Some useful web-sitesThe NHS provides comprehensive information and useful links at NHS Choices:http://www.nhs.uk/Conditions/Cancer/Authoritative information and various kinds of other support are provided by many other organisations including:American Cancer Society: http://www.cancer.org/Comprehensive information.Bowel Cancer UK: http://www.bowelcanceruk.org.uk/ Information and support.Brain Tumour Charity: www.thebraintumourcharity.org/Information and support.Breast Cancer Care: http://www.breastcancercare.org.uk/Specialist breast care nurses provide practical advice, medical information and support to women concerned about breast cancer.Volunteers who have had breast cancer themselves assist in giving emotional support to cancer patients and their partners.British Association for Counselling and Psychotherapy:http://www.itsgoodtotalk.org.uk/Provides a directory listing counsellors and the types of problems for which they offer counselling.Enquirers can be referred to an experienced local counsellor.British Red Cross: http://www.redcross.org.uk/Help with mobility, including loan of wheelchairs and escort services to and from hospital.Children with Cancer UK: http://www.childrenwithcancer.org.uk/Information for children and their families.Cancer Research UK: http://www.cancerresearchuk.org/Comprehensive information from the world’s largest cancer research charity.Carers UK: http://www.carersuk.org/Information and support for carers..Carers Trust: http://www.carers.org/Information and support for carers.Colostomy Association: http://www.colostomyassociation.org.uk/Information, support and advice.Cruse Bereavement Care: http://www.cruse.org.uk/Information and support.Kidney Cancer UK: http://www.kcuk.org/Information and support.Leukaemia & Lymphoma Research:  http://leukaemialymphomaresearch.org.uk/Information on leukaemias, lymphomas and related conditions.

Leukaemia CARE:  http://www.leukaemiacare.org.uk/Information and support to people with leukaemia, lymphomas and related conditions.Lymphoedema Support Network:  http://www.lymphoedema.org/Information.Lymphoma Association: http://www.lymphomas.org.uk/Information and support.Macmillan Cancer Support: http://www.macmillan.org.uk/Information, financial and other support for patients and their families.Marie Curie Cancer Care: http://www.mariecurie.org.uk/Runs Marie Curie hospices and provides a community nursing service day and night.National Association of Laryngectomee Clubs:  http://www.laryngectomy.org.uk/Information and support for people with a laryngectomy and their carers.National Cancer Institute: http://www.cancer.gov/Comprehensive information from the institute which coordinates the National Cancer Program in the USA.National Institute for Health and Care Excellence [NICE]: http://www.nice.org.uk Detailed guidance on how best to manage a wide variety of  conditions and reports on the clinical and cost-effectiveness of many individual medications and other treatments. This is all based on a very rigorous assessment of the available evidence. Oesophageal Patients Association: http://www.opa.org.uk/Information and support for patients with oesophageal and stomach cancer.Pancreatic Cancer UK: http://www.pancreaticcancer.org.uk/Information and support.Patient.co.uk: http://www.patient.co.uk/Information on most types of cancer.Penny Brohn Cancer Care: http://www.pennybrohncancercare.org/Formerly known as the Bristol Cancer Help Centre, the centre offers complementary care intended to address physical, emotional and spiritual needs.The components include relaxation, healing, visualisation, counselling, diets, meditation, music and art therapy, and support is also given to other family members and carers.There are residential and single day courses.Charges are made for services, but discretionary financial assistance is available.Prostate Cancer UK:  http://www.prostatecanceruk.org/Information and support.Relate:  http://www.relate.org.uk/home/Advice and counselling for people with emotional, sexual or other problems in their relationships with spouses and partners.There are branches throughout the UK.Roy Castle Lung Cancer Foundation: http://www.roycastle.org/Information and support.Royal Marsden: http://www.royalmarsden.nhs.uk/Comprehensive information from London’s world renowned cancer hospital.Sue Ryder: http://www.sueryder.org/Has homes and day care centres caring for patients with many different disabilities and diseases, including cancer.Services include long-term care, respite care  and support at home.Urostomy Association: https://www.urostomyassociation.org.uk/Information, advice and support on issues such as appliances, work situation and marital problems.IRELAND Irish Cancer Society: http://www.cancer.ie/Information on all aspects of cancer, home care, rehabilitation programmes and support groups.Cancer Focus Northern Ireland:  http://cancerfocusni.org/Information and support.SCOTLAND Cancer Support Scotland: http://cancersupportscotland.org/ Emotional and practical support.WALES Tenovus:  http://www.tenovus.org.uk/Information and support in English and Welsh.

In recent years, increasing numbers of people with cancer have chosen to try one or more types of ‘complementary’ or ‘alternative’ treatments in addition to what may be called conventional, orthodox or ‘mainstream’ medical care. Many of these people say that they have benefited from complementary medicine as far as their emotions, general sense of well-being and some symptoms are concerned, but there is very little evidence of an impact on long term cancer control or cure. A great number of seemingly persuasive claims have been made for many treatments, but unfortunately most do not stand up to careful scrutiny.

 

Many different treatments may be offered under the complementary medicine umbrella, and most have been developed outside mainstream medicine. You normally have to pay for them although some, such as aromatherapy massage, are offered free in some hospitals and hospices.

 

Types of complementary therapy

 

Acupuncture

 

An ancient form of Chinese medicine in which fine needles are inserted at specific points. A wide variety of techniques is available, ranging from a traditional Chinese approach to Western adaptations. There is some evidence that acupuncture may help in pain control although this has not been scientifically proven. It may also help with hot flushes. There is good evidence that acupuncture at a point just above the wrist can help in reducing nausea and vomiting from chemotherapy.

 

Homoeopathy

 

Based on the principle that ‘like cures like’, homoeopathic remedies contain infinitesimal quantities of substances which it is believed would in larger amounts produce similar symptoms to the illness being treated. Practitioners believe that these help the body to heal itself. However, there is no scientific evidence of benefit from homoeopathy as an anti-cancer treatment.

 

Hypnotherapy

 

Several clinical trials of hypnosis in cancer care have now been conducted. There is encouraging evidence that it is helpful in controlling anxiety, pain, nausea and vomiting.

 

Massage (including aromatherapy and reflexology)

 

Gentle massage can help patients to relax and may help relieve muscular pain and stiffness. It can be a pleasurable physical experience, leading to a feeling of improved well-being. Aromatherapy involves oils with pleasant aromatic scents from a wide range of plants being massaged gently into the skin. Reflexology is a type of foot massage, and there is evidence from clinical trials that it can help in reducing stress. Massage directly over a cancer which can be felt near the surface is probably best avoided.

Meditation

 

This involves calm contemplation, controlling or directing your thoughts and emotions by using one of a range of techniques to shut out distraction. This can help some individuals achieve a sense of inner peace and relief of anxiety, and possibly some relief of pain also.

 

Relaxation

 

A number of techniques are available, including breathing exercises, muscle relaxation and imagery (see visualisation), all designed to encourage a sense of physical and mental calm and to combat anxiety and tension. There is some evidence that relaxation therapy can help in pain control.

 

Spiritual healing

 

Healers may have differing spiritual or religious beliefs, but all claim to transfer some form of healing energy. Healing is usually considered to come from a divine origin, through prayer and meditation. Healing may or may not involve touch and some healers actually work from a distance. Those receiving healing may experience relaxation and a feeling of inner peace.

 

Visualisation

 

This involves using the imagination to conjure up images that the individual may find helpful as an aid to relaxation, meditation or symptom control. Some people find it helpful to imagine their immune system fighting their cancer.

 

Diets and vitamins

 

The need to try to maintain an adequate and balanced nutritional intake, and to avoid obesity, is discussed elsewhere. A great number of widely differing alternative diets have been advocated over the years by complementary medicine practitioners. ‘Gerson’ and ‘macrobiotic’ diets are but two examples. Large amounts of vitamins have been quite a common feature. However, although special diets may sound a good idea, there is no convincing evidence that they can influence the chance of cure or help keep a cancer under control.

 

Some people feel that by going on special diets they are being constructively involved in the fight against their cancer and that this helps them psychologically. Unfortunately, others find their diet unpleasant and difficult to stick to, difficult and time consuming to prepare and expensive.

 

Carrots often feature prominently in special diets. They are rich in beta-carotene, which is converted to vitamin A in the digestive tract. There is some evidence suggesting that low dietary levels of vitamin A or beta-carotene may lead to an increased risk of cancer, and there are studies in progress looking at whether supplements of beta-carotene or related substances known as retinoids can reduce cancer incidence. So far there is no good evidence that they can and, surprisingly, long-term high-dose beta carotene supplements may even increase the risk of lung cancer among current and former smokers.

 

Retinoids have been shown to have some efficacy in the treatment of some human tumours but, like high doses of natural vitamin A, they can cause side effects, including nausea, vomiting, headache, skin changes and psychiatric disturbance. There is no good evidence that they can improve the chance of cure, apart from being used in combination with chemotherapy to treat a rare type of leukaemia. Consuming large amounts of carotene-containing foods can sometimes cause the skin to turn yellow.

 

It has been suggested that vitamin C can render normal tissues less susceptible to destruction by chemicals released by cancer cells. It was reported in one study that patients given high doses of vitamin C lived longer than expected, but subsequent randomised trials have provided no evidence of benefit.

 

There is evidence to suggest that antioxidants like vitamins A, C and E, co-enzyme Q10 and selenium might reduce the effectiveness of some chemotherapy drugs and radiotherapy. It seems sensible to avoid taking such supplements whilst receiving conventional cancer treatment.

 

Herbal medicine and other preparations

 

It should not be forgotten that various anti-cancer drugs of proven efficacy used in mainstream medicine originate from plants. Herbal medicines have considerable appeal to some, stemming particularly from their being thought of as ‘natural’.

 

Outside orthodox oncology, several herbal preparations have been claimed to have particular benefit for cancer patients. One example is iscador, a fermented mistletoe extract given by injection. It is claimed that it exerts its beneficial effects both by killing cancer cells and by beneficially altering the body’s immune system. Although there have been anecdotal claims of efficacy, there is no evidence to support this from properly conducted clinical trials. Patients receiving iscador in one trial fared less well than those not receiving it.

 

Another example is laetrile, which has sometimes been described, incorrectly, as ‘vitamin B17’.  The principal ingredient of this substance is amygdalin, found in apricot stones and almonds. It has been suggested that laetrile causes toxic hydrogen cyanide to be released selectively within cancer cells. There is no scientific justification for this hypothesis and unfortunately careful clinical study has again produced no evidence of efficacy. Several cases of cyanide poisoning have been linked to laetrile therapy. The herbal mixture Essiac and shark cartilage both have their supporters, but again there is no consistent objective evidence that either is effective.

 

Di Bella therapy, a mixture of natural and synthetic substances, had a strong following after many anecdotal claims of efficacy. However, in 11 studies of almost 400 patients only 3 patients showed any evidence of benefit and their responses were only partial. Another study of over 300 patients showed that overall patients receiving Di Bella therapy had a worse survival compared with other patients.

 

While there seems to be a paucity of good evidence for the anti-cancer efficacy of complementary herbal treatments, a recent trial has demonstrated at least a short term improvement in cancer related fatigue from taking American ginseng.

 

It seems inevitable that useful anti-cancer effects will be found for other herbal and other natural substances, but proving benefit depends on careful scientific evaluation, not anecdotal claims. Once the evidence is sufficiently convincing such medications will inevitably become part of orthodox treatment. Some substances certainly seem worthy of further study. For example, in China and Japan there have been a number of studies which appear to demonstrate immune system stimulation and some improved anti-cancer treatment results from preparations derived from certain mushrooms.

 

The importance of the mind

 

There is quite a common belief among complementary therapists that a person’s psychological make-up is relevant to the development and subsequent course of their cancer. It has been suggested that some people are cancer prone by virtue of their personality, but there is no good scientific evidence to support this. Nor is there conclusive evidence that the psyche influences survival chances for cancer patients. There is some evidence that it can, and quite a few mainstream oncologists believe that it does, but even if psychological factors do exert some influence on outcome this is not necessarily of any help in practice.

 

There is good evidence that psychological stress can reduce resistance to infection. Some complementary therapists believe that psychological stress can encourage the development of cancer, and that it is possible to enable people with the disease to fight it more effectively by changing their frame of mind. The role of stress in causation remains a controversial issue, with different studies arriving at different conclusions, but a recent comprehensive study has reassuringly shown no relationship between work related stress and the risk of a variety of common cancers. Neither is there any good evidence that stressful events increase the risk of relapse.

 

There have been numerous reports on the part played by a person’s innate psychological characteristics, sometimes suggesting that those who are freely able to express emotion or distress tend to survive longer than those who suppress or deny their emotional feelings. One study of women with breast cancer who underwent psychological assessment at diagnosis found that those who had reacted to cancer by denial or who had a ‘fighting spirit’ did rather better than those who had responded with stoic acceptance or feelings of helplessness or hopelessness. However, other studies have failed to show a relationship between such psychological factors and outcome. .

 

So far there is inconclusive evidence to support any benefit from psychological therapy over and above that of improving psychological well-being, which is of course very important in itself. One study on breast cancer patients suggested that regular psychologist-led sessions aimed at reducing distress and improving mood following surgery improved long term survival. But the sessions also covered diet, exercise and smoking cessation and it is not certain which component(s) may have contributed to the apparently improved outcomes. Another study reported that women with closer social ties and better emotional support had fewer recurrences of breast cancer, but yet another reported that psychosocial factors, including friendships, marital history and job satisfaction had no influence on outcome.

 

A trial on a small number of women with advanced breast cancer demonstrated increased survival in those randomised to participate in weekly supportive group therapy and self-hypnosis for pain control. Another small study demonstrated increased survival in people with melanoma skin cancer who had received ‘psycho-educational intervention’ including stress management, enhancement of coping skills and supportive group psychotherapy.

 

Such results are very interesting but other similar studies have failed to show that such additional psychological support makes people live longer. More research needs to be done before we have conclusive results, but there does not appear to be any evidence that cancer patients benefit in terms of survival from having less social interaction or emotional support. The weight of the evidence is perhaps now beginning to suggest that at least for some patients with some cancers their chances of long term survival may possibly be enhanced slightly by additional measures aimed at improving psychological well-being. For people experiencing anxiety or other emotional distress achieving the latter will of course at least have an immediate impact on their quality of life. It may also help them to communicate better with those treating their cancer, and to adhere to their anti-cancer treatment.

 

Considering complementary treatment

 

There are more things in heaven and earth than are currently dreamed of by practitioners of mainstream medicine. However, it should not be forgotten that most of the progress that has been made in the fight against cancer has been as a result of critical scientific evaluation.

 

Most complementary treatments have not been exposed to or have not withstood the rigours of scientific testing. Nevertheless, there is no doubt that many people say that they feel better as a result of complementary therapy. The extent to which this is actually the result of the treatment itself remains controversial and it seems likely that there may be other less tangible factors at work. Much of the benefit may be as a result of the promotion of relaxation.

 

Also a complementary therapist is often willing and able to give you as much time and personal attention as you want – something that is not always possible for your doctors, however well intentioned they may be. This may be conducive to patients deriving ‘placebo effect’ benefit. The placebo effect, whereby patients derive symptomatic benefit merely as a result of their belief that they are receiving an active treatment, is potentially important in both complementary and conventional medicine.

 

It’s also true that many people simply feel better for trying to do something to help themselves, especially when conventional medicine may have little to offer them. They may feel more in control through availing themselves of some form of complementary treatment, rather than continuing merely to accept passively what is on offer from mainstream medicine. It also seems likely that, if for whatever reason patients feel better in themselves, they may then be able to cope better with the demands and side effects of their conventional treatment.

 

Whether or not complementary treatments can influence the outcome as far as the cancer is concerned is obviously a very important issue. Many of those offering and receiving them believe that the chance of survival will be improved, but there is little evidence to support this. There is understandable concern about people with cancer having their hopes raised unrealistically. There is in particular a great amount of misleading information accessible on the internet, including fraudulent claims for so-called ‘miracle cures’.

 

Complementary treatments are often considered as part of a ‘holistic’ or ‘whole person’ approach to care, implying that conventional medicine is more concerned with the disease than with the patient. The pressures on the service and the resulting constraints on time may quite often result in patients getting this impression, but most doctors would maintain that good conventional medicine has always been holistic.

 

Most complementary treatments for people with cancer in Britain are offered in good faith. However, you also need to be aware of the possibility of being exploited commercially by the unscrupulous. Marketing strategies for non-orthodox treatments include both giving complex pseudo-scientific rationales and making superficially attractive conceptual claims, neither of which stand up to close inspection. Non-conventional methods may be hailed as ‘natural’ and much may be made of the toxicity of some conventional treatments, but some alternative treatments can themselves be toxic or unpleasant.

 

If you are thinking about some kind of complementary therapy, it is worth mentioning this to your doctor, who may be able to give you some useful advice. In any case, your doctor should know about any treatment you are having in order to take it into account when assessing your progress, or possibly when faced with new symptoms or other changes in your condition. There is growing evidence that several complementary treatments can interact detrimentally with conventional anti-cancer treatments and with other medications such as anti-coagulants, either by reducing their effectiveness, or increasing toxicity.

 

You should be wary of any therapist who says or implies that their treatment can cure you or shrink the cancer, and you should make sure that you are clear in your own mind about what you expect the treatment to do for you. You should establish at the outset how much the treatment will cost, how long it will take, and how soon you can reasonably expect to feel any benefits. Do not stop taking any conventional treatment without first discussing it with your doctor.

 

KEY POINTS

• People often feel better psychologically after having complementary therapy

• Complementary therapies have not been proved to be of benefit in improving survival or the chance of cure

• Some complementary treatments can interact harmfully with conventional treatments

• Most complementary medicine is offered in good faith, but you should be wary of being exploited by unscrupulous practitioners while you are at your most vulnerable

We have made great progress in cancer care in recent years. There are many reasons for this, but the following are among the most important factors:

 

• The use of already established treatments in different ways, for example, by giving drugs or radiotherapy in addition to surgery (adjuvant therapy).
• Technological development, including scanners, lasers and improved radiotherapy machines.
• The development of better anti-cancer drugs and drugs capable of reducing significantly the side effects of some treatments.
• Greatly increased understanding of the fundamental nature of the disease.

 

These developments have resulted in a large number of promising or proven new approaches, many of which are now part of routine care. The speed of change is accelerating: there is an ever-increasing number of new drugs, technologies and concepts arriving on the scene. Unfortunately, however, some new treatments don’t live up to their initial promise. What seems to work in the laboratory sometimes has a frustrating tendency not to work in real people. Sometimes a new treatment appears initially to be an improvement, but is found eventually to be no better than that which was previously available.

 

Why trials are done

 

There is of course only one way to evaluate a new treatment, and that is to try it out on volunteers. It is only because entirely new and experimental treatments were tried out on patients in the past that we are where we are now, but all such research must be conducted and planned meticulously.

 

A totally new treatment is first evaluated in a fairly small number of patients who are observed very closely indeed, with particular attention being paid to detecting any side effects. It is at this stage that a drug may be tried at varying dosages, with the aim of discovering the optimum dosage. This is sometimes called a ‘phase I’ trial.

 

At a later stage, if the new treatment is showing some possibly useful effect, it may be tried out in a greater number of patients with particular cancers. They are closely monitored to detect both the advantages and disadvantages of treatment in ‘phase II’ trials.

 

At a still later stage the value of a promising new treatment for patients with a particular cancer may be assessed in what is known as a ‘randomised controlled’ or ‘phase III’ trial. This usually involves comparison of the new treatment with what has hitherto been the standard treatment.

 

In a randomised trial usually half the patients will receive the standard treatment and half the experimental treatment. Who gets what is decided at random, in a process similar to tossing a coin. Sometimes the proportions are slightly different and sometimes more than two treatments are compared, with patients being divided into three or four groups. Everyone involved in a trial gets potentially effective treatment for their illness, but at this stage it will not be clear whether or not the new treatment is better than the standard approach.

 

It is important that neither the patient nor the doctor decides which treatment the patient will receive. If there was an element of choice some types of patients might opt for – or be advised to receive – one treatment rather than another. As a result, the two groups might end up being not exactly comparable. Then it might not be possible to tell whether any differences in the response to treatment in the different groups were caused by the particular treatment they had received, or by differences between the patients, or by a mixture of the two.

 

The underlying principle behind a randomised controlled trial is that different treatments are given to groups of patients that are very similar, so that any differences in the way the two groups respond can reasonably be put down to the treatment that they have received.

 

The similarity between the groups is ensured partly by the random allocation of patients to the different treatments and partly by having large numbers of patients, usually at least hundreds, in the trial. By having large numbers, any differences occurring by chance in the make-up of the patient groups will tend to be ironed out.

 

As an analogy, it wouldn’t be surprising to find a variation in height of several inches within a first form class of secondary school children. However, it would be very surprising if the average height of all first form children in one city was three inches less than in another city not many miles away.

 

In the not so distant past only a fairly small percentage of patients were entered into trials. This was a pity because there can be no doubt that progress in treatment would have been made more quickly if more people had been included in trials. The entering and monitoring of patients in trials can be time-consuming and the resources available have not always been sufficient to cope. But since the millennium national cancer research networks have been established within each of the countries of the United Kingdom, backed by substantial governmental investment intended to provide much better support for trials. A major aim has been to increase the recruitment of patients to those carefully chosen and meticulously designed trials which seem most likely to lead to yet further improvements in what can be offered to future patients. The results have been impressive and approximately 20% of new cancer patients are now being entered into trials.

 

Ethical considerations

 

A clinical trial can be conducted only with the approval of the local ethical committee, comprising non-medical people and doctors who are not immediately involved in the treatment of the people being entered into the trial. The committee must satisfy itself that there is no evidence that patients will be disadvantaged if entered into the trial.

 

It is unethical for doctors to invite patients to enter a trial if they already believe that one of the treatments being assessed is superior. Thus, a randomised clinical trial can proceed only if there is genuine uncertainty about which of the treatment options being assessed, if any, is superior. It is quite common for new treatments to be found to be no better than or not as good as already existing treatments, when compared with them in a randomised trial. It is a mistake to assume that all new treatments are better. The progress of trials is kept under close review and you can be reassured that the trial will be stopped if one treatment is clearly turning out to be better.

 

Taking part in a trial

 

Patients who take part in a trial may have to attend clinics more often and for longer than if they were not in a trial. This is because very thorough assessments are being made of both treatment efficacy and any side effects, which would not otherwise be quite so necessary or perhaps even feasible.

 

It has been claimed that patients treated in trials (whatever treatment they receive) tend to do rather better than those treated outside trials. While the evidence for this is somewhat controversial, it does seem clear that patients treated within trials are in general likely to fare at least as well as those treated outside trials. Certainly patients in trials tend to have their progress monitored more closely. There is probably also a tendency for treatment centres and units with particular expertise to be more enthusiastic about entering their patients into trials.

 

The choice is yours

 

If you are invited to join a trial you are under absolutely no obligation to accept and your refusal will have no effect on the standard of your care: you will still receive the best available conventional treatment. You should not feel that you are under any pressure to join a trial and you must have enough time to make the decision that is right for you.

 

Some people are happy to make their mind up one way or another almost straightaway, but others will want to take away written information about the trial and think about it over a few days.

 

You can be included in a clinical trial only with your written consent, having received all the information you require about it beforehand, and you are entitled to leave it at any time if you wish.

KEY POINTS

• Progress in the fight against cancer depends on patients being treated in clinical trials

• All clinical trials are very carefully vetted

• Patients in a trial cannot receive any treatment that is known to be inferior

• Patients treated in trials fare in general at least as well as those treated outside trials

• A patient can be entered into a trial only with his or her informed consent

Coming to terms with a diagnosis of cancer and all that follows from it isn’t easy for anyone, yet many people don’t make sufficient use of the various kinds of support on offer. Your needs won’t be exactly the same as anyone else’s, but it is important that you voice your concerns, whatever they may be, before, during and after treatment. Getting the right kind of supportive care may also make it easier for you to persevere with difficult treatment and thereby benefit from it.

 

You may need rather more than just treatment directed against your cancer. You may require attention to physical symptoms, which can be very varied. Some will be caused by the cancer, some by treatment and others by something completely unconnected. Often the best way of relieving symptoms is by treating the underlying cause. If this is not possible symptoms can usually be abolished or ameliorated in other ways.

 

You should not feel embarrassed about asking for psychological help. Anxiety and depression are understandably common in people with cancer. Often such feelings are not too difficult to cope with and short-lived, but if they become more troublesome there is usually a variety of different forms of effective help available.

 

Other forms of help that you might possibly need include:

• professional assistance of various kinds with rehabilitation
• help with household tasks and other practical assistance
• specialised nursing care in hospital, at home or in a hospice
• financial help: a wide variety of state benefits and charitable financial grants is available for people with cancer and those caring for them at home
• advice on travel insurance

 

It can quite often take a little while to get over the effects of some of the more intensive treatments with surgery, radiotherapy or drugs. You can usually help your own recovery by eating sensibly and resting whenever you feel tired. Ask your doctor for advice about any plans to return to work or possible changes to your lifestyle. Some people need a fairly long period of convalescence whereas others will be better off returning to normal activity straightaway. There’s usually no reason why you shouldn’t continue with your normal activities if you want to and feel up to it. Indeed, many people seem to cope better with treatment and to return more rapidly to normal life afterwards through continuing to be active and involved in the world outside.

 

In the longer term you are very likely to be advised to lead as normal a life as possible. Obviously, if you have had potentially curative treatment for a smoking-caused cancer, of the larynx or lung for example, you’ll be left in no doubt that you should give up smoking. Similarly, if you’ve had treatment for skin cancer you would be wise to avoid excessive exposure to sunlight and use high factor sunscreens. If you try to follow the advice you’re given, you will be doing everything in your power to prevent a recurrence.

 

For many patients, particularly those who have had potentially curative treatment, there is much to be said for adopting a fairly healthy lifestyle if at all feasible. This is likely to improve their quality of life. There is also evidence that avoiding obesity, moderating alcohol intake and getting a reasonable amount of regular exercise (say at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous intensity activity per week) can even help to increase the chance of ultimate cure, or slow down tumour progression, for patients with some types of cancer.

 

For some of those for whom cure is not possible and who need continuing or palliative care, the value of the help available from nurses cannot be overstated. Community or district nurses can pay regular visits to patients’ homes and offer a variety of services including bathing, giving medication and providing support for carers. They may also be able to arrange for the provision of practical aids, for example handrails, or ramps for wheelchairs.

 

Macmillan nurses have undergone special training in symptom control and counselling. They are often based in hospices but visit patients regularly both in their own homes and in hospital, to offer advice and to check that they are receiving all the care they need. Marie Curie nurses can help out with some of the nursing care at home, thereby providing most valuable relief in some situations, especially at night. Macmillan and Marie Curie nurses offer both advice and practical assistance to family members and other carers. They can usually be contacted via your GP or community nurse.

 

Palliative care from specialist nurses and/or physicians is often more effective if provided at a relatively early stage. Early involvement can also help ease the burden on other family members.

 

Follow-up

 

Once your treatment is finished, you may well be given ‘follow-up’ appointments in the hospital outpatient clinic. Usually this is done for very good reasons, such as to assess the results of treatment, to deal with any side effects, and to answer questions or give advice on rehabilitation and lifestyle. However, in some circumstances hospital follow-up, particularly if continued over a long period, is not always the best use of time and energy for either you or your hospital doctor.

 

One important reason for routine follow-up is the possibility of detecting recurrent cancer at an early and hopefully still curable stage. If your cancer is more advanced and/or incurable, you may be offered routine consultations with the aim of ensuring that your symptoms are being well controlled or that any new ones are treated promptly. Sometimes follow-up can help to ensure proper care for those experiencing side effects from treatment. But these reasons do not necessarily make it essential to have routine follow-up in hospital. In some circumstances your GP may be happy to share or even supervise follow-up and only send you back to the hospital if there seems to be a problem. This can often work well, and it may spare you unnecessary travel.

 

However, there are some people for whom follow-up in hospital is essential. This includes particularly those who need specialist internal examinations at regular intervals, for example those who have been treated for ‘head and neck’, bowel or bladder cancers. You are also likely to need specialist follow-up after curative treatment for certain other cancers, including cervical or testicular cancer, leukaemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, sarcomas and some skin cancers. Should you have a recurrence of one of these cancers, further treatment may have a greater chance of success if the recurrence is discovered at an early stage. Many women who have had curative treatment for breast cancer need mammograms and occasionally breast ultrasound scans, but it is worth mentioning that other investigations are of no value as part of routine follow-up, and can only cause unnecessary anxiety.

 

For some other patients follow-up X-rays or scans may be necessary in certain specific situations, for example to detect an early possibly curable recurrence not causing any symptoms in patients who have undergone surgery for bowel cancer. Blood tests may also be required, such as blood counts for people who have been treated for leukaemia and ‘tumour marker’ concentrations for some of those who have had treatment for prostate, testicular or bowel cancer. However, very many people do not need any further investigations unless there is any cause for concern. Attending for follow-up consultations can understandably be an anxious time for many patients, but nevertheless most say that they find regular check-ups reassuring.

 

Family and friends

 

If you are fortunate enough to have help close at hand from loved ones and close friends, you may well find that they are your main and most valuable source of psychological and practical support. The majority of cancer patients will at some time depend heavily on those close to them, but it is important to recognize that accessing such help is not always straightforward.

 

It is really not at all surprising that cancer can sometimes put a strain on relationships. This can happen to anyone, but there is a tendency for relationships with previous difficulties to be more vulnerable. Most people find ways to face and overcome new strains and stresses, especially if they are able to share their feelings with each other. For many couples, facing a battle with cancer together makes the relationship even stronger.

 

Relationships outside the family can also be altered by cancer. Some friends will handle the situation very well and provide valuable understanding, emotional support and practical assistance, whereas others find it difficult to cope. They may become more distant and some even lose touch completely. Most friends will want to help, but some feel uncomfortable and unsure about how to go about it. The perception that friends are drawing away can be an additional burden, especially if you had expected more of them. It may be helpful to take the initiative by ringing them up or by asking for practical help or for a visit, so that they can be brought back in touch and be made to feel useful and needed. Be wary, however, of those who are inclined to make negative comments about your treatment and future prospects based, as they usually are, on relative ignorance.

 

 

Close relatives and friends have an important role to play in helping to maintain your morale, but most people dislike false cheerfulness. If those close to you refuse to consider the possibility of an unfavourable outcome or to recognise your fears and concerns, you may feel less inclined to talk openly to them. Families and friends shouldn’t try to ‘put on an act’ – it is usually best to say and do what comes naturally. Nor should you allow them to turn you into an invalid if you feel that you are perfectly able to live a normal or near-normal life.

 

Carers sometimes have a very substantial burden to carry, and being a loved one or close friend of someone with cancer can be a lonely existence. Most carers will regard it as important to do what they can to keep up the spirits of the person with the cancer, despite the fact that their own morale may sometimes be faltering. Caring may involve endless trips to hospital, preparing meals, providing treats, listening, offering a shoulder to cry on and many practical chores. Most carers do this very willingly, but the price can sometimes be high for them. It is therefore important that carers’ own needs are also recognized, especially their need for some time for themselves, and an occasional break.

 

The need for psychological support (see also ‘the importance of the mind’ in the final chapter)

 

Many people don’t get this kind of care when they need it, perhaps because they are reluctant to bring up the subject and perhaps because they are not asked about it. It really is worth talking to one of the team responsible for your care if you feel that you are not coping well emotionally.

 

Emotional difficulties can easily be made worse by treatment and by other symptoms such as lethargy, poor concentration and memory, irritability, sleeping problems and loss of interest in everyday activities.

 

Doctors may not always appreciate fully the need of some patients to discuss widely varying aspects of their illness: its treatment, and its impact on their lives and on family and social relationships. Nevertheless, it is an important aspect of their responsibility for you and you shouldn’t hesitate to raise matters that concern you, particularly if you don’t find it easy to talk to family or friends.

 

Many people with cancer naturally feel anxious and depressed at times. Many are afraid or feel lonely and isolated. Denial and anger are also common. All these are understandable and can be entirely normal reactions to a disturbing situation. They all tend to be much more marked in the period immediately after being told the diagnosis and around the time of starting treatment. Here ‘fear of the unknown’ can be an important aspect. As time progresses these feelings tend to settle – human beings have a truly remarkable ability to adapt to altered circumstances.

 

However, even though later on you may feel that you have come to terms with having an illness that could recur or progress, you can still feel particularly vulnerable every time you have even the slightest symptom, go for a follow-up appointment, hear about someone who has died of cancer or read a distressing article in a newspaper or magazine. Coming to the end of a prolonged course of treatment can sometimes bring its own anxiety and waiting for the results of tests can also be very stressful. These reactions too tend to diminish with time, but fears can sometimes still be quite profound even years after apparently successful treatment.

 

Surgery that changes the way you look or the way you see yourself can have a considerable psychological impact. In particular, some people who have had surgical procedures such as mastectomy, laryngectomy or colostomy sometimes feel that they are no longer attractive. They may lose their sex drive and potency. Some don’t want to look at themselves naked in the mirror or let their partners see them naked or share their bed.

 

About one in four people with cancer become rather more seriously or persistently depressed. This kind of difficulty is more likely to affect people who are receiving more toxic treatments, younger people, those with more serious cancers, those who have social difficulties and those with a past history of mental problems. Symptoms may include loss of appetite, sleep disturbance, lack of concentration, memory impairment, irritability, feelings of hopelessness and pointlessness of life, panic attacks, sweating, palpitations and shaking. Occasionally patients develop guilt feelings which are often irrational. They may believe, wrongly, that they have brought the disease upon themselves as a result of their lifestyle, or as a result of being of a certain emotional disposition. Others may worry (completely erroneously) that the disease is contagious. Some people feel a stigma and withdraw from social life.

 

Self-help and support from others

 

Many patients are able to do a lot to help themselves, for example by trying to control their thoughts. Pessimistic thoughts can so easily make the situation much worse. Many find it helpful to try to challenge negativity and to develop some confidence in their ability to cope and to change the way they feel. There is much to be said for trying to involve oneself in interests or activities totally unconnected with the cancer or its treatment. Distraction, by focusing attention elsewhere, can often help to stop or lessen a stream of pessimistic thoughts. Many people find it helpful to set goals and make plans, thereby giving more purpose to each day and a focus to life.

 

Fortunately, there is so much else that can also be done to help people who are anxious or depressed, or have other psychological difficulties, so it is important to ask for help when you need it and not try to struggle on alone. What is often most helpful is just being able to talk about your feelings to someone who understands.

 

People with more serious depression will usually benefit from short-term treatment with an antidepressant drug. Short-term treatment with tranquillisers may help those with severe anxiety. Other types of treatment can also help. For example, some patients benefit from sessions with a therapist who can teach them how to challenge negative thoughts and to use relaxation exercises. Those who have problems with body image following surgery can be helped to see themselves more positively. Specialised psychosexual counselling can be beneficial for people who have lost their sex drive as a result of their illness or treatment. Your doctor can refer you to a clinical psychologist or psychiatrist specialising in this aspect of cancer care if appropriate and, if it is not suggested, ask whether this is possible.

Counselling is increasingly becoming part of the care offered in cancer centres. It is important, however, that this is done by suitably experienced medical or paramedical staff, or by dedicated counsellors who have had proper training in counselling, rather than by merely well-motivated volunteers. For this reason, it is better to ask for your doctor’s advice rather than finding a counsellor on your own, as the wrong person can occasionally do more harm than good. Many patients find it extremely helpful to discuss widely ranging aspects of the impact of the disease on their lives, and feel much better for having had this opportunity. Many also benefit from the counselling and spiritual support provided by hospital chaplains or their own priests or ministers.

 

Emotional as well as practical help is available from some of the organisations listed in ‘Further help’. There is also a large number of self-help groups providing support and advice to people with cancer and their families. Many of these groups consist of people who have experienced cancer themselves. You may find it useful to discuss emotional and practical issues with other people who have been through a similar experience to you, although of course no two individuals or families share exactly the same circumstances. Joining a self-help group doesn’t suit everyone however. Many people just want to try to get on with their normal lives and put their cancer and its treatment behind them. Also, group morale can sometimes be lowered should things not go well for one or two members.

 

Inevitably, your reaction to your cancer will depend on your personality, which you can’t change. If you have always been an anxious person, you are more likely to dwell on your illness and your fears than someone else who is more able to put such concerns aside. However, if you are able to concentrate on getting on with your life and put your cancer behind you as far as possible, you are likely to have a far easier time than if you continue to put your cancer centre stage. It is worthwhile trying to keep a positive attitude and to make each day count.

 

It is not uncommon for people to say, some years after treatment, that having had cancer led them to re-think their priorities and that, overall, the illness was a positive influence on their lives. The challenge of cancer has enabled some people to become less concerned with trivia and to value more greatly the truly good things in their lives.

 

Physical symptom control

 

When you have had cancer, it is easy to attribute any symptom you develop after the diagnosis to cancer, but of course you are still just as susceptible to other complaints – from colds and coughs to rheumatism – as everyone else. Many symptoms have absolutely nothing to do with the cancer or its treatment. However, as a general rule it is sensible to clarify as far as possible the cause of a symptom as this can have a considerable bearing on how it is treated.

 

Pain control

 

It is important to identify the cause of any pain. It may be due to the cancer itself, but in some patients it may be due to treatment. Pain following surgery is of course not uncommon, but radiotherapy and drug treatments can also occasionally cause pain in some circumstances. Very often pain in cancer patients is completely unrelated to the cancer or its treatment and is due merely to one of those causes for pain that are so common in the rest of the population. These include arthritis, wear and tear, back problems and migraine. It is only too easy for patients with a past history of cancer to forget that they are susceptible to all the causes of discomfort, aches and pains as other people, and to worry unnecessarily that their cancer has spread or returned.

 

It is also worth mentioning that negative emotions such as anxiety, depression, anger, hopelessness and fear can easily make pain more troublesome. Thus reassurance and explanation, hope and calmness can be of great help to some patients in coping with their pain and getting on top of it.

 

If the pain is due to the cancer it usually proves possible to keep it under control, although sometimes it is necessary to resort to a variety of different measures. Treatment directed at the cancer itself, such as radiotherapy or drugs, can be very effective in controlling pain. External radiotherapy is particularly effective in relieving localised bone pain, usually within a week or two, and usually only a single treatment is necessary. More widespread pains due to bone metastases that are not satisfactorily controlled by other measures may respond well to isotope treatment with radioactive strontium or samarium injections.

 

As a general rule, pain-killing drugs (‘analgesics’) need to be taken regularly, and in sufficient potency and dosage. Many people are their own worst enemies and wait for the pain to return or to become particularly severe before taking analgesics. It is much easier to prevent a pain coming on than to make it go away when it is already there. Thus if you have recurring pain you should take your analgesic(s) at regular set times, even if you aren’t actually feeling any pain at that particular time.

 

There are three broad categories of analgesics: non-opioids, opioids, (so called because they have effects similar to the opium poppy – they can be either ‘weaker’ or ‘stronger’) and additional or ‘adjuvant’ drugs of various types. Quite often the best results are obtained using combinations of drugs from different categories. The correct drug or combination is that which is found necessary to control the pain in a stepwise approach using treatments of increasing potency until this is achieved. This is sometimes known as the ‘analgesic ladder’.

 

Step 1 involves giving non-opioid drugs such as paracetamol or one of the ‘non-steroidal anti-inflammatory drugs’ (NSAIDs) of the type often used for arthritis, such as ibuprofen, naproxen, flurbiprofen and diclofenac. Anti-inflammatory drugs are extremely useful, but unfortunately they can sometimes cause acid indigestion and very occasionally even stomach or duodenal ulcers. They should be used very cautiously in anyone with a past history of problems of this nature. There is a newer class of anti-inflammatory drug which appears to be less risky in this respect, but drugs in this class carry other risks and should only be used for carefully selected patients.

 

Step 2 involves adding a weaker opioid drug such as codeine or tramadol. Step 3 involves substituting the weaker opioid with a stronger opioid. The main stronger opioids are morphine given by mouth (orally), diamorphine given by injection and fentanyl or buprenorphine given by a skin patch. Oxycodone and hydromorphone are alternatives that may be better tolerated by some patients. A more simplified two step approach going straight from Step 1 to low dosage Step 3 now has many advocates.

 

Oral morphine remains the first line opioid drug in the management of moderate to severe cancer pain for the great majority of patients, but in a minority of patients better pain control for equal or less side effects may be obtained with one of the alternatives. Morphine may be given four-hourly in tablet or liquid form, or 12-hourly using ‘slow-release’ tablets, capsules or liquid suspension. Some slow-release capsules are suitable for administration just once a day. Pain control is usually initially best achieved using the 4-hourly quicker acting ‘immediate release’ form, before switching to one of the slow-release forms.

 

Fentanyl is available as a quick acting ‘sublingual’ [under the tongue] or ‘buccal’ [inside the cheek] tablet. These are not swallowed but are rapidly absorbed through the mouth mucous membrane into the blood stream. They can thus provide fast relief of the ‘breakthrough’ pain which sometimes occurs in people whose pain is generally fairly well controlled by regular opioids. If a patient has persistent nausea or vomiting, or difficulty with swallowing, it may be helpful to administer diamorphine by slow infusion using a ‘syringe driver’. Several analgesics, including morphine, can be administered rectally as suppositories.

 

People for whom morphine or an equivalent stronger opioid is prescribed often have reservations about taking it. Sometimes they think that it will stop working if started too soon, or that they will become addicted to it. Neither of these beliefs is correct. Another belief is that the prescription of such a drug must indicate that the situation is very serious. This too is a misconception – they are simply good analgesics that are used when pain is more severe. Some people need to take them for many years.

 

The opioid drugs do have side effects. Sometimes people become sedated or experience nausea or vomiting when they first start taking them or when the dose is increased, but both these effects tend to wear off fairly rapidly. If necessary antiemetic (anti-sickness) drugs can be given. Constipation is a more persistent problem and most people on morphine need to take a softening and stimulant laxative regularly, such as co-danthramer. A dry mouth is also quite common – frequent sips and mouthwashes can help. The effects of alcohol can be enhanced.

 

Very many patients are able to lead virtually normal lives while on an opioid, but they should be advised not to drive or engage in other skilled activities such as operating machinery when they first start on the drug, or when the dose is increased. However, once any initial sedative effects have resolved and there is no evidence of impaired performance, driving and other similar activities can safely restart.

 

Several other measures are available if necessary. These may include taking additional drugs such as steroids, or the antidepressant amitriptyline or some anti-epileptic drugs such as gabapentin and pregabalin which have been found to be often helpful in relieving pain caused by pressure on nerves or nerve damage. For patients with painful bone metastases bone-strengthening ‘bisphosphonate’ or denosumab drug treatment may be helpful.

 

There are different bisphosphonates available: zoledronic acid is given by short intravenous infusions usually monthly for the first year, but there are also daily tablet options. Denosumab is a more recent monthly antibody treatment which is slightly more effective than the bisphosphonates. As it is given by subcutaneous injection it is suitable for administration by practice nurses in the community. Both denosumab and bisphosphonates have been shown to reduce both the need for pain-relieving radiotherapy and the risk of fracture through areas of weakness. Both are now frequently recommended as preventive treatments for patients who have bone metastases but are not troubled with pain.

 

Referral to a specialist in palliative care or in pain control can be very helpful for some patients. Special pain control techniques are available at pain clinics. Nerve blocks involve the injection of local anaesthetic or other agents near to a nerve to stop it carrying pain impulses to the brain. Trans-cutaneous electrical nerve stimulation (TENS) machines produce a low electrical current which can be used to stimulate the skin near painful areas and this can also be effective in relieving pain for some patients. No one should accept uncontrolled pain as inevitable.

 

Controlling other symptoms

 

Most symptoms can be controlled or at least reduced, sometimes by dealing with the underlying cause, sometimes by treatment directed purely at the symptom and sometimes by a mixture of the two.

 

Loss of appetite (‘anorexia’)

 

This is a common symptom which may be caused directly by the cancer, treatment with drugs or radiotherapy (particularly when they cause nausea), constipation and psychological upset. Alterations in taste are common in cancer patients and can also play a part in the loss of interest in food. Anorexia can easily add to any weight loss caused directly by the cancer or its treatment.

 

Many people with poor appetite find small, frequent meals more acceptable than larger ones at conventional times, particularly if they are made to look attractive. A glass of sherry before a meal sometimes stimulates appetite, but unfortunately some people also find they no longer enjoy alcoholic drinks. If appropriate, regular exercise may help. Drug treatment with progestogens or steroids is sometimes used to stimulate appetite.

 

Breathlessness (‘dyspnoea’)

 

There are a number of possible causes. Some of these involve disruption of the normal functioning of the lungs by the cancer. One of the more common causes is an accumulation of fluid (‘pleural effusion’) between the outer surface of the lung and the inner surface of the chest wall. The fluid presses on the lung preventing an adequate intake of air. Fortunately, it can be removed very easily and quite comfortably by sucking it out (‘aspiration’) via a thin needle inserted gently into the fluid through the chest wall. If a pleural effusion is a recurrent problem it can usually be prevented by sealing the inner and outer surfaces together by injecting one of a variety of agents into the space between them. This is a fairly simple procedure known as a ‘pleurodesis’.

 

Other causes of breathlessness include primary or secondary growths involving the lung tissue itself, chest infections, anaemia and clots (‘pulmonary emboli’) in the blood vessels in the lungs. Most can be treated effectively and if cancer is infiltrating the lung steroids may be helpful. If the cause is difficult to deal with distress can be relieved by morphine, tranquillisers and oxygen.

 

Constipation

 

This is quite a common problem. It is usually the result of poor dietary intake, analgesics, immobility, some anti-sickness drugs or combinations of these. Other possible causes include an obstruction in the bowel and a raised blood calcium level. For most patients prevention is better than cure. Making sure that your diet includes more high-fibre foods such as wholemeal cereals and bread, fresh fruit, pulses and vegetables, and that you keep up your intake of fluids, may be enough to stop you becoming constipated. Some people will need to take laxatives such as co-danthramer regularly, especially if they are on opioid analgesics. Suppositories or enemas may be necessary to solve the problem in some instances.

 

Diarrhoea

 

Unfortunately, this is quite often a side effect of radiotherapy to the abdomen or pelvis, and of some cytotoxic drugs. It usually responds well to any of a variety of medications, including codeine phosphate and loperamide. However, sometimes it is necessary to stop the anti-cancer treatment for a while to allow the diarrhoea to subside. It is important to make sure that you drink enough fluid to replace what you are losing, and it is also usually helpful to cut out or cut down on high-fibre foods, including fruit and green vegetables. Patients receiving radiotherapy that would be likely to cause diarrhoea are usually advised to alter their diet preventively.

 

Normally water is progressively removed from the bowel contents as they move downwards. The contents of the small bowel and the first part of the colon are thus normally rather liquid. This explains why bowel looseness is quite common in people with stomas. Taking methylcellulose can help to firm up the motions. Occasionally diarrhoea can actually be a consequence of constipation, when the more liquid content of the upper bowel seeps past a solid obstruction lower down.

 

Difficulty with swallowing (‘dysphagia’)

 

This may be the result of a tumour growing within the oesophagus, or of pressure on the oesophagus from outside, such as by enlarged glands within the centre of the chest. Solids usually cause more problems than liquids with this type of dysphagia and many patients may be helped to maintain an adequate nutritional intake by having soft, sloppy or liquidised food. A short-term slight improvement can sometimes be achieved with steroid medication. Apart from treatments directed against the cancer itself, rapid substantial relief can often be obtained by inserting a hollow tube or stent down into the oesophagus under sedation or a general anaesthetic (‘intubation’).

 

Pain on swallowing can be caused by inflammation resulting from ‘heartburn’ which is reflux of stomach acid up into the oesophagus, and by chest radiotherapy and infection with thrush (‘candidiasis’). Simple and effective remedies are available for all these causes. See also ‘Nutritional advice and support’.

 

Fatigue

 

Most patients with cancer experience some fatigue at some stage due to the effects of the cancer itself or to the effects of treatment. Contributory factors may include anaemia, poor nutrition, sleep disturbances, distress, anxiety and depression, and these can quite often be helped by treatments such as iron supplements, sleeping tablets for just a few days and blood transfusions, or by nutritional advice or psychological support.

 

In the past patients were advised to take periods of rest and limit their physical activity when fatigued. While you may well need more rest than usual during treatment and for some time after, we now know that once correctable causes have been dealt with, taking it easy can make fatigue worse and cause a further decline in what people are able to do. For many patients regular exercise will help reduce fatigue, maintain muscle strength,  lessen anxiety and depression, and improve their quality of life.

 

A recent trial has suggested that cancer related fatigue can be improved, at least in the short term, by taking American ginseng. The steroid drug dexamethasone can also reduce fatigue for a while in people with more advanced disease.

 

Lymphoedema

 

Normally tissues are constantly being irrigated by a colourless fluid which flows through small lymphatic channels into lymph nodes, which act as filters and help protect against infection. This fluid, called ‘lymph’, eventually drains into the bloodstream, but if the lymphatic channels become blocked it can accumulate causing ‘lymphoedema’ – a boggy swelling of the tissues. It occurs most often in the limbs, and sometimes in the breast.

 

Lymphatic blockage may be caused by the cancer itself or, a little more commonly, by treatment with surgery or radiotherapy. This is another area where there have been considerable advances in treatment in recent years, including specialised massage and the fitting of elastic arm or leg compression stockings which help stop fluid building up.

 

If you experience this particular problem, you should be able to see one of the many breast care or Macmillan nurses who have been specially trained in lymphoedema care. You may be taught how to practice a technique of gentle massage known as ‘simple lymphatic drainage’ yourself. But if the swelling is more severe more intensive measures may be recommended. These include a specialised form of massage performed by a trained therapist, known as ‘manual lymphatic drainage’.

 

Good skin care is important, particularly as tissues affected by lymphoedema tend to be rather vulnerable to infection, which can easily make the lymphoedema worse. You should try to avoid any injury to the overlying skin and to make sure that you get very prompt antibiotic treatment at the first sign of any infection.

 

Nausea and vomiting

 

These symptoms are most commonly caused by drug treatments, particularly analgesics and chemotherapy. Nausea resulting from analgesics such as morphine usually disappears quite quickly even though you continue taking the morphine. Radiotherapy can sometimes cause sickness as well, particularly when given to the abdomen. Nausea and vomiting resulting from chemotherapy or radiotherapy can now quite often be prevented if you are given antiemetic drugs before treatment begins.

 

Occasionally the cancer itself can give rise to these symptoms, sometimes by causing a rise in the blood calcium concentration (‘hypercalcaemia’) which can be treated effectively with bisphosphonate drugs. Other causes include constipation, bowel obstruction and metastatic disease in the liver.

 

If you do develop nausea or vomiting, there is a range of drugs available. Depending on the particular drug, they may be given by mouth or by injection, by continuous infusion through a small needle inserted beneath the skin, using a battery-powered syringe driver (avoiding the need for repeated injections), or by suppository.

 

Particularly effective are steroids such as dexamethasone and the ‘HT3-receptor antagonist’ drugs such as ondansetron, granisetron and palonosetron, which are used for the prevention and treatment of nausea and vomiting caused by chemotherapy or radiotherapy. Aprepitant is a powerful new drug of a different class, specifically indicated for the prevention of nausea and vomiting caused by chemotherapy. These drugs can have their own side effects, however. For example, steroids can cause fluid retention, flushing, dyspepsia and insomnia, and HT3-receptor antagonists can cause transient constipation and headache.

 

In many situations other possibly less powerful antiemetics such as metoclopramide, domperidone, prochlorperazine, levomepromazine, cyclizine or haloperidol are quite sufficient. Metoclopramide and domperidone should only be used for short periods and in low dosage – very rarely severe neurological complications can occur if they are taken to excess, particularly by young or elderly people.  Some patients benefit from the sedative and anxiety lessening drug lorazepam. This can be particularly effective for those patients whose strong anticipation of experiencing nausea and vomiting from treatment seems to be a significant factor in their suffering these very side effects. Quite often certain drugs are used in combination.

 

Eating little and often may be preferable to sticking to normal meal times. It can also be helpful to drink liquids at least an hour before or after meals rather than with the meal.

 

Nutritional advice and support

 

Some of the causes of weight loss, such as loss of appetite, nausea, difficulty with swallowing and disordered metabolism as a result of the cancer are discussed elsewhere, as is the rôle for certain alterations to your diet. As a general rule it makes good sense in most situations to try to maintain a ‘normal’ or ‘healthy’ balanced diet sufficient in protein, calories, vitamins and fibre.

 

Patients undergoing treatment causing significant weight loss or other nutritional problems may well benefit from specialist individualized dietary advice and support. This can help them maintain both their nutritional intake and, as a result, their quality of life.

 

Further procedures may be required for people who are unable to swallow adequate amounts of food and fluid because of obstruction, pain or soreness (as can occur with some intensive treatments for head and neck cancer), or other interference with the swallowing mechanism. For some, nutrition may be maintained by inserting a very narrow tube into the stomach via the nose and throat – a ‘nasogastric tube’, which is then used to deliver liquid food rich in protein and calories.

 

Others may need feeding via a narrow tube inserted directly into the stomach through the skin of the upper abdomen. This is inserted quite easily and quickly and with usually little discomfort, under local anaesthesia and sedation. The doctor undertaking the procedure needs to identify the right position for inserting the tube from the inside by performing a gastroscopy and these tubes are known as ‘percutaneous endoscopic gastrostomy’ or PEG tubes.

 

Hospice care

 

Hospices have a tremendous amount to offer when it comes to palliative care. They provide physical symptom relief and psychological and spiritual support, both within the hospices themselves and in people’s own homes. Hospice-based care provided by palliative care physicians, specially trained nurses and other health care professionals, helps people with cancer to have the best possible quality of life, as well as offering emotional and practical support to family and friends.

 

If you’ve never been inside a hospice, you might think they are depressing institutions, but nothing could be further from the truth. They are cheerful places where care is offered in a relaxed and unhurried atmosphere. Most hospice care is given to those who are no longer curable, but many of those who can benefit from it are very far from being terminally ill. Many people enjoy significant improvement in quality of life for prolonged periods as a result of hospice expertise. There is never nothing that can be done.

 

It is very common for people to be admitted to a hospice for some days for assessment and detailed attention to symptoms, and then to return home much more comfortable. Hospices can also take people in for a few days so as to give their family members or other carers a break. This is sometimes called respite care.

 

KEY POINTS

• Help is available for most of the physical and psychological problems that affect people with cancer or who have had treatment for it

• People with cancer, or who have had treatment for it, can do a lot to help themselves

• When feasible, adopting a healthy lifestyle after potentially curative treatment, including getting plenty of exercise, should help make you feel better and may even improve the chance of success. This approach can also be helpful for many people receiving palliative treatment

• People who have had treatment for cancer often experience symptoms that have nothing to do with the cancer or its treatment

• Good pain control can be achieved for the great majority of those people experiencing pain

• Pain-killing drugs should usually be taken regularly, not just when the pain begins

• Early palliative care service involvement can benefit both patients and other caregivers

Unlike surgery and radio-therapy, drug treatment is ‘whole body’ or ‘systemic’ treatment. Anti-cancer drugs are carried by the bloodstream to almost every part of the body. Thus it is possible for drugs to kill cancer cells wherever they are. Drugs are particularly useful, therefore, in the treatment of cancers that have spread from the original tumour to other parts of the body, or when there is a significant chance that they may have done so even though this cannot be detected.

There are five possible reasons for giving anti-cancer drugs:

1. To try to destroy the cancer by the drug treatment alone, aiming for a complete cure (radical or curative treatment).
2. To try to shrink the cancer sufficiently to achieve symptom improvement or prolongation of life (palliative treatment).
3. To try to improve the chance of cure by eradicating any residual microscopic disease left behind after surgery or radiotherapy, or by shrinking the cancer sufficiently to make these treatments easier or more successful (adjuvant treatment).
4. To try to improve the effectiveness of radiotherapy by giving it at the same time (adjuvant treatment).
5. To try to prevent cancer developing.

 

It is essential whenever feasible to monitor the effectiveness of drug treatment when it is being given to a patient with demonstrable cancer. There is no point in continuing with a particular treatment and its possible side effects if it is not achieving the desired result. The effectiveness of treatment can be monitored by assessing symptoms, by clinical examination, by X-rays or scans and by blood tests including for tumour marker levels, depending on the type of cancer and on the particular circumstances.

 

There are three main categories of drugs that are used to treat cancer: cytotoxic, hormonal (endocrine) and targeted therapy. Cytotoxic (cell poisoning) drug treatment is commonly known as ‘chemotherapy’. Chemotherapy often has a significant effect on normal cells as well as cancer cells, potentially resulting in a variety of side effects. In contrast, hormonal treatments are usually much gentler. However, chemotherapy is active against a far wider range of cancers than hormonal treatment and it also tends to act rather more quickly. Targeted therapies are a relatively recent development. These are medications that have been specifically designed to interfere with particular proteins within the cells of particular cancers that are crucial to their multiplication and malignant behaviour, and in general they tend to be rather better tolerated than chemotherapy.

 

It is important to remember that it is relatively unusual to be able to predict reliably whether a particular cancer will respond to a particular drug or combination – different people with the same type of cancer will often respond very differently to the same treatment, whether hormonal, cytotoxic or targeted. With some types of cancer and in some situations the chance of a very good response is extremely high, but there are others where the chance is low. However it seems highly likely that in the future genomic testing on a patient’s cancer will become increasingly used to identify those people most likely to benefit from treatment in general and from particular drugs.

 

It is also important to remember that some anti-cancer drugs can interact with other drugs, and with alternative or complementary medications, including herbal preparations. These can sometimes increase the side-effects of anti-cancer treatment, while under other circumstances they may reduce its effectiveness. The doctor responsible for your anti-cancer treatment should be made aware of any other medication you may be taking.

 

Many anti-cancer drugs, particularly chemotherapy agents, are administered in hospital. But much treatment is also taken orally by patients in their own homes, particularly hormonal drugs. Unfortunately many people fail to take such medications regularly, exactly as prescribed, and that this can substantially reduce their effectiveness. If you are on such treatment it is very important that you do take it reliably. If for whatever reason you find this difficult you must discuss this with your doctor.

 

Space here is insufficient for detailed descriptions of drug treatments. Further and much more specific information on the very many anti-cancer drugs, and their use in treating particular cancers, is available from some of the sources listed under ‘Further help’. If you want very detailed information on a particular drug you can usually access online the ‘Summary of Product Characteristics’ produced by the relevant drug company by searching for the name of the drug followed by ‘SPC’. It is important to realise however that the great majority of patients only experience few if any of the large number of possible side effects that are listed for almost every drug.

 

Chemotherapy

 

Chemotherapy works by interfering with ‘mitosis’ (cell division). Just like radiotherapy, if it is completely successful in stopping cancer cells dividing, the tumour will eventually disappear as its cells die of ‘old age’ without being replaced.

 

Cytotoxic chemotherapy, rather like radiotherapy, is particularly active against both cancer cells and normal cells that are dividing. When chemotherapy is successful, its effect is often seen most quickly in cancers where the cells were dividing rapidly beforehand. Similarly, the side effects tend to be prominent in those tissues or organs where the normal cells are usually dividing quickly. These include the bone marrow where the blood cells are made, the hair follicles and the inner lining membrane of the bowel.

 

As with radiotherapy, giving chemotherapy involves trying to strike the right balance between killing cancer cells on the one hand, and avoiding intolerable side effects on the other. Fortunately, considerable advances have been made in recent years in lessening the side effects of chemotherapy, which are now much less troublesome than many people imagine. Indeed, some forms of chemotherapy now cause virtually no unpleasant symptoms whatsoever. Somewhat surprisingly, friends and relatives still occasionally lead patients to expect chemotherapy to be much more unpleasant than it really is.

 

There are many different cytotoxic drugs, working in a variety of different ways. There are now well over 50 drugs in common or quite common usage, and a vast number of combinations of them. They are used to treat a wide range of different cancers and in a wide variety of circumstances. Individual drugs vary considerably in how well they work against particular cancers.

 

Combining drugs

 

A proportion of the cells of any cancer may be resistant to a particular individual drug, even if that drug is very effective against the remainder. This is why chemotherapy quite often involves taking combinations of drugs in the hope of lessening the chance of treatment failure because of resistance. Also, lower doses of individual drugs can be used in combinations than might be needed if they were being given singly, and this can sometimes lessen particular side effects.

 

When prescribing such ‘combination chemotherapy’ your doctor will choose a regimen comprising drugs that are often active against your particular type of cancer, but which have rather different side effects. The chosen combination may also incorporate drugs that interfere with different stages of cell division. However, the regimen will ultimately be based on its track record in treating large numbers of people with the same kind of cancer in the past.

 

Having chemotherapy

 

Sometimes chemotherapy may be taken by mouth (‘orally’), but more often it is given by injection into a vein (‘intravenously’ or ‘IV’). Having a chemotherapy intravenous injection started usually feels just like having blood taken for a blood test. You might feel a coolness or other unusual sensation in the area of the injection.

 

You will probably have chemotherapy intermittently, say once every three weeks, twice a month or perhaps weekly in the outpatient clinic. Usually it is administered as a single injection or ‘infusion’ (using a ‘drip’) into a vein on the hand or lower arm over a few minutes or sometimes over several hours. Sometimes injections are repeated daily for a few days, and sometimes a drug is infused continuously over a day or a few days, with two- to three-week intervals in between courses. There are very many different treatment schedules.

 

You may need to stay in hospital if you are having more intensive or toxic treatment. Infusional chemotherapy quite often requires you to be treated as an inpatient on the ward, although it is often possible to administer some drugs by continuous infusion at home using a small pump strapped to the body. This method is used particularly for those patients who are treated by continuous infusion over prolonged periods.

 

If you need prolonged infusions or very frequent injections, or if there is difficulty in getting into your veins, you may have a ‘central venous catheter’ or ‘line’ inserted. These are thin flexible tubes which have their inner end positioned in a large vein inside the chest and the other end outside, so that drugs can be injected into it. The outer end may be on the front of the chest (Hickman or Groshong catheters) or in the arm in the case of ‘peripherally inserted central catheters’ (‘PICC lines’) which are put in via an arm vein.

 

Sometimes the outer end of the catheter is not brought out through the skin but is attached instead to an ‘implantable port’, a small container placed surgically just underneath the skin of the chest wall. Injections are then made through the skin into the port. These ports are not suitable for everyone, and some patients don’t like having to have a needle put in every time they have treatment, but they are barely visible and they do allow people to engage in many activities, including swimming, with little if any difficulty. All these devices can also be used for taking blood samples.

 

Very occasionally chemotherapy is given via a catheter inserted into an artery directly supplying a cancerous liver or limb. If a limb is treated in this way it is possible to isolate both the arteries and veins of the limb from the rest of the blood circulation during treatment, and thereby expose the cancer to very much higher concentrations of drugs than would be tolerated if they were being given as conventional systemic treatment. This technique is known as ‘isolated limb perfusion’.

 

Each individual period of chemotherapy administration, whether given in a single dose or over a few days, is commonly known as a ‘cycle’ or ‘course’, although sometimes single injections or infusions are called ‘pulses’. Chemotherapy injections or infusions are given by specially trained staff, usually by highly trained nurses.

 

How long does chemotherapy last?

 

Just how long your chemotherapy treatment will continue depends on a number of factors. When given with the aim of cure or as an adjuvant treatment there will probably be a clearly defined duration (provided of course there is no evidence that it is not working satisfactorily), based on past clinical experience and research. Many courses last from three to six months, but occasionally longer. When the aim is to relieve symptoms or prolong life, how long the treatment lasts depends very much on the type of cancer, the efficacy of treatment and any side effects. Some patients may do best with a finite course of treatment, perhaps 6 cycles over about 4 months, followed by a rest. Others may benefit from continued treatment, particularly if it is well tolerated. If there have been some troublesome side effects the full benefit of treatment may only become apparent after it has finished and the side effects have worn off.

 

Side effects

 

These days many people find that chemotherapy causes few serious problems and, although you will probably experience some side effects, these are often not at all severe. They vary enormously according to the drugs and dosage used and your general health. There are, however, some side effects that are quite common to a large number of drugs. The gaps in between treatment courses allow the normal cells to recover, particularly the bone marrow cells, which are generally more sensitive than other normal cells to chemotherapy.

 

Effects on the blood (and why blood counts have to be checked)

The bone marrow produces the blood cells, of different types. The red cells carry oxygen around the body, the white cells (also known as ‘neutrophils’, ‘leucocytes’ or ‘granulocytes’) fight infections and the platelets clot the blood to seal leakages in blood vessels. A deficiency of red blood cells is known as anaemia. A deficiency of white cells is called ‘neutropenia’ or ‘leucopenia’, and ‘thrombocytopenia’ is a deficiency of platelets. It is worth mentioning that all these different types of cells start off as identical immature ‘stem cells’, which through successive divisions eventually become mature functioning red cells, white cells or platelets. Although the stem cells mostly live in the bone marrow a small number can also be found in the blood stream.

 

Most cytotoxic drugs interfere temporarily with bone marrow function, particularly the production of white cells and platelets. Bone marrow toxicity is the most common and generally the most important side effect of chemotherapy. The concentration (‘level’ or ‘count’) of the white cells and the platelets in the blood will usually fall during the week or so after chemotherapy, the extent depending on both the drug(s) used and the dosage.

 

Once neutropenia reaches a certain severity, you are at an increased risk of getting an infection and your immune system is less able to deal with it. For this reason, you will probably be advised to try to avoid close contact with people with infections, and with children who have recently received immunisation with a ‘live’ vaccine. You may also be advised to pay extra attention to personal hygiene, dental and skin care, and to avoid squeezing pimples as this can release bacteria into your bloodstream. Such precautions are especially important if you are receiving particularly intensive treatment. Patients who are having or have recently had chemotherapy should check if it’s all right for them to have any immunisation themselves. They will usually be advised to avoid ‘live’ vaccines (those containing living organisms).

 

If you are having chemotherapy, you should always tell your doctor immediately if you have any signs of an infection, particularly a fever, chills or sweating. If this happens your blood count will usually be checked straightaway. If your white cell count is below a certain level, you will probably have to have ‘broad-spectrum’ antibiotics intravenously to help your body’s own immune system fight off the infection, while waiting for the count to recover.

 

Very occasionally, thrombocytopenia becomes so severe that you start to bleed or bruise very easily and, again, you should report this to your doctor promptly. If necessary you can then be given a transfusion of platelets from donated blood while waiting for your marrow to recover. If your platelet count is low you must make every effort to avoid even minor injuries. Anaemia caused by chemotherapy is usually a much less urgent problem. However, it can cause skin pallor and symptoms such as weakness, tiredness and breathlessness.

 

Normally the blood count recovers fairly rapidly, but it is important that it has returned to normal by the time you have your next course of treatment. If not, it is usually necessary to postpone further treatment until the count has recovered, and sometimes it is then decided to reduce the chemotherapy dosage. If further chemotherapy were to be given when the count was already low, there would be a greatly increased risk of serious complications. This is why your blood count is checked routinely before each course or pulse of chemotherapy.

 

Sometimes marrow-stimulating ‘growth factor’ (also known as ‘granulocyte colony-stimulating factor’ or GCSF) injections are given after chemotherapy to hasten white cell recovery. On occasions a red blood cell production stimulant, epoetin, is given to patients with troublesome anaemia, but usually this is dealt with more rapidly, simply and possibly more safely by blood transfusion.

 

Sickness

Nausea and vomiting are well-known side effects of chemotherapy, but they are now much less of a problem than they used to be. Several drugs cause this only to a slight degree, if at all. If you are taking drugs that cause more troublesome sickness, the problem can usually be prevented or greatly lessened by modern antidotes. Anti-sickness drugs (called ‘antiemetics’) are now often given routinely to stop symptoms developing, sometimes starting the day before the chemotherapy is given (see section on ‘Nausea and vomiting’).

 

Hair loss

Another well-known and common side effect is hair loss or ‘alopecia’, although not all drugs cause it. Hair is sensitive because the cells in the hair follicles divide rapidly. Sometimes alopecia is only slight, but with some drugs it becomes virtually total. Hair loss usually begins about two to two and a half weeks after the start of treatment and short-lived scalp tenderness shortly before the hair starts coming out is common. Hair always regrows once chemotherapy is completed, usually starting to do so about three weeks after the last course. You may find that at first your hair is curlier than before, and this can persist for up to a year or so. Occasionally some regrowth occurs during chemotherapy. Hair loss can occur on all parts of the body, but it is the hair on the scalp that is affected most.

 

Fortunately, society’s attitude to hair loss has changed considerably in recent years, perhaps partly as a result of changing fashions and partly because we are all more used to seeing and reading about people who have lost their hair after cancer treatment. Although you may well be understandably upset at the thought of losing your hair, you will probably find that in reality you cope with it better than you expected.

 

If you’re not happy to leave your head uncovered (although increasing numbers of people are), you should choose a wig or hair- piece before your hair starts falling out. It’s usually a good idea to shave off your remaining hair or at least cut it short once it starts coming out significantly.

 

You may be offered the option of a technique called ‘scalp freezing’ to try to lessen hair loss. It involves wearing an extremely cold cap for some time before and after a chemotherapy injection. The cold causes the scalp blood vessels to constrict, thereby reducing the drug supply to the hair follicles. It’s not suitable for everyone and, although it can work well for some patients, it’s not always successful. It does prolong considerably the time involved in receiving chemotherapy and it can be uncomfortable.

 

Other side effects

Many people feel a little unwell for a day or two after chemotherapy, or sometimes for longer. Tiredness is also very common and occasionally it can last for some while after treatment. Another common side effect is altered taste, with patients losing their ability to appreciate normally certain flavours in both food and drinks. Many complain of a metallic taste. Most side effects stop fairly quickly, but some can be persistent and very occasionally permanent. Always report any troublesome symptoms during treatment – quite often there is something that can be done about them. Of course, not all such symptoms are in fact caused by the chemotherapy and other possible causes may need looking into.

 

A rare side effect of chemotherapy is skin damage at the site of the injection. Some drugs have the ability to cause quite serious ulcers if they leak out of the vein into the surrounding tissues. The staff who administer your chemotherapy are highly trained and take the utmost care when giving drugs, but even so this problem can still happen very occasionally. Tell whoever is giving your injection immediately if you experience any pain or discomfort at the injection site while the injection is proceeding, as this may be the first indication of a leak.

 

Chemotherapy with some drugs can stop the ovaries or testicles working normally. This can result in impaired fertility or infertility, and some women may have an early menopause. This effect of chemotherapy on female fertility can be lessened by administering the hormonal ‘LHRH agonist’ drug goserelin by monthly injections starting before the chemotherapy. Goserelin temporarily makes the patient effectively post-menopausal by shutting down the ovaries and in this quiescent state they are less vulnerable to chemotherapy damage.

 

Deep-frozen storage or ‘cryopreservation’ of sperms (‘sperm banking’) is offered to younger men about to receive treatment that may render them infertile. Cryopreservation of embryos or non-fertilised eggs are possible options for some women faced with losing their fertility. This requires the use of fertility drugs to stimulate the ovaries to produce eggs which are then removed. This is done using a needle inserted through the vagina while the patient is sedated, the operator using ultrasound scanning to guide the needle tip to the ovary. The eggs are then either immediately frozen, or fertilised in the laboratory by sperms from a partner or donor to create embryos ready for freezing.

 

There are many other potential side effects of chemotherapy, some being peculiar to particular drugs. However, it’s also true to say that most people either don’t experience them or don’t find them unduly troublesome, or find that they can be satisfactorily treated or even prevented. Most people say that chemotherapy was rather less troublesome than they had anticipated. All side effects are more likely and more severe in people who are receiving more intensive treatment. They include mouth ulcers, sore eyes, cystitis, diarrhoea, nail changes, numbness of extremities, rashes, slightly impaired concentration and memory, and depression. Sometimes sucking ice for about half an hour before and during the administration of chemotherapy can help prevent or lessen mouth ulceration. Very rare side effects from some drugs include lung, heart or kidney damage, and causing another cancer to develop many years later.

 

Reading about all these possible side effects can be alarming if you are about to undergo chemotherapy, but it’s worth stressing that many people are able to continue with normal life and work for much of the time in between chemotherapy courses. Indeed, those who do so often seem to cope better with it all. For most patients keeping active both physically and mentally will help lessen tiredness, stress and anxiety. It will help keep muscles strong, prevent weight gain and reduce the risk of getting blood clots in your leg or lung, which are potentially serious occasional complications. It may also help the speed of recovery once your treatment is finished. Of course keeping active is not going to be right or possible for everyone, in particular for some people receiving palliative treatment for more advanced disease. If you are unsure you should speak to your oncologist or the nurses giving your treatment.

 

Stem cell transplants

 

Sometimes chemotherapy is given in very high dosage, which inevitably affects the bone marrow severely. Such intensive treatment is suitable only for people with some types of cancers, particularly the leukaemias, the lymphomas and myeloma. It has such a profound effect on the blood that the person being treated needs to be ‘rescued’ by being given a transplant of healthy bone marrow stem cells. These cells restore the ability of the body to produce normal red and white blood cells and platelets. A transplant thus makes it feasible to give much higher doses of chemotherapy than would otherwise be possible, thereby improving the chance of a cure for people with some cancers.

 

If you are having a transplant using your own stem cells (an ‘autologous’ transplant), it must be removed before intensive chemotherapy. Alternatively, it may be taken from a ‘donor’ whose marrow matches yours very closely (an ‘allogeneic’ transplant). A close match is important, otherwise it will be ‘rejected’ later by your immune system. Many donors are close relatives, usually brothers or sisters, but unrelated donors can also sometimes provide marrow that is a good match.

Most transplants are now performed not by removing and replacing actual marrow, but by removing stem cells from either your own or a donor’s blood-stream. These are essentially marrow cells that have been stimulated to leave the marrow in large numbers by injections of growth factors. A drip is put into a vein in each arm. Blood is taken from one arm into a machine that removes the stem cells and it is then returned via the other drip. The whole procedure takes three or four hours. The stem cells are frozen and stored until they are given to you via a drip when required.

 

If actual marrow is being used for the transplant, the removal or ‘harvest’ is done by inserting a special needle into the marrow of the bones at the back of the pelvis under general anaesthetic. Only a fairly small proportion of the total marrow is removed, leaving ample to meet the donor’s immediate requirements. It is replaced fairly rapidly by division and multiplication of the remaining marrow cells. The removed marrow is frozen and stored until given to you via a drip after the high-dose chemotherapy. The marrow cells then find their way via the bloodstream to your bones, where they start to manufacture blood cells again.

 

Sometimes a well-matched donor can’t be found for someone who needs an allogeneic transplant. In this situation blood from the umbilical cord of a newborn baby can be a very useful source of stem cells. After birth the blood left behind in the placenta and the umbilical cord, which is very rich in stem cells, is usually wasted by being thrown out with these tissues. But it can be frozen and stored until needed. The number of stem cells obtained by this method is however less than with the other methods and this technique is currently only suitable as a treatment for children or small adults.

Hormonal treatments

 

Some cancers depend on hormones for their growth. Hormonal treatments work by preventing cancer cells getting or using the hormones that they need. They tend to have much less effect on normal cells than chemotherapy. However, hormonal treatments are effective only in the treatment of the relatively limited range of cancers that are potentially susceptible to hormonal influences. These are principally those of the breast and prostate, but some cancers of the inner lining of the uterus (‘endometrium’) and thyroid will respond to hormonal treatment. Hormonal drugs are most commonly  given in tablet form. All hormonal treatments tend to be more effective against slower growing cancers. They work more slowly than chemotherapy and they may need to be taken for some months for any effect to become apparent.

 

Breast cancer

 

The female sex hormone oestrogen can stimulate breast cancer cells to divide and multiply. The chain reaction within the cells that achieves this is triggered by oestrogen molecules first linking up with ‘oestrogen receptor’ proten molecules inside the cells.  Hormonal treatments for breast cancer are only prescribed for those patients whose cancer can be shown on laboratory testing (immunohistochemistry) to be ‘oestrogen receptor’ positive. Oestrogen receptors are also known as ‘ER’ because of the American spelling ‘estrogen’.  What follows specifically concerns the treatment of breast cancer in women, but rarely breast cancer occurs in men and it too can respond very well to hormonal treatment.

 

Tamoxifen, taken as a single daily tablet, works by interfering with the linking up or binding of oestrogen to the oestrogen receptor. It was for decades by far the most commonly prescribed drug for women with breast cancer but is now used rather less frequently than other drugs. But it is still commonly used and highly effective for some patients and when given as an adjuvant treatment following surgery it improves the chance of cure. Adjuvant tamoxifen has in the past been recommended to be taken for five years, but recent research has shown that it can be even more effective if taken for ten years. Tamoxifen can also be very valuable as a palliative treatment.

Most women tolerate tamoxifen well, but it can sometimes cause side effects such as hot flushes, slight weight gain and vaginal discharge. Very infrequently it can cause vaginal bleeding. If you develop this you should tell your doctor so that the reason can be investigated. The cause is usually some benign thickening of the inner lining of the womb, but very occasionally there may be an early cancer of the lining requiring surgery.

 

In more recent years a group of hormonal drugs known as ‘aromatase inhibitors’ have been used increasingly for post-menopausal patients with breast cancer. They are also given as a single daily tablet and they work by inhibiting the normal production of oestrogen by non-ovarian tissue in the body, particularly fatty tissue. They thus subtantially lower the levels of oestrogen in the body and this has an inhibitory effect on cancer cells which would otherwise have been encouraged to grow by the oestrogen. These drugs are not effective in reducing hormone levels to a sufficiently low level if the ovaries are still producing oestrogen, so they are only used for women who have gone through the menopause or for younger women whose ovaries have been removed or rendered functionless by treatment with an LHRH agonist.

 

Overall the aromatase inhibitors are slightly more effective than tamoxifen when given both as adjuvant and palliative treatments (although for some patients the additional benefit is negligible) and they can also further improve the chance of cure when given as an adjuvant treatment for some patients following a course of tamoxifen. In general these drugs, anastrozole, exemestane and letrozole, are fairly well tolerated but hot flushes, vaginal dryness and mild joint acheing are quite common. They can also cause bone thinning and a bone density measurement is often undertaken to identify those patients at risk – some may need to take additional medication, for example vitamin D and calcium supplements, to maintain good bone health.

 

There are other hormonal drugs available for breast cancer patients, including toremifene given daily as a tablet, and goserelin and fulvestrant given by infrequent injections. The choice of hormonal drug depends on a variety of factors,  including menopausal status and side effects, and whether the treatment is adjuvant or palliative. Goserelin is one of the LHRH agonists, already referred to, which make pre-menopausal women hormonally post-menopausal. The effect is equivalent to a surgical oophorectomy, but only temporary. When used palliatively hormonal drugs can often keep cancers in remission and control symptoms for very long periods, but usually the cancer will eventually become resistant and escape control. However, if a woman has responded well to one of these drugs, there is then quite a good chance that she will respond well to another.

 

Hot flushes are quite a common side effect in women taking hormonal treatment for breast cancer. Often they are not unduly troublesome, but if they are impacting significantly on quality of life additional treatments are available which quite often lessen them. These include the antidepressant drug fluoxetine, the pain killers and anticonvulsants gabapentin and pregabalin and another drug, clonidine, all in fairly low dosage. There is some evidence that acupuncture can also help. Hormonal drugs are in general probably best avoided.

 

Both tamoxifen and raloxifene, taken for five years, can now be used to lower the risk of breast cancer in women at high risk of the disease.

 

Prostate cancer

 

This type of cancer is usually highly responsive to hormonal treatments that stop male sex hormone (androgen) stimulating the cells to divide. At one time this was best achieved by castration – removing the testes, an operation known as ‘bilateral orchidectomy’. But the same effect can now be achieved by using one of the closely related LHRH agonist group of drugs including goserelin, leuprorelin, and triptorelin, which in ‘slow release’ form can be given by injection just once every four or twelve weeks. Another drug in the same group, buserelin, is given via an intra-nasal spray.

These drugs can, however, occasionally stimulate cancer growth in the period immediately after they are first given. This effect can be blocked by taking one of the ‘anti-androgen’ group of anti-prostate cancer drugs, such as flutamide, cyproterone and bicalutamide, in tablet form shortly before the first injection and for about three weeks afterwards. The anti-androgens can also be very effective treatments in their own right.

 

Prostate cancers usually eventually become resistant to castration or its drug equivalent. Some patients with advanced disease may then benefit from a newer hormonal treatment, abiraterone, which lowers androgen levels in the body even further. It does this by blocking the production of androgen that continues to take place in (non-testicular) tissues elsewhere in the body.

 

Hormonal treatments for prostate cancer are usually well tolerated but they can cause loss of sexual desire and impotence. They are quite often recommended for men with more advanced cancers that are not suitable for surgery or radical radiotherapy, but they can also be used to shrink down a primary cancer to try to give the surgery or radiotherapy that is to follow a better chance of success.

 

Targeted therapies

 

Targeted therapies are aimed at specific changes within cancer cells that contribute to their ability to divide or spread.  Because these drugs have such precise molecular targets they tend not to have some of the side effects common with chemotherapy, or not to the same extent, although they can have other side effects of their own. Tamoxifen is in fact a targeted treatment because of its specific action in blocking the binding of oestrogen to breast cancer cells, but the term ‘targeted’ is generally used to describe more recently designed and developed drugs.

 

The number of these drugs is increasing rapidly and approximately 30 are currently licensed for clinical use in Europe. Some are relatively small molecules that can penetrate the cancer cell easily but others are antibodies – much larger molecules which stick to the surface of the cancer cell and then disrupt its function.  The body normally produces antibodies – complex ‘magic bullet’ chemicals – to target specific invading bacteria or viruses, but it is now possible in the laboratory to manufacture antibodies that target very specific proteins within some particular types of cancer cell. For example, they may interfere with the ability of ‘growth factor’ molecules to stimulate cell division or the formation of new blood vessels to feed the cancer. These drugs can also stimulate the body’s own immune system to destroy cancer cells.

 

There is an increasing number of encouraging reports of the efficacy of targeted drugs in treating a variety of cancers. But unfortunately cancer cells tend to become resistant to them just as they do to chemotherapy or hormonal treatments. The best use of these drugs may be in combination with chemotherapy or hormonal drugs, or with other targeted drugs. At present the rȏle of the majority of these agents is confined to helping control rather than eradicate  cancer, but a small number can increase the chance of cure when added to conventional chemotherapy for patients with some types of cancer. A well-known example is trastuzumab (Herceptin) for people with a particular genetic (‘HER 2 positive’) type of breast or stomach cancer. Another is rituximab for patients with an aggressive type of lymphoma. There have been recent encouraging reports of the potential of targeted drugs in stimulating the immune system’s response to melanoma and in treating advanced thyroid cancer. Unfortunately many of these drugs are highly expensive and their availability is often restricted in situations where their effectiveness seems likely to be very limited.

 

Other agents

 

A number of treatments have been developed which are intended to destroy cancer cells using the same mechanisms that the body’s immune system uses to fight infections. White blood cells produce proteins known as cytokines and two types of cytokine, interferon and interleukin, can be manufactured and administered in high dosage by injection to treat patients with some types of cancer. Side effects can be troublesome, for example, flu-like symptoms and lethargy, but these drugs show useful anti-tumour effects in a proportion of patients with some of the rarer types of cancer. These include myeloma, some types of leukaemia and lymphoma, kidney cancer, melanoma and the type of ‘Kaposi’s’ sarcoma that some patients with AIDS develop.

 

There are drugs that can sensitise tissues to damage by a particular type of light emitted from a special lamp or laser. The light is directed where it is needed following administration of the drug. Laser light can be transmitted down fibreoptic cables that have been introduced into hollow organs and even directly through tissues into deep-seated tumours. The maximum impact of this treatment, known as ‘photodynamic therapy’ or PDT, can be focused accurately and it is proving to be very useful in treating cancers and pre-cancers involving the skin, oesophagus, bladder and lung. It can eradicate completely small superficial growths and it can provide useful palliation for selected patients with advanced cancers.

 

The bone strengthening drugs known as ‘bisphosphonates’ have for long been used to lessen bone damage and improve pain control in patients whose cancer involves their bones, but these drugs can also exert an anti-cancer effect.  It has recently been confirmed that bisphosphonate treatment, particularly the intravenous drug zoledronic acid, can help reduce the risk of recurrence in post-menopausal women who have had potentially curative treatment for breast cancer.

Using vaccines to stimulate the immune system to fight the cancer is an experimental approach that is showing some promising early results, particularly in melanoma, bowel and kidney cancer.  It seems likely that in the future gene therapy, currently only experimental, will become commonplace. This involves inserting genes that instruct cancer cells to produce proteins which interfere with the cell’s malignant behaviour. There are several ways of getting genes into cells, including using viruses. There have been some promising early trial results but, as with several other new treatments, its high cost may prove to be at least a partial barrier to its widespread use.

KEY POINTS

• Drug treatments have the potential to destroy cancer cells wherever they may be

• There are three main types of drug treatment for cancer: cytotoxic chemotherapy, hormonal treatment and targeted treatment

• If you are taking anti-cancer medication at home it is very important that you take it reliably, exactly as instructed – if this is difficult tell your doctor

• It is often difficult to predict the response to drug treatment

• Anyone who is having chemotherapy should report any fever very promptly

• Many people these days find that chemotherapy causes fewer problems than expected

• Most patients experience few if any of the large number of possible side effects that are listed in the comprehensive information available for every drug

• Most patients will benefit from keeping active during treatment

• Let your doctor know what other drugs or medications you are taking, including any herbal preparations

How it works

 

Most radiotherapy is given using a beam of high-energy X-rays which are more powerful than those used for taking ordinary X-ray pictures and given in longer bursts – for example, a minute or so, compared with less than a second for diagnostic pictures. These beams shed their energy into the cells of the tissues through which they pass. You have to lie still during treatment, but you don’t feel anything and from your point of view the only difference from having an ordinary X-ray is that radiotherapy lasts longer. You don’t become radioactive.

 

The target

 

Radiotherapy targets the DNA in the cell nucleus because, if this is damaged sufficiently, cells will lose the ability to replicate. If cells in a cancer that die naturally are not being replaced by new ones, not only will the cancer stop growing, it will also become smaller and will eventually wither away and disappear.

 

Normal cells are affected to some extent by radiotherapy too. Fortunately, normal cells in general have a greater ability to repair radiation damage than cancer cells. The therapy is done in such a way as to ensure that cancer cells receive the highest dose of radiation, while minimising as far as possible the amount that reaches nearby normal cells. This may be done by using crossed beams focused on the tumour or by shielding some of the normal tissue (see below).

 

How cancers respond to treatment

 

Cancers vary considerably in their sensitivity to radiotherapy: some types are more likely to be totally eradicated than others. How quickly they respond to treatment is also very variable. Some cancers will continue to shrink slowly and eventually disappear long after a course of radiotherapy has been completed, possibly over many weeks. Others will respond much more quickly, particularly those in which the cells were dividing rapidly before treatment.

 

In general, smaller cancers have a greater chance of being completely destroyed by radio-therapy than larger ones. This is partly because of the sheer volume of tissue involved, but also because larger tumours tend to outgrow the blood vessels supplying them, resulting in a reduced blood supply and thus less oxygen at their centre. Oxygen is very important to the process of DNA damage caused by radiation. Oxygen is carried to the tissues by the red blood cells, so if the tumour has a poor blood supply, or if there is a lowered concentration of red cells in the blood (anaemia), radiotherapy may be less effective. Thus curing anaemia by a blood transfusion can, in certain circumstances, make radiotherapy more successful.

 

Another reason why radiotherapy may sometimes not achieve complete tumour destruction is that the tumour cells continue to replicate rapidly in between daily treatments. One way of trying to deal with this that is occasionally used in certain situations is to give radiotherapy two or three times per day in a very short and intensive course of treatment. This is known as ‘hyperfractionated’ and ‘accelerated’ treatment.

 

Another way of enhancing the effectiveness of radiotherapy is to give chemotherapy as well, at the same time. This has, for example, improved cure rates for patients with certain lung, cervical and oesophageal cancers, although the side effects from such combined treatment tend to be more marked.

 

Radiotherapy can destroy a cancer only if it is possible to target the beams so that they encompass the whole of the tumour. It can be used to treat rather larger portions of tissue than can often be dealt with by surgery, but is nevertheless a fairly localised form of treatment. Another crucial factor is the ‘dose’ of radiotherapy, measured in units called ‘grays’. Some cancers will respond well to relatively low doses whereas others may need very high doses if they are to be destroyed.

 

Radiotherapy is usually given in quite high dosage (radical radiotherapy) when it is given by itself with the intent of completely destroying a cancer.

 

A slightly lower dose is given when radiotherapy is being given as an adjuvant treatment to prevent a cancer returning after surgical removal. The dosage is usually considerably lower when the treatment is palliative. In this situation the aim is to cause sufficient tumour shrinkage to alleviate symptoms, but not to eradicate the cancer completely.

 

Side effects of radiotherapy

 

If you are receiving low-dosage radiotherapy you may not notice any side effects whatsoever, but those receiving high-dose treatment can usually expect to experience some. What they are, and their severity, depend on the part and amount of the body being treated, the dose of radiotherapy and also on how sensitive a particular individual is to treatment.

 

The most common side effects occur during or immediately after treatment and are short lasting, when they are described as being ‘acute’ They usually disappear quite quickly after treatment. A few people may develop so-called ‘late’ side effects several months or even sometimes several years after treatment. These effects can be long lasting (‘chronic’) or even permanent. It is fairly unusual for long-lasting effects to be particularly troublesome, but small risks are often justifiable when aiming for cure.

 

Short-term effects

 

The normal tissues that tend to be most sensitive to radiotherapy in the short term are those where the cells are normally dividing quite rapidly to replace those lost by wear and tear. These include the skin and the membranes lining the mouth, throat, oesophagus, bowel and bladder. Inflammation, soreness, diarrhoea and urinary frequency are thus quite common side effects, depending on the part of the body being treated. Some patients get skin soreness rather like sunburn, but unless a superficial tumour is being treated it is now unusual for this to be severe, as modern radiotherapy beams can deliver the maximum dose deep, away from the surface.

Other quite common acute side effects include tiredness, nausea (particularly if the upper abdomen is being irradiated), and hair loss if treatment beams go through the scalp. This is not usually permanent, although there may be patches where the hair does not regrow if radiotherapy is being given in fairly high dosage for a brain tumour. Bone marrow  is also very sensitive to radiation but this is usually only a problem in the unusual event of treatment being given to a large part of the body containing a large proportion of the total amount of marrow.

 

Before having radiotherapy you will be warned about the more common side effects and probably given advice about how, for example, to care for your skin or change your diet to try to prevent the reaction becoming at all severe. If your abdomen or pelvis is being treated you may be recommended to cut out high-fibre foods, including fruit and green vegetables, until the reaction has settled. This is because they can make diarrhoea worse. If necessary, you may be given one of the various medications available to lessen side effects. Occasionally it is necessary to interrupt the course of treatment for a week or so to allow side effects to settle.

 

Tiredness and other acute side effects of treatment can sometimes interfere considerably with normal living, but many people have only slight if any side effects. You may well be able to continue working during your treatment and your doctor may encourage you to do so if you feel up to it. While it’s sensible not to push yourself too much if you feel tired or unable to carry on with your normal life, there is usually much to be said for remaining fairly active if at all possible, unless advised to the contrary. However this may not be appropriate for everyone and if you are unsure you should discuss this with your oncologist or the radiographers treating you.

 

Long-term effects

 

Tissues that tend to be sensitive to radiotherapy in the longer term include the lungs, kidneys, the eye lenses (where cataracts may form), and the testes and ovaries (possibly resulting in infertility). However, significant damage to these tissues can usually be avoided by careful treatment planning or, if attempting to preserve fertility, occasionally by surgically moving (‘transposing’) the ovaries a little, so that they are missed by most of the irradiation. If such measures are not possible, deep frozen storage or ‘cryo-preservation’ of sperms, embryos or eggs  may be appropriate for those who may want to have children in the future.

 

Other occasional long-term effects include arm swelling or lymphoedema as a result of treatment to the armpit after surgery for breast cancer, and bowel damage following radiotherapy for cancer of the cervix. In the past some women having radiotherapy for left-sided breast cancer experienced long-term effects on their heart, but as a result of modern refinements in radiotherapy planning and delivery this risk is now extremely low.

 

Radiotherapy can cause mouth dryness if the salivary glands are being treated and this can predispose to both tooth decay and gum disease. Patients at risk for this problem should have a specialist dental assessment before treatment, and be given advice about caring for their teeth in the future. Vaginal dryness can also be a consequence of pelvic radiotherapy and lubricants may be necessary for normal sexual function. Growing tissues are also very sensitive to radiotherapy and this has important implications for treatment for children.

 

Finally, there is a very low risk that the radiation might itself cause another cancer many years later. However, this risk almost always pales into insignificance when compared with the potential benefit from treatment.

 

How radiotherapy is given

 

Treatment from the outside

 

Radiotherapy is usually given to a fairly localised part of the body. It is given mostly using high-energy, deeply penetrating, ‘megavoltage’ X-ray beams produced in large machines called linear accelerators. Sometimes, less penetrating, lower-energy, ‘orthovoltage’ beams produced by much smaller machines are used to treat relatively superficial growths, particularly skin cancers. Electron beams produced in linear accelerators are also used sometimes to treat fairly superficial tissues. All these methods involve beams of radiation being ‘shone’ into the body from outside, and are known sometimes as ‘external’ radiotherapy.

 

External radiotherapy is given in a ‘treatment room’ which has specially thick walls to prevent radiation escaping from it. The treatment is given under the supervision of the radiographers who control the treatment machine. During the actual treatment the radiographers will stay outside and the patient is alone in the room. This is because if they stayed inside they would themselves receive, over a period of time, a significant cumulative dose from ‘scattered’ radiation. They do keep a close eye on you, however, via closed circuit television or by looking through a special radiation-proof window.

Planning and prescribing treatment

 

Radiotherapy can vary enormously in complexity. Some treatments are technically quite simple. When treating skin cancers the oncologist merely has to draw on the skin to indicate the area requiring treatment, and then specify the dose, the number of treatments and their frequency. The radiographers can then begin treatment straightaway. The patient has to lie very still in the appropriate position and the radiographers ensure that the beam is directed accurately to the right area and for the correct amount of time to give the required dose.

 

But most treatments are rather more complex, using at least two and sometimes several radiation beams entering the body from different angles and converging at the site of the cancer or the part of the body to be treated. You may need to have a CT or MRI scan beforehand to define as accurately as possible the position, size and shape of the cancer. Meticulous planning is required. This will involve your lying on a couch in a ‘simulator’, a machine that looks rather like a linear accelerator, but which produces X-ray images or scans of the part of the body to be treated. Physicists using computers then work out how best to arrange the treatment beams so that they will deliver the required dose to the intended target with great accuracy, while keeping the dose to the surrounding normal tissues to a minimum.

Sometimes the beams will be shaped specially to achieve this, using ‘multi-leaf collimators’ inside the treatment machine. Such special shaping of the beams can in certain situations be used to deliver high dose treatment to a volume of tissue that conforms closely and 3-dimensionally to the shape and extent of the tumour. This is known as ‘conformal radiotherapy’.  Whatever treatrment technique is chosen, once the oncologist has checked the resulting ‘treatment plan’ and prescribed the treatment, radiotherapy can then begin.

 

To be certain that the treatment beams are entering the body at the correct positions, ‘reference points’ are often marked on the skin, either with felt-tip pens or as pinprick-sized tattoos. If felt-tip pen marks are used you will be warned not to wash them off! Final accuracy checks may be made on the simulator by taking X-ray images corresponding to the treatment beams, or by producing precise pictures of the tissue being irradiated on the radiotherapy machine itself.

 

As accuracy is so vital you may be fitted with an ‘immobilisation mould’ or ‘shell’, sometimes also known as a ‘jig’, especially if you are having radiotherapy to the head or neck. This is an individualised transparent plastic mould which fits like a glove over the part of the body being treated and which is fixed to the treatment couch, so stopping you moving even very slightly during treatment. An additional benefit is that the entry points of treatment beams can be marked on the plastic surface without resorting to skin tattoos. Other types of immobilisation devices are also quite often used.

 

A fairly recent technical development is ‘intensity-modulated radiation therapy’ (IMRT). This is high precision three dimensional conformal radiotherapy in which the beams are not only customized by being meticulously shaped, they are also tailor-made by having variation in the intensity of the radiation across each beam. This further facilitates the delivery of a high dose to the cancer whilst minimising the dose to the surrounding normal tissues. In theory this should result in an increased chance of cure and/or better tolerability. Yet another advance in accuracy can be obtained with ‘image-guided radiation therapy’ (IGRT) in which the radiation beams are adjusted to take account of any slight change in tumour or patient position during a course of treatment and even during individual treatment sessions, for example with breathing. This fairly new development is effectively four-dimensional treatment and it may become increasingly used for cancers in certain parts of the body that are more prone to change in position.

Another highly precise form of treatment is ‘stereotactic’ radiotherapy, also known as ‘radiosurgery’, where very small beams entering from very many different angles are focused in a highly precise manner on a very small part of the body. This is used for some people with small tumours in or near the brain, whose heads are immobilised completely during treatment using a special frame. Radiosurgery is now being used increasingly to destroy small tumours in other parts of the body. It is given with machines such as the Gamma Knife which delivers narrow radiation beams (‘gamma rays’) from a helmet containing a couple of hundred sources of radioactive cobalt, or the CyberKnife – a small linear accelerator which rotates around the patient whilst focusing a narrow beam of high energy X-rays on the tumour.

 

How long does treatment last?

 

Although most individual radiotherapy treatments take only a couple of minutes or less to deliver, all the position and other accuracy checks often mean that you are in the treatment room for 10–15 minutes per session.

 

Sometimes, particularly when the main aim of treatment is to relieve symptoms, only one or two sessions or ‘fractions’ are required. In other instances treatment may continue once a day for perhaps from three up to six or seven weeks. For long courses such as this you will probably have weekends off. However, occasionally a more intensive short programme may be preferred, involving ‘continuous’ hyper-fractionated and accelerated treatment (‘CHART’) two or three times per day including over the weekend.

 

Treatment from the inside

 

Some cancers are best treated by placing small amounts of a radioactive ‘isotope’ inside the patient, either within or very close to the growth. This is known as ‘brachytherapy’. The isotope emits rays known as ‘gamma rays’, but which have identical properties to X-rays. This makes it possible to deliver a high radiation dose to the cancer cells, while normal tissues a little further away receive only a considerably reduced dose. This can decrease the chance of troublesome side effects.

 

This method is used frequently in the treatment of cancer of the cervix, when the radioactive isotope is inserted into the uterine cavity and upper vagina under anaesthesia. The isotope may be left in place overnight, with the patient in a special room on the ward. However most patients are now treated with a much quicker ‘high-dose rate’ technique using a more powerful isotope, with an individual treatment being completed in a special treatment room in a matter of minutes. This is then repeated a few times over several days.

 

Such treatments are known as ‘intra-cavitary’, because the source of the radiotherapy is placed within a body cavity. It is quite often given in addition to a course of external treatment. Intracavitary radiotherapy is also being used increasingly as a palliative treatment for patients with lung and oesophageal cancer.

For patients with other growths, for example, some prostate, breast and tongue cancers, small amounts of the isotope may be placed actually within the cancerous tissue, which is ‘implanted’ using special needles or other penetrating devices, under anaesthesia. This is known as ‘interstitial’ brachytherapy and is being increasingly used as an alternative to surgery for patients with small prostate cancers. Intracavitary and interstitial treatments are often given using computer-controlled equipment which propels tiny isotope pellets by compressed air through hollow tubes which have been inserted by the oncologist while the patient is anaesthetised. Once in place in the cavity or inside the tumour, the pellets are left there for the required amount of time. They can then be sucked back into a lead-lined safe in which they are stored safely.

 

In another type of radiotherapy you may be given an injection of a radioactive isotope or asked to swallow it. It is then carried round the body in the bloodstream. The isotopes used in this form of treatment have a strong tendency to ‘home in’ on certain tissues such as benign or malignant thyroid tissue (radioactive iodine) and bone metastases (radioactive samarium and strontium). These radioactive isotopes emit electrons (also known as ‘beta rays’) which have a very short range, but which can destroy cancer cells when released by the isotope very close to them. As the cell-killing effect is directed predominantly against the cancer cells, these treatments usually cause few side effects.

 

KEY POINTS

• Radiotherapy, like surgery, is a localised form of treatment

• Radiotherapy has the potential to destroy a cancer completely while leaving the surrounding normal cells intact

• You don’t feel anything during treatment

• Cancers vary considerably in their sensitivity to radiotherapy

• High-dose radiotherapy given for cure often carries a risk of long-term side effects, but this is usually very low and well worth taking

• There have been major technological advances in radiotherapy planning and delivery in recent years, making it easier to give the right dose exactly where it is needed

• Most patients will benefit from keeping active during treatment

If your doctor has reason to suspect that you may have cancer, you are likely to be referred initially to a surgeon. This is partly because, as already explained, some kind of surgical procedure is very often required to make a definitive diagnosis, and partly because surgery is the best treatment or the best initial treatment for many types of cancer. Where cancer is discovered, its extent may also be established in the course of an operation; sometimes this is an important aim of the procedure. Examples include armpit lymph node removal (a ‘sentinel node biopsy’ or ‘axillary nodal dissection’) for women undergoing surgery for breast cancer, and a thorough inspection of the abdominal cavity (during a ‘staging laparotomy’) for women undergoing removal of ovarian cancer.

 

It is only understandable that most people will feel nervous about having to have an operation. However, the overwhelming majority of cancer operations proceed very straightforwardly and satisfactorily. It is of course inevitable that the results are not always perfect, but it is not feasible to discuss in detail here the possible short- or long-term adverse effects of particular operations, which may vary from relatively minor procedures lasting a few minutes to major undertakings over many hours. A small number of patients may not be strong enough to undergo the surgery that would otherwise be recommended.

 

Some operations inevitably leave substantial long-term effects on appearance, function or both. Others carry risks of certain side effects for some patients, for example arm swelling (see ‘lymphoedema’) after axillary nodal dissection and impotence after surgery for rectal or prostate cancer. Any such risks will normally be discussed in detail with you beforehand, but if you feel you need more information don’t be afraid to ask for it.

 

Some patients only need to spend a very short time in hospital afterwards, others two or three weeks or even longer. Some are able to return to a normal lifestyle almost straightaway, whereas others may take some months to recover fully after major operations. Although most patients will feel some discomfort in the period immediately after the operation, they can nevertheless expect nowadays to receive a high standard of postoperative care including very good pain control.

 

Commonly used surgical terms

Resection

The removal of a tumour or organ; words ending in ‘-ectomy’ mean the same thing. For example, removal of a lung lobe containing a cancer may be called a ‘pulmonary lobectomy’ and removal of a cancer-containing prostate gland a ‘prostatectomy’. Removal of lymph glands that the cancer may have spread to is sometimes called a ‘lymphadenectomy’.

 

Words ending in ‘-ostomy’

When one of the body’s internal tubes is blocked by a tumour or when part of it has to be removed, the surgeon may need to bypass the obstruction and create an inlet or outlet by joining the tube to an artificial opening made in the skin (a ‘stoma’ – see below). For example, joining the wind-pipe or ‘trachea’ to the overlying skin is called a ‘tracheostomy’ and may be temporary or permanent, depending on the circumstances. Joining the end of the small bowel (‘ileum’) or large bowel or colon to a stoma in the abdominal skin are called an ‘ileostomy’ and ‘colostomy’ respectively. These too may be temporary or permanent.

 

Stoma

An artificial opening in the skin to allow the contents of the underlying tube to exit the body. After an ileostomy or colostomy, for example, a bag will be fitted over the stoma to collect the bowel contents, and modern designs enable the great majority of people who undergo this procedure to lead virtually normal lives.

 

Surgery for cure

 

In most cases, the surest way of eradicating a localised cancer is, where possible, to excise it (cut it out) with an adequate margin of surrounding tissue which may appear normal to the naked eye, but which may have been infiltrated by microscopic cancer cells. Such ‘radical’ surgery of course cannot cure a cancer that has spread to distant parts of the body, unless the metastatic cancer can also be dealt with. Sometimes, even though the cancer is indeed localized, compete removal turns out to be technically impossible because of the extent of infiltration into surrounding tissues or involvement of other vital organs.  On occasions the surgeon may not know until the operation is underway whether he/she will be able to remove all the cancer.

 

Most cancer surgery is conducted as a carefully planned or ‘cold’ procedure, the diagnosis having already been made with near or absolute certainty. However, a small minority of people are first discovered to have cancer during an emergency operation made necessary by complications of the cancer, such as perforation or obstruction of the bowel. In this situation, the results of surgery unfortunately tend to be rather less good. This is because these tumours are quite often at an advanced stage and also because the person concerned may not be in good general health.

There has been a trend in recent decades towards less radical surgery for some tumours. For example, providing the size and position of the growth are favourable, it is often possible to remove a cancer from a woman’s breast, together with sufficient surrounding tissue (‘wide local excision’), while avoiding the need to remove the whole breast (mastectomy). This operation is then usually followed up with radiotherapy to the breast to get rid of any remaining microscopic traces of cancer, and the prospects for cure are just as good as with mastectomy. A similar combination of less aggressive surgery and radiotherapy can also be used to treat the much rarer soft tissue sarcomas.

In other situations surgery may be more extensive than might immediately seem to be necessary. For example, some women with breast cancer are advised to have a thorough removal of lymph nodes from their armpits, in addition to surgery to the breast itself. This is known as an ‘axillary nodal dissection’ or ‘axillary clearance’ and is quite often recommended if it has already been shown that cancer has spread to one or more lymph nodes  (see ‘sentinel node biopsy’). Not only can this procedure eradicate any metastases that might be present in the nodes, it can also give useful information about the chance of the cancer having spread microscopically to other parts of the body. The risk of this increases the greater the number of lymph nodes that are involved. The results of the lymph node analysis can sometimes thus be used to inform patients on how advisable it would be for them to have adjuvant chemotherapy to maximise their chance of cure.

But an axillary clearance can carry a risk of arm swelling caused by lymphoedema and the sentinel node biopsy technique was developed with the main aim of avoiding this risk for patients who do not have involved lymph nodes. Fortunately we now know that not all patients with involved nodes need an axillary clearance. Recent research has shown that some women with smaller involved nodes can perfectly safely avoid further surgery, relying instead on drug treatments or radiotherapy to deal with any possible microscopic spread to the other nodes.

Laparoscopic and robotic surgery

Recent decades have seen a growth in the use of ‘key-hole’ or ‘laparoscopic’ surgery. The surgeon makes a small number of quite small cuts through the skin, through which an instrument rather like a telescope, a ‘laparoscope’, is inserted together with other small instruments necessary to carry out the operation. The procedure can take longer than conventional surgery but being less disruptive, it usually results in less pain and discomfort, a quicker return to normal function, a shorter hospital stay and fewer complications. This type of surgery is now routine, for example, for patients needing removal of a longstandingly inflamed gall-bladder, and it is being used increasingly for patients with some types of cancer. In experienced hands it seems to be as effective as conventional surgery for some patients with kidney, colon and prostate cancers.

Robotic surgery is a type of laparoscopic surgery where the surgeon is assisted by a machine or robot. The instruments are actually manipulated by the arms of the robot, but under the control of the surgeon who has an excellent view of the internal structures with high powered three dimensional magnification.

Surgery for metastases

 

Surgery has long been known as a potential cure for many people whose cancer has spread to nearby lymph nodes, but in recent years surgery has also been offered to increasing numbers of carefully selected patients whose cancer has spread more distantly via the bloodstream, to a localised fairly small and removable part of the lung, liver or brain. Sometimes chemotherapy will be given first with a view to shrinking the secondary cancer and making it more easily removable. There tends to be a better chance of success when there is a long interval between treatment of the primary growth and the development of the metastasis. However it is not uncommon for patients newly diagnosed with bowel cancer to have both the primary growth and one or a small number of liver metastases removed successfully at the same operation, or at separate operations a short while apart. Some liver metastases can be destroyed by heat, ‘radiofrequency ablation’, which involves inserting a probe through the liver tissue into the growth.

 

High-intensity focused ultrasound (HIFU)

 

This is another technique which utilises heat to destroy cancerous tissue. The heat is generated by a carefully focused beam of high-intensity ultrasound. This relatively new treatment is now increasingly been offered as an option for some men with localised prostate cancer. It is administered via a probe inserted into the rectum, under general or spinal anaesthesia. The evidence regarding its long term efficacy and side effects is at present somewhat limited and it has not yet been compared with standard therapies. But results so far suggest that it might be as effective as more conventional surgery and with possibly a reduced risk of some side effects.

Surgery to improve quality of life

 

Reconstructive surgery

 

Considerable progress has also been made in restoring appearance or function after operations to remove cancer. For example, many women who have had a breast removed are now offered surgery to create a ‘new’ breast, either by inserting some form of artificial ‘implant’ beneath the muscle underlying the skin, or by building up a new ‘breast’ using muscle and fatty tissue (a ‘flap’) from the back or lower abdominal wall. The results, although not perfect, are frequently highly satisfactory and quite often excellent. They can make a huge psychological difference for those women who understandably find it very difficult to live with the loss of a breast.

 

Such reconstructive procedures require considerable surgical expertise. This is provided by specialist breast or plastic surgeons. As well as contributing to the care of some patients with breast cancer, plastic surgeons perform a very important rȏle  in helping to restore appearance and function after major surgery for cancers involving the mouth and throat and other nearby structures. Some reconstructive procedures are done at the time of tumour removal, with the plastic surgeon operating together with the surgeon who removes the tumour. Others may be done some time later.

 

The artificial material used in any form of reconstructive surgery is known as a ‘prosthesis’ Some people with bone sarcomas of the limbs undergo bone replacement prosthetic surgery after removal of the growth, avoiding the need to amputate the limb.

 

Palliative surgery

 

Surgical procedures are also performed to relieve symptoms. Sometimes this is in conjunction with other treatments aimed at destroying the cancer.

 

Prosthetic tubes or ‘stents’ may be inserted to relieve obstruction caused by a growth. This is often done for people with cancer of the oesophagus and sometimes for patients with rectal cancer. Obstructions within the abdomen are sometimes relieved by ‘by-pass’ operations. Metal prostheses may be inserted into a bone that has been fractured or substantially weakened by a metastatic tumour. This is known as ‘internal fixation’ – it restores strength to the bone and allows a rapid return of normal or near-normal use to the limb. Lasers are sometimes used to bore a hole through tumours obstructing the oesophagus or one of the major air tubes or ‘bronchi’ within the lung. A tracheostomy may be necessary when a tumour is obstructing the voice box or larynx and causing difficulty in breathing.

 

A tumour that is pressing on the spinal cord can cause leg weakness by interfering with the nerve supply to the muscles. This can sometimes be relieved by partial removal of the tumour by a neurosurgeon or orthopaedic surgeon. Some people with breast and prostate cancers benefit from surgical removal of their ovaries or testes, operations known respectively as ‘oophorectomy’ and ‘orchidectomy’. These cancers are very often susceptible to hormonal influences. Removing the sources of these hormones can bring about marked tumour shrinkage which often lasts for a long time, although these days the same effects are more commonly achieved with drugs which suppress hormone production.  Finally, surgical procedures are also undertaken occasionally to control bleeding from a growth.

 

KEY POINTS

• Confirmation of a diagnosis of cancer is usually established by some form of surgical procedure

• Surgery cures more cancers than any other treatment used alone          

Once a diagnosis of cancer has been confirmed, and all other necessary investigations completed, the patient is then given advice by his or her doctor on what should happen next. Priority is likely to be given to treatment directed against the cancer, but it is important that the overall plan for care takes account of physical symptoms, psycho-logical well-being and family and other social circumstances.

 

There are three main types of treatment for cancer: surgery, radiotherapy and drugs. Overall, surgery is the single most effective treatment in curing cancer, but different types of cancer are treated in very different ways. Both radiotherapy and drugs have the ability to destroy cancers while leaving the surrounding normal tissues completely intact. However, some cancers do not respond well to radiotherapy or drugs and are best treated by surgery. Others may be difficult or impossible to remove by an operation, but may respond well to other treatment.

 

When a cancer can be treated surgically, there is often no alternative treatment worth considering. However, radiotherapy may be equally or even more effective for some people with certain types of cancer, for example, some of those arising in the head and neck region or cervix. In such circumstances radiotherapy may be the best option because it is not disfiguring, doesn’t affect important functions such as the ability to speak or to swallow, or sometimes merely because it is simpler.

 

For many patients the best chance of cure is achieved now by combinations of treatments. Some patients have to be admitted to hospital, particularly for surgery and intensive drug treatments. However, many are able to have their treatment as outpatients. Patients need to know what treatment is likely to involve and most find it helpful to understand the reasons for what is being recommended.

 

The aim of treatment

 

Whenever possible the goal of treatment is to eradicate the cancer completely, and this is now a realistic prospect for more and more people. This is partly because cancer is now often diagnosed at a relatively early stage, but partly also because treatments have improved. If your cancer has not spread from its original site the outlook is often excellent.

 

However, some cancers have already obviously spread widely by the time they are first discovered, while others that appear localised have in fact spread to form undetectable microscopic metastases. In general the outlook for patients with these cancers is less favourable, but nevertheless cure is now possible for a growing minority. These include those whose cancer is of a type that responds very well indeed to drug treatment, such as Hodgkin’s disease and testicular tumours, and also those who have microscopic spread from other cancers which are often sensitive to drug treatment, such as breast cancer.

 

Treatment aimed at cure is quite often called ‘radical’. Treatment aimed at relieving symptoms or prolonging life may be described as ‘palliative’. Anti-cancer treatments can often provide excellent palliation. When used in this way they are usually rather less intensive than radical treatments, and as a result they are generally much better tolerated.

 

When aiming for cure a high risk of troublesome side effects may be acceptable. However, when cure is not possible there may be little justification for a powerful treatment if there is a significant chance that its side effects will be at least as troublesome as the symptoms for which it is being offered. It is for this reason that the aim of treatment should be clear at the outset. However, just because a treatment is palliative does not mean that it cannot exert a very substantial effect against the cancer. Indeed, some people lead normal lives with their cancers shrunken and under control for many years as a result of palliative treatment.

 

It is important that any symptoms are dealt with as well, while anti-cancer treatment of one sort or another is being considered or given. These treatments may not deal satisfactorily with some symptoms, or they may be slow to work. Fortunately there are very many other ways of relieving symptoms which may be used in addition to anti-cancer treatment, and sometimes instead of it. Often quite simple measures will suffice, but some patients require rather more help and support. This can often be provided very well by their general practitioners or by the hospital doctors treating their cancer and the nurses who assist them, but some patients benefit greatly from more specialised symptom-relieving or ‘palliative’ care.

 

Increasing numbers of doctors and nurses now specialise in what is called ‘palliative medicine’ and provide care in patients’ homes, in hospitals and in hospices (see ‘Further care’). The growth in palliative medicine and in hospice-based care in recent decades has made an enormous contribution to the improvement in quality of life for people with cancer, particularly those with more advanced or incurable disease. However, it should not be forgotten that palliative care can also help patients whose cancer is curable: it should be available for anyone who has persistent troublesome symptoms, whatever the cause. Palliative care is often more effective if given at an earlier rather than a later stage in the course of the illness. Early palliative care involvement can also help make things easier for other caregivers, particularly family members.

 

Choosing the right treatment

 

When planning and discussing your treatment with you, your doctor will want to be sure that it is tailored to your individual needs. There can be vast variation from one cancer to another in terms of how it looks under the microscope, its size, extent and behaviour. But treatment for cancer needs to take into account not only the cancer, but the patient. No two people with cancer are exactly alike, physically or psychologically. Their particular social circumstances may also be very relevant. Many aspects usually need to be considered before a decision is made about treatment.

 

Nevertheless, many patients fall into certain categories for which treatment is fairly uniform. In more recent years there has been a welcome trend towards increased standardisation of treatment. This helps to ensure that patients receive treatment that is widely considered to be appropriate by experts on their type of cancer. The latest research findings are quite frequently reviewed by panels of experts, usually leading to the  publication of ‘guidelines’. These contain recommendations based on what is agreed to be currently the best way of managing patients with particular cancers in the light of the latest evidence. They have played a major rȏle in eliminating undesirable variations in the quality of care. Many authoritative guidelines are now easily accessible on the internet.

 

All cancer treatments have side effects. These may be minimal, for example those from minor operations, regimens of low-dose radiotherapy and some drugs that may cause no noticeable upset at all. You may well be able to continue working and to lead a normal or near-normal life while you are having courses of radiotherapy and chemotherapy. At the other end of the spectrum are some very major operations or highly intensive radiotherapy or drug treatments, which can themselves make people very ill and which may even carry a small risk of death.

 

The treatment you are recommended to have will depend largely on the nature, position and extent of your cancer, but it is important that careful consideration is given to the risks and potential benefits of treatment for each individual patient. If you are otherwise healthy and feeling robust you will probably be willing to accept a high chance of troublesome side effects from a treatment that offers a good chance of cure. In fact, the majority of those people with very serious tumours are prepared to undergo fairly unpleasant treatments for only a small chance of cure or a small improvement in the chance of cure. However, if there is realistically no prospect of cure the possible advantages and disadvantages of palliative treatment will need to be considered. Your general health may be an important factor – you are likely to cope much better with treatment, and to benefit from it, if you are otherwise fit than if you are relatively frail.

 

Your age is another factor. Older patients tend not to cope quite as well with some treatments as younger patients, but it seems likely that in the past the extent to which this is the case has been overestimated and overstated. Some elderly people can tolerate some treatments with surgery, radiotherapy and chemotherapy just as well as younger patients.

 

It may seem surprising, but the best option for some people is to have no treatment directed specifically against their cancer. This is sometimes because the treatments available don’t work very well on their particular cancer or are more likely to do harm than good. In other cases it may be because the cancer is a ‘mild’ type which may grow only very slowly or even not at all over several years, and which may have little or no impact on duration or quality of life.

 

Combining treatments

 

The careful use of combinations of different types of treatments is another reason for the continually improving results. In particular, drug treatments and radiotherapy are now quite often given in addition to surgery for some cancers, with the aim of eradicating any microscopic traces of cancer not removed by the operation. Surgery may fail to remove a cancer completely either because there are cancer cells left behind at the operation site, or because of metastases. If the amount of residual cancer is indeed of only microscopic proportions, there may then be quite a good chance that it can be eradicated completely by further treatment with radiotherapy or drugs or a combination of the two. Radiotherapy, being a local treatment, has only a local effect, whereas drugs have the potential to act throughout the body. Some patients with cancers for which the main treatment is radiotherapy will also benefit from additional treatment with drugs, often given at the same time.

 

The use of additional radiotherapy or drug treatment in this way is known as ‘adjuvant’ treatment. On occasions it is given before surgery, sometimes with the aim of making an operation possible or easier. For example, some women with fairly large breast cancers may be given drugs that shrink the tumour sufficiently to enable the surgeon to remove it without taking away the whole breast. Similarly, a course of radiotherapy, possibly with chemotherapy as well, may make it possible for a surgeon to remove a large and otherwise inoperable rectal cancer.

 

Organisation of cancer services

 

You may well be able to have your treatment at a cancer unit in your local district hospital, particularly if you’re having surgery or chemotherapy. However, you may need to travel to a cancer centre further away from home if you need radiotherapy, more specialised surgery or intensive chemotherapy.

 

Modern radiotherapy requires very expensive equipment and highly trained specialist staff, so it makes sense to concentrate facilities in cancer centres in large towns or cities. Some surgical and drug treatments require equally specialised techniques and expertise. Thus you may have to travel considerable distances for treatment, but this is usually worthwhile. You may be reassured to know that you are being cared for by staff who are experienced in treating your particular condition, especially if you have a less common type of cancer.

 

There is good evidence that treatment tends to be more successful if it is supervised or given by doctors who specialise in treating particular cancers. Almost all cancer surgery is now undertaken by surgeons who have undergone relevant specialist training and who have special expertise in performing particular operations. The same philosophy applies to the oncologists and other doctors involved in the care of cancer patients, and to nursing and other ‘paramedical’ staff.

 

Hospital doctors

In addition to surgeons the following types of specialist doctors are frequently involved in the care of cancer patients.

Oncologist

Any doctor who specialises in cancer treatment, but usually in practice one who supervises treatments with radiotherapy or drugs. Clinical oncologists specialise in both radiotherapy and drug treatments; medical oncologists specialise purely in drug treatments.

Haematologist

A doctor specialising in abnormalities of the blood who will supervise your treatment if you have leukaemia and usually also if you have lymphoma or myeloma.

Palliative care physician

A doctor who specialises in the control of symptoms, particularly those resulting from more advanced cancers.

Working together

You are likely to be cared for by two or more specialists who will work together to decide the best treatment for you. It is now routine for specialists to hold regular meetings to discuss individual patients. Such ‘multidisciplinary meetings’ often involve a variety of different medical specialists, as well as other staff, particularly clinical nurse specialists, and they help to ensure that patients receive a high standard of overall care. Ideally, most patients undergoing surgery for cancer should have an opinion from an oncologist. You have the right to ask for this if it isn’t offered.

 

Although it is usually doctors from one or more of the above categories who supervise the care of cancer patients, other specialists are also key players in the team:

 

Pathologist

A doctor who examines tissue under the microscope and who confirms and categorises cancers.

 

Radiologist

A doctor who arranges and interprets X-rays and scans, and may sometimes undertake some specialised surgical biopsies or treatments that have to be done under X-ray or scan supervision.

 

The medical hierarchy

Consultant

A specialist – a senior hospital doctor who holds the ultimate responsibility for your care, or at least for part of it, but who is unlikely to be involved personally in every aspect. However, he or she will regularly hold outpatient clinics and ‘ward rounds’ to see new patients and to review the progress of those under their care. You can ask to see your consultant if you need to discuss something in particular.

Associate Specialist

A specialist who has trained to a high level but who does not hold the ultimate responsibility of a consultant.

Specialty Registrar (StR)

A doctor who is training to be a consultant. He or she may have very considerable experience and be expecting to become a consultant before long. Registrars supervise much of the day-to-day care on wards but also work in outpatient clinics. Surgical registrars frequently undertake operations or assist in them, depending on their seniority and experience.

Foundation Doctor (FY1 and FY2)

Formerly known as junior and senior house officers these are fairly recently qualified doctors who are concerned largely with providing care on the wards.

Specialty Doctor, Staff Grade Practitioner, Clinical Assistant and Hospital Practitioner

Other doctors of varying experience who are not intending to train to become consultants but who provide valuable assistance in various aspects of hospital care.

Your general practitioner

He or she may possibly know you and your family well, but whether or not this is the case they will continue to be responsible for coordinating much of your overall care, particularly that provided at home. You will probably have been referred to the hospital consultant in the first instance by your GP, and he or she will normally be able to provide or arrange any necessary supportive care, both during and after treatment and at any other stage, as required.

 

Your GP will also see you if you have any other illnesses while your cancer is being treated, and should be able to provide help or advice with psychological or social problems. The doctors in the hospital will keep your doctor informed about your hospital treatment and progress. Although your cancer treatment is given or supervised at the hospital, your GP remains of great importance in your overall care.

 

Paramedical staff

Clinical nurse specialists

These may play an extremely important part in your care. For example, oncology or chemotherapy nurses will administer your chemotherapy, while breast care, lymphoedema specialist and stoma care nurses are an essential part of the teams caring for people with breast, bowel and bladder cancer. They can give a lot of practical advice and for many patients they become an important point of contact with the hospital.

Therapeutic radiographers

These are highly trained to give the radiotherapy that has been prescribed by oncologists and to help with planning it. They have a broad training in oncology and often provide or arrange supportive care as well. They also become important points of hospital contact for patients receiving radiotherapy, who often get to know them quite well during more prolonged courses of treatment.

Macmillan and palliative care nurses

These give expert advice on symptom control and provide emotional support at home, hospital or the hospice.

Community nurses

These provide care in your home, and include district nurses and practice nurses.

You may also come into contact with other health professionals, such as physiotherapists, occupational therapists and dietitians during your treatment and/or during rehabilitation after your treatment. Medical social workers can offer practical advice and may help to arrange financial assistance and social support (for example, meals on wheels or help with housework), nursing or residential home accommodation.

Dealing with doctors

You may well feel nervous and unsure of yourself when you have to see a doctor to discuss your condition, but it is important for you to talk as well as listen. Unfortunately, pressure of work may mean that the specialist has less time to give to any one individual than he or she ideally would like, so you need to make the best use of the time available.

Your specialist usually needs to know about any current symptoms, your general health and past medical history, and any particular concerns you may have about any aspect of the cancer or its treatment. You should also mention any psychological or social concerns relating to your illness. It is a good idea to take details of any medicines you are currently taking to the consultation (or the actual bottles or packs), to ensure that the specialist has up-to-date information.

 

As explained earlier, decisions about your treatment will be tailored to you as an individual, and the doctor may well need to know your feelings before recommending a particular course of action. First or early consultations are especially important as this is when investigations, their results, the diagnosis and the implications for treatment are discussed. You should take the opportunity to raise any worries you may have and to ask about what’s on your mind. If necessary, write down a list of the questions you want to ask or points you want to raise, to use as a memory prompt. If you don’t understand something the doctor says, don’t be shy about asking for an explanation.

 

People differ as to the amount they want to know and the extent to which they want to be involved in decision-making. You may be one of those who prefer to accept explanations and treatment recommendations on trust without asking for more detailed information. However, if you do want more involvement, say so. Your doctor will be happy to explain what the recommended treatment will involve, its chance of success, what its side effects are likely to be, and how it might be expected to affect your work or lifestyle. You can also ask about any possible alternatives. You may be asked if you would like to be sent copies of any letters concerning your care. Do feel free to ask for this if it has not been offered.

 

Some people prefer to leave questions about the long-term outlook unasked for the time being, whereas others will want detailed statistical information at the outset. Everyone is different. All doctors recognise this and most will try to respond to your personal needs, but they can’t do this unless you make it clear what you want to know and, on occasions, what you don’t want to know. Only ask questions to which you are quite sure you want an honest answer.

 

It can often be difficult to remember everything that is said by a specialist during a consultation. It is usually helpful to take along your partner or someone else close to you – two memories are better than one. It is usually best to raise important questions or concerns earlier on, rather than leave them until the very end. Some patients also find it helpful to make brief notes during the consultation. Others have found it useful to tape record the consultation, although permission should always be asked for this as some doctors may find this somewhat ‘off-putting’ and disruptive to their usual way of discussing things.

 

Understanding progress reports

If you are seeing your doctor to discuss the progress of your treatment, it is helpful if you understand some of the words often used to describe how things are going on.

Response

‘Response’ is the term used to describe shrinkage of a cancer after treatment or at some stage during a course of treatment. Usually a cancer has to shrink quite significantly for this term to be used. A response may be defined as complete, when there is no evidence of any cancer remaining, or partial.

 

Remission

‘Remission’ may be used to describe a situation where the cancer has been greatly reduced and does not seem to be active or detectable, but has not necessarily disappeared. This is usually as a result of treatment, but very occasionally cancers go into remission apparently of their own accord.

 

Recurrence or relapse

A ‘recurrence’ or ‘relapse’ is regrowth of a cancer after treatment which had previously been successful in controlling the disease. Recurrences are sometimes described as ‘local’ or ‘distant’, according to whether the problem is with the original tumour or because it has metastasised. Further treatment against the cancer is quite often recommended following recurrence, especially if a cure still seems feasible, but in other situations this may not necessarily be in the patient’s best overall interest. Much depends on the particular circumstances.

 

Second opinions

You have the right to ask for a second opinion and this is normally arranged by your GP, sometimes after discussion with the specialist to whom you have been referred. Specialists looking after people with cancer understand full well why you may want to do this and are highly likely to support your request. Sometimes, particularly in complicated or difficult cases, they may suggest a second opinion themselves.

 

It is usually important that a second opinion is given fairly quickly, particularly if there is a need for prompt treatment. It is also important that the second opinion is sought from someone who has the appropriate experience and expertise and that he or she is provided with all the relevant information. However, you should realise that a second opinion that is different from the first is not necessarily a better one.

 

Consent to treatment

 

You will be asked to sign a consent form before most types of anti-cancer treatment. This goes hand in hand with ensuring that you have all the information you need about the possible risks of treatment, either verbally or in written form. This is done mainly to protect you from agreeing to a treatment through ignorance of any risks involved, but also partly to help protect the hospital legally in the event of a complication occurring despite entirely competent care.

 

You should bear in mind the fact that all medical treatments have side effects in some people. You may well become worried if you are presented with a list of possible adverse effects without realising that the chance of a severe side effect occurring is often very low. However, some anti-cancer treatments are more powerful than others and some have greater potential for doing harm. Thus some patients in some situations may find it helpful, with the help and advice of their doctor, to try to weigh up the relative chances of benefit and of harm (the ‘risk–benefit ratio’).

For the great majority of anti-cancer treatments, this ratio is substantially in your favour, but there is also no doubt that there are some possible treatments which, in certain situations, stand a rather greater chance of doing more harm than good. It is important that you have as much realistic information as you want about the potential risks and benefits of any treatment before agreeing to it.

 

Keeping active

 

While not appropriate for everyone, most people will be encouraged to engage in regular physical activity after treatment, and in so far as it is possible and appropriate, to try to return to what is normal for them concerning both lifestyle and work. But while many people are able to resume their normal lives again following treatment, often quite quickly, for others this may not be possible or advisable. For some a more gradual return to normal is the most sensible approach and they may, for example, benefit from a ‘phased’ return to work – gradually increasing part-time working until they are able to resume full-time working once again. Much depends on both the nature of their cancer and the type of treatment they have received. Advice on what is appropriate to your particular situation should be readily available.

 

Most patients receiving courses of radiotherapy or chemotherapy will also benefit from trying to keep fairly active during treatment. Too much rest can cause muscle wasting and weakness. Keeping active can often help people to cope better with treatment and to recover following it, both physically and mentally. It can help lessen tiredness, anxiety, stress, constipation and pain and it also reduces the risk of some complications. Evidence is now emerging that moderate exercise and maintaining a healthy weight may even help reduce the risk of recurrence or progression of some cancers.

 

Of course trying to maintain activity may not be appropriate for everyone, particularly for some people receiving palliative treatment for more advanced cancer. If you are unsure you should discuss this with your oncologist or the nurses or radiographers treating you.

 

KEY POINTS

• Cancer treatment has become increasingly standardised, but individual circumstances remain very important

• Your GP will play a very important part in your overall care

• Some people will need to travel some way to get the best treatment

• It is worth taking some trouble to prepare yourself before a consultation

• Consultations are opportunities for two-way communication

• Keeping active is often helpful

The great majority of cancers are discovered because of the symptoms that they cause, or because the person concerned (or their doctor) notices a lump or other abnormal appearance.A small but growing proportion of cancers are discovered as a result of doing tests on apparently healthy people who have noticed nothing abnormal.This is called ‘screening’.

Symptoms

Most of the symptoms that can be caused by cancer are far more commonly the result of relatively minor illnesses that have nothing to do with cancer.Sometimes this means that the individual concerned does not take them seriously to start with, and so delays seeking medical advice.Even when he or she does go, their general practitioner may not always feel that it is appropriate to consider cancer very seriously as a possible diagnosis at this stage.There is really no way around this.Very thorough and immediate investigation of any symptom that might possibly be caused by a cancer would rapidly cause the health service to grind to a halt, not to mention causing a lot of unnecessary anxiety.Your doctor is more likely to suspect the possibility of a potentially serious cause for a symptom if it persists, or if you have certain other symptoms as well.Some symptoms are sufficiently likely to have a serious explanation that they require further investigation as a routine matter.Symptoms that could indicate the presence of a cancer include the following.

Persistent and unexplained

• Cough
• Breathlessness
• Hoarse voice
• Difficulty with swallowing
• Pain
• Indigestion
• Weight loss
• Altered bowel habit
• Discharge from any orifice (for example, nipple or vagina)
• Fever.

 Any abnormal bleeding

• Coughing up blood
• Rectal bleeding
• Vaginal bleeding between periods
• Vaginal bleeding with intercourse
• Postmenopausal vaginal bleeding
• Blood in the urine
• Bleeding from a mole.

Anyone who has any of the above symptoms should seek medical advice promptly.The majority of people with most of these symptoms will not have cancer, but if a cancer is present it is important to diagnose it as early as possible.

Lumps and bumps

The majority of cancers are fairly deep-seated within the body and only a minority can be felt on examination by a doctor, let alone by the patient.However, cancers that are nearer to the surface, such as those involving the breast or testicle, are often discovered by the person becoming aware of a lump.Most skin cancers are also noticed first by the person concerned rather than by his or her doctor.In fact, few lumps or persistent skin changes turn out to be cancerous.However, if you do notice a lump or if you have a persistent or worsening unexplained ulcer or ‘spot’, particularly any change in appearance of a mole, you should seek medical advice promptly.

Screening for cancer

 Screening to discover cancers at an early and more curable stage can help to reduce the number of deaths from a few important types of cancer.However, screening has its problems.If your test result shows up an abnormality that eventually turns out not to be cancer, as often happens, you will have had to go through further investigations and you may have experienced a lot of unnecessary worry and possibly some unnecessary discomfort.Screening can sometimes reveal the presence of a very slow-growing cancer or a pre-cancerous growth that would not in fact have caused any problems had it not been discovered.As a result some people may receive treatment that is not really necessary.Screening is generally both fairly inefficient and expensive: usually a very large number of people have to be screened to discover one cancer for which earlier diagnosis makes the difference between the success and failure of treatment.It can however sometimes be considerably more effective for individuals who are at a considerably raised risk of developing a certain type of cancer, for example if they have a strong family history.It is important to remember that screening is not foolproof – however carefully and skilfully done it will fail to spot some cancers.If you develop concerning symptoms you should always seek medical advice as usual and not feel reassured by having recently had a clear screening examination.Some terms mentioned in the immediately following sections are explained later in this chapter.

Breast cancer screening

Women are currently offered mammography every three years from the age of 50 up to 70, and beyond on request.The age range for routine screening is now in the process of being extended slightly, with invitations being offered to women in their late 40s and up to 73 years.The majority of abnormalities seen on the X-ray pictures are not cancerous, but further investigation including an ultrasound examination of some of them is recommended, sometimes leading to removal of a small piece of tissue (a ‘core biopsy’) for microscopic analysis.A few of these abnormalities are then discovered to be cancerous or pre-cancerous.The breast cancers discovered in this way are usually small and very treatable and screening reduces, albeit by not a large amount, the average participant’s already fairly low chance of dying from breast cancer.Screening seems to have played a relatively small part in the great improvement in the chance of a cure from breast cancer seen in recent decades: recent estimates suggest that one in approximately 300 women will avoid death from breast cancer as a result of screening over a 20 year period and that for each life approximately three other women will receive unnecessary treatment.If you receive an invitation to attend for screening mammography you should read the accompanying information carefully.

Cervical cancer screening

Sexually active women should have a cervical smear test every three to five years between the ages of 25 and 65. (Women who have never had sexual intercourse rarely get this type of cancer.) When you have a smear test an instrument called a speculum is inserted into the vagina to enable the cervix (neck of the womb) to be seen.The cervix is then scraped gently with a wooden spatula to collect a reasonable number of cells.These are smeared on to a piece of glass and examined under the microscope.The procedure may be a little uncomfortable, but is not normally painful.The test can discover pre-cancerous abnormalities which can easily be dealt with.It can also discover cancers at a very early stage, when the cure rate is high.Most of the abnormalities discovered in this way are only minor changes, which may require no further investigation, or merely a repeat smear or more frequent smears for a while.However, some abnormalities require further investigation in a procedure called ‘colposcopy’, which involves examining the illuminated cervix with a type of magnifying glass.Tiny samples or ‘punch biopsies’ can be removed from any abnormal areas.This is briefly uncomfortable but it should not be painful and only lasts about 10 minutes.If potentially pre-cancerous areas are discovered, further treatment to destroy the cells is recommended.This may involve ‘laser evaporation’ (a concentrated beam of light vaporises the abnormal cells), ‘cryotherapy’ (the abnormal cells are destroyed with a freezing probe) under local anaesthetic, or ‘diathermy’ (the abnormal cells are burnt by an electrical probe) under general anaesthetic.In a small percentage of women the colposcopy may suggest that the abnormality is more serious and a ‘cone biopsy’ (removal of the central lining of the cervical canal) under a general anaesthetic may be necessary.This may well remove all the affected tissue but, occasionally, a more deeply infiltrating growth is discovered which requires more extensive treatment.Very few women die from cancer of the cervix and, of those who do, almost 90 per cent have never had a routine smear.

Bowel cancer screening

Screening that detects bowel cancers at an earlier stage has been shown to cut the number of deaths from this disease.This commonly involves testing stool specimens for small amounts of blood which are not normally visible to the naked eye.Although the cause of such bleeding is usually something other than cancer, sometimes further investigation by colonoscopy or barium enema will reveal the presence of a cancer before it has grown sufficiently to cause symptoms.Screening using such ‘faecal occult blood’ testing every two years is now offered routinely throughout the UK  to people in their sixties and to slightly younger and older age groups depending on the country in which they they live.

Prostate cancer screening

This can be done by testing the blood for a chemical often produced by these cancers  – ‘prostate-specific antigen’ or ‘PSA’.If the PSA is raised a ‘digital rectal examination’ or ‘DRE’ is usually recommended (the prostate can easily be felt by a doctor wearing a rubber glove gently inserting a finger into the rectum) and very possibly further investigations including scanning and biopsy.But benignly enlarged prostates can also caused a raised PSA and benign enlargment is very common as men get older: three out of four men with a raised PSA do not have prostate cancer.The value of routine PSA testing is controversial – screening can detect some prostate cancers at an early stage, but it can also result in unnecessary treatment with surgery or radiotherapy and unpleasant side effects including incontinence and impotence.The prostates of most old men dying from other conditions can be found to contain small cancers.Most cancers occurring in elderly people are slow growing and are unlikely to cause problems during the remainder of an individual’s life if left untreated.The latest evidence indicates that screening can reduce the average participant’s already low chance of dying from prostate cancer, but only very slightly.A very large number of men must be screened to prevent one death from prostate cancer, possibly even more than 1000.In the future ‘genomic testing’ (see below) of early prostate cancers might become widely used to identify those cancers which do potentially pose a threat to life and really need treatment.This could make prostate cancer screening rather more effective and less controversial.

Lung cancer screening

Screening by routine chest X-rays and microscopic examination of sputum for cancer cells has been proven not to be worthwhile.Screening using CT scanning seems to be more effective in picking up early cancers and there is now evidence that this can reduce slightly the chance of dying from lung cancer in heavy smokers.However, the majority of lung cancers appear to carry an unfavourable prognosis from an early stage and at present by far the best hope of significantly reducing deaths from this disease is through a reduction in smoking.

Cancer in families

In theory, it makes sense to screen people who are known (or who are likely) to have inherited a genetic predisposition to cancer.However, fewer than ten per cent of cancers have a clear-cut or identifiable inherited cause.Cancer is a common disease and, when it affects two or more members of the same family, the strong probability is that this is pure chance.Occasionally it may be the result of a shared environmental factor such as smoking.Hereditary cancer may be suspected when two or more close relatives – parents, brothers or sisters – have either the same cancer or different ones that can sometimes be genetically related, such as those of the breast and ovary.Other hallmarks are the development of the cancer at a young age and a tendency to have bilateral (for example, in both breasts) or multiple tumours.Some of those with a strong family history may have inherited an identifiable faulty gene.If so it is by no means certain that they will develop a cancer, although inheriting some genes can give an 80 to 90 per cent or even higher risk of developing cancer at some stage.The same type of cancer can sometimes occur in two or more members of a family without any particular genetic abnormality being identifiable.The risk for other members of the family may then be increased, but not usually to a high level.If you are worried that you may be at an increased risk of cancer because of your family history, you should discuss this with your own doctor.If appropriate you may be referred for a specialised opinion from a clinical geneticist who will want very detailed information about your relatives.You may or may not be offered genetic testing (see below).You may eventually be told that you have little or nothing to worry about.But if you are at increased risk you will be given some idea of how high the risk is.A predisposition to a variety of rare cancers can be inherited, for example certain tumours of the thyroid and other hormone-producing glands.As far as the more common types of cancer are concerned, the main types that are occasionally inherited are those of the large bowel (colon and rectum), the breast and the ovary.Bowel cancer can occasionally run in families through inheritance of a faulty ‘adenomatosis polyposis coli’ (APC) gene or ‘hereditary non-polyposis colorectal cancer’ (HNPCC) gene.Affected individuals develop multiple benign bowel polyps at an early age and these subsequently become malignant in almost all cases.Breast cancer is inherited in only five to ten per cent of cases.The known faulty genes that substantially increase the risk of breast cancer include those known as ‘BRCA-1’, ‘BRCA-2’ and ‘TP53’.A woman who has inherited a faulty BRCA-1 or BRCA-2 gene has up to about a 75 per cent chance of developing breast cancer at some stage in her life.A faulty BRCA-1 gene also confers an increased risk of ovarian cancer.However, many women with a family history of breast cancer do not have an inherited mutation of one of these genes.They may be at an increased risk through having another at present unidentifiable genetic abnormality, but the level of risk is usually then much lower, for example below 30 per cent for those with a mother or sister with the disease.BRCA gene abnormalities increase the risk of some other cancers as well, including both breast and prostate cancer in men.Genetic testing is offered to apparently healthy women if they are thought to be at risk of  having a faulty gene predisposing to breast or ovarian cancer.This would be because they are related to someone known to have a faulty gene or if there is a strong family history (and a living family member who has had breast or ovarian cancer is available for testing).Testing is also often offered to women who have been diagnosed with breast cancer and have a suggestive family history.Genetic testing is carried out on a blood sample.It is however only performed if the individual concerned still wants it done after counselling, which requires very detailed discussion of all the implications, which can be profound.These include consideration of what will be done if a cancer-predisposing gene is discovered, feelings about living with the certain knowledge of high risk, what other family members will be told and the consequences for parenthood.Eligibility for insurance is another potential concern although in the UK there is currently an agreement that people can take out substantial amounts of insurance without having to disclose the results of genetic tests.Recommendations as to what should be done for those individuals confirmed as being at high risk vary enormously according to the cancer concerned, individual circumstances and preferences.Someone who is facing a high risk of developing hereditary bowel cancer may well be advised to have their colon and rectum removed surgically in their teens or twenties, before the disease has had a chance to develop.When this is done, the small bowel can be joined to the anus, avoiding the need for a permanent ‘stoma’, which is discussed later.For women with a high risk of breast cancer, choosing the best form of preventive treatment is less straightforward.Some women will opt for prophylactic (that is, preventive) removal of both breasts (bilateral mastectomy).Although this does reduce very substantially the chance of getting breast cancer, it is however not a complete guarantee – a small number of women have developed cancer in the small amount of breast tissue that is left behind after mastectomy.Some women opt instead for a programme of close surveillance involving regular mammography and/or MRI scanning.Hormonal drugs can reduce the risk of breast cancer and two of these, tamoxifen and raloxifene, are now available for women at high risk.Women at increased risk of ovarian cancer may opt to have both ovaries removed surgically as a preventive measure (bilateral ‘oophorectomy’) but, surprisingly, this again is not guaranteed to completely prevent the disease.Screening to detect ovarian cancer at an early stage using ultrasound scanning and blood testing for the CA-125 ‘tumour marker’ produced by ovarian cancer is an alternative strategy.

Medical assessment

If your symptoms suggest the possibility of cancer, or if your doctor finds something unusual during an examination or as the result of a screening test, you will probably need further assessment and tests, depending on the circumstances.Some further investigation may be arranged by your GP, but at some stage you are likely to be referred to a hospital consultant for an opinion on what should be done next.What is appropriate can vary greatly from one individual to another.Waiting for appointments, further investigations and their results can inevitably be very worrying, but support is usually available from a variety of people and organisations (see ‘Further care and support’ and ‘Further help’).

Clinical assessment

If you do need further assessment, the first step is likely to be a consultation with a specialist in an outpatient clinic where you will be asked more detailed questions about any symptoms, such as their severity and duration.You can also expect to be asked about your general health and other aspects that may be relevant, such as previous illnesses, any medication you may be taking, present or past occupations, and your home circumstances.It is often helpful if you have all such information ready to hand.This ‘history taking’ will then usually be followed by a physical examination which will tend to concentrate on the part of your body that is giving cause for concern, although you may also have a more generalised examination.This assessment does not always help in making a diagnosis, but sometimes the doctor will strongly suspect a cancer because he or she finds, for example, a lump that has particular features suggesting malignancy.The physical examination may include taking a look inside some part of your body using instruments: for example, your voice box (‘laryngoscopy’), rectum (‘proctoscopy’) or cervix (by gently inserting a speculum into the vagina).

Further investigations

Biopsy

Although a lump may feel or appear cancerous a definite diagnosis of cancer can usually be made only by a pathologist, a doctor who specialises in assessing cells and tissues by studying them through a microscope.He or she will recognise the characteristic changes in appearance that confirm that cancer is present.The removal of a piece of tissue for diagnostic purposes is known as a ‘biopsy’.Part of a lump or, if feasible, a whole lump (excision biopsy) may be removed during an operation performed under local or general anaesthetic.Sometimes a thin core of tissue may be removed by a special type of needle device which avoids the need to cut into tissue with a scalpel (‘core biopsy’).

Alternatively, cells from the abnormal tissue may be sucked (‘aspirated’) into a thin needle attached to a syringe.This is called a ‘fine needle aspiration biopsy’ and is usually uncomfortable only very briefly.The cells can then be smeared on to a glass slide.Cells for microscopic examination can also be obtained by scraping the tissue concerned, as in cervical smear testing, or from tissue fluids such as sputum, fluid surrounding the lung (‘pleural effusion’) or urine.The microscopic examination of very thin processed slices taken from a lump of tissue is known as ‘histology’, whereas the examination of a cellular smear is known as ‘cytology’ Histology can give rather more information because the pathologist is able to assess not only the appearance of individual cells (that is, the bricks) but also the way the tissue is constructed (the architecture).Cytology is based on the appearance of individual cells.It is capable of establishing the presence of a cancerous process but gives less qualitative information than histology.It also suffers from the potential problem that the cells removed from abnormal tissue by fine needle aspiration may not be representative – the needle may not have sucked up any cancerous cells, even though some were actually present.This risk of a ‘false-negative’ result is not usually a problem with histology.However, a positive cytology result is usually sufficient to justify setting in train further treatment.For many cancers this will involve surgical removal, when tissue will become available for histological examination.Both histology and cytology have become increasingly complex, as the techniques used to assess the biopsy tissue have becme progressively more sophisticated.In particular a technique called ‘immuno-histochemistry’ often enables the pathologist to differentiate between cancers that would otherwise appear identical.The further information obtained can be very helpful, for example, in assessing more accurately the prognosis and the chance of response to certain treatments.In recent years it has become increasingly common, using highly sophisticated technology, to analyse the genes present within the cells of a particular cancer, looking for mutations or abnormal activity of certain genes.This is known as ‘genomic testing’ and, being done on the cancer itself, it contrasts with the genetic testing (mentioned in the earlier ‘Cancer in families’ section) done on an apparently normal blood sample to see if a person is carrying a gene which predisposes them to getting cancer.Genomic testing can provide prognostic and other information – for example it can sometimes help in identifying those people who are more likely to need additional chemotherapy following surgery for breast cancer – and it can help in choosing the best drug treatment for some patients with bowel cancer.It seems likely that in future this will become more widely used in an increasingly personalized approach to cancer management.Biopsies are also sometimes performed in an attempt to establish the extent of the disease, because this can influence substantially the choice of treatment.For example, someone who has a swollen neck gland diagnosed as lymphoma may undergo a bone marrow biopsy to see if there are lymphoma cells in the marrow.Women with newly diagnosed breast cancer will usually have a biopsy taken from any suspiciously enlarged lymph node in the armpit.However if no suspicious nodes are seen on ultrasound scanning this does not exclude microscopic spread of cancer to one or more of these nodes.It is now routine for most such patients undergoing surgery for the cancer in their breast to have at the same time removal of a crucial lymph node from the armpit (‘sentinel node biopsy’), this node having been meticulously localised after injecting a dye and a radioactive substance into the primary tumour.If this sentinel node ‘draining’ the primary tumour is clear of cancer, it is highly likely that all the other nodes in the armpit will also be clear and the patient can then avoid more extensive armpit surgery with its potentially troublesome side effects.

Words ending in ‘-oscopy’

The term ‘-oscopy’ merely means ‘taking a look’ (skopein is Greek for ‘to see’).Most cancers arise from the inner lining of tubes or containers such as the voice box (larynx), air passages in the lungs (bronchi), swallowing tube or gullet (oesophagus), stomach (for which the medical adjective is ‘gastric’), large bowel (colon and rectum) and bladder (sometimes referred to as ‘cyst’).It is possible to inspect all these structures using a variety of instruments and to take biopsies from any suspicious areas.The names given to these inspections, together with the organs involved, are as follows:

• laryngoscopy: voice box
• bronchoscopy: lungs
• gastroscopy: stomach
• colonoscopy: colon
• sigmoidoscopy: the S-shaped lower end of the colon and rectum
• cystoscopy: bladder,

Other types of inspection include the following:

• nasendoscopy: the air passageway from the nostrils to the larynx
• mediastinoscopy: the tissues behind the breast bone or sternum to assess whether or not a lung cancer has spread to the lymph glands there
• colposcopy: the cervix or neck of the womb
• laparoscopy: the abdominal cavity

Some of these can be performed in the outpatient clinic, some require sedation and some a general anaesthetic.Many now involve the use of fibreoptic technology, which enables the doctor to see down a flexible cable inserted gently into the relevant opening in the body, or through a small cut.Sometimes it is easier for your doctor to see, feel and assess the extent of the growth, and possibly to take a biopsy, while you are under a general anaesthetic.This is known as an examination under anaesthetic or ‘EUA’.

Blood tests

These are unlikely to provide the doctor with much useful information to help make the diagnosis unless the malignancy is of the white blood cells themselves (leukaemia), or if the cancer is one of those types that produce a characteristic chemical or ‘tumour marker’ which can be measured in the blood.These include most cancers of the prostate and testis and myeloma, and some cancers of the bowel, breast, ovary and thyroid gland, but quite often there can be other non-cancerous causes of raised marker levels.Nevertheless, blood tests can be useful in providing some information on your general state of health.Sometimes they can also suggest that a cancer may have spread to other organs such as the bones or liver.This is when the concentration of certain chemicals known as ‘enzymes’, normally released into the blood by these organs, is above the normal range as a result of damage caused by the cancer.However, these tests are not foolproof – there are usually several possible causes of such abnormalities other than spread of the cancer.

X-rays and scans

Often the first clear indication of the presence of a cancer is an abnormal appearance on an X-ray or scan, for example, an abnormal white shadow on a chest X-ray caused by a solid lung cancer occupying a space that would normally be filled with healthy air-containing spongy lung tissue.Tumours can also show up on a breast X-ray (mammogram) or on a barium X-ray of the oesophagus, stomach or bowel.A mammogram is an X-ray picture of the breast taken with the breast compressed between two flat plates.This can sometimes be uncomfortable.Breast cancers usually give characteristic appearances on mammograms, particularly very small white flecks caused by minute deposits of calcium within the cancerous tissue,When barium is swallowed (barium swallow or meal) or inserted into the bowel via the rectum (barium enema), it shows up densely white on the X-ray, outlining the inner surface of the oesophagus, stomach or bowel.Normally the lining appears smooth but the presence of a cancer can cause it to appear irregular or bulge inwards.Sometimes other types of ‘dye’ or ‘contrast medium’ showing up white on an X-ray or scan are injected into the bloodstream via a vein.For example, the blood may carry the dye to the kidney which then excretes it into the urine.X-rays taken of the kidney and bladder (intravenous urogram [IVU] or pyelogram [IVP]) can then show up these organs quite clearly and an abnormal appearance may suggest that a cancer is present.You may need to have one of the various forms of scanning as part of the process of diagnosing cancer or assessing its extent.Computed tomography (CT) and magnetic resonance imaging (MRI) scans require you to lie still in what is usually a large doughnut-shaped structure.CT scanning is now usually very quick.MRI scanning takes somewhat longer, perhaps 15 to 20 minutes, and tends to be rather noisy.These scanners can produce very impressive pictures of cross-sections or ‘slices’ of the part of the body being investigated, and they are often much better at showing growths than simple X-rays.You may have to swallow or have an injection of a ‘contrast medium’.This can help to make any cancer present show up even more clearly.Ultrasound scanning often involves moving a probe over the skin overlying the relevant part of the body, or sometimes inserting a probe into the rectum, vagina or oesophagus.Images are produced on a screen by detecting very high-frequency, inaudible, ‘sound’ waves reflected off the internal tissues.Isotope scanning is the creation of a picture by a ‘gamma camera’ which detects gamma rays emitted from the body after you have been injected with or swallowed a radioactive substance known as an isotope.The most common type of isotope scan performed for cancer patients is a bone scan.The injected isotope is carried around the body by the bloodstream, but it tends to home in on or ‘concentrate in’ any areas of bone where there is an attempt at healing any damage, which could have been caused by a tumour that has spread from another part of the body.The high concentration of the harmless isotope at such sites results in their appearance as ‘hot spots’ on the gamma camera picture of the skeleton.Interpretation can sometimes be difficult, however, and hot spots can often be caused by things other than cancer, such as degenerative disease (‘wear and tear’).Another type of scanning, positron emission tomography (PET), is used in the assessment of some patients with particular cancers.PET scans can sometimes detect tumours that are invisible on other types of scans.It takes advantage of the tendency for special sugars injected into the bloodstream to be ‘taken up’ or absorbed by cancer cells much more rapidly than by normal cells.The sugar molecules have ‘radioactive labels’ attached to them, causing the cancerous tissue to ‘light up’ on the scan pictures.As well as being used in the initial assessment of people suspected of or diagnosed as having cancer, X-rays and scans are used very commonly to assess response to some treatments, particularly drug treatments.They are sometimes used in certain very specific situations to detect an early curable recurrence not causing any symptoms and they are also used to investigate symptoms which might possibly be caused by a recurrence in someone who has been treated for cancer in the past.However, it is important to realise that none of these ‘radiological’ investigations scans are foolproof: even the most sensitive ones may fail to pick up a very small cancer and they quite often show suspicious abnormalities that turn out to be completely benign.

Tumour staging

Once a biopsy has confirmed the presence of a cancer, it will often be allocated to a certain ‘stage’.This describes the size category of the cancer and also indicates whether or not there is evidence that it has invaded adjacent tissues or has spread via the lymphatic vessels to the lymph glands, or through the bloodstream to more distant sites.Various staging systems are in use but ‘TNM’ staging is the most widespread.’T’ refers to the primary tumour, ‘N’ to the lymph nodes and ‘M’ to distant spread (metastasis).A number is allocated to each letter.For example, a woman with a breast cancer three centimetres in diameter which has affected some of the lymph nodes in her armpit, but who does not have any evidence of more distant spread, could be said to have a ‘T2N1M0’ tumour.Here ‘T2’ indicates a primary tumour between two and five centimetres in diameter, ‘N1’ denotes involved but removable lymph nodes confined to the armpit, and ‘M0’ indicates that there has been no detectable distant spread.Staging can be helpful in estimating prognosis, making recommendations for treatment, and in assessing and comparing the results from treatment.

KEY POINTS

• You should always see your doctor promptly if you have any abnormal bleeding or an unexplained lump

• Screening for some cancers can save lives but does have its downsides, and very many people have to be tested for one to benefit

• Most cervical cancers can be cured, but almost 90 per cent of those who die from this disease have never had a routine smear

• Analysis of a specimen of tissue under the microscope is essential for confirmation of a diagnosis of cancer

• X rays and scans are not foolproof 

More than one in three of us will develop cancer. There are now probably more than two million people in Britain who have had treatment for cancer, not far short of one in 25 of the population. The majority of these are long-term survivors. Attitudes are changing and for most people cancer is no longer the taboo subject that it used to be. People who have cancer now find it easier than in the past to talk about their diagnosis in the same way they would about most other illnesses. Being able to share their feelings also makes it easier for their family and friends to offer support.

 

You may already be aware that advances in medical science have had a major impact on the outlook for people with cancer. Of course the news is not all good, but the future for many cancer patients is now rather more hopeful than for many of those with other illnesses that traditionally have been much less feared. We are rapidly learning more about what exactly goes wrong when cells become cancerous and these discoveries are leading to exciting new treatments. In recent years some treatments for some patients have become progressively more customized, not infrequently based on the precise genetic make-up of their particular cancer. It seems highly likely that cancer management will become increasingly personalized over coming years.

 

Cancer has become increasingly common and this trend also seems likely to continue. The main reason for this is that people are living longer and cancer is to a large extent a disease of older people – two thirds of cancers occur in those aged over 65. It has been estimated that by 2020 almost one in two Britons dying from any cause will have been diagnosed with cancer at some time in their lives. It has also been estimated that more than four in ten cancers could be prevented by lifestyle changes such as not smoking, cutting back on alcohol, maintaining a healthy body weight and avoiding excessive sun exposure.

 

Although cancer has become more common, at the same time the chances of a cure have been steadily increasing. Over the past few decades the percentage of people surviving cancer has increased dramatically, and those people who can’t yet be cured are living longer and have a better quality of life. It is increasingly proving possible to provide long term cancer control for many patients, rather like managing raised blood pressure or diabetes.

 

Improvements have come about as a result of earlier diagnosis, better treatments, better supportive care and better organisation. Anyone who has cancer should now be able to expect ‘state of the art’ treatment as well as having access to wide-ranging support from both the NHS and many charitable and voluntary organisations.  There are also opportunities for patients and other lay people to become actively involved (‘user involvement’) in the planning and provision of cancer services, at both local and national levels. The pace of change is rapid and it has been necessary to revise Understanding Cancer very substantially since the first printed edition was published in 2000. Human papilloma virus (HPV) vaccine, offered to 12 and 13 year old girls since 2008, will substantially reduce the number of people developing cancer of the cervix and some other cancers. Drug treatments to prevent breast cancer in those at high risk of the disease have recently become routinely available.

 

Another improvement is the better knowledge that patients now have about their disease and treatment options. Studies have shown that a substantial majority of patients now want as much information as possible, whether the news is good or bad. Patients are becoming progressively better informed in several ways and in general they are less content than in the past to be passive partners in decision-making about their care. A very large amount of excellent written information is available from a variety of sources and much is now provided routinely in most hospitals providing care for people with cancer. But it is important to be aware that not all sources of information are reliable, particularly some of those to be found on the internet, and that even reliable information is not necessarily helpful or applicable and can on occasions cause unnecessary distress.

 

Understanding Cancer does not deal with the causes of cancer nor does it discuss particular cancers in detail but, where they and their treatments are mentioned, it concentrates on the more common types. Mention of anti-cancer or symptom controlling drugs is largely confined to those that patients might be expected to take in their own homes. When specific drugs are mentioned their non-proprietary ‘approved’ names are generally used rather than their manufacturers’ proprietary names. Much more detailed information is available from the authoritative sources listed under ‘Further help’ and, most importantly, from patients’ own doctors, nurses and other health care professionals.

 

This e-book aims merely to give a brief introduction to what is known about the nature of cancer, what can now be done for people who get it, and what treatment and care in general are likely to involve. Later sections assume that you have become familiar with some concepts and terms introduced earlier on. Thus, although much of the book may well be irrelevant to your own situation, you may nevertheless find it most useful if you read at least the first three chapters as an introduction. It is worth mentioning that the study of everything to do with cancer is known as oncology – ‘onkos’ is the Greek word for lump.

 

Although there is an enormous amount to celebrate in our battle against cancer very many patients still have unmet needs – physical, psychological, social and financial. Quite often these stem from a lack of understanding and a lack of awareness of what help is available. It is of particular concern that survival rates for patients with some types of cancer tend to be lower in poorer than in richer patients. There is evidence that less well-off people are in general less likely to take up screening, less likely to see their GP when they have early symptoms, and are less assertive about their treatment and overall care. Understanding Cancer has been written for anyone who has cancer, their families and friends and other interested lay people, in the hope that they will find it informative, helpful and easy to understand.

KEY POINTS

• Well over one in three of us will develop cancer and about two million people in Britain have had treatment for the disease

• Treatment and support for people with cancer is improving all the time