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Cancer Symptoms & Treatment


Receiving a diagnosis of cancer presents numerous challenges: learning about your disease, selecting the physicians who will care for you, and making decisions about your treatment. Then come the day-today challenges: integrating the treatment schedule into your life, coping with the symptoms and side effects of the treatments, and finally making the transition to being a cancer survivor.

We hope our texts will provide information and support to help you in meeting these challenges. We have included information about cancer and cancer treatment, but the focus is on managing the symptoms of the disease and the side effects of treatment. Equally important is information we hope will help you and your family cope with the emotional and practical concerns that come up during this time.


(6) Cancer Symptoms & Treatment

 Breast cancer - Symptoms and treatment

Cancer Treatment Types

What is Chemotherapy?



Radiation Therapy

Why do cancer treatments cause side effects? Is my treatment more likely to work if I get more severe side effects?

Despite the most careful precautions for treating a  cancer safely, most treatments cause side effects. For many types of cancer, surgery to remove the tumor is an important part of the treatment. However, depending on the type of cancer and the extent of surgery performed, there may be changes in how your body looks or functions. Chemotherapy and radiation therapy work primarily by attacking the cancer cell’s ability to divide. Because normal cells also need to divide for the body to function normally, they may also be damaged by treatment, causing side effects. Radiation therapy and some types of chemotherapy may also injure organs in the body.

Some side effects occur during or shortly after treatment and resolve completely after treatment is completed. Acute or early side effects generally resolve within weeks or a few months after treatment is completed.

 Examples are drops in blood counts, nausea, vomiting, diarrhea, and mouth sores. Long-term side effects may persist for months or years after treatment. Examples are nerve damage or fatigue. Late side effects may not show up for months or years after treatment are completed.

Examples are infertility, heart or lung problems, or cataracts. Although these are rarer than early or long-term effects, these are permanent and can cause significant problems. Planning treatment for any one person always involves balancing the risks of treatment with the potential benefits.

Your doctor will discuss these with you before you begin treatment so that you understand the goals of treatment and the potential side effects you may experience. A common myth is that the severity of side effects indicates the effectiveness of treatment. Some people might even avoid taking medication to relieve their side effects, thinking that their treatment will work better. This is not true. Some people who have successful treatment with a long-term cure have minimal side effects. Unfortunately, others have very severe side effects during treatment, even requiring hospitalization, and yet their cancer does not respond to treatment and continues to grow and spread.

The severity of side effects is usually linked to the type of treatment you are receiving. Some treatments are known to cause significant side effects; others are very well tolerated. Your general state of health, your level of activity, and how well you are eating and drinking can also affect how you tolerate treatment. Taking medication to manage side effects does not interfere with the treatment. In fact, it helps you feel better so that you can eat and drink well and maintain your usual activities as much as possible.

Lisa’s comment:

Even though I uttered the word myth countless times to my own patients, when I experienced minimal side effects from chemotherapy and radiation therapy (at first) I found myself thinking: “I wonder if this is working!” Intellectually, I knew it was, but emotionally. . . . Funny.

Planning treatment always involves balancing the risks with the potential benefits. The severity of side effects is usually linked to the type of treatment you are receiving.

How does my doctor evaluate whether my treatment is working? What if my treatment doesn’t work?

During regular visits throughout your treatment, your doctor evaluates how you are doing. These visits are necessary to see how you are tolerating the treatment, if you are having side effects, and, if so, how severe they are. The doctor may order medication to relieve the side effects and may even make adjustments in your treatment dose or schedule. Another reason for these visits is to see how your cancer is responding to the treatment. If you have had the cancer removed by surgery or destroyed by chemotherapy or radiation therapy, the doctor wants to be sure that the cancer has not recurred (reappeared). If the cancer could not be removed or destroyed, the doctor wants to be sure it is not progressing (growing) or metastasizing (spreading to other areas). The doctor reviews any symptoms you are having and performs a physical examination.

Blood tests are done, and at periodic intervals radiologic studies, such as CT, MRI, or PET, are performed to see images of the body. The specific types of studies depend on the type of cancer you have.  If you are tolerating treatment well and there is no sign that the disease has recurred, progressed, or metastasized, your doctor will continue the treatment.

Depending on your situation, the treatment may be planned for a defined period of time (e.g., 6 months) or given indefinitely. However, if you develop a recurrence or if the tumor progresses or metastasizes while you are on treatment, the cancer cells may have become resistant to the treatment you are getting. If so, your doctor will recommend discontinuing your current treatment and discuss other options with you.

If your energy level is good, if your weight is fairly stable, and if you are able to be up and around most of the day, you are more likely to have a good response to active treatment, so your doctor will probably recommend a new type of treatment.

If you have been hoping for a cure, hearing that your disease has recurred or spread is distressing. You may find yourself experiencing again many of the feelings you had when you were first diagnosed: anger, sadness, worry, or even difficulty accepting the reality of what the doctor is telling you. You may feel frightened that you will develop new physical symptoms. You may feel concerned about family and friends. You may be worried about the financial implications for your family.

You may feel spiritually distressed. There are ways to cope. Getting accurate information from your doctor is particularly important as you consider what comes next. Some people find it helpful to have their doctor fully explain the details of their illness and prognosis. Others prefer not to hear the details and just focus on the plan. Decide what you want to know and communicate this to your family and doctor.

In making decisions about treatment if your cancer recurs or spreads, talk with your doctor about the goal of the treatment being recommended. Consider whether this matches your own goals. Talk with your family and doctor about what is most important to you at this time in your life. A resource that may be helpful during this time is When Cancer Returns, published by the National Cancer Institute.

If you have been hoping for a cure, hearing that your disease has recurred or spread is distressing. There are ways to cope.

What happens after my cancer treatment is completed? How do I adjust to being a survivor?

Completing treatment for cancer and becoming a survivor bring new challenges. When your treatment is completed, your doctor will schedule regular follow-up visits to be sure you are recovering from treatment, to make sure you have not developed any long-term side effects from treatment, and to evaluate the status of your tumor. Your doctor will ask about symptoms, perform a physical examination, draw blood for laboratory analysis, and order radiologic studies, such as CT, MRI, or PET. The specific blood tests and radiologic studies depend on the type of cancer you have. These studies help the doctor determine whether the tumor has grown back (recurrence) or cells have begun to grow in other parts of the body (metastasis). If all the tests are negative, if you have no signs or symptoms of cancer, and if there is “no evidence of disease,” the doctor may say you are in remission. When these circumstances continue over a number of years, the doctor may say you are cured.

Initially, your doctor may want to see you every 2 to 3 months. Over time, the visits will be farther apart, going to every 6 months and then to once a year. If you have received combined treatments, clarify with your doctors-your surgeon, medical oncologist (who prescribes chemotherapy), and radiation oncologist (who prescribes radiation therapy)-when you should see each of them.

For many people, the days immediately before their doctor’s appointments and the days waiting for the results of diagnostic tests are times of anxiety and worry. Completing treatment for cancer brings other challenges as well. Among these may be adjusting to changes in your body, recovering strength after treatment, resuming your usual activities, returning to work, and explaining your illness to friends and colleagues. In addition, despite the fact that your treatment is over, you may find it difficult at times to balance the hopefulness that the disease will not come back with the knowledge that the future is always uncertain. Each of these challenges presents a new hurdle to overcome.

Give yourself time as you transition into feeling “normal” again. Draw on your usual methods of coping, as well as those you learned after your diagnosis and during your treatment.

Three resources may be helpful to you as you adjust to your life as a cancer survivor:

1. Facing Forward Series: Life After Cancer Treatment, published by the National Cancer Institute, covers post-treatment issues such as follow-up medical care, physical and emotional changes, changes in social relationships, and workplace issues.

2. The Cancer Survivors Network of the American Cancer Society ( offers recorded discussions on issues and provides an opportunity to interact with other survivors.

3. The National Coalition for Cancer Survivorship (, an advocacy organization for cancer survivors, has valuable information, including a Cancer Survival Toolbox.

Despite the fears and uncertainties, some people find that being diagnosed with cancer gives them the opportunity to think about their lives in new ways.

Relationships often become stronger and enriched by the experience. Sometimes people choose to shift the priorities in their life, ensuring that they are spending their time doing what is most important to them.

Mary Ann’s comment:

After my cancer treatment was completed 3 years ago, my oncologist followed up with CT scans on a scheduled basis—first year, every 3 months; second year, every 6 months.

There were also follow-up blood and urine tests. Fortunately for me, the CT scan picked up a recurrence of my cancer at the 2-year marker. Tiny tumors appeared in the lining of my right lung and on the tail of my pancreas. It was a very scary time for me and my family. However, because of the good follow-up care, these tumors were caught at a very early stage and I was fortunate enough to be eligible for a clinical trial at Memorial Sloan-Kettering Cancer Center. I am in my 8th month of this trial and today I can say that it appears that my tumors have shrunk and calcified. Am I out of the woods permanently? Probably not but with good follow-up care, I expect to live for a long time.


Remission - A disappearance of all signs and symptoms of cancer.

Completing treatment for cancer and becoming a survivor bring new challenges.


(7) Cancer, Symptoms & Treatment

 Prostate cancer: Essential facts

Prostate Cancer


How can I be sure to get the information I want from my doctor?

Pete’s comment:

Before meeting with my oncologist, I write my questions on an index card. My wife is always with me to ask additional questions and take notes if necessary. By using this approach, I feel much more relaxed and in control. I also find that my oncologist’s nurse practitioner is extremely helpful and provides follow-up answers to a number of questions.

Mary Ann’s comment:

It is very important to establish a good rapport with your doctor and the nurses who care for us. We have to realize that these medical professionals want what is best for us. However, we do not always hear what we are being told, and it is important to bring along someone who will remain objective and keep track of the information given to you by the medical staff and prompt you to ask the questions that you always think of after you leave the doctor’s office. Don’t be afraid to ask any question regarding your care. It’s far better for the staff to know what is on your mind so that they can put you at ease with whatever decisions you make.

It’s important to feel comfortable with your doctor, to trust his or her medical judgment, and to feel you can communicate. Doctors will generally try to tell you everything you need to know about your disease and treatment, but they may not tell you everything you want to know. So, first, you must decide what you want to know.

Everyone approaches a diagnosis of cancer differently.

Some people want to know every detail about their disease, treatment, and prognosis and to be involved in every decision. Others prefer to know only the basics and to have their family or doctor make the decisions for them. Of course, many people fall between these extremes. In addition, at various points in time, you may want to know different things. When you are first diagnosed, your concerns will be different from those you may have during treatment or when you are no longer receiving treatment.

Each time you visit your doctor, decide beforehand what questions you have. Talk with members of your family or anyone else you can speak openly with to focus your thoughts and concerns. Write your questions down on a piece of paper. There are no stupid questions, so include everything that concerns you.

When you see your doctor, state at the beginning of the visit that, before you leave that day, you would like to ask questions. That helps your doctor plan extra time to speak with you.

Here are some questions you may want to ask when you first meet with your oncologist:

• Is the cancer localized, or has it spread to other sites?

• What other diagnostic tests do I need?

• Can this cancer be surgically removed?

• What choices do I have to treat the cancer?

• What treatment do you recommend and why?

• What is the goal of this treatment?

• What are the risks of this treatment?

• How will you know if the treatment is working?

• What are the alternatives to this treatment?

• How will I feel during and after treatment?

• What side effects will I have from treatment?

• What are the possible long-term effects of treatment?

• What do I need to do to care for myself during treatment?

• Will I be able to work and continue my usual activities during treatment?

• For what reasons should I call your office?

When answering your questions, your doctor may present a lot of information and use terms that are unfamiliar or confusing. As you listen, you may feel anxious or afraid and find it difficult to understand everything that is being said. If you don’t understand something, ask the doctor to explain it.

You may find it helpful to bring a family member or friend with you to your doctor visits. They can be a second set of ears, can take notes while the doctor is speaking, and can review the answers with you when you get home. If something is still unclear when you get home, call the office the next day. The nurse who works with your doctor may also be able to answer many of your questions. You are entitled to have your questions answered; be persistent.

Some patients find they are more comfortable not getting detailed answers to questions, but family members may have many questions. Identify one person to be the family spokesperson, coming to office visits and contacting your doctor as needed to ask questions. The family spokesperson can use the same suggestions just described to clarify what everyone wants to know and to be sure to get everyone’s questions answered.

Before each visit with your doctor, write your questions down on a piece of paper.

If you don’t understand something, ask the doctor to explain it.

How can I find clinical trials that may be appropriate for me?

Clinical trials are research studies designed to test the effectiveness of new treatments on humans. If you are interested in participating in a clinical trial, hold off starting treatment until you have investigated the options. Ask your doctor for recommendations and whether it is safe for you to delay your treatment. Your doctor may also be able to help you find clinical trials available for you and determine whether you are eligible for them.

The following resources provide listings of clinical trials for particular cancers and cancer symptoms:

• National Cancer Institute:

• National Institutes of Health:

• Coalition of Cancer Cooperative Groups:

• Centerwatch:

• National Comprehensive Cancer Network (NCCN):

How can I find out about complementary or alternative therapies?

Complementary and alternative medicine (CAM) refers to a wide variety of approaches to improving health and treating disease that the traditional medical community does not recognize as standard or conventional.

When used in addition to conventional methods of treatment, they are referred to as complementary; when used instead of conventional methods of treatment, they are referred to as alternative.

There are several reliable sources of information about complementary and alternative therapies. Because of the rapidly changing state of knowledge about this area of medicine, the Internet provides the most up-to-date information.

The following websites provide general information on these therapies:

• Cancer Information Service of the National Cancer Institute:

• National Center for Complementary and Alternative Medicine of the National Institutes of Health:

• Memorial Sloan-Kettering Cancer Center:

• MD Anderson Cancer Center:

• American Academy of Medical Acupuncture:

The following organizations provide information specifically on dietary supplements, including vitamins, minerals, and botanicals (plants or plant parts valued for their medicinal properties; includes herbal products; commonly prepared as a tea, an extract, or a tincture):

• Office of Dietary Supplements of the National Institutes of Health:

• Center for Food Safety and Applied Nutrition of the U.S. Food and Drug Administration:

• American Botanical Council:

Finally, for scientific bibliographic citations related to particular therapies, see the

• National Library of Medicine:


 Botanicals - Plants or plant parts valued for their medicinal properties; includes herbal products; commonly prepared as a tea, an extract, or a tincture.


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Cancer Complementary and Alternative Medicine - National Cancer Institute


How do I decide whether to use one of the complementary or alternative therapies that my family or friends is recommending?

Before beginning treatment with any complementary or alternative therapy, obtain as much information as you can about it.

 Here are some specific questions to consider:

• Do the promises sound too good to be true, such as promises that are inconsistent with the information you are receiving from your doctor or from other sources of information?

• What evidence supports the claims of effectiveness? Were scientific, rigorously controlled clinical trials conducted? Or is the evidence only anecdotal, that is, based on the author’s personal experience or claims of satisfied customers?

• What are the risks of using this treatment? What is the evidence regarding safety? How are data collected to evaluate safety?

• If someone is providing the therapy, what are the person’s qualifications, certifications, or licenses? Some practitioners are now licensed by state medical boards or accredited by professional organizations.

• Is the source of information about the therapy also the seller? If so, the seller may have a vested interest in convincing you to purchase the product.

Two Internet sites provide tips to help with decisions about using a complementary or alternative therapy:

• National Center for Complementary and Alternative Medicine of the National Institutes of Health:

• Center for Food Safety and Applied Nutrition of the U.S. Food and Drug Administration:

Before making a final decision about the use of any complementary or alternative therapy, discuss your thoughts and intentions with your doctor. Many of these therapies can be used safely with the traditional treatments you are receiving. However, some can interfere

with your treatment, cause serious side effects when combined with your treatment, or may actually be harmful.

Before making a final decision about the use of any complementary or alternative therapy,

discuss your thoughts and intentions with your doctor.

How can I evaluate information on the nternet to be sure it is complete, accurate, and up-to-date?

 Pete’s comment:

The sheer amount of information on the Internet can be intimidating and confusing. By concentrating on several credible and reputable sites, I get good background data, which increase my knowledge without overwhelming me. I  also find that cancer center websites are a good source of information. If I have questions, I refer to my oncology team for clarification.

The Internet has created the opportunity for you to get instant access to an enormous amount of information without ever leaving your home. However, because the information posted on the Internet is not controlled or regulated, a great deal of it may not   be accurate.

When viewing a site, a number of things can help you determine whether it is reliable and likely to have complete, accurate, and up-to-date information:

• Ownership or sponsorship of the site: The owner or sponsor of the site pays for it to be maintained. The owner or sponsor may be a government agency, a nonprofit organization, a medical center or hospital, a pharmaceutical company, or an individual. The sponsor can influence what content is presented.

Consider whether the sponsor may benefit by presenting a biased point of view.

• Purpose of the site: Click on “About this site.” The site’s purpose should be clearly stated and will help determine whether it has a particular point of view.

• Editorial board: Many sites have an editorial board that reviews all the information posted. Review the list of people on the editorial board, and check their credentials and affiliations to be sure they are medically qualified to make these decisions.

• Source of information: The authors of the information should be identified. Review their credentials and affiliations to be sure they are truly experts in the field. If the information is obtained from other sources, these also should be acknowledged.

• Evidence: References to scientific research findings and published articles that back up the information should be included.

• The date information was updated: The site should include a statement indicating the date the information was last reviewed and updated. Medical information must be current to be useful.

• Privacy: The site may ask for information about you. If so, it should clearly state how the information will be used and how your privacy will be protected.

Before acting on any information you have obtained from the Internet, discuss what you have found and what you are considering with your doctor.

 Because the information posted on the Internet is not controlled or regulated, a great deal of it may not be accurate.

 I feel so overwhelmed by all the information I’m getting. How do I make decisions about my treatment?

Pete’s comment:

After receiving my lung cancer diagnosis, my wife and I were overwhelmed.We decided to take it one step at a time and move slowly. The first thing we felt was necessary was to get a second opinion at another institution. Our primary concern was being comfortable with the oncologist and his medical team. We also were very aware of the proximity of the potential treatment center and if the treatment was covered by my medical insurance.

After being diagnosed with cancer, one of the most stressful periods of time is when you have to make decisions about your treatment. A number of things can help you sort out the available options and select the best one for you.

First, be sure you have all the relevant information. Are you clear about your clinical situation and the choices being presented to you?

Second, be sure you have seen all the treating specialists to hear their recommendations directly. Internists (physicians who specialize in the diagnosis and medical treatment of adults) or surgeons can provide you with direction, but they will not be able to give you detailed information about chemotherapy or radiation therapy.

If these treatments are being recommended, schedule appointments with a medical oncologist (who prescribes chemotherapy) and a radiation oncologist (who prescribes radiation therapy). Clarify with each doctor the goals of treatment. Also ask about the potential side effects or risks of treatment.

This approach will help you weigh the choices for yourself. Once you are clear on the options posed by your doctors, consider whether it would be worthwhile to obtain a second opinion, perhaps with a specialist at an academic center or comprehensive cancer center. Doctors who specialize in treating particular types of cancer have more experience with this disease and may have a different perspective about treatment. In addition, they may be able to offer you treatment on a clinical trial.

Have a family member or friend accompany you to all these appointments. They can provide a second set of ears to hear the information presented and take notes for you while the doctors are speaking.

When you get home, you will also have someone to review all the information with you to be sure you understand it correctly.

In making your final treatment decision, consider several other factors. Financial issues are important.

• What are the costs of the various treatment options, including treatment on a clinical trial?

• Does your health insurance cover treatment by any doctor or only by doctors affiliated with your health insurance plan?

• Will treatment on a clinical trial be covered?

• What percentage of the costs will be reimbursed to you and what will be the out-of-pocket expenses? Logistical issues are also important.

• Where would you have to go for treatment?

• Will it be easy to get back and forth, or will you have to travel long distances or even relocate to a different city for a period of time?

Finally, consider your emotional reactions to the doctors you have met.

• Did you feel you could trust the doctor and his or her medical team?

• Did you feel you were given adequate time to have all your questions answered?

• Did you feel treated respectfully and courteously by the staff in the office?

It is important to feel comfortable with the doctor you choose, because the two of you will be partners in the journey that lies ahead.

In the end, it comes down to you. Consider everything about your current life situation: how old you are; your general state of health; your responsibilities to your family and work; the emotional, physical, and financial costs of treatment; and all that you may possibly gain from treatment. The most difficult part of this process is that there is no right decision other than the one that feels right to you.


Internists - Physicians who specialize in the diagnosis and medical treatment of adults.

There is no right decision other than the one that feels right to you


(9) Cancer Symptoms & Treatment

Breast cancer - Symptoms and treatment

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I want to have the best quality of life possible. Should I refuse to take any treatment so I won’t have side effects?

 One of the most difficult aspects of being diagnosed with cancer is living with uncertainty about the future. Coupled with that is the fear of side effects from treatment. These feelings can lead to questioning whether it is worthwhile to get treatment. But your decisions about treatment should be based on knowledge, not on fear.

Speak with your doctor to get the information you need. The side effects and the likelihood of long-term control or cure are based on the type of cancer you have, on the stage of disease, and on the treatment you receive. Everyone responds differently to treatment; no one can predict precisely what will happen to you. However, your doctor can explain what he or she hopes to achieve and what you will most likely experience during and after treatment. Consider this information when making your decision.

When a cancer is curable, making the decision is relatively easy because the goal is easy to understand. Many treatments are easily tolerated, with minimal disruption in your usual routines, and many side effects from the treatment resolve without any long-term consequences.

Even for those who cannot be cured, obtaining treatment offers a number of benefits. Many types of cancer can be controlled with treatment for a long period of time, even for a number of years. Equally important, treatment can improve the quality of your life. It can lessen or prevent symptoms of the disease, and it can prevent or delay complications from the growth of the cancer. For specific questions to ask your doctor to ensure you get the information you need to make the decision about undergoing treatment for your cancer.

What is palliative care and how can I get referred to a palliative care program?

Palliative care addresses the medical, physical, emotional, social, and spiritual needs of patients to help them achieve the best possible quality of life. Historically, palliative care was associated with hospice care and was reserved for patients at the end of life who were no longer receiving active treatment for their disease. However, in recent years the focus of palliative care has expanded to include all patients who could benefit from this approach, even those receiving active treatment and with a good prognosis. Many hospitals have established palliative care programs for their patients.

Although oncologists have a great deal of experience in managing pain and other symptoms, for some patients the usual interventions are not effective. In these cases, a referral to a palliative care specialist may be helpful. Palliative care specialists are physicians who are specially trained in techniques to manage pain and other symptoms.

If you feel your pain or other symptoms are not adequately controlled, ask your doctor about seeing a palliative care specialist. An Internet site that can provide additional information about palliative care and help you find a nearby provider is Get Palliative Care (

What are advance directives? How can I be sure my wishes are known?

Advance directives are legal documents in which you indicate who you want to make medical decisions for you and/or what type of medical care you want to receive if you become unable to make decisions or speak for yourself in the future. Although the specific laws and terminology for advance directives vary from state to state, there are two basic types:

• A living will

• A health care proxy

A living will is a document in which you state specific instructions regarding your health care, outlining which medical interventions you want to have performed and which you want to have withheld, given a variety of circumstances.

For example, if you were to lose the ability to eat and drink, would you want to receive artificial nutrition through a feeding tube or by means of intravenous fluids? If your heart were to stop beating, would you want to have your chest compressed or have your heart shocked? If you were to stop breathing, would you want a tube placed down your throat and connected to a respirator, which would breathe for you?

When making these decisions, specify the circumstances in which you want your wishes followed. If the medical problem is treatable and reversible, you may want all medical measures taken to resuscitate and support you. If the medical problem results from progressive cancer that can no longer be controlled, you may not want any aggressive measures taken to resuscitate you or to prolong your life. Deciding not to accept aggressive care to prolong your life is not the same as withholding other medical care. You can still receive pain medication, antibiotics, food and fluid, and other supportive measures. However, the goal of treatment shifts from cure to comfort care.

Making these decisions is very difficult, and you need to think about what you want for yourself. A living will provides you the opportunity to state your decisions so that people can act on them.

One significant limitation to a living will is that you can’t foresee all possible health-related circumstances.

Decisions might have to be made that you have not specified in writing. These problems can be avoided by completing another legal document called a health care proxy, or durable power of attorney for health care. This document allows you to designate a health care agent, who is a person designated to make health care decisions for you if you are not able to. The designated person acts as your agent, deciding which medical interventions should be performed and which should be withheld. Although the terminology varies from state to state, all states recognize a health care proxy.

When selecting a health care agent, be sure to choose among people you trust, those who will make decisions based on what you want for yourself, not on what they want for you or on what they would want for themselves if they were in your position. You can choose your health care agent among family members or friends. Talk with candidates about what you want for yourself in a variety of circumstances. Talk about the issues just described with regard to resuscitation and life-prolonging measures like artificial nutrition and intravenous fluid. Be as specific as you can be. Then confirm with the person you choose that he or she will honor your wishes and be willing to speak for you. You can change your health care agent, as well as your decisions about what you want done, at any time.

Let your family and friends know whom you have selected as your agent so that, if the need arises, everyone can support the person in making the necessary decisions. If you have completed a living will, share this with the family as well. Inform all of your doctors and everyone else on your medical team of your wishes and provide them with copies of any advance directive documents you have signed.

Having a discussion about what you would want if you were unable to make decisions for yourself is difficult for most people. Sometimes the patient wants to bring up the subject but is afraid the family will be distressed by the conversation. Sometimes the family wants to bring it up but is afraid of alarming the patient. It is always better to talk about these things when you are feeling well and when no imminent crisis is looming.

With this type of preparation, you can calmly think about what you want and clearly talk about it with others.

You can initiate the discussion in several ways. You could say something like, “I want to be sure that, if I were to become sicker, you would know what I want done.” A family member could initiate the discussion by saying something like, “If you were to become sicker and couldn’t tell me what kind of care you wanted, I wouldn’t know what to do. Can we talk about this?” Some people find that their family does not agree with the decisions they have made, making a difficult discussion even harder. This makes it all the more important to have an advance directive to ensure your wishes will be honored.

You can obtain state-specific advance directive documents from your lawyer, your doctor, your local hospital, or Caring Connections (

Your decisions about treatment should be based on knowledge, not on fear.

Palliative care - A philosophy of care that helps patients achieve the best possible quality of life.

Advance directives - Legal documents in which you indicate who you want to make medical decisions for you and/or what type of medical care you want to receive if you become unable to make decisions or speak for yourself in the future.

Living will - A document in which you can state specific instructions regarding your health care, outlining which medical interventions you want to have performed and which you want to have withheld, given a variety of circumstances.

Health care agent - A person designated to make health care decisions for you if you are not able to.



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Will I have pain? What are the options available to treat my pain?

 Pete’s comment:

When I was first diagnosed, I had peripheral pain, which would flare up in my back throughout the day. I was put on Tylenol 3 (acetaminophen with codeine) to help manage it. This worked well and after several sessions of chemotherapy, the pain subsided and I was able to cut back on the medication. Eventually, the pain disappeared completely.

Pain has long been considered an unavoidable consequence of having cancer. However, with new pain medications and a better understanding of how to use them effectively, cancer pain can be well controlled in almost all people.

Not everyone with cancer develops pain. If a tumor grows or spreads, it may press on or invade surrounding organs or nerves. Depending on the location of the tumor, this pressure may cause pain. In addition, procedures used to diagnose or treat cancer may cause pain, such as having a biopsy to take a sample of tissue for diagnosing the type of cancer or having surgery to remove all or part of a tumor.

Pain may be experienced in many different ways, for example, discomfort, aching, a gnawing feeling, a sharp stabbing sensation, or cramping. Pain may be mild or severe, and it may be intermittent or continuous.

Many people are concerned about taking pain medication. Some feel that withstanding the pain is a sign of strength. Some people feel it is a part of having cancer that they have to accept. Some people are afraid of “masking” a problem-if they treat the pain, they think their doctor will not be able to follow their response to treatment. There is no benefit at all to having pain. Regardless of how mild it is, chronic pain can be very disabling. It affects your energy level, your appetite, your ability to sleep, your desire to be with friends and family, and your mood. Tell your doctor or nurse about any discomfort you have, no matter how mild. Try to describe it accurately so that they can decide on the best treatment for you and monitor the effectiveness of the treatment. When describing your discomfort, include the following information:

• Where you feel the pain

• How severe the pain is (Many doctors and nurses will ask you to rate the severity, for example, using a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain you can imagine.)

• What the pain feels like (e.g., sharp, achy, gnawing)

• Whether you have the pain all the time or only at certain times

• What makes it worse and what makes it better

• How it affects your ability to sleep, your appetite, your activity, your desire to be with friends and family, and your mood

Medications for treating pain are called analgesics. Many different analgesics are available, and they are often prescribed in a stepwise approach, starting with a mild analgesic and progressing to a stronger one as needed until your pain is controlled. First-line over the-counter analgesics includes acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen). If these medications are not effective, your doctor will prescribe an opioid or narcotic analgesic (e.g., morphine, oxycodone, hydromorphone, fentanyl). Other medications are effective in relieving pain when used in combination with analgesics: certain antidepressant, anticonvulsant, anti-inflammatory, and steroid medications.

Pain medications come in many forms: tablets, liquids to swallow, liquids to be absorbed under the tongue, skin patches, and rectal suppositories. Also, solutions can be given intravenously (into the vein) via a portable pump. The pump is often set to deliver a steady dose of medication into the bloodstream with extra doses that you can deliver as needed. The pump is set up to allow so-called patient-controlled medication administration with a limit to prevent overdose.

Chronic pain medication works most effectively when given on a regular schedule around the clock. This regimen keeps a steady level of pain medication in your bloodstream to prevent you from experiencing pain. New long-acting medications are very helpful because they last for many hours or even days. You don’t need to take long-acting medication as frequently as you do the immediate-release (short-acting) forms. However, even with long-acting medication, most people require an immediate-release pain medication for what is called break-through pain. This is pain or discomfort that you experience during the day or night despite taking the long-acting medication.

When using the immediate-release pain medication, take it as frequently as you need to based on the instructions on the bottle. If you wait too long between doses and the pain becomes severe, the medication will not work as quickly or as effectively. If you find you need the immediate-release pain medication frequently during the day or that it is not effective, ask your doctor about increasing the dose of the long-acting medication.

Of all the many different types of pain medication, what works for one person may not work as well for another. Finding the right medication and the right dose and schedule to keep you without pain might take some time. Be persistent in working with your doctor and nurse until you find a regimen that works for you. If you do not feel satisfied with the degree of relief you are getting, ask the doctor about a referral to a pain specialist. You can also find a pain specialist by calling the Cancer Information Service of the National Cancer Institute or the American Cancer Society.

Some people are concerned about taking pain medication because they are afraid that, if they take it for milder pain, it won’t work if they need it later for severe pain. Many pain medications, particularly narcotics, have no maximal dose. In other words, the dose can be increased indefinitely over time, so that you can be sure to get good pain relief if you need it at some point in the future, no matter how severe your pain may be.

There are several reasons to call your doctor about pain:

• You are not getting adequate pain relief from your medication.

• On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, your pain is at a level of 5 or higher most of the time.

• You are not able to sleep because of pain.

• You are not taking the full dose of pain medicine because of its side effects.

For more information on how to manage pain, the National Cancer Institute has a booklet entitled Pain Control: A Guide for People with Cancer and Their Families.

This is available on the Internet

 For more information, search on these other Internet sites:


• American Cancer Society:

• Oncology Nursing Society:

• American Society of Clinical Oncology:


Analgesics - Medications for treating pain.

There is no benefit at all to having pain

 Finding the right medication and the right dose and schedule to keep you without pain might take some time.

What can I do about the side effects I get from my pain medication?

Pete’s comment:

My pain medication, like most, had a side effect of constipation. This was managed by a combination of Colace and Senokot. I also included prunes in my diet and drank plenty of fluids. After several weeks, constipation was no longer a problem and I was able to eliminate the medication.

Some people are concerned about taking pain medication because of the side effects. Common side effects from pain medication are sleepiness, nausea, and constipation.

• Sleepiness generally passes after a few days. However, if the sleepiness persists, ask your doctor or nurse about adjusting the dose or adding another medication to counteract it.

• Nausea also commonly passes after a few days on pain medication. If it does not, ask your doctor about trying a different pain medication or about taking medication to relieve the nausea.

• Unfortunately, constipation from pain medications does not pass. Taking a combination of a stool softener (e.g., docusate) and a laxative (e.g., senna, bisacodyl, lactulose, polyethylene glycol) on a regular basis can help. Newer medications may be more helpful for some patients on high doses of narcotics for a long time. These are MiraLAX (polyethylene glycol), a powder taken mixed in water, and Relistor (methylnaltrexone bromide), an injection. Ask your doctor or nurse about which medications you should take for constipation, what dose, and how often you should take them. Increasing the amount of liquid you drink during the day will also help reduce the likelihood of constipation.

If you become dizzy or confused from the pain medication, tell your doctor or nurse. Switching the dose or type of medication will usually resolve this problem.

I am afraid of taking my pain medication because I don’t want to get addicted. What should I do?

Some people are concerned about taking pain medication because they are afraid of becoming addicted. Pain medication does not cause addiction when it is taken to treat pain. However, when taken on a regular basis, it does cause tolerance, that is, your body physically adjusts to the level of medication in your bloodstream. If you stop the medication suddenly, you can develop withdrawal symptoms.To prevent these symptoms, if you no longer need your pain medication, taper down the dose of medication gradually rather than stopping it suddenly. Your doctor or nurse will review with you exactly how to do this. Tolerance to the medication is not addiction, which is a desire or craving for the medication to feel high rather than to have your pain relieved. Research studies show that it is extremely rare for patients with cancer to develop addiction from pain medication.


Addiction - A desire or craving for the medication to feel high rather than to have your pain relieved

Pain medication does not cause addiction when it is taken to treat pain.

 Are there other treatments for pain that do not rely on taking medication?

For some types of pain, surgery may be helpful by removing all or part of the tumor causing the pain. However, surgery is not an option for many people; in that case, other treatments may be offered. Radiation therapy is effective in treating some types of cancer pain. With external beam radiation therapy, a beam of energy is directed from a treatment machine at precise angles toward a defined target in your body. The therapy can reduce pain by shrinking a tumor that is pressing on or invading surrounding organs or nerves. If you do not feel your pain is controlled adequately with your medication, ask your doctor if radiation therapy would be helpful. However, if your cancer has spread widely throughout your body, external beam radiation is unlikely to be effective for you. For people who have bone metastasis (spread of the primary tumor to the bone) in multiple areas of the body, treatment with a radioactive isotope may be helpful. Strontium-89 is injected into the blood, travels through the body, and collects in the bone where the tumors have spread. It then emits radiation to those areas to shrink the tumors, thus reducing the pain.

If pain is caused by pressure on a nerve, a procedure called a nerve block can sometimes be performed. This involves injecting a local anesthetic or alcohol into or around the nerve near the point where the tumor is pressing. The injected substance blocks the transmission of messages from the nerve to the brain, so that you are no longer aware of the pressure. Blocks may also be done surgically; that is, the nerves are cut to relieve the pain. If you do not feel your pain is controlled adequately with your current medication, ask your doctor if this would be helpful.

A variety of nonmedical strategies may be helpful in treating pain, either alone or in combination with your pain medication: distraction, relaxation, imagery, prayer, meditation, and acupuncture. Specialists in these techniques can perform them or train you to use them to control your pain. If you are interested in them, ask your doctor or nurse for a referral, or contact the National Center for Complementary and Alternative Medicine.


 Nerve block - Injecting a local anesthetic or alcohol into or around the nerve near the point where the tumor is pressing



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