOFHEPATITIS"ORINFECTIONMAYINCLUDE
the following:
s Pale stools or
s Fever
dark urine
s #HILLS
s Yellowing of the
s 3KINRASH
skin
s Joint pain and
s Pain in the upper
inflammation
right side of the
s Tiredness
stomach
s Loss of appetite
s Nausea
If you have any of the serious side effects listed above, you may need to stop taking
AFINITOR for a while or use a lower dose. Follow your healthcare provider’s instructions.
Who should not take AFINITOR?
$ONOTTAKE!&).)4/2IFYOUAREALLERGICTOEVEROLIMUSORTOANYOFTHEINGREDIENTSIN!&).)4/23EEFULL0RESCRIBING)NFORMATIon for a complete list of ingredients
in AFINITOR.
Talk to your healthcare provider before taking this medicine if you are allergic to:
sSIROLIMUS2APAMUNE®)
sTEMSIROLIMUSTorisel®)
Ask your healthcare provider if you do not know.
What should I tell my healthcare provider before taking AFINITOR?
Tell your healthcare provider about all of your medical conditions, including if you (check all that apply):
Have high blood cholesterol levels
Are scheduled to receive any vaccinations.
You should not receive a live vaccine or be
around people who have recently received a live
vaccine during your treatment with AFINITOR. If
you are not sure about the type of immunization
or vaccine, ask your healthcare provider.
Have any infections
Have other medical conditions
Have or have had kidney problems
Have or have had liver problems
Have diabetes or high blood sugar
Previously had hepatitis B
Are pregnant, or could become pregnant.
AFINITOR can cause harm to your unborn baby.
You should use effective birth control while
using AFINITOR and for 8 weeks after stopping
treatment.
Are breastfeeding or plan to breastfeed. It is not
known if AFINITOR passes into your breast milk.
You and your healthcare provider should decide if
you will take AFINITOR or breastfeed. You should
not do both.
If you have checked any of the boxes above, be sure to discuss with your doctor before taking AFINITOR.
Tell your healthcare provider about all of the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. AFINITOR
may affect the way other medicines work, and other medicines can affect how AFINITOR works. Using AFINITOR with other medicines can cause serious side effects.
Know the medicines you take. Keep a list of them, and show it to your healthcare provider and pharmacist when you get a new medicine. Especially tell your healthcare
provider if you take:
s St. John’s wort (Hypericum perforatum)
s Medicine for:
s Medicines that weaken your immune system (your
body’s ability to fight infections and other
– HIV-AIDS
– Fungal infections
problems)
– Heart conditions
– Bacterial infections
or high blood
– Tuberculosis
pressure
– Seizures
Ask your healthcare provider or pharmacist if you are not sure if your medicine is one of those taken for the conditions listed above. If you are taking any medicines
for the conditions listed above, your healthcare provider might need to prescribe a different medicine or your dose of AFINITOR may need to be changed. You should
also tell your healthcare provider before you start taking any new medicine.
How should I take AFINITOR?
Your healthcare provider will prescribe the dose of AFINITOR that is right for you. Take AFINITOR exactly as your healthcare provider tells you to. Your healthcare
provider may change your dose of AFINITOR if needed.
s Use scissors to open the blister pack
s Swallow AFINITOR tablets whole with a glass of water. Do not take any tablet
that is broken or crushed
s Take AFINITOR 1 time each day at about the same time
s Take AFINITOR the same way each time, either with food or without food
s If you take too much AFINITOR contact your healthcare provider or go to
the nearest hospital emergency department right away. Take the pack of
AFINITOR with you
s If you miss a dose of AFINITOR, you may still take it up to 6 hours after the
time you normally take it. If it is more than 6 hours after you normally take
your AFINITOR, skip the dose for that day. The next day, take AFINITOR at
your usual time. Do not take 2 doses to make up for the 1 that you missed.
If you are not sure about what to do, call your healthcare provider
s You should have blood tests before you start AFINITOR and as needed
during your treatment. These will include tests to check your blood cell
count, kidney and liver function, cholesterol, and blood sugar levels
What should I avoid while taking AFINITOR?
You should not drink grapefruit juice or eat grapefruit during your treatment with AFINITOR. It may make the amount of AFINITOR in your blood increase
to a harmful level.
What are the possible side effects of AFINITOR?
AFINITOR can cause serious side effects. See “What is the most important information I should know about AFINITOR?” for more information.
Common side effects of AFINITOR in people with advanced hormone receptor-positive, HER2-negative breast cancer include:
s Mouth ulcers. AFINITOR can cause mouth ulcers
and sores. Tell your healthcare provider if you
have pain, discomfort, or open sores in your
mouth. Your healthcare provider may tell you to
use a special mouthwash or mouth gel that does
not contain alcohol, peroxide, iodine, or thyme
s Infections
s Feeling weak or tired
s Cough, shortness of breath
s Diarrhea and constipation
s
s
s
s
s
s
s
s
s
s
Rash, dry skin, and itching
Nausea and vomiting
Fever
Loss of appetite, weight loss
Swelling of arms, hands, feet, ankles, face or
other parts of the body
Abnormal taste
Dry mouth
Inflammation of lining of the digestive system
Headache
Nose bleeds
s Pain in arms and legs, mouth and throat, back
or joints
s High blood glucose
s High blood pressure
s Difficulty sleeping
s Hair loss
s Muscle spasms
s Feeling dizzy
s Nail disorders
Tell your healthcare provider if you have any side effect that bothers you or does not go away. These are not all the possible side effects
of AFINITOR. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects.
You may report side effects to the FDA at 1-800-FDA-1088.
Keep AFINITOR and all medicines out of the reach of children.
General information about AFINITOR
Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use AFINITOR for a condition for which it was not
prescribed. Do not give AFINITOR to other people, even if they have the same symptoms or condition you have. It may harm them.
This leaflet summarizes the most important information about AFINITOR. If you would like more information, talk with your healthcare provider. You can ask your
healthcare provider or pharmacist for information written for healthcare professionals. For more information call 1-888-423-4648 or go to www.AFINITOR.com.
Manufactured by:
Novartis Pharma Stein AG
Stein, Switzerland
Distributed by:
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936-1080
© 2013 Novartis
3/13
The brands listed are the trademarks or registered trademarks of their respective owners and are not trademarks or register marks of Novartis.
AFB-1052568
general information | clinical trials
N
Should You Participate in a Clinical Trial?
Nearly all of the cancer-fighting drugs and
devices currently available exist only because
they were thoroughly tested beforehand.
These tests, known as clinical trials, are research studies designed to evaluate the safety
and effectiveness of new drugs or other types
of therapies. They are conducted in humans
only after they have been tested and found
to be safe and promising in laboratory and
animal studies. The trials, which are generally conducted in academic and community
cancer centers, are developed to evaluate different methods of treatment.
Before deciding whether or not to participate, learn how clinical trials are carried out,
the types and phases of trials, and the benefits and risks.
Types of cancer clinical trials
Five types of cancer clinical trials exist.
Treatment trials and quality-of-life trials are
specifically for individuals who have cancer.
Prevention, screening and diagnostic trials are often done among broader groups
of individuals, many of whom do not have
cancer. The information here is limited to
treatment trials. These evaluate whether a
new treatment (e.g., drug, surgery, radiation
therapy) or new combination of treatments
is better than the treatment currently considered to be the standard of care.
Biologic therapies
Many of the clinical trials conducted in the
last several years have focused on biologic
therapies. Some biologics work with your
immune system while others act directly
against the cancer cell. The purpose of biologic trials is to find the specific weakness
of cancer cells to different agents. Biologic
trials may examine how effective multiagent biologics are with or without standard
chemotherapy treatments.
Understanding treatment trials
Most treatment trials are done as part of
the development of a new drug or therapy
after the agent has been shown to destroy
cancer cells in studies of animal models
or cancer cells grown in the laboratory.
The U.S. Food and Drug Administration
(FDA) reviews the results and approves (or
rejects) the use of the drug in studies with
humans. Some cancer treatment clinical
trials involve a drug that has already been
approved by the FDA but for a type of cancer different from the one to be studied in
the current clinical trial.
Cancer treatment trials are designed in
phases, with each trial providing the building blocks of knowledge for the next trial
10
phase. These clinical trials are classified as
phase I, II or III.
Phase I trials are the first studies in which
a new drug or treatment is evaluated in humans. The goal is to determine how the drug
should be given (e.g., orally or intravenously), how often the drug should be given and
what dosage is most effective for killing cancer cells while causing the fewest side effects.
The goal of phase II trials is to determine
how well a drug works and how safe it is in
a greater number of patients. Phase II trials
usually involve participants that have the
same type of cancer.
Phase III trials compare the new drug
with the current standard of care. Phase III
trials are also done to evaluate other types
of treatment, such as radiation and surgery,
and combinations of treatments. Phase III
participants are randomly assigned to receive either the experimental drug or treatment or the current standard treatment.
Phase III trials often involve patients
treated at many different treatment facilities to determine the benefit among a broad
representation of participants. Patients are
usually followed for several years after treatment so that long-term survival benefit and
other outcomes (such as late side effects)
can be determined. Most studies are blinded, which means information about which
treatment group each study participant is in
is not given to researchers or participants.
Blinding helps prevent the results from being influenced by the expectations of the researchers or participants.
When the results of a phase III trial indicate that a new drug leads to better outcomes
for patients and is safe (the side effects are
minimal and/or manageable), a special committee reviews the results and then recommends approval of the drug by the FDA.
Ensuring your safety
Every trial has several levels of safeguards
and follows a set of rules called a protocol.
The protocol defines the eligibility criteria,
specifies the tests to be done and the procedures to be used, describes the medications
and their doses, and decides the length of
the study. Before the study begins, a scientific review panel evaluates the protocol carefully to make sure the trial is based on sound
science. An institutional review board (IRB)
also evaluates the protocol to ensure that
patients will be treated ethically and that
the risks involved in the trial are reasonable
compared with the possible benefits.
A second safeguard is the informed consent process, which requires that the research team explain all the details about
the trial, including the purpose, tests and
treatment involved, and possible risks and
benefits, so that you can make an informed
decision about volunteering for the trial.
The third safeguard is safety monitoring throughout the trial. Both the IRB and
a special committee monitor the trial to
reduce potential risks. The committee will
stop a trial if safety concerns arise or if either
the experimental treatment or the standard
treatment is overwhelmingly more beneficial than the trial agents.
What to expect if you participate
The research team will give you specific instructions, evaluate your health at the beginning of the trial, monitor it carefully during
the trial, and stay in touch after it ends. To
receive the greatest benefit, you should carefully follow the instructions and remain in
contact with the research staff. Trials may
be conducted in a hospital, doctor’s office
or community clinic, and health insurance
usually covers the costs of treatment.
Evaluating benefits vs. risks
There is a risk that a new treatment may not
be effective for you. You may experience serious, unpleasant or life-threatening side effects
from the treatment. In addition, your protocol
may require more time spent at the study site,
additional hospitalization or complex dosage
requirements. However, clinical trials also
give you access to new treatments not widely
available as well as cutting-edge medical care.
By participating in medical research, you also
help others with a similar disease to share the
benefits of new discoveries.
ADDITIONAL RESOURCES
BreastCancerTrials.org:
www.breastcancertrials.org
Center for Information and Study on
Clinical Research Participation:
www.searchclinicaltrials.org
CenterWatch: www.centerwatch.com
Clinical Trials Advocacy Group (Prostate
Cancer): www.cancertrials4prostate.org
Clinical Trials Search:
www.clinicaltrialssearch.org
Coalition of Cancer Cooperative Groups:
www.cancertrialshelp.org
EmergingMed Navigator:
www.emergingmed.com
My Clinical Trial Locator:
http://myclinicaltriallocator.com
National Cancer Institute:
www.cancer.gov/clinicaltrials/search
National Comprehensive Cancer Network:
www.nccn.org/patients/default.asp
National Institutes of Health:
www.clinicaltrials.gov
Pa t i e n t Re s o u r ce .co m
Investigational Clinical
Study Now Enrolling
ALTERNATIVE (EGF114299): A Phase III Open-Label Study
of Lapatinib, Trastuzumab, and Endocrine Therapy in Patients Who
Received Neo-/Adjuvant or First-line Trastuzumab (IV) and Endocrine Therapy
You may be eligible for the study if you meet the
following requirements:
U You are a postmenopausal woman with breast cancer
tumors that are HER2+/HR+ (ER+ and/or PR+) that
have spread to other parts of your body (metastatic
breast cancer, MBC)
U You have previously received endocrine therapy
(antihormonal therapies such as aromatase
inhibitors and selective estrogen receptor modulators)
U You have previously received treatment with
trastuzumab in combination with chemotherapy
(directly before or after breast cancer surgery [neoadjuvant or adjuvant] and/or as first-line treatment
for MBC)
– You have received no more than one trastuzumabcontaining regimen for MBC
– If this clinical trial would provide your second-line
of therapy for MBC, your MBC must have
progressed during or following the first-line therapy
U You have adequate organ function, as determined by
your study doctor
U Your study doctor determines that you should not
receive chemotherapy at this time for treatment of
your MBC
1st or 2nd line MBC
Target enrollment:
525 patients
You would not be eligible for the study if you meet
any of the following requirements:
U Your breast cancer has spread to your brain and/or
central nervous system
U You have any of the following serious heart conditions
– Irregular heartbeat (arrhythmia) that is not under
control with medications
– Chest pain (angina) that is not under control
with medications
– A history of congestive heart failure
– A heart attack (myocardial infarction) within
6 months of entering the trial
U You have current, active liver or bile duct disease
Monthly study-related medical procedures that are not
standard of care are provided at no cost to participants.
Study Design
Each of the drugs provided in this study are approved to
treat MBC in the US. However, some of the drug combinations provided in this study (lapatinib+anastrozole,
lapatinib+exemestane, trastuzumab+AI and lapatinib+
trastuzumab+AI) are considered investigational.
If you can participate, you will receive
1 of 3 possible treatments. You have
the same chance of receiving any of
these treatments.
Lapatinib + Trastuzumab + AI*
Trastuzumab + AI*
Lapatinib + AI*
*AI = Aromatase Inhibitor chosen by your doctor - letrozole, anastronzole, or exemestane
Contact:
US GSK Clinical Trials Call Center
877-379-3718 or [email protected]
For more information, please
visit: www.clinicaltrials.gov
(identifier NCT01160211)
general information | types of treatment
Types of Treatments
T
Learn About Your Options
The type of cancer treatment or combination of treatments your doctor recommends
depends on several factors. These include
the type of cancer you have, the stage of disease, your age, overall health and family history. The three main cancer treatments are
surgery, chemotherapy and radiation therapy. However, new drugs and other types of
treatments are continually being developed
– such as targeted therapy, hormone therapy,
biologic therapy, stem cell transplantation
and ultrasound therapy – which provide
more options and can be used alone or in
combination with the three main treatment
types. These new options offer renewed
hope of better outcomes for cancer patients.
Your treatment plan will include the primary treatment, which is the definitive treatment designed to potentially eliminate the
disease. Often, surgery is the primary treatment, but radiation therapy or chemotherapy
also may be primary treatment approaches.
In some cases, your treatment plan will
include an additional treatment, known as
adjuvant therapy. Adjuvant therapy is given
after primary treatment to destroy any microscopic deposits of cancer cells that may
remain or that may be too small for laboratory testing or imaging studies to detect.
This follow-up treatment decreases the risk
of your cancer coming back (recurring),
which can help increase your survival.
Finally, your treatment plan may include
neoadjuvant therapy, which is given before
the primary treatment. The purpose of neoadjuvant therapy is to help shrink a tumor,
often to make it easier to surgically remove.
Surgery
The treatment for most people with a solid
cancerous tumor is some type of surgical
procedure. Surgically removing a tumor
offers the best chance for cure, especially
if cancer cells have not spread beyond the
original site to other parts of the body. Surgery also may be useful in staging a cancer
and in relieving or preventing symptoms
that might otherwise occur later.
Many advances have been made in the
techniques used for removing tumors, including minimally invasive approaches such
as laparoscopy and robotic surgery. These
new techniques increase the likelihood of
a shorter recovery time with fewer side effects, but they may not be the best option for
some people.
Radiation therapy
Radiation therapy is the use of high-energy
X-rays or proton beams to destroy or damage cancer cells. These treatments are given
either externally with radiation machines
called linear accelerators or cobalt machines, or given internally through radioactive material implanted in the body, swallowed or injected.
External-beam radiation therapy is the
most common type and is used for a wide
variety of cancers. This type of treatment
is similar to a conventional X-ray, except
the radiation beams are strong enough to
kill cancer cells. New techniques, such as
intensity-modulated radiation therapy, enable doctors to target the radiation dose
directly on the precise site of the tumor,
causing less damage to healthy cells in the
pathway of the radiation beam.
Radiation therapy can also be delivered
directly through radioactive seeds implanted in or near a tumor, known as brachytherapy. The radioactive seeds may stay in
place either temporarily or permanently.
Temporary radioactive seeds are implanted
and removed with a catheter inserted into
the part of the body with the tumor. Permanent seeds are inserted into tissues and will
stop giving off radiation after a few weeks or
months. Brachytherapy is done most often
for prostate, head and neck, gynecologic and
lung cancers, and most recently, for some
cases of early-stage breast cancer.
Radiopharmaceuticals are another type
of radiation therapy, known as systemic radiation therapy. These substances include a
radioactive component, such as radioactive
iodine, that destroys cancer cells. A patient
either swallows the substance or receives
it by injection. Radiopharmaceuticals are
used most often for bone and thyroid cancers and lymphomas.
The latest development in radiation
therapy is proton-beam therapy. Protons
are atomic particles that are e-asier to control than X-rays. This therapy can therefore avoid a lot of damage to healthy tissue
or organs surrounding a tumor by precisely targeting the location and size of the
tumor. Proton-beam therapy is ideal for
treating oddly shaped tumors or tumors
located in areas where X-ray therapy can
damage healthy tissue in critical places,
such as the brain.
Conventional chemotherapy
Conventional chemotherapy is also known
as systemic therapy because the drugs travel
through the bloodstream to all parts of the
body. Chemotherapy may be given intravenously through a small tube inserted into a
vein, or orally by a pill.
Conventional chemotherapy is usually
delivered in cycles, with treatment periods
followed by recovery periods in an on-again,
off-again manner. Treatment often consists
of combinations of drugs, sometimes given
simultaneously and at other times given one
12
Pa t i e n t Re s o u r ce .co m
types of treatment | general information
after another. A combination of chemotherapy drugs is known as a regimen.
virus, which can cause liver cancer, and human papillomavirus types 16 and 18, which
are responsible for about 70 percent of cervical cancer cases. Vaccines for other cancer
types are under investigation.
Targeted therapy
Targeted therapy is treatment with drugs or
other substances that block the growth and
progression of cancer. They do so by interfering with specific molecules involved in
tumor growth and progression. The targeted
therapy agents block or modify the molecules on or inside cancer cells that alter signaling pathways, which are complex systems
that direct basic cell functions, such as cell
division and death.
Targeted therapy is used for a wide variety of cancer types, including breast, lung,
colon and kidney cancers, as well as certain
types of leukemia. Many types of targeted
therapy drugs can be taken by mouth and
are usually given in combination with another type of therapy—most often conventional chemotherapy.
Most targeted therapy drugs are either
small-molecule drugs or monoclonal antibodies. Both types are made in a laboratory
and are designed to locate and bind to specific substances inside or on the cancer cells.
Small-molecule drugs can pass through
the cell membrane and act on a target inside
the cell. Many small-molecule drugs are tyrosine kinase inhibitors (TKIs), which act
against specific signaling pathways involved
in tumor growth. Some examples of TKIs are
imatinib (Gleevec), sunitinib (Sutent), erlotinib (Tarceva) and dasatinib (Sprycel).
Monoclonal antibodies cannot pass
through the cell membrane and instead are
used against targets found on the cell surface. Examples of these include trastuzumab
(Herceptin), rituximab (Rituxan), cetuximab (Erbitux), panitumumab (Vectibix)
and alemtuzumab (Campath-1H).
Some monoclonal antibodies target proteins involved in the development of blood
vessels within a tumor. Targeting these proteins blocks the growth of new blood vessels,
thereby cutting off the blood supply to the
tumor. Without a blood supply, the tumor
cannot grow. The formation of new blood
vessels is known as angiogenesis, and these
drugs are known as antiangiogenic agents.
Bevacizumab (Avastin) is an example of an
antiangiogenic agent.
Hormone therapy
Hormones that occur naturally in the body
drive the growth of some cancers. For example,
estrogen fuels the growth of some breast cancers, and testosterone aids in the growth of
prostate cancer. Hormone therapy acts to block
the stimulating effect of hormones, thereby
slowing or stopping the progression of cancer.
Hormone therapy for breast cancer,
also known as endocrine therapy, includes
Pa t ie n tResource.com
Hematopoietic stem cell
transplantation
tamoxifen (Nolvadex) and aromatase inhibitors (Arimidex, Aromasin, Femara). These
drugs are called antiestrogen agents because
they inhibit the production of estrogen or
interfere with its action.
Hormone therapy for prostate cancer involves either surgery or drugs and is often
called androgen-deprivation therapy. Surgical removal of the testicles eliminates the
source of about 90 percent of testosterone
in a man. Alternatively, several drugs are
available to interfere with the production
of testosterone.
Biologic therapy
Biologic therapy, also called immunotherapy, helps repair or stimulate a person’s own
immune system, which is the body’s defense
against harmful organisms or substances
such as bacteria, viruses and cancer cells.
Biologic therapy is either active or passive;
active therapy stimulates a person’s own immune system to fight cancer, and passive involves the use of parts of the immune system,
such as antibodies made in a lab. The most
common type of passive immunotherapy is
treatment with a monoclonal antibody.
Some antibodies used for biologic therapy are radiolabeled, which means that they
contain a radioactive substance. These antibodies attach to cancer cells and kill them.
This treatment, also known as radioimmunotherapy, has primarily been used for some
types of non-Hodgkin lymphoma.
Another form of biologic therapy is treatment with cytokines, which are special proteins on white blood cells that help stimulate an immune response. Interleukin-2 and
interferon-alpha are two cytokines that have
been approved for treatment of metastatic
melanoma and kidney cancer.
Cancer vaccines are an additional form
of biologic therapy. A recently developed
vaccine is sipuleucel-T (Provenge), which
is FDA-approved for the treatment of advanced prostate cancer. The FDA also has
approved vaccines against the hepatitis B
Hematopoietic stem cell transplantation
helps the body produce new blood cells.
Stem cells are found in the bone marrow,
and they have a special feature that enables
them to develop into any one of the three
types of blood cells – red blood cells, white
blood cells and platelets (clotting cells).
There are two types of stem cell transplantation: autologous and allogeneic.
With autologous stem cell transplantation, a person’s own stem cells are removed
and preserved so that very high doses of
chemotherapy and/or radiation therapy can
be given to attack cancer cells without destroying the stem cells. After the conclusion
of the intensive therapy, the person’s stem
cells are infused back into the body.
An allogeneic stem cell transplantation is
the use of stem cells obtained from a donor
with healthy bone marrow whose stem cells
are a close match to those of the person to be
treated. Allogeneic stem cell transplantation
also is considered to be a form of immunotherapy because it establishes a new immune
system for a person.
Stem cell transplantation and high-dose
chemotherapy and/or radiation therapy are
used most often for leukemias, lymphomas,
multiple myeloma, germ-cell tumors and
pediatric tumors.
High-intensity focused
ultrasound therapy
With this therapy, high-intensity ultrasound
waves are focused on a tumor to heat it to
high temperatures and destroy it. Guided by
magnetic resonance imaging, high-intensity
focused ultrasound has been used to successfully treat localized prostate cancer, but
it is not yet FDA-approved for this use. The
procedure is also under investigation for the
treatment of breast, liver, brain, bone, pancreas, kidney and testicular cancer.
ADDITIONAL RESOURCES
American Cancer Society: www.cancer.org
American Society for Radiation Oncology:
www.astro.org
CancerCare: www.cancercare.org
The National Association for Proton
Therapy: www.proton-therapy.org
National Cancer Institute: www.cancer.gov
Patient Resource:
www.PatientResource.com/Cancer_
Treatments.aspx
13
What if you could help the immune
system respond to cancer cells?
PD-L1 expression helps tumor
cells evade the immune system
programmed
death-ligand 1 (PD-L1), which binds
to the PD-1 and B7.1 receptors on
Tumor expression of
T cells, deactivates T-cell–mediated
cytotoxicity. This inhibits the immune
system and allows the tumor to continue
to grow.1 Nearly all cancer types show
increased expression of PD-L1.2
PD-1
Inactivated T cell
PD-L1
TCR
B7.1
MHC
Tumor cell
PD-L1
References: 1. Mellman I, Coukos G, Dranoff G. Cancer immunotherapy comes of age. Nature. 2011;480:480-489. 2. Blank C, Gajewski TF, Mackensen A. Interaction of PD-L1 on tumor
cells with PD-1 on tumor-specific T cells as a mechanism of immune evasion: implications for tumor immunotherapy. Cancer Immunol Immunother. 2005;54:307-314. 3. Pardoll DM.
Immunology beats cancer: a blueprint for successful translation. Nat Immunol. 2012;13:1129-1132.
© 2013 Genentech USA, Inc. All rights reserved. BIO0001911700 Printed in USA.
Blocking PD-L1 may restore the
body’s adaptive immune response
Genentech is investigating the strategy
of inhibiting the interaction between
tumor-expressed PD-L1 and its receptors
on T cells; blocking this interaction may
restore the body’s adaptive immune system
to respond to cancer cells.1 Research is also
under way to validate PD-L1 as a potential
biomarker for cancer immunotherapy.3
Activated T cell
B7.1
TCR
MHC
Tumor cell death
PD-1
Explore the role of cancer immunotherapy and PD-L1
inhibition at ResearchCancerImmunotherapy.com
general information | personalized medicine
A Personalized Approach
P
to Cancer Treatment
Personalized medicine – sometimes known
as precision medicine – is an approach to
medical care that uses information about
an individual’s genes and personal environment, as well as the behavior of certain
proteins, to understand risk and to prevent,
diagnose and treat disease. This approach
has grown in use in recent years thanks to
advances in science and technology. Before
the development of personalized medicine,
cancer treatment decisions were based on
the cancer’s site of origin rather than on the
unique biologic characteristics of an individual and their disease.
Personalized medicine includes new generations of highly targeted therapies, drugs
or other substances (such as biologics) that
block the growth and spread of cancer by
interfering with specific molecules – as
well as critical communication pathways
within the cell and between cells – involved
in tumor growth and progression. Targeted
therapies are possible because of a better
understanding of biomarkers, which are
proteins and other molecules found in tissue, blood or other body fluids that are a
sign of a normal or abnormal process or of a
condition or disease. A biomarker may also
be used to see how well the body responds to
a treatment for a disease or condition.
For people with cancer, targeted therapy
represents a significant medical advance
because the treatment targets their specific
cancer. Once the biology of specific cancer
cells and certain unique molecules can be
identified in a person with cancer, doctors
can use specific drugs to stop the cancer
cells from reproducing or surviving. More
specifically, targeted therapy drugs interfere
with the cell growth-signaling mechanism.
Targeted therapy may also limit the blood
supply to cancer cells, preventing them from
growing. It also may promote the death of
specific cancer cells, stimulate the immune
system to destroy specific cancer cells or
help deliver toxic drugs to cancer cells.
Biomarkers are used to identify the best
type of targeted therapy to treat your disease. Protein biomarkers found in the blood
or urine include substances that are either
produced by cancer cells themselves or by
other cells in response to cancer. Most protein biomarkers related to cancer are used to
monitor response and/or detect recurrence
or progression of cancer after treatment
(Table 1). Molecular biomarkers are a result
of mutations (changes) in genes or in receptors on cells that have been found to identify
a subtype of cancer. Identifying subtypes is
important for determining your prognosis
and guiding treatment. Testing for molecular biomarkers is usually done on samples of
tissue taken from the tumor.
Limitations of
personalized medicine
Unfortunately, personalized medicine isn’t an
effective treatment for every type of cancer because only some cancers have at least one identified treatment target. In addition, not every
target has a drug effective in limiting cancer
growth. Because many mutations in cancer
cells can occur over time, the cancer may have
different properties in different locations in the
body and may respond differently to targeted
agents. While the cancer may initially respond
to targeted therapy, over time this response
may not last and the tumor cells may find new
ways to escape the treatment. Patients seem to
be unique in both their response to the drugs
and the duration of that response.
Table 1. Biomarkers according to type of cancer
Biomarker
Type of
sample
Function
Use
ER/PR (estrogen receptor/
progesterone receptor)
Tumor
tissue
Guide treatment
Routine testing at time of diagnosis is highly recommended, as presence of receptors is
associated with response to hormone therapy.
HER2
Tumor
tissue
Guide treatment
Routine testing at time of diagnosis for all patients with invasive breast cancer (early-stage or
recurrence) is highly recommended, as overexpression of gene is associated with response to
specific targeted therapy.
BRCA1 and BRCA2
Blood
Detect genetic risk/
guide treatment
Mutations in these genes indicate an increased risk of breast cancer and/or ovarian cancer.
Gene expression analysis
Tumor
tissue
Determine prognosis/
guide treatment
Testing recommended for distinct population (women with early-stage ER+/PR+ cancer with no
evidence of disease in the lymph nodes). Low-risk score indicates that adjuvant chemotherapy
will offer little benefit.
CA (cancer antigen)
15-3 or CA 27.29
Blood
Monitor response
May be used in conjunction with diagnostic imaging, history and physical examination.
Breast Cancer
CEA (carcinoembryonic antigen)
Blood
Monitor response
May be used in conjunction with diagnostic imaging, history and physical examination.
uPA (urokinase-type
plasminogen activator), PAI-1
Tumor
tissue
Determine prognosis/
guide treatment
Testing recommended for newly diagnosed ER+/PR+ cancer that has not spread to lymph
nodes. Low level (low risk) indicates that adjuvant chemotherapy will offer minimal benefit.
Chronic Myeloid Leukemia
BCR-ABL
Blood
Aid diagnosis
Testing done routinely, as presence of gene is distinguishing feature of the disease.
Guide treatment
Gene is associated with response to specific targeted therapy.
Determine prognosis
Testing recommended during initial workup. High level before treatment may indicate cancer
has spread.
Monitor response
Biomarker of choice for monitoring metastatic colorectal cancer during chemotherapy.
Detect recurrence/
progression
Testing recommended during follow-up of nonmetastatic disease to detect recurrence or
metastasis.
Colorectal Cancer
CEA
16
Blood
Pa t i e n t Re s o u r ce .co m
personalized medicine | general information
Biomarker
Type of
sample
Function
Use
KRAS
Tumor
tissue
Guide treatment
Testing recommended, as overexpression of gene is associated with lack of response to some
targeted therapies.
MMR
Tumor
tissue
Determine prognosis
Testing recommended, as the mutation is associated with good prognosis.
Gene expression analysis
Tumor
tissue
Determine prognosis/
guide treatment
Testing recommended for distinct population (people with Stage II disease); low-risk score
indicates that adjuvant chemotherapy will offer little benefit.
Tumor
tissue
Aid diagnosis
Testing done routinely, as presence of mutation is distinguishing feature of the tumor.
Guide treatment
Presence of mutation associated with response to specific targeted therapies.
Blood
Aid diagnosis
Testing recommended at initial workup; very high levels can indicate liver cancer (but high
levels can be increased in other noncancerous conditions).
Detect recurrence/
progression
Testing done throughout follow-up if level was initially elevated.
Colorectal Cancer (continued)
Gastrointestinal Stromal Tumor
KIT
Liver Cancer
AFP (alpha-fetoprotein)
Melanoma
LDH (lactate
dehydrogenase)
Blood
Determine prognosis
Testing recommended at initial workup, as level is a factor in determining stage of disease.
Testing done throughout follow-up of Stage IV disease (metastatic melanoma); high level is
predictor of poor prognosis.
BRAF
Tumor
tissue
Guide treatment
Testing recommended for metastatic melanoma, as gene mutation is associated with response
to specific targeted therapies.
S-100
Blood
Determine progression
Evidence is currently insufficient to recommend testing, but level is elevated in most individuals
with metastatic melanoma.
Multiple Myeloma
Beta-2-microglobulin
Blood
Determine prognosis
Testing recommended at initial workup, as level is a factor in determining stage of disease.
Monitor response
Measured throughout follow-up; high level indicates high tumor burden (and poor prognosis).
Non-Small Cell Lung Cancer
EGFR
Tumor
tissue
Guide treatment
Testing is recommended, as some targeted therapies are more effective when gene is
overexpressed.
KRAS
Tumor
tissue
Guide treatment
Testing recommended, as overexpression is associated with lack of response to some targeted
therapies.
ALK-EML4
Tumor
tissue
Guide treatment
Testing recommended, as presence of gene mutation is associated with response to a specific
targeted therapy.
Blood
Aid diagnosis
Testing recommended at initial workup (if symptoms suggest ovarian cancer).
Detect recurrence/
progression
Testing done throughout follow-up.
Ovarian Cancer
CA (cancer antigen) 125
Pancreatic Cancer
CA (cancer antigen) 19-9
Blood
Determine prognosis
Testing recommended at initial workup; high level is associated with poor prognosis.
Monitor response
Testing done during active treatment for locally advanced metastatic disease; increase in
level may indicate recurrence. (Decreased level after surgery or chemotherapy indicates better
survival.)
Screening
Usefulness as screening tool is debated, as the level is elevated in benign conditions of the
prostate.
Aid diagnosis
Testing recommended at initial workup, as level is factor in determining stage of disease.
Detect recurrence/
progression
Testing done throughout follow-up.
Prostate Cancer
Prostate-specific antigen (PSA)
Blood
Testicular Cancer
AFP
Blood
Aid diagnosis
Testing recommended at initial workup, as level is a factor in determining stage of disease.
hCG (human chorionic
gonadotropin)
Blood/
urine
Aid diagnosis
Testing recommended at initial workup, as level is a factor in determining stage of disease.
LDH
Blood
Guide treatment
More aggressive treatment is recommended if elevated levels persist.
Blood
Detect recurrence/
progression
Testing done throughout follow-up.
Thyroid Cancer
Thyroglobulin
Pa t ie n tResource.com
17
general information | pain management
P
Finding Relief From Cancer Pain
Pain is a leading fear for many people with
cancer. But cancer doesn’t have to mean
pain. You are entitled to having a doctor
who is totally committed to relieving any
pain you may experience as a result of cancer
and its treatments, and one who also makes
sure that any side effects from attempts at
pain control are acceptable to you. So, if you
don’t already have someone like that on your
multidisciplinary health care team, ask for a
referral. Improved pain control can lead to
improved survival, so the more in check you
and your doctor can keep your pain, the better your overall outlook.
Causes of cancer pain
For many people, cancer pain can come
from the cancer itself. As a tumor spreads, it
can press on an internal organ, bone or joint,
creating pressure that leads to pain. A tumor
can also cause pain by damaging nearby tissues and nerves as it grows into them, and
by producing chemicals that disrupt the balance of that area of the body.
While cancer treatments can be beneficial,
they can sometimes cause pain as well. For
example, if you have surgery to treat your
cancer, you may experience pain as your
body heals and recovers from the procedure. Chemotherapy and radiation therapy
can also cause pain by damaging healthy
cells, which can result in painful side effects
such as burning sensations, mouth sores,
diarrhea, nerve damage and more. You
should not avoid these treatments because
they may cause pain. Rather, you should keep
an open dialogue with your doctor about any
pain you experience so it can be controlled.
18
Types of cancer pain
Everyone experiences pain in different
ways, but it’s useful to distinguish among
the main types:
• Acute pain usually comes from injury or
damage to bodily tissues. It comes on as
a direct result of a trauma – surgery, for
example – so the cause can usually be
readily diagnosed. Standard pain medication is often effective.
• Chronic pain, also called persistent pain,
lasts long after the bodily injury heals
and can be more resistant to medical
treatments. It can be very taxing on both
your body and your emotional state.
However, using the various treatments
available today, chronic pain can be
effectively managed in the vast majority
of people.
• Breakthrough pain includes severe
flares of pain that “break through” regular pain medications. Sometimes these
flares are related to an event, such as
coughing, and sometimes they’re sudden
and unpredictable. These outbreaks can
be mild to severe and can last for up to
an hour a few times a day, but breakthrough pain can still be managed using
various techniques.
Confronting the myths
of pain medication
✖
✔
✖
✔
✖
✔
Management of cancer pain
The options for managing cancer pain are
numerous, and it can be helpful to think
of them as tools in a toolbox. Sometimes
just one tool can fix the problem, but other
times the whole toolbox will be required. In
addition, you’ll sometimes need to use tools
in a particular sequence, while other times
you may need to jump back and forth between tools.
The following descriptions of various
pain relief techniques are meant to provide
you with a general overview of what’s available. That way, if your doctor doesn’t mention one or more of them as options for your
care, you’ll be equipped to ask whether they
might be right for you.
• Pharmacotherapy is the treatment of
cancer pain through the administration
of medications, including non-opioid,
opioid, adjuvant and topical analgesics.
! Non-opioid analgesics are often available over-the-counter and include
aspirin, ibuprofen (Advil, Motrin),
acetaminophen (Tylenol), etc.
! Opioid analgesics require a prescription
and help decrease both the perception of pain and the reaction to pain.
Codeine, oxycodone and morphine are
all examples of opioid analgesics.
! Adjuvant analgesics, including certain
✖
✔
✖
✔
Myth: If I take narcotics regularly,
I may become addicted.
Fact: While people can become tolerant to a pain medication (meaning
ever-increasing doses are required
to achieve the same effect), it is not
the same as addiction. People with
cancer who take pain medication as
directed by their doctors usually do
not become addicted.
Myth: If I start taking pain medication early on, I will run out of options for pain relief in the future.
Fact: Many pain-relieving medications and procedures are available.
There will almost always be options
if pain becomes more severe.
Myth: I don’t want to have
unpleasant side effects from pain
medications.
Fact: Side effects do occur with
some pain medications, but they
can be managed and some will
decrease or disappear over time.
Unacceptable side effects are a
reason to ask your doctor about
formulating an alternative plan for
pain relief.
Myth: Increasing pain means the
disease is getting worse.
Fact: Pain and severity of disease
are not necessarily related, but
increasing pain should prompt a
conversation with your doctor to
evaluate the cause and develop a
plan for more acceptable pain relief.
Myth: I don’t want to bother
the doctor. Having pain should
be expected.
Fact: Although pain is common,
your doctor and other members
of your treatment team should
always be willing to help find ways
to control your pain so you can
enjoy a better quality of life.
antidepressants and anticonvulsants,
aren’t primarily designed to control
pain, but they can sometimes be used
for this purpose, especially in cases
where damaged nerve cells result in
neuropathic pain.
See RELIEF FROM CANCER PAIN, page 21
Pa t i e n t Re s o u r ce .co m
For Adults on Strong Chemotherapy
Help Boost Your Natural Defenses
with Neulasta® (pegfilgrastim)
After Every Chemo Cycle
What Can Happen to White Blood Cells
During Strong Chemo
Strong chemotherapy can lower the
QXPEHURILQIHFWLRQÀJKWLQJZKLWH
blood cells in your body, putting you
at risk of infection.
Neulasta® Helps Boost
White Blood Cells
Injected 24 hours after each cycle of
chemotherapy, Neulasta® may help
boost your white blood cell count,
and reduce your risk of infection while
undergoing strong chemotherapy.
Indication
Neulasta® is a prescription medication used to reduce the risk of infection (initially marked by fever)
in patients with some tumors receiving strong chemotherapy that decreases the number of infectionÀJKWLQJZKLWHEORRGFHOOV1HXODVWD® may not prevent all infections.
Important Safety Information
Do not take Neulasta® if you have had an allergic reaction to Neulasta®SHJÀOJUDVWLPRUWR
NEUPOGEN® (Filgrastim). Tell your doctor if you have a sickle cell disorder before using Neulasta®.
Ruptured spleen (including fatal cases), a serious lung problem called acute respiratory distress
syndrome (ARDS), serious allergic reactions, and sickle cell crises can occur. Call your doctor or seek
emergency care right away if you have: pain in the left upper stomach area or left shoulder tip pain
(symptoms of an enlarged or ruptured spleen); shortness of breath, trouble breathing, or a fast rate of
breathing (symptoms of ARDS); shortness of breath, wheezing, dizziness, swelling around the mouth or
H\HVIDVWSXOVHVZHDWLQJDQGKLYHVV\PSWRPVRIDQDOOHUJLFUHDFWLRQRULI\RXKDYHSDLQRUGLIÀFXOW\
breathing (symptoms of sickle cell crises). The most common side effect you may experience is aching
in the bones and muscles.
If you have any questions about this information, be sure to discuss them with your doctor. You are
encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch
or call 1-800-FDA-1088.
Please see brief summary of Important Product Information on the previous page.
You may be at risk of infection throughout all of your chemotherapy treatment.
Discuss infection risk factors with your healthcare provider, and ask if Neulasta® is right for you.
Help limit your co-pay
(based on eligibility)
Co-Pay
Coupon
Card
The Amgen FIRST STEP™ Program can help eligible patients with
commercial insurance cover their deductible, co-insurance, and/or
co-pay requirements. Certain limitations apply.
Log on to www.AmgenFIRSTSTEP.com or call 1-888-657-8371 for
a complete list of eligibility requirements and program restrictions.
Learn more at www.Neulasta.com
© 2012 Amgen Inc. All rights reserved.
65494-R3-V2
BRIEF SUMMARY OF PATIENT PACKAGE INSERT
Neulasta®
(pegfilgrastim)
This brief summary of the patient package insert provides information and
instructions for people who will be receiving Neulasta or their caregivers.
This brief summary does not tell you everything about Neulasta. You
should discuss any questions you have about treatment with Neulasta
with your doctor.
What is Neulasta?
sSickle Cell Crises. You may have a serious sickle cell crisis if you have
a sickle cell disorder and take Neulasta. Serious and sometimes fatal
sickle cell crises can occur in patients with sickle cell disorders receiving
filgrastim, a medicine similar to Neulasta (pegfilgrastim). Call your doctor
right away if you have symptoms of sickle cell crisis such as pain or
difficulty breathing.
What are the most common side effects of Neulasta?
Neulasta is a man-made form of granulocyte colony-stimulating factor (G-CSF),
which is made using the bacteria Escherichia coli. G-CSF is a substance
produced by the body. It stimulates the growth of neutrophils (nu-tro-fils),
a type of white blood cell important in the body’s fight against infection.
The most common side effect you may experience is aching in the bones
and muscles. If this happens, it can usually be relieved with a non-aspirin
pain reliever, such as acetaminophen.
Who should not take Neulasta?
What about pregnancy or breastfeeding?
Do not take Neulasta if you have had:
Neulasta has not been studied in pregnant women, and its effects on
unborn babies are not known. If you take Neulasta while you are pregnant,
it is possible that small amounts of it may get into your baby’s blood. It is not
known if Neulasta can get into human breast milk. If you are pregnant, plan
to become pregnant, think you may be pregnant, or are breastfeeding, you
should tell your doctor before using Neulasta. If you become pregnant during
Neulasta treatment, you are encouraged to enroll in Amgen’s Pregnancy
Surveillance Program. You should call 1-800-77-AMGEN (1-800-772-6436)
to enroll.
sA serious allergic reaction to Neulasta® (pegfilgrastim) or to
Neupogen® (filgrastim).
What important information do I need to know about
receiving Neulasta?
Occasionally pain and redness may occur at the injection site. If there is a
lump, swelling, or bruising at the injection site that does not go away, talk
to the doctor.
Neulasta should only be injected on the day the doctor has determined and
should not be injected until approximately 24 hours after receiving chemotherapy.
The needle cover on the single-use prefilled syringe contains dry natural
rubber (latex), which should not be handled by persons sensitive to
this substance.
What should I tell my healthcare provider before
taking Neulasta?
If you have a sickle cell disorder, make sure that your doctor knows about
it before you start using Neulasta. If you have a sickle cell crisis after getting
Neulasta, tell your doctor right away.
If you have any questions, talk to your doctor.
How should Neulasta be stored?
Neulasta should be stored in the refrigerator at 2° to 8°C (36° to 46°F),
but not in the freezer. Neulasta should be protected from light, so you should
keep it in its carton until you are ready to use it. Avoid shaking Neulasta.
If Neulasta is accidentally frozen, allow it to thaw in the refrigerator before
injecting. However, if it is frozen a second time, do not use. Neulasta can
be left out at room temperature for up to 48 hours. Do not leave Neulasta
in direct sunlight. For all questions about storage, contact your doctor, nurse
or pharmacist.
What are the ingredients in Neulasta?
Each syringe contains pegfilgrastim in a sterile, clear, colorless,
preservative-free solution containing acetate, sorbitol, polysorbate 20,
and sodium.
What are possible serious side effects of Neulasta?
sSpleen Rupture. Your spleen may become enlarged and can rupture
while taking Neulasta. A ruptured spleen can cause death. The spleen
is located in the upper left section of your stomach area. Call your doctor
right away if you have pain in the left upper stomach area or left shoulder
tip area. This pain could mean your spleen is enlarged or ruptured.
sA serious lung problem called Acute Respiratory Distress Syndrome
(ARDS). Call your doctor or seek emergency care right away if you have
shortness of breath, trouble breathing, or a fast rate of breathing.
sSerious Allergic Reactions. Neulasta can cause serious allergic
reactions. These reactions can cause shortness of breath, wheezing,
dizziness, swelling around the mouth or eyes, fast pulse, sweating, and
hives. If you start to have any of these symptoms, call your doctor or
seek emergency care right away. If you have an allergic reaction during
the injection of Neulasta, stop the injection. Call your doctor right away.
Neulasta® (pegfilgrastim)
Manufactured by:
Amgen Inc.
One Amgen Center Drive
Thousand Oaks, California 91320-1799
This product, its production, and/or its use may be
covered by one or more US Patents, including US
Patent Nos. 5,824,784; 5,582,823; 5,580,755,
as well as other patents or patents pending.
© 2012 Amgen Inc. All rights reserved.
www.neulasta.com
1-800-77-AMGEN (1-800-772-6436)
v 9.0
XXXXX-RX-VX
pain management | general information
Relief from Cancer Pain
continued from page 18
Keeping Track of Cancer Pain
A pain diary is an easy way to track what
pain you’re experiencing and what painrelief methods are working, and it will
help your medical team modify your care
to make you as comfortable as possible.
Use a consistent pain scale, like rating
your pain from 0 to 10 (with 0 being no
pain and 10 being the worst pain imaginable), and write down answers to questions like:
• What does the pain feel like?
Topical analgesics are either sprayed
on or rubbed into the skin, directly
over the painful area. They can include
one or more medications and are often
made-to-order by a compounding
pharmacy. Topical analgesics may cause
less severe side effects than other analgesics because they’re not ingested.
• Percutaneous pain techniques refer to
procedures that access inner organs and
tissues by puncturing the skin with a
needle. They include ablative techniques,
nerve blocks, kyphoplasty, vertebroplasty
and sacroplasty.
! Ablative techniques include various
procedures used to turn off nerves
that signal pain, thereby providing
pain relief.
! Nerve blocks usually involve injecting a pain-killing medication around
certain nerves that send pain signals
to your brain. Nerve blocks can be
used on sympathetic, peripheral and
cranial nerves.
! Kyphoplasty, vertebroplasty and
sacroplasty are all procedures in
which bone cement is injected into
the spine or sacrum to stabilize the
area and relieve pain.
• Neurosurgical approaches to pain relief
seek to lessen pain at its source—in the
neural pathways and processing centers
of the spine and brain. Recent medical innovations have opened up many
more neurosurgical pain relief options
than were available in the past, including
electrical stimulation, which can “jam”
pain pathways and block pain, as well as
intracranial and spinal ablation, which
can turn off specific brain and spinal cord
fibers that include pain-carrying nerves.
• Intrathecal drug delivery, also called
a “pain pump,” sends pain medication
directly to your spinal cord using a small
•
•
•
•
•
•
•
•
!
Pa t ie n tResource.com
•
•
•
•
Is it mild or severe?
Is it constant or does it come and go?
Is it dull or sharp?
When do you feel pain (morning,
night, random times)?
Are there specific triggers, like
bending or stooping?
How long does the pain usually last?
What helps relieve your pain?
Are you experiencing any side effects
from your pain medications?
pump that’s surgically placed in the
abdominal wall. Because the medication
goes directly to your spinal cord rather
than first traveling through your entire
system, it’s effective in much lower doses
than oral medications and without the
usual side effects.
Palliative oncology, also called supportive
oncology, can help mitigate cancer pain
through palliative surgery, radiation therapy and chemotherapy. Palliative radiation
therapy and chemotherapy can shrink a
tumor that is causing pain, or palliative
surgery can be done to remove part or all
of such a tumor, stabilize the spine and
keep organs functioning, thereby reducing
pain. Palliative radiation therapy may also
relieve pain caused by bone metastases
(the spread of cancer to bone).
Physiatry, or physical medicine and
rehabilitation, helps relieve pain through
customized therapy programs designed
to enhance mobility, overcome disabilities
and avoid painful activities when cancer
or its treatments have affected how you
move and function. Anti-inflammatory
injections are also a part of this technique.
Alternative and complimentary strategies include yoga, acupuncture, reflexology, massage therapy, aromatherapy,
art therapy, music therapy and animal
therapy. While these strategies may not
single-handedly solve cancer pain, they
do have role in pain management.
Psycho-behavioral strategies involve
activities such as deep relaxation and
meditation. They are useful in calming
psychological symptoms such as anxiety
and depression, which often accompany
cancer pain and can get in the way of
its treatment.
Keep in mind that there are risks and
benefits associated with all types of pain re-
lief techniques, so always review them with
your health care team before beginning any
type of regimen.
Speak up about cancer pain
Cancer pain is often undertreated because
many patients are reluctant to discuss it.
Don’t fall into that category. Ask about pain
management right from the start, and continually alert your doctor at the first sign of
pain. A pain diary, as discussed in the box
below, can help you monitor your pain,
know what to report and decide when to call
your doctor. Pain relief works best when it’s
done proactively rather than reactively, and
ideally, pain should be addressed long before
it becomes an emergency.
In addition, if you’re having unacceptable
side effects from pain medications, such as
extreme fatigue, constipation, etc., discuss
those issues with your doctor as well. Efforts
can be made to employ different strategies
to both get you the necessary pain relief and
avoid unacceptable side effects. The goal is a
satisfactory quality of life.
ADDITIONAL RESOURCES
American Chronic Pain Association:
www.theacpa.org
Cancer Pain Research Consortium:
www.facebook.com/
cancerpainresearchconsortium; for
questions, you can reach the administrative
center of the Consortium at the Center for
the Relief of Pain, at 816-363-2500
Cancer Support Community:
www.cancersupportcommunity.org
Pain
National Cancer Institute: www.cancer.gov
Coping with Cancer: Supportive and
Palliative Care (Managing Physical Effects)
Pain Control: Support for People with Cancer
PainfromCancer.org:
www.painfromcancer.org
U.S. Pain Foundation:
http://uspainfoundation.org
21
general information | side effects
U
Prevent or Control Side Effects
Unfortunately, cancer treatment can cause
unpleasant side effects, but they don’t have
to be debilitating. New drugs and medication methods have shown improvement in
quality-of-life issues in recent years. And
your health care team can help you prevent,
manage and reduce the amount and duration of your side effects during and after
treatment. The key is to practice prevention whenever possible because prevention
is easier than controlling symptoms once
they have begun. A number of options can
help you prevent, minimize or control some
of the most common side effects of cancer
treatment.
Reduce nausea and vomiting
Depending on how likely nausea and vomiting are to occur after your particular treatment, your doctor may prescribe a combination of antiemetic drugs. These drugs
are commonly prescribed even before side
effects begin as a way to prevent them from
happening at all. For antiemetics to be effective, you must take them “around the clock”
as your doctor has ordered and not on an “asneeded” basis.
Some other practical tips can help minimize nausea and vomiting:
• Eat several small meals throughout the
day rather than three big meals.
• Try eating a light meal a few hours before
your scheduled treatment.
• Drink plenty of fluids in small amounts
throughout the day.
• Avoid unpleasant and strong odors.
• Keep hard candy or mints around to
eat periodically.
• Rest after eating, but don’t lie flat.
Some people have also been helped by progressive muscle relaxation, biofeedback, guided imagery, acupuncture and self-hypnosis.
Fight fatigue
Fatigue is another common but manageable
side effect. To fight it:
• Conserve energy by setting priorities for
activities and asking friends and family
for help.
• Balance activity and rest by participating
in regular physical activity, such as
power walking and bike riding, taking
frequent rest periods or short naps, and
getting eight hours of sleep each night.
Remaining active has been scientifically
proven to reduce fatigue caused by
common cancer treatments.
• Engage in activities that provide relaxation or distraction from fatigue, such as
deep-breathing exercises, yoga, imagery
22
techniques, reading, playing games,
praying or meditating.
• Talk to your doctor about managing
symptoms that may contribute to fatigue,
such as pain, nausea, vomiting and
depression.
• Eat a well-balanced diet to promote healing.
• Ask your doctor about psychostimulant
drugs if your fatigue is severe; these can
help counteract drowsiness and raise your
energy level.
Handle hair loss
The best way to manage hair loss is to think
about what will make you feel most comfortable with your appearance. Some people
choose to wear a wig or head covering, such
as a scarf or hat. Others choose to cut their
hair short or shave their head completely
before treatment begins so that hair loss will
not be as noticeable.
Ask your doctor or nurse when to anticipate hair loss. Most chemo drugs generally trigger the hair to begin falling out
10 to 15 days after the first cycle of treatment. Being gentle with your hair may help
make hair loss more gradual and improve
the regrowth of your hair. Use a soft brush
or wide-toothed comb; use a gentle, pHbalanced shampoo; and avoid hair coloring
and heating devices, including dryers, rollers and irons. Your hair may start to grow
back curly while you’re still on chemotherapy, but it likely will return to its natural texture in eight to nine months.
If you plan to wear a wig, ask your oncologist to give you a prescription for a
“skull prosthesis due to alopecia caused by
chemotherapy.” You can then try submitting
your wig bill to your insurance company for
partial or full payment, depending on your
health care plan. It’s important that the prescription reads “skull prosthesis” instead of
just “wig” so the claim is not rejected.
It is difficult to prevent chemo-related
hair loss, but scalp cooling, also known
as cold cap therapy, has been effective in
preventing hair loss in 80 to 90 percent
of people receiving chemotherapy. It involves wearing a helmet-shaped cap filled
with -27 F soft gel packs before, during
and after chemotherapy for a total of eight
hours. The cold temperature reduces blood
flow to the scalp, which means the chemotherapy drugs don’t reach the hair follicles
to destroy those cells. While not recommended by all oncologists, you should talk
to your doctor if you’re interested in learning more.
How you ultimately choose to handle
hair loss is a personal decision, and the right
choice is the one that makes you feel best.
Minimize diarrhea
You can prevent or minimize diarrhea
through small changes to your eating habits:
• Drink six to eight glasses of fluid per day.
• Avoid beverages with alcohol or caffeine.
• Eat bland, low-fiber foods.
• Eat foods high in protein, calories and
potassium that are easy to digest.
• Eat more frequently but in smaller
amounts.
• Avoid foods that are high in fat.
• Avoid very hot and cold beverages.
Some medicines to control diarrhea are
available over the counter, but you should
not take these without first talking to your
doctor, who may give you instructions for
taking these drugs that differ from the drug
label. If your diarrhea is severe, your doctor
can prescribe other medications.
Severe diarrhea may cause discomfort
in the rectal area. To help soothe the area,
clean the external rectal area with warm
water and soap after bowel movements,
soak in a warm bath or use a water-repellent cream.
Focusing on foods that match the previously listed recommendations will not only
help you combat diarrhea but also will help
you avoid gaining weight during treatment,
which is a common occurrence.
Counter constipation
If you are at risk for constipation, your
doctor may tell you to take a stool softener,
such as docusate (Colace), and a gentle
laxative, such as senna (Senekot, ex-lax,
Correctol) or bisacodyl (Dulcolax), on
a regular basis. You should use a laxative
only if your doctor has ordered it. You can
help avoid constipation by drinking plenty
of fluids; eating foods high in fiber, such
as fresh fruits, vegetables and whole grains;
and exercising as much as possible. Power
walking is a great exercise to keep your GI
tract on track.
Cope with “chemo-brain”
Chemotherapy can often cause “chemobrain,” which is commonly described as
a “mental fog.” Other treatments, such as
radiation therapy or some types of immunotherapy, can also cause some cognitive
dysfunction.
Use the following measures to help you
cope with chemo-brain and improve your
mental processing:
See CONTROL SIDE EFFECTS, page 24
Pa t i e n t Re s o u r ce .co m
WE BELIEVE YOUR IMMUNE SYSTEM
MAY HELP FIGHT CANCER.
And through clinical trials we
are assessing investigational
cancer therapies that work with
the body’s immune system.
JOIN AN IMMUNO-ONCOLOGY
CLINICAL TRIAL.
At Bristol-Myers Squibb, we are researching immuno-oncology, a new area of
cancer research that involves investigational agents that are designed to work
directly with the body’s immune system.
If you or someone you love has been diagnosed with cancer,
ask your oncologist if enrolling in a clinical trial involving an
immuno-oncology agent would be an appropriate option.
Now enrolling adults with advanced
or metastatic disease in:
s,UNGCANCER
s-ELANOMA
s2ENALCELLCARCINOMA
s/THERCANCERTYPES
Ask your oncologist if enrolling in a clinical trial would be
right for you. And visit BMSStudyConnect.com for help in
finding a clinical trial near you.
Make the Connection at "-33TUDY#ONNECTCOM
For instant access to BMSStudyConnect.com on your mobile
device, scan here.
© 2013 Bristol-Myers Squibb Company. All Rights Reserved.
137901 08/2013
general information | side effects
Control Side Effects
• Use a calendar or daily planner to keep
all of your important information in one
place. Write down all appointments,
activities, medication schedules, important dates (such as birthdays and
anniversaries), to-do lists, phone
numbers and addresses, and names of
movies you want to see and books you
want to read.
• Exercise your brain to strengthen your
mental ability. Do crossword puzzles or
other word or number games, complete
jigsaw puzzles, play card games, play a
musical instrument, learn a new hobby or
learn a new language.
• Get physical exercise to improve your
mental alertness. Walk, swim, ride a bike,
do aerobics, practice yoga or garden.
• Don’t try to multitask. Focus on one thing
at a time.
• Ask for support. Tell friends and family
that you’re having cognitive problems;
laugh about your memory and attention
problems together; ask people to repeat
information or to write down new
information, such as phone numbers
and dates.
If your chemo-brain gets worse or continues for many months after treatment,
additional treatment options exist. A drug
commonly used to treat Alzheimer’s disease – donepezil hydrochloride (Aricept) –
has been effective for some people as have
stimulant drugs, such as methylphenidate
(Ritalin). Occupational therapy or vocational
rehabilitation may also be helpful in improving the skills you need for daily living or for
performing your job.
Battle neutropenia
Neutropenia is a low number of neutrophils,
a type of white blood cell that helps prevent
infections throughout the body. Neutropenia increases your risk of infection and also
makes it more difficult for an infection to
resolve if bacteria enter the body. The lower
the neutrophil count, the greater the infection risk.
During treatment, your white blood cell
count will be checked often so that precautions or treatment can be started if appropriate. Neutropenia cannot be prevented,
but studies have shown that the most effective way to prevent infection is frequent
handwashing. If your neutrophil count is
extremely low, your doctor may delay your
next treatment and have you follow “neutropenic precautions,” or extra measures to
prevent infection.
24
continued from page 23
Some people with an extremely low neutrophil count may benefit from treatment
with a growth factor. These are special proteins that can stimulate the bone marrow to
produce more white blood cells and are usually given as an injection under the skin.
Monitor mouth sores
Visit your dentist before starting any cancer treatment to get your gums and teeth as
healthy as possible. Once you begin treatment, check your mouth twice a day so that
you can detect mouth sores early. In addition, brush your teeth and apply lip balm 30
minutes after eating and every four hours
in between. Also avoid products that may
dry or irritate your mouth, such as lemon
glycerin swabs or mouthwashes that contain alcohol.
If you develop mouth sores, your doctor
may suggest rinsing your mouth with special
solutions. You also may receive a prescription for a topical pain medication or a medication that coats the lining of your mouth.
To help minimize discomfort and promote
healing, follow these tips:
• Drink plenty of fluids each day.
• Use a straw.
• Eat soft foods, cut in small pieces.
• Avoid foods that may irritate the mouth,
such as hot, spicy, greasy or fried foods;
salty or high-sugar foods; sharp or
crunchy foods; citrus fruits and juices; alcohol, caffeine and carbonated beverages.
• Do not use tobacco.
Remedy dry mouth
Ease the discomfort of dry mouth by keeping
your mouth moist. Try sucking on ice cubes
or taking frequent small sips of liquids. Use
gravy, sauce or broth to make food easier to
swallow, and chew sugar-free gum or suck
on sugar-free hard candies. If you have severe dry mouth, your doctor or dentist may
prescribe a drug, such as pilocarpine (Salagen), to stimulate the production of saliva, or
an artificial saliva substitute in the form of a
spray, gel or tablet.
Address skin and nail reactions
Skin reactions are usually mild to moderate
but can become severe if not treated early.
It’s important to note that skin reactions are
side effects of treatment, not allergic or infectious reactions.
Skin reactions caused by radiation therapy are usually minor and do not require
treatment, but reactions caused by targeted
therapy drugs can range from mild to severe. Rashes that are in a limited area, do not
cause discomfort and are not infected usually
do not need to be treated. If the rash spreads
over a larger area and causes itchiness or
pain, however, your doctor may prescribe a
mild corticosteroid cream, such as hydrocortisone, or an antibiotic gel, such as clindamycin gel. Severe rashes usually are also treated
with an oral antibiotic and perhaps an oral
corticosteroid, such as methylprednisolone
(Medrol) or prednisone.
Taking special care of your skin can help
also ease discomfort from reactions. Use
gentle soaps and moisturizers, bathe in lukewarm – not hot – water, pat your skin dry
rather than rubbing it, and wear loose-fitting
clothing. Also avoid scratching areas of dry
skin, using skin care products that contain
alcohol and being in the sun without protective clothing and sunscreen.
In addition, take extra care of your nails by
keeping them short, using cuticle removers
and cuticle cream, and wearing nail polish.
Excessive exposure to water can lead to fungal infections of the nail bed, so wear gloves
when doing chores, such as washing dishes,
washing the car or gardening.
Comfort flu-like syndrome
If your treatment is likely to cause flu-like
syndrome, your doctor may recommend
acetaminophen (Tylenol) or an anti-inflammatory drug, such as ibuprofen or naproxen,
before treatment begins. Once the syndrome
occurs, your doctor will manage it by targeting the symptoms: acetaminophen for fever,
nonsteroidal anti-inflammatory drugs for
muscle aches, and antiemetics for nausea
and vomiting. Drinking plenty of fluids, taking cool baths and resting can help you feel
more comfortable.
ADDITIONAL RESOURCES
American Cancer Society: www.cancer.org
Coping with Physical & Emotional Changes
Symptoms and Side Effects
American Society of Clinical Oncology
(patient website): www.cancer.net
Managing Side Effects
Look Good…Feel Better:
http://lookgoodfeelbetter.org
National Cancer Institute:
www.cancer.gov (Search “side effects”)
National Center for Complementary and
Alternative Medicine:
www.nccam.nih.gov/health/cancer
Patient Resource:
www.PatientResource.com/Treatment_
Side_Effects.aspx
The Rapunzel Project:
www.rapunzelproject.org
Pa t i e n t Re s o u r ce .co m
Committed to the
ever-changing world
of cancer care
Teva Oncology, a top 10 oncology company in the US,*1
offers multiple therapies for hematologic malignancies
and has an approved product for supportive cancer care.
Our diverse pipeline of compounds and biologics holds
great promise for future therapies in hematologic
malignancies, solid tumors, and supportive care.
By combining our global heritage with therapeutic
innovation, we provide more treatment choices for
patients with cancer.
Explore the depth of Teva Oncology.
Visit TevaOncology.com
*Excluding supportive care.
Reference: 1. EvaluatePharma®, March 2013.
©2013 Cephalon, Inc., a wholly owned subsidiary of
Teva Pharmaceutical Industries Ltd. All rights reserved.
ONC-40170 April 2013. Printed in USA.
breast cancer patient story
Glamorous
AMERICAN ICON
CONFRONTED FEAR to fight
breast cancer
J
Jaclyn Smith burst onto the American scene in 1976 when she
played the calm and cool Kelly Garrett in the original “Charlie’s
Angels” television series. She went on to portray strong characters in more than 50 film and television appearances, including Jacqueline Bouvier Kennedy and Florence Nightingale. Also
well known for her business savvy, she trailblazed her own selfbranded clothing and home décor products with Kmart as well as
her own lines of skin care products, fabrics and wigs, which are
available at www.jaclynsmith.com.
However, when the award-winning icon faced a breast cancer diagnosis in 2002 at the age of 55, she
had to battle back fear. “Once you hear the
word ‘cancer,’ you are paralyzed,” she said.
“Your world stops spinning and the first
thing you ask is, ‘Am I going to make it?
Am I going to be here for my children and
my family?’”
Fortunately for Jaclyn, she trusted her
doctor and had a supportive close-knit
family and girlfriends surrounding her. And
perhaps most importantly, the cancer was
detected early.
“Fear is the worst,” she said. “You
have to face it because if you don’t, it just
bites you in the back and stops you in your
tracks. But as I talked with my doctor and
my husband, Brad – who is a surgeon and
researcher – and shared my concerns with
my close friends, I educated myself and
that helped calm my fears.” Calming those
fears, she said, was also crucial for her children.
“It was important to me to not show my fear to my kids. Cancer is a family affair and affects everyone. If they saw me as
normal as I could be, with my head held high, that spilled over.”
Summer 2002: diagnosis and treatment
It was more than a decade ago when Jaclyn was in the middle
of a busy spring at home in Los Angeles, preparing to take her
teenage daughter to New York City to attend a dance camp. She
was checking tasks off her to-do list, and one of those was her
annual mammogram.
The scan showed something suspicious, but Jaclyn was in
excellent health and wasn’t concerned. The follow-up tests included a needle biopsy, an ultrasound and a core biopsy, but she
was still so sure that everything was fine she went back for the
results by herself.
“My doctor is a good friend of ours,” she said. “When the
results came back, he told me that he had mixed news. The
bad news was that I had cancer. The good was we had caught
it early at Stage I and it was very small – the size of a point of a
pencil. At that point, I guess I sort of panicked. I told him, ‘Just
take my breast off.’ You don’t hear anything after you are told
you have cancer. That’s why you should never go back for the
results alone.”
Jaclyn was ready to act quickly, but her doctor and husband
26
cautioned her to slow down and consider her options. She and
Brad both did extensive research and chose the recommended
treatment of a lumpectomy and radiation.
“I had the surgery and was fortunate because that summer
when I had radiation, I was surrounded by my family and my girlfriends,” she said. “They were so supportive that I did not go to
a single radiation appointment by myself. Not everyone has the
luxury of those kinds of friends, but there’s a large number of
support groups where you can make good friends.”
The summer of 2002 turned out to be extremely busy for Jaclyn,
and in hindsight, she views it as a blessing.
She had just launched a furniture line, made
a cameo appearance in the new “Charlie’s
Angels” movie and also had a recurring role
on CBS’ “The District.” During this same
time, she also went for her radiation treatments.
“My career had a resurgence, and for
some reason, I had an abundance of energy—despite the radiation,” she said.
“It was almost like God said, ‘You aren’t
going to sit around and feel sorry for yourself. You are going to work!’ My daughter
decided to forego her camp so she could
be home with me. My son was at ease
once I assured him that everything was
going to be fine. Plus, everyone on the
set of ‘The District’ could not have been
more supportive.”
Survivor and advocate
After completing radiation, Jaclyn was cancer-free and has remained that way since 2002. Maintaining a balance of work and
family, she continues to make television appearances and expand
her retail lines.
Because she had always made her health a priority, Jaclyn did
not have to make substantial lifestyle changes. However, she did
take anastrozole (Arimidex) for five years as adjuvant therapy and
also began her personal regimen of alternating mammograms
and MRIs every six months, which she still continues.
In 2006, Jaclyn was ready to share what she had learned from
her experience and crisscrossed the country for two years with
the Strength in Knowing program. She told her story to encourage
and help educate women about breast cancer and its risk factors.
She also feels strongly about annual mammograms. “Early detection is the key,” she said. “If I had waited another year, the
cancer would have been more advanced. The most important
thing is to have a doctor you trust who advises you, have a mammogram every year and do self-examinations as well.”
In retrospect, Jaclyn said that cancer changed her, and while
challenging, the change was for the better. “Having cancer can
make you a stronger, braver person. I was always pretty positive,
but I am a private person as well. I found strength and healing
in reaching out to others. But it also taught me that I could overcome my fears, to never give up and always have hope.”
Pa t i e n t Re s o u r ce .co m
Types of Cancer
Inside this section
Lung Cancer
Breast Cancer
Prostate Cancer
Colorectal Cancer
Leukemias & Multiple Myeloma
Gynecologic Cancers
Melanoma
types of cancer | lung cancer
L
Lung Cancer Overview and Staging
Lung cancer is the second most commonly
diagnosed cancer in both men and women,
and the most lethal in both genders in the
United States. This type of cancer forms in
cells that line the airways (bronchi) of the
lung. Four main pathologic types of lung
cancer exist: adenocarcinoma, squamous
cell carcinoma, large cell carcinoma and
small cell carcinoma.
Small cell carcinoma most often spreads
to other sites and may grow much faster than
the other types. At one time, the other three
types were classified together as non-small
cell lung cancer. However, this term is no
longer used when pathologists classify lung
cancers because researchers have found differences in the way each type of non-small
cell lung cancer develops and how it is best
treated depending on its histology (microscopic characteristics).
Lung cancer is usually staged twice. The
first staging produces a “clinical stage,”
which is based on the results of your physical exam and imaging tests. A pathologist
will then assign a pathologic stage after
examining tissue from the tumor, lymph
nodes and other sites taken by biopsy. This
examination provides more details about the
Table 1. AJCC system for classifying lung cancer
Classification
Definition
Tumor (T)
Tx
The primary tumor cannot be assessed OR there is evidence of cancer according to
laboratory studies but no tumor seen on imaging studies or with bronchoscopy
T0
No evidence of primary tumor
Tis
Carcinoma in situ (in place)
T1
Tumor is 3 centimeters (about 1 inch) or smaller in its largest dimension, surrounded by lung
or visceral pleura (lining covering the outside of the lung), with no evidence of tumor in the
main bronchus (airway)
T1a
Tumor is 2 cm (about 3/4 inch) or smaller in its largest dimension
T1b
Tumor is more than 2 cm (but not more than 3 cm) in its largest dimension
T2
Tumor is more than 3 cm but not more than 7 cm (about 2-3/4 inches); OR tumor has any of
the following features:
• Involves main bronchus, 2 cm or more below the carina
• Invades visceral pleura
• Associated with atelectasis (collapse of part of the lung) or obstructive pneumonitis
(inflammation of lung tissue) that extends to the hilar region but does not involve the
entire lung
T2a
Tumor is more than 3 cm but not more than 5 cm (about 2 inches) in largest dimension
T2b
Tumor is more than 5 cm but not more than 7 cm in largest dimension
T3
T4
Tumor is more than 7 cm OR directly invades any of the following: chest wall, diaphragm,
phrenic nerve, mediastinal pleura, parietal pericardium; OR tumor in the main bronchus
less than 2 cm distal to the carina but without involvement of the carina; OR associated
atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the
same lobe as the primary tumor
Tumor of any size that invades any of the following: mediastinum, heart, great vessels,
trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina OR presence of
separate tumor nodule(s) in a different lobe of the lung with the primary tumor
Nodes (N)
cancer. The accuracy of the pathologic stage
is important for choosing the best treatment
options and predicting the outcome.
Lung cancer is staged according to a system developed by the American Joint Committee on Cancer (AJCC) and the Union
for International Cancer Control (UICC).
The system is based on data from around
the world collected by the International
Association for the Study of Lung Cancer
(IASLC). This “TNM” system classifies the
cancer by tumor (T), node (N) and metastasis (M) and is used as the foundation for the
overall stage of lung cancer (Table 1). The T
(tumor) category describes the size and location of the primary tumor. The N (node)
category describes lymph node involvement,
or whether cancer cells are found in nearby
lymph nodes. The location of these nodes
shows how much the disease has spread.
The M (metastasis) category describes distant metastasis, or how much the cancer has
spread to other parts of the body.
Once the lung cancer has been classified
according to this system, an overall stage is
assigned. These are further subdivided to
group tumors that are associated with similar outcomes. This grouping allows doctors
to more accurately predict the outcome according to the stage (Table 2).
The TNM classification and the staging system for lung cancer were updated in
2009 and the updated system stages both
non-small cell and small cell lung cancer.
Talk with your doctor to make sure that
your lung cancer is staged according to the
updated system, which can provide a more
accurate prediction of outcome and suggest
different treatment options.
Table 2: Stages of lung cancer
according to AJCC classification
Stage
TNM classifications
0
Tis, N0, M0
IA
T1 (T1a or T1b), N0, M0
IB
T2a, N0, M0
IIA
T1 (T1a or T1b), N1, M0
T2a, N1, M0
T2b, N0, M0
Nx
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Cancer cells are found in peribronchial and/or hilar lymph nodes and intrapulmonary nodes
on the same side as the lung with the primary tumor
IIB
T2b, N1, M0
T3, N0, M0
N2
Cancer cells are found in mediastinal and/or subcarinal lymph nodes on the same side as the
lung with the primary tumor
IIIA
N3
Cancer cells are found in mediastinal or hilar lymph nodes on the opposite side from the
primary tumor OR in the scalene or supraclavicular lymph node(s) on the same or opposite
side as the lung with the primary tumor
T1 (T1a or T1b), N2, M0
T2 (T2a or T2b), N2, M0
T3, N1 or N2, M0
T4, N0 or N1, M0
IIIB
Any T, N3, M0
T4, N2 or N3, M0
No distant metastasis
IV
Any T, any N, M1a or M1b
Metastasis (M)
M0
28
Pa t i e n t Re s o u r ce .co m
Helping to make access
to the therapies you need easier
Novartis Oncology is committed to helping patients living with cancer
receive the medicines they need. Patient Assistance NOW Oncology offers
quick and easy access to information about the broad array of support and
reimbursement programs available.
You can get information about our Patient Assistance NOW Oncology
support programs in 2 ways:
r
Call 1-800-282-7630 to speak with a member of our knowledgeable staff
dedicated to making access to our programs as simple and convenient
as possible; or
r
Visit our website at: www.OncologyAssistanceNow.com
Support for Patients Includes:
r Insurance verification
r Assistance with denials/appeals
r Coding/billing questions
r Patient assistance for low-income and
uninsured patients
r Medicare education
r Therapy-specific support programs for
out-of-pocket costs
r Alternative assistance searches and referrals
to federal or state assistance programs
r Referrals to independent charitable
foundations for assistance with co-pay costs
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936-1080
r Patients prequalified via phone screening
for the Patient Assistance Program (PAP)
will be sent a 30-day supply of their needed
medication while completing the application
r Convenient provider portal to access
program services or check the status
of patients enrolled
© 2012 Novartis
10/12
T-PAN-1052066
types of cancer | lung cancer
F
Lung Cancer Treatment Options
Four types of treatments are most often used
in some combination for lung cancer: surgery, radiation therapy, chemotherapy and
targeted therapy. The specific treatment approach depends on:
• Type of lung cancer (adenocarcinoma,
squamous cell carcinoma, large cell
carcinoma or small cell carcinoma)
• Stage of disease
• Location of the tumor
• Overall lung function and general health
of the patient
Also, recent studies show that certain genetic mutations (changes) in the tumor tissue
are important in selecting effective treatment.
Surgery
Surgery offers the best chance for cure of
early-stage (Stage I or II) cancers. Some types
of surgery to remove a lung tumor include:
• Sublobar resection (wedge resection) –
A small part of the lung containing the
tumor is removed.
• Lobectomy – The lobe of the lung containing the tumor is removed.
• Pneumonectomy – The entire lung is
removed.
During any of these operations, the surgeon also removes nearby lymph nodes to see
if cancer cells have spread beyond the lung.
Surgery may also be part of a multidisciplinary approach for Stage IIIA adenocarcinoma, squamous cell carcinoma or large cell
carcinoma, but it is rarely used for Stage IV
disease. Surgery is also done for Stage I or
IIA small cell lung cancer, but this type is
usually not detected until a later stage.
Lobectomy is considered the standard
surgical option, but sublobar resection is often used when the lesions are very small or
when lung function is poor.
Chemotherapy
For Stage III patients, chemotherapy is given
with chest radiotherapy at the same time or
occasionally before or after surgery, and adjuvant chemotherapy (chemotherapy given
after surgery) is the standard treatment for
Stage II and III (and sometimes Stage IB) adenocarcinoma, squamous cell carcinoma and
large cell carcinoma. Chemotherapy may also
be given before surgery or radiation therapy
to help shrink the tumor first. This is known
as neoadjuvant chemotherapy treatment.
Chemotherapy with supportive care is also
given for Stage IV cancer of any type (including small cell lung cancer), and chemotherapy may also be given as maintenance therapy
after the end of standard chemotherapy to
30
help delay the progression of cancer. For
Stage IV patients, targeted therapies may be
given alone or with chemotherapy.
The choice of specific drugs depends on the
histologic type of lung cancer. For example,
the drug pemetrexed (Alimta) has been less
effective for squamous cell carcinoma than for
adenocarcinoma or large cell carcinoma.
When chemotherapy is the initial treatment, it is usually given as a combination of
two drugs. One of these is a platinum drug
such as cisplatin or carboplatin. Adding a
third chemotherapy drug, however, has not
been shown to increase survival. If the cancer
does not respond to the initial treatment or if
the cancer progresses, different chemotherapy
drugs may be tried. The targeted therapy bevacizumab (Avastin) may also be given with
chemotherapy for selected patients.
Other chemotherapy drugs used for lung
cancer include paclitaxel (Taxol), docetaxel
(Taxotere), nab-paclitaxel (Abraxane), etoposide, pemetrexed (Alimta), gemcitabine
(Gemzar), ifosfamide, irinotecan (Camptosar), mitomycin and vinblastine.
For advanced non-small cell lung cancer,
researchers have also found that some chemotherapy drugs, such as pemetrexed or the
targeted drug erlotinib, given as maintenance
therapy (beyond the traditional number of chemotherapy cycles) may help improve survival.
Maintenance therapy is used primarily for people with advanced non-small cell lung cancer
that has not spread or grown after treatment
with certain types of chemotherapy drugs.
Radiation therapy
Radiation treatment is delivered from a machine outside of the body, called externalbeam radiation therapy, and is usually used
in combination with chemotherapy (known
as chemoradiation therapy) and/or surgery.
Chemoradiation therapy gives the best outcomes for most patients with Stage III lung
cancer of all types. Chemoradiation therapy is
also the most commonly used treatment for
Stage IIB or III small cell lung cancer and is
sometimes given in combination with surgery.
A special type of localized radiotherapy
called stereotactic body radiotherapy is
sometimes used for people with Stage I or II
disease who are not eligible for surgery. This
type of radiation to localized sites may help
alleviate symptoms. Radiation to the brain
is often given after treatment for small cell
lung cancers.
Targeted therapy
Targeted therapy is treatment with drugs
that target a specific cell pathway in the body
and block signals that cause cancer cells to
multiply. The type of targeted therapy used
may depend on specific genetic mutations
(changes) in the tumor tissue. Some examples of targeted drugs include:
• Erlotinib (Tarceva) – This drug inhibits the
epidermal growth factor receptor (EGFR),
blocking a signal that tells the cells to grow.
It’s most effective when an EGFR mutation
is present in the lung tumor and is the initial therapy for these patients. For patients
without this mutation, it is used for cancer
that has spread or grown after receiving
at least one course of chemotherapy, or as
maintenance after initial chemotherapy. • Afatinib (Gilotrif) – This drug was
recently approved as first-line (initial)
treatment of metastatic non-small cell
lung cancer that tests positively for an
EGFR mutation.
• Crizotinib (Xalkori) – This drug inhibits
another recently identified genetic
change, a fusion of the ALK and EML4
genes (ALK-EML4). Crizotinib targets
the pathway that helps cancer cells to
grow in tumors that have this genetic
change. This drug is used to treat advanced non-small cell lung cancer that
has tested positively for ALK-EML4. It
may be used before or after chemotherapy in these patients.
• Bevacizumab (Avastin) – This drug inhibits a signal protein called vascular endothelial growth factor (VEGF), which stops the
blood supply to the tumor. It’s used to treat
advanced nonsquamous non-small cell
lung cancer in combination with carboplatin and paclitaxel in people who have not
received prior chemotherapy.
Current targeted therapy drugs are not effective for small cell lung cancer.
Talk openly with your doctors about
treatment options and their side effects, and
ask about the effect of treatment on your
daily activities and quality of life. Lung cancer is difficult to control with the treatments
currently available, so many doctors encourage people to consider a clinical trial for the
opportunity to receive the newest possible
treatment (see page 10).
ADDITIONAL RESOURCES
International Association for the Study of
Lung Cancer: www.iaslc.org
Lung Cancer Action Network (LungCAN):
http://lungcan.org
Lung Cancer Alliance:
www.lungcanceralliance.org
National Lung Cancer Partnership:
www.nationallungcancerpartnership.org
Pa t i e n t Re s o u r ce .co m
lung cancer patient story
She Took Control
and Her Persistance Paid Off
Elizabeth Lacasia worked for a biotech company as an oncology
product strategist before she herself was diagnosed with nonsmall cell adenocarcinoma in 2007. She and her husband were
married two years before her diagnosis, and they live in a house
they recently designed and built together. Elizabeth enjoys gardening, traveling and creative writing, and through persistent selfadvocacy at every step, she has learned to come to terms with
her Stage IV lung cancer.
I
It was at a Christmas sing-along in 2005 when I first noticed my
breathing didn’t seem quite right. Later on I developed a persistent cough, so I made an appointment to see my doctor. Because
I was a healthy nonsmoker in my 40s, he said it was just allergies
or acid reflux and prescribed an allergy medication. But my cough
didn’t go away. I saw several other general practitioners throughout the year, during which time my cough progressed to the point
where I was coughing up fluid.
In late 2006 I finally had a more comprehensive workup, which
included a chest X-ray and a CT scan that revealed several tumors in my lower left lung. The largest was about the size of
a pingpong ball. I was diagnosed with non-small cell adenocarcinoma. More specifically, my subtype was invasive adenocarcinoma (formerly called bronchioloalveolar carcinoma) – a very
rare, slow-growing and difficult-to-treat lung cancer. I immediately
had a lower left lobectomy, after which my surgeon told me I was
cured. Unfortunately, about a year later a wedge resection verified
that the cancer had returned and spread throughout my lungs.
Several weeks after my surgery, I began treatment as part of
a clinical trial, including eight cycles of carboplatin (Paraplatin),
gemcitabine (Gemzar) and bevacizumab (Avastin). I then continued on Avastin as a maintenance therapy.
In 2008, I pursued a second opinion from another thoracic
oncologist, as lung cancer is an especially complex disease and
treatment philosophies differ. It was the best decision I ever
made. My new oncologist told me about and conducted molecular genetic testing on
my tumor tissue. This
panel of simultaneous
tests produced a profile
of my unique disease,
including the chemotherapies and targeted
therapies that might be
effective. We discovered my cancer was
resistant to the most
toxic
chemotherapy
included in my initial
treatment regimen. If
we had conducted this
testing panel beforehand, the combination of drugs would have been different and I
might have had a greater and longer initial response.
Using this information when my cancer progressed in 2009,
my oncologist suggested that I participate in another clinical trial,
“
“
In fighting
cancer, you can’t
be passive. You
have to become
an informed
participant.
Pa t ie n tResource.com
Elizabeth
which combined erlotinib (Tarceva) and pemetrexed (Alimta) in
a way that could help short-circuit disease mutation. I’m still in
the same clinical trial, now taking Tarceva as a single agent. I’m
stable and no active disease is apparent on my periodic CT scans.
My oncologist says I’ll be on chemotherapy for the rest of my life
as I still have active disease, but my treatment regimen has been
quite a success!
I have some side effects, including fatigue, intestinal issues
and extremely dry skin. But in the grand scheme of things,
these are all minor concerns. A B12 shot helps with my fatigue,
probiotics and fiber help modulate my intestinal issues, and nail
conditioners and body lotions help address my skin concerns. I
also now suffer from asthma and mild COPD, but I have a supportive pulmonologist who – in addition to my oncologist and
general practitioner – helps optimize my overall quality of life.
When I was first diagnosed, I was frightened. But by learning
about my options, becoming involved with the Bonnie J. Addario Lung Cancer Foundation and participating in the Writing
through Cancer program, I’ve learned to confront my fears and
find peace, as there’s renewed hope for people with lung cancer. Now that I’m a veteran of this disease, I try to be for others
the person I wish I’d had when I was diagnosed—a relatable
and helpful resource.
This is your body and your life. I firmly believe that if I hadn’t
been such a strong self-advocate – both in getting my initial
diagnosis and in eventually switching to an oncologist whose
philosophy aligned with my own – that I might not be here today.
In fighting cancer, you can’t be passive. You have to become an
informed participant in choosing your treatment regimen. Don’t
be afraid to ask your doctor challenging questions, and try to take
it one day at a time. Focus on what you can do and make sure
you’re in capable hands for the things you can’t.
31
types of cancer | breast cancer
B
Breast Cancer Overview and Staging
Breast cancer is cancer that forms in breast
tissue, usually in the milk ducts (tubes that
carry milk to the nipple) or less often in the
breast lobules (glands that make milk). Breast
cancer is the most commonly diagnosed cancer among women. Although breast cancer
can also develop in men, it is rare.
Breast cancer is classified by “staging,” a
process that determines how much cancer is
in the body and where it is located. Staging
describes the severity of the cancer, based
on the original tumor and how much it has
spread. Knowing this information helps
your doctor plan your treatment.
The managing physician does clinical
staging of the cancer based on the tumor’s
characteristics, which are assessed through a
physical exam, X-rays and/or other imaging
studies and laboratory results. A pathologist
then does pathologic staging by examining
tissue specimens removed during surgery or
a biopsy.
Breast cancer is staged according to a system
developed by the American Joint Committee
on Cancer (AJCC). This TNM system classifies
the cancer by tumor (T), node (N) and metastasis (M) and is used as the foundation for the
overall stage of breast cancer (Table 1).
• The T (tumor) category describes the
primary tumor. It is the same for both
clinical and pathologic staging. This
category describes the size and location
of the tumor.
• The N (node) category describes
lymph node involvement – the lymph
nodes that have evidence of breast
cancer cells. The location of these
lymph nodes is important because it
shows how much the disease has spread.
The pathologic N (node) category
(sometimes denoted as pN) shows how
many lymph nodes are involved and the
amount of tumor cells actually found in
the nodes.
Table 1. AJCC system for classifying breast cancer
Category
Definition
Tumor (T)
Tx
Cannot be assessed
T0
No evidence of primary tumor
Tis
Tumor has not started growing into the breast tissue (known as carcinoma in situ)
T1
T1mi
T1a
T1b
T1c
2 centimeters (about ¾ inch) or less
1 millimeter or less
Larger than 1 mm but not more than 5 mm (0.5 cm)
Larger than 5 mm but not more than 10 mm (1 cm)
Larger than 10 mm but not more than 2 cm
T2
Larger than 2 cm but not more than 5 cm (almost 2 inches)
T3
Larger than 5 cm
T4
T4a
T4b
Any size
Tumor extends into the chest wall
Presence of edema (swelling), thickening of the skin, or ulceration (a sore, painful area
where the breast skin/tissue is breaking down
Signs of both T4a and T4b
Inflammatory cancer (breast is red, swollen and warm)
T4c
T4d
Nodes (N)
Nx
Lymph nodes cannot be evaluated
N0
No metastasis or micrometastasis found in any lymph nodes
N1
N1mi
N1a
N1b
N1c
N2
N2a
N2b
N3
N3a
N3b
N3c
Micrometastases*
Metastasis in 1 to 3 axillary lymph nodes (nodes under the arm), with at least one metastasis
of more than 2 mm (0.5 cm)
Metastasis in internal mammary lymph nodes (nodes on either side of the sternum
[breastbone]): with micrometastases or macrometastases detected through a sentinel lymph
node biopsy (but not clinically detected)
Metastasis in 1 to 3 axillary lymph nodes and in internal mammary lymph nodes
Metastasis in 4 to 9 axillary lymph nodes
Metastasis in clinically detected internal mammary lymph nodes but no metastasis in
axillary lymph nodes
Metastasis in 10 or more axillary lymph nodes OR in the infraclavicular lymph nodes (nodes
under the clavicle [collarbone])
Metastasis in internal mammary lymph nodes and in 1 or more axillary lymph nodes
Metastasis in supraclavicular lymph nodes (nodes above the clavicle)
Metastasis (M)
M0
No distant metastasis (cancer has not spread to other parts of the body)
M0(i+)
Microscopic or molecular evidence of tumor cells in bone marrow, circulating blood or
nonregional nodal tissue (but no clinical evidence of metastasis)
M1
Evidence of distant metastasis (cancer has spread to other parts of the body)
*Refers to a small cluster of tumor cells, no larger than 2 millimeters.
32
Pa t i e n t Re s o u r ce .co m
breast cancer | types of cancer
• The M (metastasis) category describes
distant metastasis (spread of cancer to
another part of the body), if any. Staging
for the M category is mainly clinical.
However, a new M subcategory is based
on the presence of tumor cells that can
be detected only by using a microscope
or molecular testing. The most common
sites of distant metastasis in breast cancer
are the bones, lungs, liver and brain.
Once the cancer has been classified according to this system, an overall stage is assigned. Five main stages (designated 0 to IV)
are further divided to group tumors that have
similar outcomes (prognoses). This grouping
allows doctors to more accurately predict the
outcome according to the stage (Table 2).
AJCC also recommends testing for estrogen and progesterone receptors (ER and
PR) and human epidermal growth factor receptor-2 (HER2). The doctor considers the
stage and these other factors in selecting the
most appropriate treatments.
Stage IA
Table 2. Stage of breast cancer
according to AJCC classifications
Stage
TNM classifications
0
Tis, N0, M0
IA
T1*, N0, M0
IB
T0 or T1*, N1mi, M0
IIA
T0 or T1*, N1**, M0
T2, N0, M0
IIB
T2, N1, M0
T3, N0, M0
IIIA
T0-T3, N2, M0
T3, N1, M0
IIIB
T4, N0-N2, M0
IIIC
Any T, N3, M0
IV
Any T, Any N, M1
ADDITIONAL RESOURCES
American Society of Clinical Oncology
(patient website): www.cancer.net
Breast Cancer: Staging
CancerQuest (Winship Cancer Institute,
Emory University): www.cancerquest.org
Breast Cancer: Pathology Report and Staging
*T1 includes T1mi.
**T0 and T1 tumor with micrometastases in node(s) only are
excluded from Stage IIA and are classified Stage IB.
Tables adapted from AJCC Cancer Staging Manual,
7th edition (2010)
Stage IB
Subcutaneous fat tissue
Tumor is
2 cm or
smaller
Pectoralis major muscle
Patient Resource:
www.PatientResource.com/
Breast_Cancer.aspx
Stage IIA
Lymph nodes
2nd rib
OncoLink: www.oncolink.org
Breast Cancer: The Basics
Tumor is larger
than 2 cm but
smaller than
5 cm
Multiple
lymph node
metastasis
Tumor is 2 cm or smaller
Nipple
Micrometstases
in lymph nodes
Stage IIB
Tumor is larger
than 2 cm but
smaller than
5 cm
Stage IIIA
Multiple
lymph node
metastasis
Stage IIIC
The tumor can
be any size
but has not
spread to
distant
parts of
the
body
Tumor is larger
than 2 cm but
smaller than
5 cm
Stage IIIB
Multiple
lymph node
metastasis
Tumor has spread
to the chest
wall or caused
swelling or
ulceration
of the
breast
Multiple
lymph node
metastasis
Stage IV
Multiple
lymph node
metastasis
Tumor can
be any size
Multiple
lymph node
metastasis
Metastases
Brain
Lung
Liver
Bone
"Patient Resource LLC
Pa t ie n tResource.com
33
types of cancer | breast cancer
B
Breast Cancer Treatment Options
Table 1. Chemotherapy options
Breast cancers can vary quite a bit, so a
number of treatment options can be effective. In addition to traditional treatments
– such as surgery, radiation therapy and
chemotherapy – hormone therapy and targeted therapy are important for providing
personalized treatment for many women
with breast cancer.
Drugs or combinations of drugs that may
be used as adjuvant therapy to treat breast
cancer:
•
•
•
•
•
•
•
•
•
Surgery
Surgeons use two types of surgery for the primary treatment of breast cancer. A lumpectomy is a “breast-conserving treatment” that
leaves the breast intact. The surgeon removes
only the tumor (lump) and a small amount
of healthy tissue around the lump. The surgeon may also remove some lymph nodes
from under the arm. If the tumor is larger
than 5 centimeters (about 2 inches), doctors
usually do not recommend a lumpectomy.
However, if a woman has a tumor of this size
and a strong desire to save the breast, chemotherapy or hormone therapy before surgery
can often shrink the tumor enough for the
surgeon to remove it safely.
A mastectomy is often done for larger
tumors, especially those that have spread to
nearby lymph nodes. Some women with a
small breast cancer also choose a mastectomy to ease their worry about the tumor
coming back, and some want to avoid radiation therapy. Mastectomies today are much
less extensive and disfiguring than those
done years ago, thanks to new and better
surgical techniques. At one time, a mastectomy meant removing the whole breast as
well as the muscles under the breast and all
of the lymph nodes under the arm. This was
known as a “radical mastectomy.” Today, a
radical mastectomy is only done for tumors
that are extensive or have invaded the chest
wall and cannot be shrunk by other therapy.
More often, surgeons perform a “total” or
“complete” mastectomy, which preserves
the chest wall muscles.
•
•
•
With either surgery, surgeons also remove
lymph nodes under the arm. A pathologist
then examines the nodes for signs of cancer
cells. This step is called “lymph node staging” and helps doctors determine the stage
of the breast cancer. To lessen the number of
lymph nodes removed, surgeons use a procedure called “sentinel lymph node biopsy.”
The number of lymph nodes removed depends on whether cancer cells are detected
in the “sentinel” nodes, which are those closest to the breast cancer.
After a mastectomy, women have many
options for reconstructive surgery. This is
usually done by a plastic surgeon, who rebuilds the breast to make it look, as much as
possible, as it did before surgery.
Radiation therapy
Radiation therapy is almost always done after a lumpectomy to destroy any remaining
cancer cells. Research shows that women
with a small tumor who have breast radiation therapy after a lumpectomy live as long
as women who have a mastectomy.
Table 2. Hormone therapy options
Menopausal
status
Hormone therapy options
Postmenopausal
• aromatase inhibitors: anastrozole (Arimidex), letrozole (Femara),
exemestane (Aromasin)
• selective estrogen-receptor modulator: tamoxifen (Nolvadex), toremifene (Fareston)
• fulvestrant (Faslodex)
• progestin: megestrol acetate (Megace)
• high-dose estrogen (ethinyl estradiol)
• androgen (male hormone): fluoxymesterone (Halotestin)
Premenopausal
•
•
•
•
•
34
tamoxifen (Nolvadex)
luteinizing hormone receptor hormones (LHRHs): goserelin (Zoladex), leuprolide (Lupron)
progestin: megestrol acetate (Megace)
high-dose estrogen (ethinyl estradiol)
androgen (male hormone): fluoxymesterone (Halotestin)
•
•
•
cyclophosphamide (Cytoxan, Neosar)
docetaxel (Taxotere, Docefrez)
doxorubicin (Adriamycin)
epirubicin (Ellence)
fluorouracil (5-FU, Adrucil)
methotrexate (multiple brand names)
paclitaxel (Taxol)
AC (doxorubicin and cyclophosphamide)
AC followed by T (doxorubicin and
cyclophosphamide, followed by paclitaxel or
docetaxel)
CAF (cyclophosphamide, doxorubicin
and 5-FU)
CEF (cyclophosphamide, epirubicin
and 5-FU)
CMF (cyclophosphamide, methotrexate
and 5-FU)
EC (epirubicin and cyclophosphamide)
TAC (docetaxel, doxorubicin and
cyclophosphamide)
TC (docetaxel and cyclophosphamide)
Drugs that may be used to treat recurrent or
metastatic breast cancer:
•
•
•
•
•
•
•
•
•
vinorelbine (Navelbine)
capecitabine (Xeloda)
protein-bound paclitaxel (Abraxane)
pegylated liposomal doxorubicin
(DOXIL, LipoDox)
gemcitabine (Gemzar)
carboplatin
cisplatin
ixabepilone (Ixempra)
eribulin (Halaven)
After a mastectomy, the doctor decides
on the need for radiation therapy to the upper chest. The doctor mainly looks at the
number of lymph nodes involved, the size
of the tumor and whether cancer cells were
found in the healthy tissue around the tumor. If the breast cancer has metastasized
(spread), the woman may receive radiation
therapy for the parts of the body to which
the cancer has spread.
Chemotherapy
Chemotherapy may be used as the primary
treatment for metastatic breast cancer. It
may also be used before the primary therapy to shrink a large tumor, or after the primary therapy as an “adjuvant,” or additional, treatment. Many chemotherapy drugs
are approved for treating breast cancer
(Table 1). Chemotherapy is usually given as
a combination of two or three drugs, sometimes given together and sometimes given
after one another (sequentially). When
chemotherapy is given as the primary treatment of metastatic disease, single agents
given sequentially is preferred.
Pa t i e n t Re s o u r ce .co m
breast cancer | types of cancer
Hormone therapy
Adjuvant hormone therapy is used only
for women with tumors that have estrogen
and/or progesterone receptors (noted as
ER+/PR+). Estrogen drives the growth of
these tumors, so drugs that lower or block
estrogen in the body can help stop the cancer from returning. Tamoxifen (Nolvadex)
is the oldest, most well-known hormone
therapy drug. Another drug of this type is
toremifene (Fareston).
Aromatase inhibitors are another type of
hormone therapy and work only in postmenopausal women. Examples of these include anastrozole (Arimidex), exemestane
(Aromasin) and letrozole (Femara).
Another type of hormone therapy blocks
the mechanism that causes the ovaries to
make estrogen. This can be achieved by surgery, radiation therapy or drugs called “luteinizing hormone-releasing hormone (LHRH)
analogs” such as goserelin (Zoladex).
Hormone therapy drugs differ in how they
work, who can use them and what side effects
can result. Talk to your doctor about options
available for your type of cancer (Table 2).
Targeted therapy
Targeted therapy agents have had a great impact on survival and quality of life for many
women and are usually used in combination
with other drugs (Table 3). Trastuzumab
(Herceptin) was the first targeted therapy
developed for any cancer. It is effective
only for breast tumors with high amounts
of the HER2 protein and is known as an
anti-HER2 agent. Newer anti-HER2 agents
include lapatinib (Tykerb) and pertuzumab
(Perjeta). In 2013, the FDA also approved
ado-trastuzumab emtansine (Kadcyla),
which combines trastuzumab with another
chemotherapy drug, and can be used to treat
late-stage (metastatic) breast cancer.
The many treatment choices for breast
cancer can seem overwhelming, especially
for women with early-stage disease. Your
doctor and health care team can help you
understand the risks and benefits of each
treatment before deciding on a plan. Learn
as much as you can about your own type of
cancer and tumor. The more you know, the
better able you are to work with your doctors to make informed decisions.
ADDITIONAL RESOURCES
Adjuvant! Online:
www.adjuvantonline.com
National Cancer Institute:
www.cancer.gov/cancertopics/types/breast
American Cancer Society:
www.cancer.org/cancer/breastcancer/index
National Comprehensive Cancer Network:
www.nccn.com/cancer-guidelines.html
American Society of Clinical Oncology
(patient website): www.cancer.net
Patient Resource:
www.PatientResource.com/Breast_Cancer.aspx
Table 3. Targeted therapy options
Targeted therapy agent
Type of breast cancer
Approved/recommended treatment
trastuzumab (Herceptin)
HER2+, node-positive or
node-negative
• In combination with chemotherapy regimen of doxorubicin plus cyclophosphamide, followed by either
paclitaxel or docetaxel
• In combination with chemotherapy regimen of docetaxel and carboplatin
• As a single agent following chemotherapy that includes an anthracycline (doxorubicin,
epirubicin, pegylated liposomal doxorubicin)
HER2+, metastatic
• In combination with paclitaxel for first-line treatment
• As a single agent after failure of one or more chemotherapy regimens
ER+/PR+, HER2+
• In combination with letrozole
HER2+, metastatic
• In combination with capecitabine after failure of anthracyclines, taxanes (paclitaxel or docetaxel)
and trastuzumab
pertuzumab (Perjeta)
HER2+, metastatic
• In combination with trastuzumab
ado-trastuzumab
emtansine (Kadcyla)
HER2+, metastatic
• For patients previously treated with trastuzumab, another anti-HER2 agent and taxanes
everolimus (Afinitor)
Hormone receptorpositive, HER2-, metastatic
• In combination with exemestane (Aromasin)
lapatinib (Tykerb)
Pa t ie n tResource.com
35
breast
cancer
patient
story
types of
cancer
| subject
Survivor Fought Hard
S
to be Around for Her Daughters
Misty Smith was just 35 years old when she was diagnosed
with Stage II triple-negative breast cancer in November 2011.
Despite an incorrect initial diagnosis and the development of an
autoimmune lung disease, she beat her cancer and is now on
the road to recovery. Misty works as a third-grade teacher and
has two daughters of her own, ages 6 and 18. She enjoys taking
pictures, going on walks, getting pedicures and spending time
with her family.
Y
You know what your body should feel like, so if you think something is wrong, push your doctors to investigate further. If I hadn’t
done that during my run with breast cancer, things may have
turned out very differently.
Back in 2011, I’d had a head cold for a couple of weeks and
was having some pain around my breast. I thought I’d just pulled
a muscle, but one night I decided I wanted to have it checked out
anyway. While I was taking a shower the following morning, I felt
a lump and knew I needed to accelerate my appointment.
My family doctor got me in right away and, after a quick exam,
referred me to a nearby hospital for a mammogram and an ultrasound. The test results revealed what the doctors deemed to be a
fluid-filled cyst, and they immediately drained it with a needle aspiration. Three days later, the lump was back. A second ultrasound
the following week confirmed that the cyst had returned and that
it was already the same size as it had been before it was drained.
At that point, I asked for a referral to a surgeon. He did yet another ultrasound followed by another needle aspiration. And just
like the time before, the lump returned only a few days later. I’d
had enough, so I told my surgeon I wanted it out. He respected
my wishes and removed the cyst on Nov. 18. Four days later on
Nov. 22 – a date I’ll never forget – my surgeon called me to say
that what we’d thought was a cyst was actually cancer. I had
Stage II triple-negative breast cancer—specifically, invasive (infiltrating) ductal carcinoma.
As soon as I hung up the phone, the tears began to flow. I
cried for hours, mostly because I was terrified that my daughters
would have to go through life without their mom. Luckily, I’m
blessed with some amazing family and friends, and within the
hour I was surrounded by several of them. I
don’t know how
I would’ve made
it through the
night alone.
I soon underwent surgery, including a lumpectomy and lymph
node dissection
in which they removed 24 lymph nodes from under my left arm.
A month later, I had another surgery to have a chemotherapy port
installed, and I then began eight rounds of chemotherapy. The first
four treatments were with the drugs doxorubicin and cyclophosphamide (Cytoxan), and the last four treatments were with the
drug paclitaxel (Taxol). The side effects were tough, and after the
“
“
This journey has taught
me that I’m truly
blessed and that life is
never guaranteed.
36
Following breast cancer, Misty Smith now
spends as much time as possible with her
two daughters.
Misty
third and fourth rounds, I was
actually hospitalized for about
a week due to dehydration and
extreme nausea, among other
things. Emotionally, I had a difficult time, too, but I knew I had to
fight with everything I had to be
there for my girls.
Following chemotherapy, my
doctors ordered a few followup scans, the results of which
hit me like a ton of bricks. They showed spots in my lungs, liver
and under my arms. It looked as if my cancer had spread and
advanced to Stage IV.
To find out exactly what was going on, my oncologist ordered
a mediastinoscopy to obtain a biopsy. To everyone’s surprise, the
results showed not metastasized cancer but a granulomatous inflammation. As it turned out, I had developed an autoimmune
lung disease called sarcoidosis, which is what was showing up
on the scans. Sarcoidosis treatment involves high doses of steroids, which I took and will need to continue to take each time
the disease flares up. After confirming that I didn’t have Stage IV
cancer, I underwent radiation therapy 33 times to round out my
initial treatment plan.
I wouldn’t have made it through all of this without my family and
friends. They were with me at almost every treatment appointment and even put on a benefit in my honor. I also received a lot
of support from the school district I work for and my community.
This journey has taught me that I’m truly blessed and that life
is never guaranteed—none of us are promised tomorrow. I spend
every second I can with my children, and it meant the world to
me to see my little girl start kindergarten and my oldest start college. I’m much stronger physically, mentally and emotionally than
I ever thought I was, and I’m just so thankful that I had doctors
who listened to me when I knew something wasn’t right.
Pa t i e n t Re s o u r ce .co m
prostate cancer | types of cancer
A
Prostate Cancer Overview and Staging
After you receive a diagnosis of prostate cancer, your doctor will try to determine how
far the cancer has progressed within the
prostate gland and whether it has spread to
nearby tissues or other parts of your body.
This process is called cancer staging. Staging
prostate cancer helps your doctor choose the
best treatment options for you.
The doctor managing your overall treatment will assign a clinical stage, which is
based on the prostate-specific antigen (PSA)
levels, the results of a physical exam and,
often, imaging studies, such as a bone scan
and computerized tomography (CT) scan
and, on occasion, magnetic resonance imaging (MRI). If you have a biopsy or surgery,
a pathologist will assign a pathologic stage
after examining tissue specimens removed
during the biopsy or surgery.
The most widely used staging system was
developed by the American Joint Committee on Cancer (AJCC). This system classifies the cancer by tumor (T), node (N) and
metastasis (M), and together this “TNM”
classification provides a description for the
overall stage of cancer (Table 1).
• The T (tumor) category describes the
size and location of the primary tumor.
• The N (node) category describes how
many lymph nodes have evidence of
cancer cells (known as “lymph node
involvement”). Regional (or “nearby”)
lymph nodes are defined in this category
as involved when assessed by imaging
tests or microscopic examination.
• The M (metastasis) category describes
distant metastasis, or how much the cancer has spread to other parts of the body.
In addition to the TNM system, doctors
use two other factors for staging:
• A Gleason score shows the grade of the
tumor, or how similar the tumor tissue
Table 1. AJCC system for classifying prostate cancer
Classification
Definition
Tumor (T)
Tx
Tumor cannot be evaluated (because of lack of information)
T0
No evidence of primary tumor
T1*
Tumor is not detected during a digital rectal exam (DRE) and cannot be seen on imaging studies*
T2
T2a
T2b
T2c
Tumor can be detected during a DRE and is present in the prostate only
Tumor is in half or less of one side (lobe) of the prostate
Tumor is in more than half of one prostate lobe but has not invaded the other lobe
Tumor is in both prostate lobes
T3
T3a
T3b
Tumor extends outside of the prostate
Tumor extends outside the prostate on one side or both sides
Tumor has spread to seminal vesicles (glands on each side of the bladder)
T4
Tumor has spread to tissues near the prostate other than the seminal vesicles,
such as the bladder
Nodes (N)
Nx
Nearby lymph nodes were not evaluated
N0
No cancer cells are found in nearby lymph nodes
N1
Cancer cells are found in nearby lymph nodes
Metastasis (M)
M0
M1
M1a
M1b
M1c
Cancer has not spread beyond nearby lymph nodes
Cancer is detected in tissue beyond nearby lymph nodes
Cancer is detected in distant lymph nodes
Cancer is detected in the bone
Cancer is detected in another organ or site but not in the bone
*When a tumor is found during surgery not related to prostate cancer, it is further classified as T1a (tumor cells in 5 percent or less
of removed prostate tissue) or T1b (tumor cells in more than 5 percent of removed prostate tissue). A tumor is classified as T1c if
found during a needle biopsy (usually done because of a high PSA level).
is to normal prostate tissue. The score
ranges from 2 to 10. The pathologist
gives a low score when the tumor looks
more like normal prostate tissue and a
higher score when the cancer looks less
like normal tissue. A high Gleason score
means that the tumor is more aggressive,
and the higher the score, the more likely
it is that the tumor will spread.
• The PSA level in blood is roughly correlated with how much cancer there is.
Table 2. Stage of prostate cancer according to AJCC classification
Stage
TNM classification
Gleason score
Prostate-specific antigen (PSA) level
I
T1(a-c), N0, M0
T2a, N0, M0
6 or less
6 or less
Less than 10
Less than 10
IIA
T1(a-c), N0, M0
T1(a-c) or T2a, N0, M0
T2a, N0, M0
T2b, N0, M0
7
6 or less
7
7 or less
Less than 20
10 or higher, but less than 20
Less than 20
Less than 20
IIB
T2c, N0, M0
T1 or T2, N0, M0
T1 or T2, N0, M0
Any score
Any score
8 or higher
Any level
20 or higher
Any level
III
T3(a-b), N0, M0
Any score
Any level
IV
T4, N0, M0
Any T, N1, M0
Any T, Any N, M1
Any score
Any score
Any score
Any level
Any level
Any level
Pa t ie n tResource.com
A low PSA level is associated with better
survival outcomes. The PSA level at the
time of diagnosis is used in staging and
also to follow the disease after therapy.
Doctors use the AJCC classification,
Gleason score and PSA level at diagnosis
to determine an overall stage of disease and
make decisions about treatment. Five main
stages (0 to IV) are further divided to group
tumors that are associated with similar outcomes (Table 2). This grouping allows doctors to more accurately predict the outcome
and recommend appropriate therapy.
Some doctors may use the older
Whitmore-Jewett staging system and assign
Stage A, B, C or D to your cancer. Ask your
doctor to explain the staging system used or
to translate the stage into one determined by
the AJCC system, which has been shown to
provide more information on prognosis.
ADDITIONAL RESOURCES
Prostate Cancer Foundation: www.pcf.org
The Prostate Net: www.prostate-online.org
Us TOO International Prostate Cancer
Education & Support: www.ustoo.org
37
types of cancer | prostate cancer
T
Prostate Cancer Treatment Options
The treatment options for prostate cancer
depend on the stage of the cancer and an estimate of how quickly the cancer will spread
beyond the prostate gland itself. Choices are
made based on a man’s age and the expected
benefits of each treatment and its side effects.
Watchful waiting
If your cancer is limited to the prostate and
expected to grow slowly, your doctor may
recommend monitoring your cancer closely and beginning treatment if the cancer
shows signs of progressing. This approach
is very safe for low-stage, low-grade tumors
and also avoids unnecessary and sometimes harmful treatments. With watchful
waiting – also called “active surveillance”
– your doctor will measure your prostatespecific antigen (PSA) levels and perform a
digital rectal exam (DRE) regularly. If your
PSA level rises sharply or your DRE results
change, your doctor may need to do another
biopsy of your prostate.
Surgery
The type of surgery your doctor recommends depends on the stage of the disease
and your general health (Table 2, page 37).
A radical prostatectomy is the most common surgery for prostate cancer. In this procedure, the prostate and some surrounding
tissue are removed. The procedure may be
done either as an open procedure through
an incision in the body or laparoscopically,
or with a robotic surgical system. Laparoscopic surgeries require only small, keyholesize incisions in the body, so they are much
less invasive than an open procedure.
Cryosurgery is another minimally invasive approach that freezes and destroys
cancer tissue. Also called “cryotherapy” or
“cryoablation,” this procedure is done with
very thin needles inserted through a small
incision between the scrotum and rectum.
Radiation therapy
Prostate cancer treatment often uses externalbeam radiation therapy (EBRT) using a technique called “intensity-modulated radiation
therapy” (IMRT). This allows delivery of high
doses of radiation to the prostate while sparing the normal tissues around the prostate as
much as possible. To accomplish this, many
medical centers also use three-dimensional
conformal radiation therapy (3-D CRT) to
find the exact location and shape of the tumor.
Proton therapy, another form of EBRT,
uses beams of protons (atomic particles)
to precisely target and destroy tumor cells
in the prostate. Radiation oncologists will
also use computerized tomography (CT),
38
magnetic resonance imaging (MRI) and
other imaging technologies during radiation
therapy to improve the accuracy and precision of the therapy. This is called “imageguided radiation therapy” (IGRT).
Brachytherapy is another technique in
which radioactive seeds are placed in and
around the tumor. These seeds give off continuous low doses of radiation to the tumor
and are left in the prostate permanently.
ADT
Androgen deprivation therapy (ADT) reduces the supply of male hormones (such
as testosterone) to keep prostate cancer cells
from growing. This therapy may be combined with surgery or radiation therapy to
treat prostate tumors at high risk of spreading or returning after treatment. ADT is also
the main treatment for tumors that have already recurred or spread.
Known as medical castration, ADT reduces the levels of male hormones, which are
produced in the testicles. (Surgical removal
of the testicles may also be done.) ADT usually consists of any of the following drugs:
• LHRH (luteinizing hormone-releasing
hormone) analogs – These include drugs
such as leuprolide (Eligard, Lupron), goserelin (Zoladex) or triptorelin pamoate
(Trelstar Depot), which are known as
agonists, or degarelix (Firmagon), an
antagonist. Antagonists are usually used
only in men in whom prostate cancer has
spread to lymph nodes or bones.
• Anti-androgen drugs – These drugs
block the action of androgens. Examples
are flutamide, enzalutamide (Xtandi) and
bicalutamide (Casodex).
• Drugs that prevent adrenal glands, fatty
tissue and prostate cancer cells from
making androgen – Examples include
abiraterone (Zytiga) and ketoconazole
(Nizoral).
• The female hormone estrogen
• Combinations of LHRH analogs and
anti-androgen drugs (primarily flutamide
or bicalutamide)
• Abiraterone, enzalutamide and ketoconazole are currently used only when other
ADT drugs have stopped being effective.
Chemotherapy
Chemotherapy is used primarily for prostate
cancer no longer responding to ADT, known
as castration-resistant (or hormone-refractory) disease. Drugs used for this type are
docetaxel (Taxotere), which is used as firstline (initial) treatment and has been shown to
improve survival, and cabazitaxel (Jevtana),
which is used when treatment with docetaxel
has failed. Mitoxantrone (Novantrone) may
also be prescribed but is almost always used
when docetaxel and cabazitaxel are no longer
effective. These drugs are all given in combination with prednisone, a type of steroid.
Biologic therapy (immunotherapy)
Biologic therapy drugs work with the immune
system, the body’s natural defense against
disease. Sipuleucel-T (Provenge) is an immunotherapy drug that fights prostate cancer
by boosting the immune system. It’s FDAapproved for treating metastatic, castrationresistant prostate cancer in men who have few
or no symptoms. Before treatment, the patient’s white blood cells are removed through
a process called leukapheresis. The immune
cells in the blood are then separated out, modified in a laboratory and injected back into the
patient. These enhanced cells stimulate other
immune cells to kill prostate cancer cells.
Radiopharmaceuticals
Radiopharmaceuticals are drugs that contain a radioactive substance. One radiopharmaceutical used to treat advanced prostate
cancer that has spread to bone is radium
Ra-223 dichloride (Xofigo). This drug carries the radioactive substance directly to the
bones to kill cancer cells. Radium Ra-223
can be used only when prostate cancer has
spread to bones but no other organs.
Targeted therapies
Targeted therapies are designed to block
the action of newly recognized genes and
proteins thought to enhance cancer growth.
Under study is a type of drug called a “c-Met
inhibitor,” which targets a protein needed for
prostate cancer to grow. Monoclonal antibodies are also being studied for castrationresistant prostate cancer. These antibodies
are made in a lab and block the activity of a
specific target on the surface of a cancer cell.
Other treatments
Several treatments are available for bone
complications, such as pain and fractures,
that may accompany metastatic disease:
• Denosumab (Prolia) is an osteoporosis
drug used in men with prostate cancer
who are receiving ADT and are at high
risk of bone fractures. It’s also approved for
men with bone metastases.
• Strontium and samarium are radioactive
agents that may be injected into the veins to
reduce bone pain due to metastatic cancer.
• Zoledronic acid (Zometa) blocks the
breakdown of bone and is used to reduce
bone complications due to metastatic
prostate cancer.
Pa t i e n t Re s o u r ce .co m
NOVEL TARGETED THERAPIES
FOR CANCER PATIENTS
www.algeta.com
prostate cancer patient story
Super Bowl MVP
Len Dawson was an NFL quarterback for 19 years. And in 1970,
No. 16 led the Kansas City Chiefs to a victory over the Minnesota Vikings in Super Bowl IV and was named the Most Valuable
Player of the game.
Len retired from the NFL in 1976 as one of the best forward
passers of all time and in 1987 was inducted into the Professional
Football Hall of Fame. After his playing days, Len began an impressive career in sports broadcasting and currently serves as the
sports director at KMBC-TV in Kansas City and the color analyst
for the Chiefs Radio Network. He also hosted HBO’s “Inside the
NFL” from 1977 to 2001 and worked as an analyst for NBC’s AFC
coverage from 1977 to 1982.
Then in 1991 at the age of 56, Len was diagnosed with earlystage prostate cancer. He put to use the tools he learned as a
quarterback to analyze the situation and beat his newest opponent. He has now been cancer-free for more than two decades.
L
Len is no stranger
ger to adversity. “As a quarterback things
didn’t always go
o my way, so I learned to make adjustments,” he explained.
ained. “When my doctor said, ‘You have
cancer,’ I knew I just needed to make some adjustments
and deal with it.”
Len owes the early discovery of his prostate cancer to
his wife, Linda. He was in New York taping “Inside the NFL” for
or HBO when she read an article in the newspaper
spaper about Sen. Bob Dole’s
prostate cancer. She also saw an advertisement in that same
me paper for free prostate
cancer
c
screenings at a local hospital
that
that Friday. Linda knew her husband
was
w busy, so she called and made an
appointment
for him at 9 a.m. When
a
Len
L
returned home to Kansas City on
Thursday
T
night, she told him about it.
“Like a typical man, my first reaction
was
w
to say I wasn’t going,” he said. “I
didn’t
d
think I needed to because I didn’t have
any
a symptoms of prostate cancer. She held
her
h ground, though, and said if I didn’t
want
w
to go I had to call and cancel
myself.
m
I decided that this was a
battle
b
I wasn’t going to win, so I
kept
the appointment.”
k
The doctor performed a
prostate
specific antigen
p
(PSA)
( PSA) blood test and a
digital
rectal examinad
tion
tion (DRE). He found
an
abnormality,
a
so
s he told Len to
schedule
an uls
trasound
trasound and a
Len Dawson
biopsy.
Sure
b
during his 1970
enough,
e
the
Super Bowl
MVP season
results
of
results
4
40
L en
Was Victorious On and Off the Field
tests revealed early-stage prosthose follow-up
follow
tate can
cancer.
ncer. Fortunately it was caught early, so
it was sstill confined to the prostate gland and
hadn’t yyet spread throughout his body.
Len rece
received a second opinion from a doctor in N
New
ew York, who confirmed the original diagnosis.
agnos
sis. After carefully considering all of his
treatment
trea
tme options, he ultimately decided
have a radical prostatectomy to get
to
o ha
the cancer out of his body. The surgeon used a nerve-saving technique,
ge
which left him with no lasting side efwh
fects. Len stayed in the hospital for
fec
two days after his surgery, and it took
tw
him about six months before he was
back to normal. He has been cancerbac
ffree ever since.
“As a quarterback and a broadcaster, I
“A
on the fast track for a long time,” he
was o
w
explained.
“I’ve slowed down with age,
ex
plain
really enjoy putting my feet up and
and I re
relaxing.
relaxi
ing. But I know my health is important
so I’m still very active with what I can do. The
difference
differe
nce is that now my workouts consist of
golf instead of training camps.”
rounds of g
Len cconsiders
that initial screening appointons
the luckiest thing that has ever hapment to b
be th
“As the seventh son of a seventh
pened to him.
h
supposed
son, I am sup
ppos to have good luck,” he explained.
“I am very lucky
that my wife made that appointment
y th
never
would have done it myself.”
for me because I neve
er wo
Len now recommendss that
th all men over the age of 50 get
they have any symptoms. “Even the
screened whether or nott the
toughest guys need to ttake
ake care of their health,” he said. “If
to find out about it as quickly as
there’s a problem, you want
w
deal
with it. In sports and in life, you’ll
possible so you can dea
al w
face adversity. It’s up to
o you
yo to make adjustments and make
things right.”
Pa t i e n t Re s o u r ce .co m
LOOK FOR THIS SEAL OF APPROVAL
ACCREDITATION FROM THE AMERICAN COLLEGE OF SURGEONS COMMISSION ON CANCER (CoC) IS
T H E H A L LM A R K O F E XC E L L E N C E
By receiving cancer care at a CoC-accredited center
you can be confident that your cancer care team
includes health care professionals from a variety of
disciplines who are committed to working together
to provide you with quality care.
When looking for quality cancer care, look for the CoC logo.
A list of accredited cancer care programs can be found
on the CoC Hospital Locator at
facs.org/cancerprogram/index.html.
types of cancer | colorectal cancer
C
Colorectal Cancer Overview and Staging
Colorectal cancer is the third most common
cancer in men and women. It begins in the
lining of the colon or the rectum, which are
parts of the large bowel or large intestine.
The colon is about 6 feet long, and the rectum and anal canal make up the last 6 to 12
inches of the large intestine.
Colorectal cancer is classified by a process called staging. This classification is
based on how deeply the tumor has grown
into the lining of the intestine and whether
or not it has spread beyond the colon or
rectum. Determining the stage of colorectal cancer is important because it helps your
doctor choose the best treatment options
for you as well as make a prognosis (predict
the outcome).
The doctor managing your care will assign a clinical stage, which is based on the
results of a physical exam, X-rays and/or
other imaging studies and laboratory results. A pathologist then classifies the tumor
according to a pathologic stage, which is
based on examination of tissue specimens
removed during surgery or a biopsy.
Colorectal cancer is staged according
to a system developed by the American
Joint Committee on Cancer (AJCC), and
this “TNM” system classifies the cancer by
tumor (T), node (N) and metastasis (M)
(Table 1):
• The T (tumor) category describes the
primary tumor, including how deeply
the tumor has grown into the layers of
tissue that line the inside of the colon or
rectum.
• The N (node) category describes lymph
node involvement, or whether cancer
cells are found in nearby lymph nodes.
The location of involved lymph nodes is
important because it shows how much
the disease has spread.
• The M (metastasis) category describes
distant metastasis, or how much the cancer has spread to other parts of the body.
Once the cancer has been classified according to this system, an overall stage is assigned. Five main stages (0 to IV) are further
divided to group tumors that have similar
Table 1. AJCC system for classifying colorectal cancer
Classification
Definition
prognoses. This grouping allows doctors
to more accurately predict the outcome according to the stage (Table 2) and select the
most appropriate treatments.
Table 2. Stage of colorectal cancer
according to AJCC classification
Tumor (T)
Stage
TNM classification
Tx
Tumor cannot be evaluated (because of lack of information)
0
Tis, N0, M0
T0
No evidence of primary tumor
I
T1 or T2, N0, M0
Tis
Carcinoma in situ; cancer cells are found only in the mucosa, the first layer of the lining of
the colon or rectum
IIA
T3, N0, M0
IIB
T4a, N0, M0
T1
Tumor has grown into the submucosa, the second layer of the lining
IIC
T4b, N0, M0
T2
Tumor has grown into the muscularis propria, the third layer of the lining
IIIA
T3
Tumor has grown into the subserosa, the deepest layer of the lining, or into tissues
surrounding the colon or rectum
T1 or T2, N1(a-c), M0
T1, N2a, M0
IIIB
T4a
T4b
Tumor has grown to the wall of the colon or rectum
The tumor has grown through the wall of the colon or rectum and invaded or attached to
nearby tissues or organs
T3 or T4a, N1(a-c), M0
T2 or T3, N2a, M0
T1 or T2, N2b, M0
IIIC
T4a, N2a, M0
T3 or T4a, N2b, M0
T4b, N1(a-c) or N2, M0
IVA
IVB
Any T, Any N, M1a
Any T, Any N, M1b
Nodes (N)
Nx
Nearby lymph nodes cannot be evaluated
N0
No cancer cells are found in nearby lymph nodes
N1a
N1b
N1c
Cancer cells are found in one nearby lymph node
Cancer cells are found in two or three nearby lymph nodes
Cancer cells are found in the subserosa, mesentery (the fatty tissue that contains the lymph
nodes and blood vessels) or tissues around the colon or rectum but not in nearby lymph nodes
N2a
N2b
Cancer cells are found in four, five or six nearby lymph nodes
Cancer cells are found in seven or more nearby lymph nodes
Metastasis (M)
M0
Cancer has not spread beyond nearby lymph nodes
M1a
Cancer has spread to one organ or site (for example, the liver, lung, ovary or distant
lymph node)
Cancer has spread to more than one organ or site or to the lining of the abdominal
cavity (peritoneum)
M1b
42
ADDITIONAL RESOURCES
American Cancer Society: www.cancer.org
How is Colorectal Cancer Staged?
American Society of Clinical Oncology
(patient website): www.cancer.net
Colorectal Cancer: Staging, with Illustrations
CancerQuest: www.cancerquest.org
Colon and Rectal Cancer: Pathology Report
and Staging
OncoLink: www.oncolink.org
Colon Cancer: The Basics
Pa t i e n t Re s o u r ce .co m
colorectal cancer | types of cancer
T
Colorectal Cancer Treatment Options
Treatment of colorectal cancer depends on
the stage of the disease, just as with other
types of cancer, and early diagnosis can lead
to a complete cure, which is why screening
is so important. Ongoing research is also
leading to personalized treatments for some
types of colorectal cancer.
Surgery
Surgery is the most common treatment for
colorectal cancer and is usually the primary
treatment for all stages of the disease. If the
cancer is localized to a single polyp – simply
a mass of overgrown tissue – or is at a very
early stage, your doctor may be able to remove it during a colonoscopy. If cancer cells
are located where the polyp attaches to the
wall of the colon, your doctor may need to
remove that part of the colon to ensure all
cancer cells are removed.
For later-stage colorectal cancer (Stages
II and III), the surgeon also removes nearby
lymph nodes. A pathologist can then check
the lymph nodes for cancer cells and determine the stage of the cancer.
Two main types of surgery can be done to
treat colon cancer:
• Open surgery – In this traditional surgery, the surgeon makes a large incision
in the abdomen.
• Laparoscopic surgery – With this type
of surgery, the surgeon passes special
instruments through a few small incisions.
One of these instruments is a laparoscope,
which has a small video camera on the
end. This allows the surgeon to see inside
your abdomen. Most patients recover faster and have less pain after a laparoscopic
procedure compared with open surgery.
For some rectal cancers, robotic-assisted
surgery can be done with a laparoscopic
procedure. With this type of surgery, the
surgeon uses special instruments that can
reach areas that may be difficult to manage with traditional instruments.
Laparoscopic and robotic-assisted surgeries are less invasive, and recovery time is
shorter. However, you and your doctor should
consider many factors before choosing either
of these procedures. The surgeon’s experience
in using these techniques is very important.
When a section of the colon is removed,
the surgeon can usually attach the healthy
ends together during the same surgery. However, sometimes the colon needs to heal before this can be done. If so, the surgeon will
make an opening, or stoma, in the abdomen
and attach one end of the intestine to the
opening. This procedure is called a colostomy
and provides a new pathway for the body to
eliminate waste. A pouch attached to the skin
around the stoma collects the waste. Most often, a colostomy is temporary. However, if the
surgeon needs to remove the anal sphincter
muscles, which control bowel movements,
the colostomy will become permanent. When
treating rectal cancers, the goal is to preserve
the anal sphincter to keep as much normal
bowel function as possible.
Chemotherapy
Chemotherapy for colorectal cancer usually
involves two or more drugs. Several effective
regimens are available for initial (first-line)
and later treatments. The most commonly
used drugs for colorectal cancer are fluorouracil (5-FU), irinotecan (Camptosar),
oxaliplatin (Eloxatin) and capecitabine (Xeloda). The drug leucovorin (folinic acid) or
levoleucovorin is often given with fluorouracil to make that drug more effective.
When cancer has spread to nearby lymph
nodes (Stage III), the doctor may give adjuvant, or additional, chemotherapy after surgery to lower the risk of the cancer coming
back. Adjuvant chemotherapy is not recommended for treating Stage I disease, and it’s
used for Stage II disease only when there is a
high risk of the cancer returning.
Chemotherapy may also be the main
treatment for advanced (metastatic)
colorectal cancer. In these cases, the treatment goal is to increase survival time rather
than cure the disease. Chemotherapy is also
often combined with radiation therapy for
the treatment of rectal cancer.
Targeted therapy
Targeted therapy involves the use of drugs or
other substances to stop cancer cell growth
by interfering with the way cells communicate. For colorectal cancer, targeted therapy
has mainly involved the use of epidermal
growth factor receptor (EGFR) inhibitors
and antiangiogenic agents. These drugs are
usually given along with chemotherapy for
metastatic disease.
EGFR inhibitors include cetuximab (Erbitux) and panitumumab (Vectibix). These
Pa t ie n tResource.com
are effective for treatment of people with
metastatic colorectal cancer, but only if
their tumors do not have changes (“mutations”) in the KRAS gene. Therefore, experts
recommend that all people with metastatic
colorectal cancer have genetic testing on the
tumor to see if KRAS mutations are present. If a patient has a tumor with the KRAS
mutation, other types of treatment, such as
standard chemotherapy, are available.
Two new drugs are available for metastatic colorectal cancer that has not responded
to previous treatment. Regorafenib (Stivarga) is used for colorectal cancer that has not
responded to chemotherapy or an EGFR inhibitor, and ziv-aflibercept (Zaltrap) is used
for metastatic colorectal cancer that has not
responded to treatment with an oxaliplatinbased chemotherapy regimen.
Another type of targeted therapy for
metastatic colorectal cancer is bevacizumab (Avastin). Known as an antiangiogenic
agent, it stops the growth of blood vessels to
the tumor. Without a blood supply, tumor
cells dies. Bevacizumab is most often given
with chemotherapy.
Radiation therapy
Radiation therapy is often used for patients
with rectal cancers or with colon cancers
that have attached to an internal organ or
wall of the abdomen. It’s also used to treat
colorectal cancer that has spread to another
organ, such as the brain or bones.
Radiation therapy is mostly used along
with chemotherapy for rectal cancers because
these tumors tend to recur near where they
originally started. This combination, known
as chemoradiation therapy, may be given after surgery (adjuvant therapy) to help reduce
the risk of the cancer coming back. Chemoradiation therapy can also be given before
surgery (neoadjuvant therapy) – a common
treatment for rectal cancers – to shrink the
tumor and make it easier to remove.
ADDITIONAL RESOURCES
American Cancer Society: www.cancer.org
Colon/Rectum Cancer
American Society of Colon & Rectal
Surgeons: www.fascrs.org
Laparoscopic Surgery – What is It?
College of American Pathologists:
www.cap.org
KRAS Mutation Testing for Colorectal Cancer
Fight Colorectal Cancer:
www.fightcolorectalcancer.org
Is KRAS Testing Right for You?
National Cancer Institute: www.cancer.gov
Colon and Rectal Cancer
National Comprehensive Cancer Network:
www.nccn.com
43
colon cancer patient story
Survivor’s Family History
S
Mary Ellen Fleming-Jones overcame a long family history when
she beat colon cancer 20 years ago. She is a retired U.S. Food and
Drug Administration chemist and has two adult daughters. When
she’s not driving patients to their cancer treatments through Cancer Action or talking to people over the phone through the R.A.
Bloch Cancer Foundation’s Hotline, Mary Ellen enjoys feeding
birds and attending live theater shows, movies and concerts as
well as fishing, reading and playing brain games.
I
I come from a “cancer family.” I have had grandparents, aunts,
uncles and cousins on both sides who have battled various types
of cancer. My father was diagnosed with colon cancer in 1978
and lymphoma in 1980. Two years later, my mother also was diagnosed with colon cancer, and then in 1988 my brother found
out he had melanoma. Many of them lost their fights.
When I was diagnosed with Stage III colon cancer in March
1993 at the age of 52, I was determined to work toward a different result. That determination paid off. I survived and began
a new, more optimistic chapter in my family’s history. My sister
and her daughter have since beaten breast cancer and two of
my cousins have conquered melanoma. While we may still be a
cancer family, we are now also a family of survivors.
A gastroenterologist first discovered my cancer during a colonoscopy and endoscopy. I went in for the procedures because of
frequent stomach pain, which I originally suspected to be from an
ulcer. When I found out the true cause, I reacted rather nonchalantly because the doctor said the mass was very small. A couple
of weeks later – at the urging of my youngest daughter – I made
an appointment with a surgeon to have it removed.
After my surgery, the surgeon told me the tumor actually was
the size of his fist—much larger than originally thought. He also
told me that the tumor had broken through my bowel wall, that
my appendix was malignant and that 23 of the 27 lymph nodes
he tested were positive for cancer. At that point, my family history flashed before me and it felt like my world was crashing down.
An oncologist came to my hospital room soon after to set
up a consultation for six weeks later. At that appointment she
helped me enroll
in a clinical trial.
I soon found out
that I was chosen to be in the
control group of
the trial rather
than in the study
group, so I didn’t
receive the newest medication.
Instead, I received 30 cycles of the chemotherapy drugs leucovorin (Wellcovorin) and fluorouracil (5-FU). I was disappointed at first, but
ultimately the treatment worked and that’s all that really matters
in the end.
Physically, my therapy was a breeze compared to what I’ve
seen others experience. I did feel fatigued and I lost 46 pounds
“
“
While we may still
be a cancer family,
we are now also a
family of survivors.
44
Mary Ellen
Didn’t Define Her Fight
due to a combination of diarrhea and loss of appetite, but overall the physical effects were minimal. Emotionally, I still have to
work at not making every health issue I have a symptom of my
cancer. Luckily, I’m not alone in that struggle. I believe that no
one should have to carry a burden alone. Thankfully, my friends
and family members do, too, so they all were a great source of
support for me during my treatment and for a long time after.
I also attended support group sessions, which were incredibly
important to my recovery.
Now that I’m a long-term survivor, I do what I can to help others. I volunteer with the Bloch Cancer Hotline and Cancer Action, talking to current cancer patients over the phone and while
driving them to their appointments. I think it helps them to hear
advice and receive support from a cancer survivor like me, but I
also get a lot of continued support from them by observing how
they cope and thrive. I truly believe that I’m actually getting more
than I’m giving through my involvement with these organizations.
My best advice for those newly diagnosed is to find a doctor
who specializes in your particular type of cancer with whom you
can communicate freely and trust. If you don’t feel a connection
with the first doctor, seek out a second opinion. This philosophy
wasn’t as prevalent when I was diagnosed, but through my volunteer efforts, I find myself encouraging people who are having difficulty communicating with their doctors or accepting a diagnosis
or treatment scheme to search for a second opinion. A doctor’s
attitude can greatly influence a patient’s handling of side effects
and, ultimately, the outcome of the treatment.
Pa t i e n t Re s o u r ce .co m
leukemias and multiple myeloma | types of cancer
C
Leukemias and Multiple Myeloma
Cancers fall into two general categories: solid and hematological (blood). When most
people think of cancer, they think of solid
cancer, which involves a tumor that grows
and sometimes spreads to other places in
the body. In contrast, blood cancers affect
the blood, bone marrow and lymph nodes
and may not create an actual tumor.
Leukemias and multiple myeloma are
both blood cancers that develop when normal blood or plasma cells transform and
grow uncontrollably. These abnormal cells
don’t mature or function properly and may
crowd out normal cells, making it hard for
them to do their work.
About bone marrow and
white blood cells
To understand leukemias and multiple myeloma, it’s important to first gain a general
understanding of bone marrow and white
blood cells, which both play a major role in
these two diseases.
• Bone marrow is the soft, spongy center
of some bones that contains immature
blood stem cells, more mature bloodforming cells, fat cells and tissues that
support cell growth.
• White blood cells (leukocytes) are a
component of blood that help the body
defend against infection. Granulocytes
and lymphocytes are two of the main
types of white blood cells:
! Granulocytes are cells with enzymecontaining granules visible under a
microscope. They develop from
myeloblasts (immature cells found
in bone marrow) into mature, infection-fighting cells. Subtypes of these
cells include basophils, eosinophils
and neutrophils.
! Lymphocytes are the primary cells in
lymphoid tissue, which is a major part
of the immune system. They develop
from lymphoblasts (immature cells
found in bone marrow) into mature,
infection-fighting cells. Subtypes of
these cells include B lymphocytes and
T lymphocytes. Plasma cells develop
from B lymphocytes. They produce
antibodies to help fight infection and
are mainly found in the bone marrow.
Leukemias
Leukemias start in the blood and bone
marrow and occur when large numbers of
white blood cells do not function properly.
The two major types of leukemia are acute
and chronic:
• Acute leukemia grows quickly and occurs when immature white blood cells
Pa t ie n tResource.com
properly and interfere with the production of healthy cells. Like CLL, CML develops slowly and may not produce symptoms in the early stages. When symptoms
do occur, they often include easy bruising
or bleeding, unexplained weight loss,
fever, fatigue, shortness of breath, pain in
the bones and night sweats.
Multiple myeloma
increase rapidly, preventing bone marrow
from making normal blood cells. Treatment should be immediate because these
fast-growing cells can quickly become
life-threatening.
• Chronic leukemia grows more slowly
and occurs when white blood cells mature
partly but not completely. These abnormal
cells don’t fight infection as well as normal
cells, and because they survive longer, they
accumulate and crowd out normal cells.
Progression tends to take months or years,
and treatment may move more slowly than
it does for acute leukemia.
Leukemias are further subdivided based
on whether they affect lymphoid or myeloid
cells. Some of the main subtypes include:
• Acute lymphocytic leukemia (ALL):
Too many stem cells develop into abnormal lymphocytes, which don’t fight
infections well. Symptoms include anemia, frequent infections, swollen lymph
nodes, abdominal pain, fever, night
sweats, appetite loss and weight loss. ALL
progresses very quickly if not treated.
• Acute myeloid leukemia (AML): Too
many stem cells develop into abnormal
granulocytes, which don’t function properly and interfere with the production of
healthy cells. This causes the same symptoms as ALL, and AML also progresses
rapidly if not treated.
• Chronic lymphocytic leukemia (CLL):
Too many stem cells develop into abnormal lymphocytes, which don’t fight
infections well. CLL develops slowly, and
patients may have no symptoms in the
early stages and little change in their health
for many years. In time, symptoms may
include fatigue, shortness of breath, swollen lymph nodes or spleen, and frequent
infections. CLL is the most common type of
leukemia in adults.
• Chronic myeloid leukemia (CML): Too
many stem cells develop into abnormal
granulocytes, which don’t function
Multiple myeloma starts in plasma cells
inside bone marrow and occurs when normal plasma cells transform into abnormal
myeloma cells and grow uncontrollably. As
these abnormal cells multiply, they prevent
the growth of healthy cells in the bone marrow. They may also damage the bone itself as
well as other organs, such as the kidneys.
Multiple myeloma may not cause any
symptoms. However, the symptoms that can
develop include bone pain (especially in the
back or ribs), bones that break easily, fever,
frequent infections, easy bruising or bleeding, difficulty breathing, kidney problems,
weakness of the arms or legs, and feeling
very tired.
Treating leukemias and
multiple myeloma
The choice of treatment is dependent on
the type and subtype of the cancer and the
stage of the disease, as well as other factors,
including the patient’s age and gender.
Leukemia treatment options include chemotherapy, targeted therapy, immunotherapy (also called biological therapy), radiation
therapy and stem cell transplantation.
Multiple myeloma treatment options include chemotherapy, targeted therapy, radiation therapy and stem cell transplantation,
as well as steroids and supportive therapies
to relieve symptoms such as infections or
bone damage. Treatment plans for multiple
myeloma most often recommend more than
one type of therapy.
Another treatment option for both leukemias and multiple myeloma is watchful waiting. Some early-stage diseases grow slowly,
so it’s better to wait until the cancer has progressed before giving other treatment.
ADDITIONAL RESOURCES
American Cancer Society: www.cancer.org
Leukemia & Lymphoma Society:
www.lls.org
The Multiple Myeloma Research
Foundation: www.themmrf.org
National Cancer Institute: www.cancer.gov
Patient Resource:
www.PatientResource.com
45
CML patient story
The
Kareem Abdul-Jabbar bounces back from CML
battle and works to help others with the disease
a
akim
lowers his arms and slowly rises from the
ffloor, extending to his full 7 feet, 2 inches, and
calmly looks at the much smaller man, poised in a fighting
stance before him. Billy-Lo, who has faked his death to find
the people trying to kill him, has battled to this level of the
pagoda to eliminate Hakim in whichever fighting style seems
to be effective. Unfazed, Hakim stares down at his visitor
through dark sunglasses, confident and relaxed. “You little
runt. What do you think you’re trying to prove?”
Of course, Bruce Lee’s character would soon overcome the
sizeable odds and beat down the imposing Hakim, embodied
by Kareem Abdul-Jabbar in 1978’s “The Game of Death.” But
looking at that sheer volume of space absorbed by Hakim, the
cool confidence of a seasoned athlete? For a few minutes, the
fight doesn’t seem fair—like maybe the film’s famous star and
protagonist doesn’t save the day after all.
Kareem is used to being larger than life.
His study of martial arts under Bruce
Lee came in the middle of an NBA career that has yet to see its equal, setting
NBA records for points (38,387), minutes
(57,446), career field goals (15,837) and
All-Star honors (19). A member of the Naismith Memorial Basketball Hall of Fame
with six NBA championship rings, a statue
of his likeness was recently unveiled in
front of the Staples Center in Los Angeles. Former Lakers coach Pat Riley summarized Kareem’s 20-year NBA career:
46
“Why judge anymore? Let’s toast him as
the greatest player ever.”
Now long retired from basketball, and
30 years after Billy-Lo, the next “runt”
in Kareem’s path came at the cellular
level: Philadelphia chromosome-positive
chronic myeloid leukemia (CML), diagnosed in 2008.
“My reaction was that I was in a fight
for my life,” he said. “I kind of saw it as a
challenge to my existence.”
It wasn’t his first run-in with cancer.
Kareem carries the genetic risk for
colorectal cancer and watched as it
claimed the lives of both his grandfather
and uncle. His father nearly died himself
from the disease, which eventually took a
large section of his intestine. Kareem was
briefly involved with a colorectal cancer
educational campaign from 2006 to 2007
to help raise awareness of the risk.
So when he began experiencing symptoms of his CML, he took notice. Always
in tremendous shape between a lifetime
of competitive basketball and an advanced yoga habit he credits for his career
longevity, he was perplexed about the
night sweats that occurred two to three
times a month.
“I’d wake up and just be soaking wet,
and I didn’t understand what was going
on,” he said. “I initially just attributed it to
the fact that I was getting older, but it was
a lot more serious than that.”
Kareem’s doctor ordered some blood
work, which showed a sky-high white
blood cell count. That was the first indication, he said, that something was awry.
“I figured I wasn’t a candidate for anything that would be life-threatening,” he
said. “It took me entirely by surprise, and
it was a very frightening moment to have
somebody tell you that you probably
have leukemia.”
His first call was to his son – in medical school at the time – who deciphered
the medical jargon and assured him that
leukemia isn’t always life-threatening, that
many drugs have been developed in the
past decade that are quite effective for
many people.
The first drug Kareem tried proved useful at first, in spite of side effects such
Pa t i e n t Re s o u r ce .co m
as severe hand cramping and fatigue.
But after the drug’s effectiveness began
to level off, Kareem switched to nilotinib
(Tasigna), which not only helped Kareem
achieve the molecular response he was
looking for but also eliminate any lifeintruding side effects.
“I’m able to do everything that I was
doing before I was diagnosed,” he said.
With his leukemia under the control of
his medication, Kareem has focused on
several new ventures, including filmmaking – the documentary “On the Shoulder
of Giants” was released in 2011 – as well
as writing. In addition to an autobiography and memoir, he recently published
a children’s book about the history of
African-American inventors and is planning a trilogy of books for kids learning about basketball and life. The first
installment – called “Sasquatch in the
Paint” and loosely based on his life – hit
bookshelves September 2013.
His advocacy efforts have also reached
across borders. Named a cultural ambassador for the United States in 2012, he’s
traveled to Brazil in a partnership with that
country to upgrade its educational system, particularly in the areas of science
and math.
Among the many responsibilities involved with these creative efforts, he’s
also in the middle of a nationwide educational campaign, appearing at summits across the country, meeting with
CML patients in various stages of their
cancer journeys.
“I’ve found that I’ve been able to do a
lot of good just sharing my story with people and letting them know that they’re not
alone and that they have the opportunity
to treat this disease,” he said. “So many
people think that once they’re diagnosed,
that’s it, and it’s just going to be a slow descent into a bad end, and it doesn’t have
to be that way.”
So while his schedule stays full – he
Pa t ie n tResource.com
hopes to eventually get back
into his piano practice if he’s
ever home long enough –
Kareem remains ever grateful for the advances that
have led to his successful
treatment and the opportunity to share his story
with others.
“Using my celebrity
just to raise awareness
really helps because
research is the key
to the ongoing elimination of threats
like this,” he said.
“So every time we
figure out a way to
treat a different aspect of the various blood
cancers,
we’re
saving
lives and making it possible
for further discoveries. So all of
these things work together to make
for progress, and there’s been
great progress in the past 10 to
12 years.”
Kareem and his doctors now
simply keep a close eye on his
blood levels with checkups and
blood work appointments every
90 days. He also stresses the
importance of a healthy lifestyle
– exercise, plenty of sleep,
good nutrition – especially
when you’re battling cancer.
That combination, along with
his treatment plan, allows him
to keep the enemy in front of
him at arms’ length.
“I kind of relied on my martial arts training,” he said.
“Sometimes you have to
eliminate everything except
the thing you have to
defeat, or it’s going
to get you.”
47
When I asked about medication options,
my doctor said TASIGNA.
TASIGNA® (nilotinib) is a prescription medicine used to treat adults with newly diagnosed Philadelphia
chromosome–positive chronic myeloid leukemia (Ph+ CML) in chronic phase. The efficacy of TASIGNA is
based on major molecular response and cytogenetic response rates. The study is on-going and more data
will be needed to determine long-term outcomes.
TASIGNA is also used to treat chronic phase or accelerated phase Philadelphia chromosome–positive chronic
myeloid leukemia (Ph+ CML) in adults who are no longer benefiting from previous other treatments, including
imatinib (GLEEVEC®), or have taken other treatments, including imatinib (GLEEVEC) but cannot tolerate them.
The efficacy of TASIGNA is based on hematologic response and cytogenetic response rates.
Visit www.tasigna.com to learn more about the response data and the safety risks observed in clinical trials for TASIGNA.
Patients should tell their healthcare provider if they experience any side effect that bothers them or does not go away.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call
1-800-FDA-1088 (FDA Medwatch).
Patients, caregivers, friends, family, and healthcare professionals in the United States can contact Novartis Corporation
with questions by calling 1-888-NOW-NOVA (1-888-669-6682), Monday - Friday, 8:30AM - 5:00PM EST.
For additional safety information, please see the Important Safety Information on the next page.
Please see Important Safety Information, including Boxed WARNING for
TASIGNA, on the next page.
Learn more at www.tasigna.com and ask your doctor if TASIGNA is a treatment option for you.
IMPORTANT SAFETY INFORMATION
IMPORTANT SAFETY INFORMATION ABOUT TASIGNA® (nilotinib)
What is the most important information to know about
prescription TASIGNA?
TASIGNA can cause a possible life-threatening heart problem
called QT prolongation.
QT prolongation causes an irregular heartbeat, which may lead
to sudden death.
Your doctor should check your heart with a test called an
electrocardiogram (ECG):
• Before starting TASIGNA
• 7 days after starting TASIGNA
• With any dose changes
• Regularly during TASIGNA treatment
You may lower your chances for having QT prolongation with TASIGNA
if you:
• Take TASIGNA on an empty stomach
• DO NOT TAKE TASIGNA WITH FOOD
° Food can affect the levels of TASIGNA in your body, which can lead
to serious side effects
° Taking TASIGNA on an empty stomach may lower your chances
of having a possibly life-threatening heart problem called QT
prolongation
° QT prolongation causes an irregular heartbeat, which may lead to
sudden death
Who should not take TASIGNA?
Do not take if you have:
• Low levels of potassium or magnesium in your blood
• Long QTc syndrome
Taking TASIGNA:
• TASIGNA should be taken exactly as instructed by your doctor. Do
not change the dose or stop taking TASIGNA unless instructed to by
your doctor.
• Take TASIGNA at least 2 hours after eating any food
• After taking TASIGNA, wait at least 1 hour before eating any food
• Avoid grapefruit, grapefruit juice, and any supplement containing
grapefruit extract while taking TASIGNA. Food and grapefruit
products increase the amount of TASIGNA in your body
° Avoid taking other medicines or other supplements with TASIGNA
that can also cause QT prolongation
° Swallow TASIGNA capsules whole with water. If you cannot swallow
TASIGNA capsules whole, tell your doctor
• If you cannot swallow TASIGNA capsules whole:
° Open the TASIGNA capsules and sprinkle the contents
in 1 teaspoon of applesauce (puréed apple)
- Do not use more than 1 teaspoon of applesauce
- Only use applesauce. Do not sprinkle TASIGNA onto
other foods
° Swallow the mixture right away (within 15 minutes)
• Do not drink grapefruit juice, eat grapefruit, or take supplements
containing grapefruit extract. It may affect the levels of TASIGNA
in the blood
• If you miss a dose, take your next dose as scheduled. Do not take
a double dose to make up for a missed dose
Before taking TASIGNA
Talk to your doctor or pharmacist about all other medication(s) you
may be taking, including prescription medicines, over-the-counter
medicines, vitamins, and herbal supplements, since they may affect
how TASIGNA works and increase your chance of serious and lifethreatening side effects.
Tell your doctor if:
• You have a heart disorder or are taking medication for the heart
• You have an irregular heartbeat
• You have QT prolongation or a family history of it
• You have liver problems
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936
©2012 Novartis
• You know that you suffer from low blood levels of electrolytes,
such as potassium, magnesium, or calcium
• You have a pancreas disorder
• You have had a surgical procedure involving the removal of the entire
stomach (total gastrectomy)
Also tell your doctor if you are pregnant, breast-feeding, or lactoseintolerant. The TASIGNA capsules contain lactose. Most patients who
have mild or moderate lactose intolerance can take TASIGNA.
Serious side effects
TASIGNA may cause serious side effects including:
• QT prolongation. Call your doctor right away if you feel lightheaded,
faint or have an irregular heartbeat while taking TASIGNA. These
can be symptoms of QT prolongation, a possible life-threatening heart
problem
• Low blood counts. Low blood counts are common with TASIGNA. Your
doctor will check your blood counts regularly during treatment with
TASIGNA. Symptoms of low blood counts include:
° Unexplained bleeding or bruising ° Blood in urine or stool
° Unexplained weakness
° Shortness of breath
• Liver damage. Symptoms include yellow skin and eyes
• Pancreas inflammation (pancreatitis). Symptoms include sudden
stomach area pain with nausea and vomiting
• Bleeding in the brain. Symptoms include sudden headache, changes
in your eyesight, not being aware of what is going on around you and
becoming unconscious
• Tumor Lysis Syndrome (TLS). TLS is caused by a fast breakdown of
cancer cells. TLS can cause you to have:
° kidney failure and the need for dialysis treatment
° an abnormal heart beat
Your doctor may do blood tests to check you for TLS
Call your doctor immediately if you experience any of these
symptoms. Your doctor may change your dose. Your doctor may have
you stop TASIGNA for some time or lower your dose if you have side
effects with it.
Common side effects
Most patients experience side effects at some time. Some common side
effects you may experience include:
• Low blood count
• Rash
• Nausea
• Fever
• Stomach (abdominal) pain
• Headache
• Itching
• Muscle and joint pain
• Tiredness
• Diarrhea
• Constipation
• Back pain
• Muscle spasms
• Weakness
• Hair loss
• Cough
• Runny or stuffy nose, sneezing, sore throat
Be sure to tell your doctor or pharmacist if you have any side effects
during treatment with TASIGNA. You are encouraged to report side
effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch,
or call 1-800-FDA-1088.
It is not known if TASIGNA is safe or effective in children.
Tell your doctor if you are pregnant or planning to become pregnant.
TASIGNA may harm your unborn baby. If you are able to become
pregnant, you should use effective birth control during treatment with
TASIGNA. Talk to your doctor about the best birth control methods to
prevent pregnancy while you are taking TASIGNA.
Tell your doctor if you are breast-feeding or plan to breast-feed. It is
not known if TASIGNA passes into your breast milk. You and your doctor
should decide if you will take TASIGNA or breast-feed. You should not
do both.
If you take too much TASIGNA, call your doctor or poison control
center right away.
Your doctor will check your heart, do regular blood tests, and take bone
marrow samples during treatment with TASIGNA. These are done to
check for side effects with TASIGNA and to see how well TASIGNA is
working for you. Your doctor should check your blood to monitor the
amount of blood cells (white blood cells, red blood cells, and platelets)
during treatment. These should be checked every 2 weeks for the first
2 months and then monthly thereafter, or as considered necessary by
your doctor.
Please see the full prescribing information, including the Boxed
WARNING, and the TASIGNA Medication Guide.
Printed in USA
3/12
AM7-1036536
Consumer Brief Summary for
TASIGNA® (nilotinib) Capsules
Read the Medication Guide that comes with
TASIGNA before you start taking it and each time
you get a refill. There may be new information.
This information does not take the place of talking
to your doctor about your medical condition or
treatment.
What is the most important information I should
know about TASIGNA?
TASIGNA can cause a possible life-threatening
heart problem called QTc prolongation.
QTc prolongation causes an irregular heartbeat,
which may lead to sudden death.
Your doctor should check the electrical
activity of your heart with a test called an
electrocardiogram (ECG):
• before starting TASIGNA
• 7 days after starting TASIGNA
• with any dose changes
• regularly during TASIGNA treatment
You may lower your chances for having QTc
prolongation with TASIGNA if you:
• Take TASIGNA:
° on an empty stomach. Do not take
TASIGNA with food.
° at least 2 hours after eating any food, and
° at least 1 hour before eating any food
• Avoid grapefruit, grapefruit juice, and any
supplement containing grapefruit extract
while taking TASIGNA. Food and grapefruit
products increase the amount of TASIGNA
in your body
• Avoid taking other medicines or supplements
with TASIGNA that can also cause QTc
prolongation
• TASIGNA can interact with many medicines
and supplements and increase your chance
for serious and life-threatening side effects
• Do not take any other medicine while taking
TASIGNA unless your doctor tells you it is okay
to do so
• If you cannot swallow TASIGNA capsules
whole, you may open the TASIGNA capsule
and sprinkle the contents of each capsule
in 1 teaspoon of applesauce (puréed apple).
Swallow the mixture right away (within 15
minutes). For more information, see “How
should I take TASIGNA?”
Call your doctor right away if you feel
lightheaded, faint or have an irregular heartbeat
while taking TASIGNA. These can be symptoms
of QTc prolongation.
What is TASIGNA?
TASIGNA is a prescription medicine used to
treat a type of leukemia called Philadelphia
chromosome–positive chronic myeloid leukemia
(Ph+ CML) in adults who:
• are newly diagnosed, or
• are no longer benefiting from previous other
treatments, including treatment with imatinib
(GLEEVEC®), or
• have taken other treatments, including imatinib
(GLEEVEC), and cannot tolerate them
It is not known if TASIGNA is safe or effective
in children.
Who should not take TASIGNA?
Do not take if you have:
• low levels of potassium or magnesium in
your blood
• long QTc syndrome
What should I tell my doctor before
starting TASIGNA?
TASIGNA may not be right for you. Before taking
TASIGNA, tell your doctor about all of your
medical conditions, including if you have:
• heart problems
• irregular heartbeat
• QTc prolongation or a family history of it
• liver problems
• had pancreatitis
• low blood levels of potassium or magnesium in
your blood
• a severe problem with lactose (milk sugar)
or other sugars. The TASIGNA capsules
contain lactose. Most patients who have
mild or moderate lactose intolerance can
take TASIGNA
• had a surgical procedure involving the removal
of the entire stomach (total gastrectomy)
• are pregnant or plan to become pregnant.
TASIGNA may harm your unborn baby. If you
are able to become pregnant, you should use
effective birth control during treatment with
TASIGNA. Talk to your doctor about the best
birth control methods to prevent pregnancy
while you are taking TASIGNA
• are breastfeeding or plan to breastfeed. It is
not known if TASIGNA passes into your breast
milk. You and your doctor should decide if you
will take TASIGNA or breastfeed. You should
not do both
What are the possible side effects of TASIGNA?
TASIGNA may cause serious side effects
including:
• See “What is the most important information I
should know about TASIGNA?”
• Low blood counts. Low blood counts are
common with TASIGNA. Your doctor will
check your blood counts regularly during
treatment with TASIGNA. Symptoms of low
blood counts include:
° unexplained bleeding or bruising
° blood in urine or stool
° unexplained weakness
• Liver damage. Symptoms include yellow
skin and eyes
• Pancreas inflammation (pancreatitis).
Symptoms include sudden stomach area pain
with nausea and vomiting
• Bleeding in the brain. Symptoms include
sudden headache, changes in your eyesight,
not being aware of what is going on around you
and becoming unconscious
• Tumor Lysis Syndrome (TLS). TLS is caused
by a fast breakdown of cancer cells. TLS can
Tell your doctor about all the medicines you
cause you to have:
take, including prescription and nonprescription
° kidney failure and the need for
medicines, vitamins and herbal supplements.
dialysis treatment
TASIGNA can interact with many medicines and
° an abnormal heart beat
Your doctor may do blood tests to check
supplements and increase your chance for serious
you for TLS.
and life-threatening side effects. See “What is
the most important information I should know
The most common side effects of TASIGNA
about TASIGNA?”
include:
Know the medicines you take. Keep a list of them • low blood count • rash
• nausea
• fever
and show it to your doctor and pharmacist when
• headache
• itching
you get a new medicine.
• tiredness
• stomach (abdominal) pain
How should I take TASIGNA?
• constipation
• muscle and joint pain
• Take TASIGNA exactly as your doctor tells you
• back pain
• muscle spasms
to take it. Do not change your dose or stop
• weakness
• hair loss
taking TASIGNA unless your doctor tells you
• diarrhea
• runny or stuffy nose,
• TASIGNA is a long-term treatment
• cough
sneezing, sore throat
• Your doctor will tell you how many TASIGNA
Tell your doctor if you have any side effect that
capsules to take and when to take them
• Do not take TASIGNA with food. Take TASIGNA bothers you or does not go away.
at least 2 hours after you eat and at least
These are not all of the possible side effects of
1 hour before you eat
TASIGNA. For more information, ask your doctor
• Swallow TASIGNA capsules whole with water.
or pharmacist.
If you cannot swallow TASIGNA capsules whole,
tell your doctor
Call your doctor for medical advice about side
• If you cannot swallow TASIGNA
effects. You may report side effects to FDA at
capsules whole:
1-800-FDA-1088.
° Open the TASIGNA capsules and sprinkle • Keep TASIGNA and all medicines out of the
the contents in 1 teaspoon of applesauce
reach of children.
(puréed apple)
- Do not use more than 1 teaspoon
General information about TASIGNA
of applesauce
Medicines are sometimes prescribed for purposes
- Only use applesauce. Do not sprinkle
other than those listed in a Medication Guide. Do
TASIGNA onto other foods
not use TASIGNA for a condition for which it was
° Swallow the mixture right away
not prescribed. Do not give TASIGNA to other
(within 15 minutes)
people, even if they have the same problem you
• Do not drink grapefruit juice, eat grapefruit, or
take supplements containing grapefruit extract have. It may harm them.
at any time during treatment. See “What is the This brief summary summarizes the most
most important information I should know
important information about TASIGNA. If you
about TASIGNA?”
would like more information, talk with your
• If you miss a dose, just take your next dose as
doctor. You can ask your doctor or pharmacist
scheduled. Do not make up for a missed dose
for information about TASIGNA that is written for
• If you take too much TASIGNA, call your doctor healthcare professionals.
or poison control center right away. Symptoms
For more information, go to www.us.TASIGNA.com
may include vomiting and drowsiness. During
or call 1-866-411-8274.
treatment with TASIGNA, your doctor will do
tests to check for side effects and to see how
Manufactured by:
well TASIGNA is working for you. The tests
Novartis Pharma Stein AG
will check your:
Stein, Switzerland
° heart
Distributed by:
° blood cells (white blood cells, red blood
Novartis Pharmaceuticals Corporation
cells, and platelets). Your blood cells
East Hanover, New Jersey 07936
should be checked every 2 weeks for the
first 2 months and then monthly
AM7-1036536
° electrolytes (potassium, magnesium)
pancreas
and
liver
function
°
° bone marrow samples
• Your doctor may change your dose. Your doctor
may have you stop TASIGNA for some time or
lower your dose if you have side effects with it
gynecologic cancers | types of cancer
Gynecologic Cancers
G
Overview and Treatment Options
Gynecologic cancers are found in a woman’s
reproductive organs, most commonly in
the uterus, ovaries or cervix. Less common
forms of the disease can also be found in the
fallopian tubes, vagina and vulva. Each subtype of the disease has its own unique signs,
symptoms and risk factors as well as treatment strategies.
Uterine cancer
Uterine cancer is the most common type
of gynecologic cancer and is classified as
adenocarcinoma or sarcoma. Adenocarcinomas account for more than 95 percent of
uterine cancers. This type of cancer begins
in the cells of the endometrium – the inner
lining of the uterus – and therefore is often
referred to as endometrial cancer. Sarcomas
account for the remaining uterine cancers
and begin in the myometrium, the outer
muscle layer of the uterus.
The good news is that the cure rate for endometrial cancer is high. Surgery is the most
common treatment option and typically begins with a total hysterectomy (removal of
the uterus and cervix) and usually some
lymph glands to evaluate for cancer spread.
Depending on the stage of the cancer, the
surgeon may instead choose to perform a
radical hysterectomy, in which the uterus,
cervix and a small part of the vagina are
removed. The ovaries, fallopian tubes and
nearby lymph nodes are generally removed
as well.
The degree of endometrial cancer is measured in stages, from Stage I, which indicates
that the cancer is contained in the uterus, to
Stage IV, which indicates that the cancer has
spread beyond the uterus to the rectum, bladder and other organs. The earlier the cancer is
detected, the greater the chance for cure.
If some cancer cells are still present after surgery, other treatment options, such
as radiation therapy, hormone therapy and
chemotherapy, are available and can be used
alone or as combination therapies. They also
can be used instead of surgery if that is not
the best option.
Ovarian cancer
Of the women diagnosed with ovarian cancer, more than half are older than age 60,
and the disease is more common in white
women than in African-American women.
The disease is also more common in women
with a family history of ovarian cancer, and
research indicates that inherited gene mutations cause some ovarian cancers.
Pa t ie n tResource.com
Ovarian cancer usually forms in the tissues of the ovaries, which produce eggs and
are the main source of the female hormones
estrogen and progesterone. Most ovarian
cancers are epithelial carcinomas, which begin in the cells on the surface of the ovary.
However, some malignant germ cell tumors
begin in the cells that produce the eggs or
arise from the tissue that holds the ovary
together. As part of the treatment regimen,
women with an increased risk of ovarian
cancer sometimes have preventive surgery,
called a prophylactic oophorectomy, in
which one or both ovaries are removed.
Tests examining the ovaries, pelvic area,
blood and ovarian tissue are used to detect
ovarian cancer, and roughly 20 percent of
ovarian cancers are found in the early stages.
Surgery, chemotherapy and radiation therapy
are the main treatments for ovarian cancer
and can be used alone or in combination.
New types of treatments, such as biologic
therapy and targeted therapies, are currently
being tested in clinical trials. Biologic therapies – also called immunotherapies – use
a patient’s own immune system to fight the
cancer. Other targeted therapies use drugs or
other substances to identify and attack specific cancer cells without harming normal cells.
Cervical cancer
Cervical cancer develops in the cervix,
which is the lower, narrow end of the uterus
leading to the vagina. It is a slow-growing
cancer that may or may not cause symptoms, but it can be found with regular Pap
tests. Cervical cancer most often affects
women between the ages of 20 and 50 and
is predominately caused by a human papillomavirus (HPV) infection, for which a vaccine is now available.
As with all types of cancer, the treatment
options for cervical cancer depend on the
stage in which the disease is discovered,
but surgery, radiation and chemotherapy –
alone or in combination – are the traditional
methods. Early-stage (Stage I) disease confined to the cervix is most often treated by
a radical hysterectomy and removal of the
lymph nodes. Women who want to preserve
the ability to bear children can instead opt
for a radical trachelectomy, in which the cervix, the top part of the vagina and the pelvic
lymph nodes are removed, but not the uterus. Cervical cancers that have progressed to
Stages II through IV are most often treated
with a combination of radiation therapy
and chemotherapy, known as concurrent
chemoradiation therapy.
ADDITIONAL RESOURCES
American Society of Clinical Oncology
(patient website): www.cancer.net
Foundation for Women’s Cancer:
www.foundationforwomenscancer.org
National Cervical Cancer Coalition:
www.nccc-online.org
National Ovarian Cancer Coalition:
www.ovarian.org
Ovarian Cancer Network Alliance:
www.ovariancancer.org
Society of Gynecologic Oncology:
www.sgo.org
Women’s Cancer Network: www.wcn.org
51
cervical cancer patient story
Survivor Beat Cervical Cancer
S
Diagnosed on Her Birthday
Anissa Norris, a 42-year-old business operations manager, had
never had an abnormal Pap test when she was diagnosed with
Stage II cervical cancer at the age of 36. Relying on the strength
and support of her family and friends, she beat the disease and
has been cancer-free for nearly eight years. Anissa and her husband of 19 years have three children who are now ages 11, 14
and 17, and their family also includes two dogs and one cat.
When Anissa isn’t spending time with her family, she can likely
be found cozied up with a good book.
G
Generally, birthdays come with gifts. My 36th birthday, however,
came with quite the opposite. It was on that day that I was diagnosed with Stage II cervical cancer.
About six months earlier, I’d begun experiencing heavy menstrual bleeding that continued to get worse. My gynecologist
determined that it was likely a cervical fibroid and scheduled a
surgery to remove it. During the procedure, my specimen was
sent to a pathologist who immediately identified it as cancerous. When I woke up from the anesthesia, my doctor broke
the news.
I was shocked. I’d never had an abnormal Pap test, which is
generally the first indication of cancer. In fact, the test I’d had
just five months prior to my diagnosis was completely normal.
My gynecologist later told me that the area where the cancer
was present had likely just not been swabbed. She explained
that the tool used for the test is similar to a mascara wand and
that, depending on an individual’s anatomy, it may not reach
all areas.
My gynecologist referred me to a gynecological oncologist
at a nearby hospital, and about a month after my diagnosis, I
underwent a radical hysterectomy with total lymph node dissection. During the surgery, my doctor also lifted my small intestine
out of my pelvic region with an omental sling and moved my ovaries under my hipbones to protect them from future radiation.
Even though my gynecological oncologist believed all of the
malignant tissue had been removed, she still felt that chemotherapy and radiation therapy were necessary to be absolutely
sure nothing was left behind. So two months after my surgery,
I began concurrent chemotherapy and radiation therapy. For five
weeks I took the chemotherapy drug cisplatin on Mondays and
received radiation therapy treatments every weekday.
While my treatment time was relatively short, it still came
with side effects. In addition to fatigue and nausea, I developed
a small bowel obstruction, which my doctor attributed to radiation damage and/or scar tissue from surgery. So a year after
my initial surgery, I had a second surgery in which a foot of my
small intestine was removed. Abdominal pain due to partial and
full blockages in my small intestine continued to plague me, and
I eventually had a third surgery to remove scar tissue and clean
up my abdominal cavity.
During that same time I was also diagnosed with celiac disease, which my doctor thinks was triggered by the physical
stress caused by cancer and its treatment. While my side effects admittedly have been tough, I remind myself that surviving
with side effects is better than not surviving at all.
52
Anissa
Anissa relied on the strength and support of
her family, friends and husband, Doug, during
her battle with cervical cancer.
Through everything, my husband was my rock. He was amazing. I also had family and friends
who went over the top to help
with meals, visits and house
cleaning as well as child care and
constant love. As a mom, it was
incredibly reassuring to know that
my children, who were 4, 7 and 10 at the time, were being cared
for by loved ones. I simply could not have done it all without the
love and support from those around me.
As time continues to pass, I continue to do better. I’ve been
cancer-free for nearly eight years, so the likelihood of recurrence
is low. I’ve also become a big advocate for the HPV immunization. Several doctors believe that cervical cancer would be
largely eradicated if young people got the series of HPV shots.
Although it was obviously too late for me, both of our teenage
children – our son and daughter – have been immunized, and
I encourage others to do the same. It’s amazing to me that if
I’d received the immunization, I likely could have avoided all of
this—my diagnosis, treatment and years of side effects.
My best advice is to always listen to your body and to be a
strong self-advocate. Ask questions, and make sure that doctors
hear what you’re saying and have a vested interest in your life.
Above all, have faith. You really are stronger than you think.
Pa t i e n t Re s o u r ce .co m
melanoma | types of cancer
M
Melanoma Overview and Treatment Options
Melanoma is an aggressive type of skin
cancer that begins in melanocytes (cells
that make the pigment melanin) and usually appears as a changing mole on the skin.
In rare cases, it can also be found in other
pigmented tissues, such as the mouth or the
eye. Even though most skin moles are benign (not cancerous), you should tell your
doctor about any mole you find on your skin
so it can be evaluated, especially when you
notice a change in the mole. When melanoma is treated at an early stage, the probability for cure is high.
Treatment of melanoma
The types of treatment used for melanoma
include surgery, biologic therapy, chemotherapy and radiation therapy. As with other
types of cancer, the treatment of melanoma
depends on the stage of disease.
Most melanomas are treated with surgery,
with removal of the cancerous tissue along
with a margin of healthy tissue from around
the tumor. This surgery is known as wide
excision. Depending on the thickness of the
melanoma, it may be necessary to surgically
remove a half-inch to a full inch of skin and
fatty tissue around the primary melanoma or
biopsy site. The affected area can usually be
closed with a plastic surgery procedure, although in some circumstances, skin grafting
may be necessary to cover the wound. When
melanoma is diagnosed at an early stage (Stage
I or II), surgery alone is usually adequate.
Precise tools can now predict the risk
of microscopic spread of melanoma to the
patient’s regional lymph nodes or beyond.
Your doctor will plan treatment and predict
survival according to many features of the
melanoma, including the tumor’s thickness,
presence or absence of ulceration (a sore) on
Pa t ie n tResource.com
the tumor surface, and mitotic rate (how fast
the melanoma is growing).
To determine whether the lymph nodes
are free from cancer, a staging procedure
known as a sentinel lymph node biopsy is
usually recommended for melanomas more
than 1 millimeter thick. (The likelihood that
a thinner melanoma has spread to lymph
nodes is very low, but thin melanomas that
display aggressive features may still be candidates for this staging procedure.) If no
cancer cells are found in the sentinel node
(the node nearest to the cancer), it is unlikely that they have spread to farther lymph
nodes, and no additional surgery is needed.
However, if the sentinel node shows cancer
cells, the removal of nearby lymph nodes is
usually necessary because they might also
contain microscopic tumor cells. Talk to
your doctor about whether a sentinel lymph
node biopsy is right for you.
Melanoma is classified into four stages,
and treatment depends on the stage.
Stage I – Stage I melanomas are subdivided into Stage IA (less than 1 millimeter thick
[about the size of a pencil point] and not
ulcerated) and Stage IB (less than 1 millimeter thick and ulcerated or 1 to 2 millimeters
thick and not ulcerated). For both of these
stages, there is no evidence that the cancer
has spread to lymph nodes or other organs.
Wide excision with sentinel lymph node biopsy is usually done for Stage IA and IB.
Stage II – These melanomas are thicker
and are classified as Stage IIA, IIB or IIC, according to how thick they are and whether
they are ulcerated. The melanoma has not
spread to nearby lymph nodes, but thicker
melanomas (especially those that are ulcerated) are more aggressive, which means they
are more likely to spread. Wide excision
with sentinel lymph node biopsy is usually
done for Stage IIA, IIB and IIC melanoma.
In addition, treatment with interferon alfa is
sometimes given after surgery for Stage IIC
melanoma. Two approved forms of the drug
are available to treat melanoma: 1) a highdose regimen, interferon alfa-2b (Intron A),
that requires a daily infusion for a month
and then injections under the skin every
three weeks for a year, and 2) a lower-dose
injection of a slow-release form, peginterferon alfa-2b (Sylatron), that is administered
by injection under the skin weekly for up to
five years.
Stage III – Stage III melanomas have
spread to the regional lymph nodes or to some
lymph vessels (thin tubes that carry fluid and
white blood cells through your body) in the
fatty tissue between the original tumor and
the regional lymph nodes. Treatment with
either form of interferon alfa is usually given
after surgery for this stage of disease.
Stage IV – Stage IV (metastatic) melanomas have spread beyond the regional lymph
nodes to other organs in the body. If the
amount of tumor is limited and accessible,
the tumor may be surgically removed. In
other circumstances, radiation therapy may
be given to relieve symptoms, such as growing tumors in the bones or brain.
With Stage IV disease, treatment is given
to attack the melanoma cells that have traveled to distant parts of the body. Until recently, only one drug was approved for the
treatment of metastatic melanoma: the chemotherapy drug dacarbazine (DTIC). Now,
a targeted therapy drug, vemurafenib (Zelboraf), is available for people with Stage IV
melanoma that has tested positively for the
BRAF gene mutation. Studies have shown
that melanomas with this gene mutation
respond to vemurafenib; in fact, the rate of
response and overall survival have been better than that for dacarbazine.
Two other targeted therapy drugs for
Stage IV melanoma that have tested positively for specific BRAF gene mutations are
trametinib (Mekinist) and dabrafenib (Tafinlar). Both of these drugs have been shown
to prolong the time until disease progresses.
Another new treatment is a biologic
drug, ipilimumab (Yervoy). This drug is
given as an intravenous infusion and has
improved overall survival for people with
metastatic melanoma.
For people with metastatic melanoma
confined to an arm or a leg, a special kind
of regional chemotherapy may be given.
Delivered in an operating room, the treatment is called hyperthermic isolated limb
perfusion (HILP). A chemotherapy drug
(usually melphalan) is given directly into
the arm or leg without exposing the rest of
the body to chemotherapy.
ADDITIONAL RESOURCES
Aim at Melanoma:
www.aimatmelanoma.org
Joanna M. Nicolay Melanoma Foundation:
www.melanomaresource.org
Melanoma International Foundation:
www.melanomainternational.org
Melanoma Research Foundation:
www.melanoma.org
Patient Resource:
www.PatientResource.com/Melanoma_
Overview.aspx
The Skin Cancer Foundation:
www.skincancer.org
53
melanoma patient story
Survivor Turns Melanoma Diagnosis
to Just a ‘Bump in the Road”
LeAnn Hankel didn’t even know she was at a
higher risk for skin cancer. So when she was
diagnosed with melanoma at age 28, this married mother of two could barely believe the
news. She quickly took action, however, relying on the love and support of her family to
get her through treatment. Now realizing the
power of early detection, she encourages others to get checked early and often.
E
Even though I had never paid much attention
to changes in my skin, I was a little worried
about a spot I noticed on my shoulder. Turns
out I should have been paying more attention
to my back.
At a routine gynecology appointment, I
mentioned the suspicious spot to my doctor. When he found out I had never been to
a dermatologist, he encouraged me to make
an appointment. Once there, I learned that my
shoulder wasn’t the problem. The dermatoloAfter briefly sidelined by melanoma, LeAnn Hankel is now
gist completed a full-body exam and found
back to plenty of family time.
two moles on my back he considered abnormal—larger than the head of a pencil eraser
bump in the road—and
and a little discolored. He promptly removed them both and sent
quite the learning experithem to the lab.
ence. Our children were
When the news came, I did not react well. After all, no one
very young at the time, so
likes to hear, “I’m sorry, but your lab results have come back
they didn’t really underpositive for cancer.” One of the two moles tested positive for
stand what was happenearly-stage melanoma. I was almost in a complete state of deing, which was how we
nial. Aren’t I too young for cancer? What about my kids? This
preferred it. And because we knew the melanoma was treatable,
can’t really be happening to me!
we wanted to keep our home routine as normal as possible.
At the time, I didn’t want to answer a bunch of questions from
My doctor explained to me that early detection saved my
people – plus I was still pretty emotional about the news – so I
life—that if it had not been spotted, the melanoma would have
kept the diagnosis to myself, aside from my close family memquickly spread to other parts of my body. This whole experience
bers, who provided a great deal of love and support.
has definitely changed my daily routine as well as our whole
Once I calmed down and was able to speak with my doctor, I
family’s routine! Before I was diagnosed, I didn’t pay much atquickly realized that I was lucky, that the melanoma was caught
tention to my skin or my daily habits, but now we are all much
early and was curable. We discussed my options, and because
more sun-safe. We still spend plenty of time outdoors, but we
the cancer was still localized and hadn’t yet spread to any lymph
make sure we include plenty of sunblock and lip balm. Plus, I
nodes, surgery was my best treatment option.
now wear sunglasses, a hat and additional clothing to cover as
The incision in my back was 3 inches wide, 8 inches long and 3
much skin as I can when we’re out in the sun. I also make sure
millimeters deep, but the surgeon was able to remove the melato keep a close eye on my skin between doctor visits to look for
noma as well as plenty of healthy skin surrounding it. My surgical
anything suspicious.
margins came back clear (no cancer detected) and the melanoma
It turns out that my complexion and family history – along with
had not spread, so no chemotherapy or radiation was needed.
regular sun exposure and plenty of other moles – had increased
I did suffer some nerve damage once the wound healed, and
my skin cancer risk without even knowing it. So it was very imI wasn’t able to bend over or lift anything for quite a while after
portant to me to educate my family about melanoma and skin
the surgery—a pretty mild side effect but extremely difficult
cancer and encourage them to get checked. In fact, not long afwhen you have a 4-month-old baby at home. Thankfully, I had
ter my surgery, my sister found a mole that tested for Stage 0
plenty of help from my husband as well as my mom, who came
melanoma. When I heard the news, my heart sunk, but I knew
to stay with us and help out with the kids while I healed. Once
that my experience, while not anything I wanted, helped her. And
I got through that, I haven’t had any permanent side effects.
that’s made it all worth it.
I’m so thankful for the support we got from my family, espeAfter all, life isn’t always fair, but it’s up to us to make the very
cially my husband, who was my biggest cheerleader. Because
best out of what we have!
of my family, I was able to chalk up my diagnosis to just a slight
54
Pa t i e n t Re s o u r ce .co m