Ask The Doc

Ask The Doc Frequently Asked Questions

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Breast

Dear Doctor:

I would like a graph or chart to show what rising cancer markers in my blood test means.

Dear Visitor:

Tumor markers are substances that can be found in abnormal amounts in the blood, urine, or tissues of some patients with cancer. Different tumor markers are found in different types of cancer. Tumor markers may be used to help diagnose cancer, predict a patient's response to particular therapies, check a patient's response to treatment, or determine if cancer has returned. In general, tumor markers cannot be used alone to diagnose cancer; they must be combined with other tests. Therefore, a chart would probably not be helpful, as the tumor marker should be interpreted by your physician and your overall state of health. More information can be found at the Cancer.gov web site.

Dear Doctor:

I had a mammogram and the radiologist report stated that there was a density that they believed was benign and recommended that I have a repeat mammogram in 4-6 months. My doctor suggested that I see a breast surgeon, which I did. He did a physical examination and an ultrasound, but could not see the spot that the mammogram showed so he s having me have a biopsy. I'm frightened, could this be cancer?

Dear Visitor:

Thank you for contacting us with your inquiry. Abnormal mammograms cause lots of concern, and any abnormality has to be addressed until here is a clear explanation for it. Having said so, immediate biopsy is only necessary when there is significant concern about potential malignancy. Did you have a repeat mammogram with compression technique? Sometimes mammograms can show a "density" that is actually a superimposition of smaller, benign areas. Think about looking down in an aquarium. If many fish are all in a line at different depths, they may look like a big fish. If something makes them move to the sides, then you see there are multiple small fish and not a big one. Compression technique makes densities that are aligned in a regular mammogram to spread to the sides. If a compression mammogram was done and was still abnormal, biopsy should be considered. Whether to proceed with biopsy would depend on the type of abnormality, size, and to a lesser degree family history of breast cancer.

A dedicated MRI of the breast may also help differentiate between a benign and a malignant process. You must discuss these issues with the breast surgeon to decide whether a biopsy is needed right now, or whether you want to first have MRI, or wait four months after the first mammogram and then obtain a repeat one before committing to biopsy.

The good news is that a needle biopsy will not disrupt normal tissue in such a way as to prevent good visualization in subsequent mammograms. Also, neither biopsy nor surgery put you at higher risk of cancer.

I hope this helps you. Please feel free to contact us with any other questions you may have.

Sincerely, Jorge Spinolo, MD, FACP

Dear Doctor:

Since 1 1/2 yrs ago I have been going for mammogram every 6 months.The doctor was watching an area. Now they are telling me I have two areas of calcification deposits consisting of three deposits each. I realize they can be cancer, or cancer can be hiding behind the deposits. My mother has had 2 different types of breast cancer. I am very concerned, should I just go ahead and ask for biopsy on both of these areas. 1991 a tumor was removed but not cancer from same breast. There is also a cyst in this breast 3mm. Thanks for any help you can give me and what is your location of office.

Dear Visitor:

Breast calcifications are usually benign, but can sometimes represent cancer. If the calcifications are changing over time, or if they appear “suspicious” according to the mammographer, then a biopsy is sometimes recommended. As a medical oncologist, I do not interpret mammograms or determine when and if a breast biopsy should be done. I think that a breast surgeon or mammographer would be the best resource for you, since they could review your mammograms and give you advice regarding the need for biopsy. Here is a list of our office locations. Kristina Bowen, MD.

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Dear Doctor:

My Wife was Diagnosed 5 years ago with Inflammatory Breast Cancer.  Treatment was 3 months Chem, followed by Modified Radical Mastectomy left breast, then 30 radiation treatments to the areas and then another 3 months od chemo consisting of Taxatere, and Herceptin.  Finished treatment 4 years ago last May.  During that four years all cancer markers, all scans showed normal.  Last September she developed a harsh dry cough that would not go away.  She received a round of antibiotics and our family doctor sent her for a CT scan of her lungs which revealed an abnormality in the right lung.  Needle biopsy showed breast cancer in the right lung.  Diagnosis:  Metastized breast cancer stage IV.  Her2 was estrogen positive and she is now on Aromosin hormone therapy.  No one will give us any idea of what to expect in the future in the way of progression of disease  or treatment to expect.  Any information you might share with us would be greatly appreciated.  Thank you.

Dear Visitor:

I'm sorry to hear of your wife's recent difficulties.  Regarding prognosis, breast cancer is very unpredictable and it can be hard to guess how any one patient will do.  Some women with stage 4 breast cancer do poorly, but many women do quite well and can live for a number of years.  Many treatment options are available to help relieve symptoms and to help patients do better and live longer.  These treatments include hormonal medicines (such as aromasin), herceptin, and many types of chemotherapy.  Her oncologist may be able to give you more specifically an idea of what to expect in your wife's case. Good luck to her.

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Dear Doctor:

I have felt a lump in my breast, however, I do not have insurance to cover a mammogram. Do you know of any resources to help me pay for a mammogram?

Dear Visitor:

Thank you for accessing the Georgia Cancer Specialists website. The Cancer Screenings in which Georgia Cancer Specialists participates are being done every other year, due to their high cost. Therefore, none are scheduled at our offices this calendar year.

If you have a lump, you should be seen as soon as possible. Low cost mammograms can be funded through Bosom Buddies, a program of Georgia Cancer Foundation. You need to have a doctor's exam in the past three months and a doctors order, however, the mammogram can be done much sooner than 6 months. More information on this program can be found at http://www.gacancerfoundation.org/bb/mammo2.html

I hope this helps, and please seek attention as soon as possible.—Wendy Hawke, MD

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Dear Doctor:

I am 31 years old with a history of breast cancer. After a CT scan and biopsy last month I found out the cancer returned to 3 lymph nodes in my chest. My doctor is using hormonal therapy to treat my cancer at the moment. I take the Lupron shot once a month and Arimedex every day. My question is: Is chemotherapy and radiation treatments the better option or is hormonal therapy the way to go?

Dear Visitor:

When breast cancer has spread to areas outside the breast, then the decision about how to treat it depends on a number of factors, including: how sick or symptomatic the patient is, where else the cancer has spread, and whether the cancer is the type that might be responsive to hormonal treatment. If the cancer is the type that may be sensitive to hormones, and if the patient is feeling relatively well and doesn't have a lot of symptoms, then hormonal treatments such as lupron and arimidex are great options. If someone has more extensive cancer or has the type that isn't sensitive to hormones, then chemotherapy may be a better choice.

It's hard to generalize about breast cancer treatment since it depends so much on the individual patient and the exact type of cancer. If you're unsure about your treatment, I encourage you to see a physician who can review your exact situation and pathology and radiology studies, and make recommendations based on them. Kristina Bowen, MD.

Dear Doc,

My older sister has been diagnosed with breast cancer. So far she completed six months of chemotherapy treatment. She, most recently, had a lumpectomy because her surgeon told her that a mastectomy was not necessary. A week after that her surgeon said that she needed to go back in to get a very small remnant of damaged tissue. A week after that surgery the surgeon told her that she had to go back in again to remove the cancer causing agents. Still, the surgeon said that a mastectomy was not necessary.

What I do not understand is when the surgeon says that if my sister gets a mastectomy then there is only a 90% chance that cancer will not form in some other part of her body. What does the cancer that was found in her left breast have to do with the rest of her body especially when they removed the cancer and they are in the process of removing the cancer agents?

Dear Visitor,

Thank you for contacting us with your inquiry. The management of cancer of the breast has two goals. First, the breast has to be treated in its entirety. This can be achieved either by removing the whole breast (mastectomy), or by removing all visible tumor (lumpectomy) and then giving radiation to the rest of the breast. This is necessary because small areas of cancer may be present outside of the region of the visible cancer. The combination of partial breast resection and radiation is as effective as mastectomy at curing breast cancer. Rare patients who have the former may experience recurrence in the breast that will need mastectomy. So, the choice is between mastectomy, which eliminates the concern about recurrence in the breast and only needs one treatment (but a much more mutilating one), or partial resection and radiation, which preserves the breast but involves six weeks of radiation and a small chance of needing a mastectomy later on.

Second, even small breast cancers may seed into the bloodstream and form metastases. This is a grave problem because metastatic cancer is incurable. The risk of not being cured with surgery alone varies and depends on the size of the breast cancer, whether it seeded to the axillary lymph nodes or not, and whether it is more or less aggressive. If I understand correctly, your sister received chemotherapy after the surgery. The goal of the chemotherapy is to kill cancer cells that had already spread outside of the breast before surgery.

I hope this clarifies your concerns. Please feel free to contact us if this is not the case, or with any other questions you may have.

Sincerely, Jorge Spinolo, MD, FACP

Colon

Dear Doctor:

I have a cousin that was diagnosed with colon rectal cancer. A cat scan was done which showed 8 nodules on his liver out of the 8, 2 of them were cancerous.  He had surgery removing a portion of the colon and rectum.  He did not require a colostomy bag but his physician has stated he must have chemotherapy.  What are his other options and how severe is the progression of the cancer since only 2 nodules were cancerous?

Dear Visitor:

Colon cancer that has spread to the liver has traveled outside of the colon itself and the surrounding lymph nodes.  This is called Stage 4 (or metastatic) disease.  The standard recommendation is for chemotherapy, as this can extend survival for patients with advanced cancer.  The chemotherapy options available for colorectal cancer have increased in the last few years, and include newer drugs called targeted therapies. 

If the cancer has traveled to the liver as the only area of spread, sometimes the possibility exists for surgical removal of the tumors in the liver.  It depends on how many of the nodules are cancerous, and where they are located in the liver.  The surgeon who performed the operation may be able to advise you on that issue.  Typically chemotherapy is still given after removal of the nodules.

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Dear Doctor:

Can you tell me a little bit about colon cancer screening?

Dear Visitor:

The National Cancer Institute (NCI) conducted a national survey (1999-2000) to identify the practices and beliefs of PCPs on colon cancer screening. Although 98% of 1,235 PCPs surveyed recommend colon cancer screening, <20% believe that 75% of their patients have been screened appropriately. NCI concluded that although awareness of colon cancer screening is high, there are knowledge gaps regarding the timing and frequency of screening.(1)Additionally, suboptimal screening delivery was evident in this PCP population.

Barriers to colon cancer screening include lack of time to educate patients and to facilitate decision-making, competing demands placed on physicians, and the need to manage acute problems. Patient barriers include lack of knowledge about colorectal cancer and fears of cancer and screening tests.(2) The U.S. Preventive Services Task Force, the American Cancer Society, and the American Gastroenterological Association recommend that men and women at average risk for colon cancer begin screening at age 50 (approximately 75% to 80% of colorectal cancers occur among people at average risk).(3)

1. Klabunde CN, Frame PS, Meadow A, et al. Prev Med. 2003;352-362.
2. Zapka JG, Lemon SC, Puleo E, et al. Ann Intern Med. 2004;141:683-692.
3. Winawer S, Fletcher R, Rex D, et al. Gastroenterology. 2003;124:544-560.

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Dear Doctor:

I have had colon cancer and understand there may be an artificial bowel sphincter or closing for the ostomy. Can you tell me more?

Dear Visitor:

Thank you for contacting us with your question. The artificial bowel sphincter is a device that is used in patients who are still passing stools via their rectum but have trouble with incontinence. It cannot be adapted to a colostomy. There is work going on in Europe and the US to create a muscle sphincter for colostomies, but to my knowledge this has only been done in dogs so far. Hopefully this procedure will become available for human beings in the near future. Currently, there are techniques of colostomy irrigation and colostomy plugs which can markedly reduce the need for a colostomy bag; I would recommend you discuss them with your ostomy specialist. You can also find out more about them at this site.—Jorge Spinolo, MD, FACP

Kidney

Dear Doctor:

My husband had one kidney removed due to cancer. He is fine but his levels of urea nitrogen (BUN) and creatine levels are high. 29 and 1.7. His remaining kidney is functioning properly but these high levels concern me.

How does nutrition effect a person with one kidney?

Dear Visitor:

I am glad to hear that your husband is doing well.  Renal cell cancer usually does not affect renal function to the extent it would affect his nutritional needs.  Since his kidney is functioning properly I would not be alarmed by the BUN and Creatine levels.  However, if he develops a decrease in renal function requiring dialysis a dietary restriction would be in order. You could then contact a dietitian specializing in renal nutrition by going to the website of the American Dietetic Association www.eatright.com and using their “Find a Dietitian” feature or contacting a dialysis center associated with the local hospital.

In the meantime he should eat more plant foods, maintain healthy weight, exercise and avoid additional herbal supplements.  Since his kidney function is decreased herbal supplements may be unsafe because the body may have difficulty clearing them.  Always check with his physician before adding additional supplements, vitamins, or medicines to his regime.

Lung

Dear Doctor:

A very close family relative has recently been diagnosed with secondary bone cancer. Her primary cancer is in the lung. She has now been given between two weeks and two months to live. She is being offered radiotherapy but chemotherapy is being ruled out. Could you possibly explain this treatment regimen a bit? Are there any alternative therapies we could attempt?

Dear Visitor:

The standard of care for the treatment of advanced (metastatic) lung cancer to the bone(s), is usually a combination of Radiation and Chemotherapy, according to the location of the primary and secondary tumor(s). Radiation is for local control of the bony disease and chemotherapy for control of other sites, most likely present in a situation like this, and also to help control the disease in the bone.

The treatment can be delivered on a clinical trial (we have at least three clinical trial options that may apply), or off clinical trial, meaning regular therapy available in the market that is considered state-of-the-art.

The final decision about the utilization of the therapeutic resources depends on the evaluation of the patient by the attending physician. We would be happy to see and evaluate the patient at one of the GCS locations that is most convenient for the patient and the care givers.

Dear Doctor:

My father recently had three abnormal spots on his lung. One was read as 2.5 cm in size, then three other were much smaller at 3 mm and were "noncalcified". The lung doctor recommend a procedure called VATS, which would mean they do surgery on his lung to remove the large nodule. Is this the right step?—Concerned Daughter.

Dear Visitor:

I very much concur with the treatment recommendation, as long as your father has a good lung function and no significant health conditions that increase his risk of surgery. A 2.5cm, irregular nodule in the lung needs to come out. The same intervention is done to diagnose what the tumor is, and at the same time, surgically removes it as the treatment. The smaller, non calcified nodules need to be watched, but nothing needs to be done about them at this time. VATS thoracotomy is a very safe and well tolerated procedure with a fast recovery (3-4 days) if no complications, and with much less pain. Those considerations are important in an elderly patient for faster recovery and fewer complications. I hope this helps in making your decision and best of luck to your father. Rodolfo E. Bordoni, MD

Dear Doctor:

One of my parents was recently diagnosed with large cell lung cancer. We want it to be removed. Will surgery cure her? What are the next steps?

Dear Visitor:

Large cell lung cancer can be treated successfully with surgery if it a) has not spread to the lymph nodes in the center of the chest or outside the chest and b) it is not attached to the heart, the windpipe, or a large vessel and does not cause pleural effusion (fluid around the lung) and c) the patient's risks from surgery are not too high due to heart, lung, or other problems.  A PET/CT and examination of the patient, including lung and heart function are needed to decide whether surgery is appropriate or not.  Patients should be seen by a primary internal medicine doctor, cardiologist (heart doctor), or pulmonary (lung) doctor.

Nutrition

Dear Doctor:

My mom, who is 71, is in the Hospital with AML. Can you make any recommendations in terms of her diet? She is on a low-bacteria diet but I'd also like to know if there are certain things she should be getting (green tea, broccoli) that can give her a boost in health and whether there are other things (sugar, caffeine) that she should avoid other than the “usuals” on the low-bacteria diet.

Dear Visitor:

I'm glad you're interested in nutrition as an important component of your mother's care. I would recommend that she have a complete nutritional assessment by a registered dietitian who can make suggestions specifically for her nutritional needs. She can ask to meet with one of the Emory dietitians or speak with her physician who can request a nutrition consult.

Most importantly I would want to make sure she is getting adequate calories (energy from foods to help maintain her nutritional status) and protein (helps to repair damaged tissue and make new tissue). These exact amounts can be determined by her dietitian. Often times patients are also facing side effects of their treatments and may have difficulty meeting their needs. If she is having difficulty eating it may be easier for her to eat small meals 5 or 6 times a day rather than 2 or 3 large meals.

Unfortunately, there is no one “power” food to help build her energy or immune system, but it is important for her to get vitamins and minerals through a variety of foods.

The idea that sugar feeds cancer is a myth. We get energy to our cells from glucose (a component of sugar). When you think of this literally, since sugar gives cells energy, this does include cancer cells. However, even if you restrict all sugar from diet (which is not a good idea), your body will go through alternative processes to break down fat and protein to make glucose for cells to have energy. So, sugar does not cause the cancer to worsen and I do not suggest avoiding carbohydrates or sugar, but I would recommend a balance of carbohydrates (especially complex carbs like fruits, vegetables, and whole grains), in addition to protein and fat.

As far as caffeine, I have not seen any studies suggesting a link between caffeine consumption and increase risk of cancer or increased risk of recurrence.

Good luck to you and your mom with your journey. I commend you for looking for all options to help optimize her overall care.

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Dear Doctor:

What foods should a person with liver cancer eat?

Dear Visitor:

The foods a person with liver cancer should eat depends on many factors.

1. Is the person taking chemotherapy and/or radiation? Has he / she lost weight?

If so, protein and calorie needs typically increase. Including high calorie, high protein foods such as peanut butter, nuts, wheat germ, yogurt, whole milk, and lean meats and fish can help meet these needs. Nutritional supplements high in calories and protein may be beneficial (such as Ensure, Boost, Carnation Instant Breakfast) or homemade shakes. Smaller, more frequent meals are usually tolerated better, especially if the person is retaining fluid in the area around the waist.

2. Is the person retaining fluid?

This is often a symptom of a person with liver disease. If so, high sodium (salt) foods should be limited to reduce fluid retention. High sodium foods include processed meats and cheeses, canned soups, soy sauce, pickles, buttermilk, and frozen convenience type foods. You can limit sodium by choosing fresh foods as much as possible or choosing the low-sodium variety of foods. Read food labels for sodium values. A food with greater than 150 milligrams of sodium per serving is considered a high sodium food.

These are general recommendations. I would not feel comfortable making more specific suggestions without knowing the patient better. I would suggest locating a Registered Dietitian (RD) in your area who could be of help. You can do this by linking to the American Dietetic Association's web site http://www.eatright.org/Public/index_7684.cfm, where you can type in your zip code to locate an RD in your area. Bethany Smith, RD, LD, CDE

Prostate

Dear Doctor:

I have a PSA screening every 3–6 months. The range has been from 3.5 to 4.9 with the % of free PSA ranging from 10-17%. I have a digital exam every 6 months which is always normal. My urologist is satisified that we do not need to proceed with any biopsy. I am 64 and have no symptoms. I know some urologists are more aggressive in their approach to treatment. What is your opinion?

Dear Visitor:

It sounds as if you are being followed closely and appropriately. If your PSA values have been fluctuating, I feel your current surveillance is adequate. If, however, there has been an upward trend in PSA (or downward trend in free PSA), you and your urologist might want take the next step with prostate ultrasound and possibly biopsy. I would suggest you discuss with your urologist and if the response is not satisfactory consider a second urology opinion. J. Bancroft Lesesne MD.

Smoking

Dear Doctor:

I know people that have stopped smoking and still develop lung cancer. Is there any thing like vitimans, detox or any treatment you can do to try or aid in repairing the damage?

Dear Visitor:

It is true that a person can develop lung cancer after having quit smoking.  Once they quit, their chance of developing lung cancer goes down, and the longer they have stopped smoking the smaller their chance is that they will develop lung cancer, but their chance will always be higher than someone who has never smoked at all.

Unfortunately, there are no vitamins or medicines that a person can take to protect themselves from getting lung cancer. As you can imagine, there is a great deal of interest among scientists in this topic and you may have heard about various substances being tested, but so far nothing has been identified.

For many years there was a lot of interest in the beta-carotene vitamins as a way to repair the lungs or protect against lung cancer but several very good scientific studies have shown that these vitamins offer no protection at all. Quitting smoking is still the number one way to decrease the chance of getting lung cancer.

There are two web sites I would like you to take a look at that might answer your questions more thoroughly. One is the American Cancer Society web site at www.cancer.org. Select “Cancer Prevention & Early Detection” then on the next screen select “Cancer Prevention". On the right hand side a box titled “Getting More Specific” will appear and you can select Lung Cancer.  You will then see several articles listed, one of which is “Can Lung Cancer Be Prevented?"

On the same site there is another section that talks about your chance of getting lung cancer once you have quit smoking. On the home page select “Quitting Smoking” (its listed under the “Health Information Seekers” section). On the next page select “Kick the Habit” then select “Reasons to Quit", then select “How the Body Recovers over Time."

For more detailed information about the studies looking at vitamins for lung cancer prevention, go to http://www.cancer.gov/cancertopics/prevention-genetics-causes/lung. This is the National Cancer Institute section on Lung Cancer Prevention.  You will see lists of articles on this topic and can select whether you want articles written for health care professionals or the general public.

Vulva

Dear Doctor:

I have a sister that has just been Diagnosed with Vulva Cancer. They have to do a total Vulvectomy. How long before they will be able to do reconstructive surgery? Is this hereditary? What is the percent of death due to this type of cancer?

Dear Visitor:

Vulvar Cancer represents 4% of cancers of the female genital tract. There will be 4000 new cases of vulvar cancer diagnosed in the US this year but only 800 deaths from vulvar cancer. The risk factors for vulvar cancer include cigarette smoking, a prior history of cervical cancer, infection with the Human Papilloma Virus and Northern European ancestry. Vulvar cancer is often detected in early, asymptomatic stages during an annual gynecologic examination. It may also present as a painless nodule, a mass or an ulcer and can often be associated with pruritis (itching). The most common type of vulvar cancer is the squamous cell type which accounts for more than 90% of the cancers. Other types of vulvar cancer exist and include adenocarcinoma, melanoma, sarcoma,basal cell cancer, and Paget's disease. The exact surgical procedure depends on the site, size and type of vulvar cancer. If the tumor has spread deeply in the tissues, removal of the lymph nodes in the groin will be necessary. Patients with positive lymph nodes(tumor filled) will require radiation therapy. Some patients will also require chemotherapy to potentiate (improve) the outcome of radiation. Reconstruction will typically be delayed until after radiation for a minimum of 3-6months.

Until the pathologist has examined the tumor and the surgical specimen the presence of lymph node involvement can not be accurate. It is the pathologic stage that determines survival. Survival statistics are recorded for women with the squamous cell tumor types. In women with Stage I disease (no lymph node involvement) survival at 1 year is 98% and at 3 years 86%; Stage II (involved lymph nodes) Survival at 1 year is 88% and at 3 years 62%; Stage III tumor involves lymph nodes and other local organs such as anus, rectum, urethra survival at 1 year is 74% and at 3 years 40%; Stage IV tumor has spread through the bloodstream to other organs such as bone, lungs, liver survival at 1 year is 48% and at 3 years is 21%.

Due to the nature of the surgery, it is advised that patients receive some psychosocial/sexuality counseling as part of their recovery/reconstructive surgery.

Cheryl F. Jones, MD

Dear Doctor:

I have chronic pain in my vulvular area. I have seen many specialists, however, no one seems to know how to help. Could I have cancer?

Dear Visitor:

The medical term for vulvar discomfort or pain is Vulvodynia and can occur the absence of visible infectious, inflammatory or neoplastic findings and in the absence of a specific clinically identifiable neurologic disorder. It is also described as a burning pain.

At Georgia Cancer Specialists, we have patients affected with vulvodynia due to prior cancer surgery, radiation therapy and estrogen deficiency syndromes. However, if you have suffered from chronic hypersensitivity and yeast infections, it is most likely that is the cause of your discomfort.

Since you comment that you have seen many specialists, I assume that you are currently without an infection and have been tested to rule out other conditions that could make you more susceptible to yeast infections and also contribute to the pain syndrome such as diabetes, interstitial cystitis,genital herpes, irritable bowel syndrome and fibromyalgia. Once all treatable and contributing factors are addressed, it often requires a combination of therapies and I strongly recommend counseling and emotional support to be included to medical therapies.

It is important to note that a treatment may not be effective for weeks to months and complete resolution may not occur. Treatment recommendations and strategies can include good vulvar hygiene, ointments are better tolerated than creams, cool packs are sometimes helpful for short-term soothing; medications such as tricyclics or Lyria for the neuropathic pain and occasionally an analgesic will need to be combine while awaiting the effect of these antidepressants on neuropathic pain.

Topical estrogen and topical lidocaine can be utilized in combination if not contraindicated with ral medications. Physical therapy is often utilized back pain and muscle spasm are associate symptoms and can included exercise, pelvic floor muscle retraining and therapeutic ultrasound. Measures such as biofeedback and relaxation techniques are helpful for some women. Topical corticosteroids and topical antifungal medicines tend to be ineffective.

I hope this information helps and that you find relief soon.

Cheryl F. Jones, MD

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Dear Doctor:

My girlfriend has been treated for dry skin and some bleeding of her vulva area for the past 3 years. She recently changed doctors and this doctor thinks it might be cancer. She goes in for a biopsy next Monday. Could this be something else. Are there other condition that have these symptoms?

Dear Visitor:

If your friend has never had a biopsy before, it is important to perform one not only to establish a diagnosis, but to identify the most important treatment. Although cancer (malignancy) should always be considered initially because of the importance of early diagnosis, the fact that the dry area has been there a while, especially if it has not changed significantly, can lead one to suspect a benign condition. Other lesions can be precancerous and require special surveillance or management. There are also infections, often viral, and other conditions that have more specific therapies that can result in improvement of her discomfort. Please encourage her to have the biopsy and feel free to re-contact GCS with the results if you have more questions. Cheryl F Jones, MD.

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Dear Doctor:

Approximately 6 years ago, I had a biopsy of vulvar lesion during a routine gynecology exam.  I am a RN and looked up the path report which to my surprise showed squamous cell carcinoma in situ of the vulva.

My gynecologist never notified me of the results and I never pursued any other testing assuming everything was OK.  I have another perianal lump (small but new) which I am going to have examined soon and would like to have more information about vulvar cancer, recurrences, treatment advice in the event that this is a recurrence of the cancer.  The first lesion had ulceration and was causing some pain with urination, etc. and this lesion has not advanced to this point but appears to be a nevus-type  which was how the first lesion was initially.  Should I have had or should I have now some sort of wide excision, or other testing at this point?

Dear Visitor:

I agree that the new lesion should be removed.  Further management will depend on findings.  Fortunately, only 4% of women with VIN (vulvar intraepithelial neoplasia, the current name for carcinoma in situ) will develop invasive vulvar carcinoma, so the odds are fairly good that the current lesion will not be invasive.  The management of VIN is simple excision, as you had in the past.  If a new area is found at this time it should  be excised as well, and the Gynecologist should perform a meticulous exam of the vulva to make sure there are no other areas.  Invasive carcinoma is treated with surgery.  Smaller tumors can be treated with wide excision (2 cm margin) followed by radiation.  Larger tumors usually need more aggressive surgery, but your description indicates that this is a small lesion.

Other

Dear Doctor:

I'm a student nurse in Belgium and I'm writing a paper about cancer-related fatigue. I've read your web site, and it has helped me a lot. However, I was wondering if you could help me to get some more information on the subject.

Dear Visitor

Cancer-related fatigue is definitely a hot topic right now. There are many resources and studies available on the internet. Here are a few reputable web sites I would recommend to assist you in writing your paper:

• Oncology Nursing Society's fatigue management information
• They also manage a cancer fatigue web site
• National Library of Medicine database

Here you will find abstracts of studies by searching under “cancer-related fatigue.” Most abstracts will provide a link to the journal where the study was published, but they often charge a fee to access those. I'm not sure how the system works in Belgium, but if you have access to a public, university, or hospital library, they may be able to access the full articles for you for a small fee, or even no charge.

• National Cancer Institute cancer fatigue information
• American Cancer Society cancer fatigue information

The American Cancer Society provides treatment guidelines from the National Comprehensive Cancer Network.

Most of these sites are from organizations in the United States and are reputable resources for cancer-related fatigue information.

Dear Doctor:

My mother is 86 years old, has been diagnosed with colon cancer, and the doctor has encouraged us to consider chemotherapy. She is in good health now, however, wouldn't the chemotherapy itself harm her more at her age?

Dear Ma’am:

Thank you for contacting us with your inquiry. The first step in deciding the risk versus the benefits of any therapy is to understand how aggressive the cancer may be. In many cancers, chemotherapy can really add time to people's life, and that time can be quality. However, each person is different and the decision must be made with the person and their doctor.

It is good to know that your mother is in overall good health. Chemotherapy would cause more harm than good in a frail patient. Also, there is some chemotherapy that is more effective, however, usually at the cost of being more toxic than others. In an 86-year-old patient, I would not recommend use of the more toxic ones.

The following numbers will give you some idea of the potential risks and benefits:

• Average survival for an 86-year-old female (without cancer): 6.5 years; 57% will live at least 5 years and 23% will live for 10 years.
• Chance of cancer returning at five years: 53% with surgery alone; 35% with relatively mild chemotherapy.
• Chance of severe complications from chemotherapy requiring hospitalization: about 20%
• Chance of death related to chemotherapy: 4%

As you can see, it is in general a better decision to give chemotherapy if one wants a chance at a longer life, since there is a benefit in about 12%, however, this must be weighed against a 1 in 25 chance of actually decreasing life expectancy by the use of chemotherapy due to its side effects.

Of course, these are all average numbers, and each individual case is different. All these factors must be considered and discussed with your oncologist to help decide the best course of action for your mother.

Please feel free to contact us with any other questions you may have. Sincerely, Jorge Spinolo, MD, FACP

Dear Doctor:

I am a prostate cancer patient who received radiation five years ago. My PSA dropped to 1 from a high of 19. Recently, my PSA rose to 7.5 and a bone scan showed a spot. Does this mean the cancer has spread and what should I do?

Dear Sir:

Thank you for contacting us with your inquiry. I'm sorry that you are experiencing additional problems. If you are not having a urinary infection (which can cause the PSA to rise), the higher-level PSA most likely indicates that there is some active prostate cancer in your body. It is difficult to determine if one area on the bone scan represents a tumor area, however, the fact that the PSA is high means that cancer cells are somewhere in your body. The standard of care in this situation is to start hormone injections, since that will treat cancer everywhere in the body, not just in the spot seen in scans.

The outcome of hormonal therapy for prostate cancer is usually good in that the cancer is controlled in almost all patients. However, unfortunately, prostate cancer is not curable once it has come back outside of the prostate.

The duration of control with your current therapy is usually measured in years, but there is wide individual variation depending on multiple factor including the place where the scan is abnormal, the Gleason score in the original prostate biopsy, and the speed at which the PSA has risen. Please feel free to contact us with any other questions you may have. Sincerely, Jorge Spinolo, MD, FACP

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