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    Learning About Your Health

    Patients' Frequently Asked Questions (PFAQ): Cancer

    Breast Cancer

    Am I still at risk for breast cancer if I have no history of it in my family?

    Only 10-15% of breast cancer cases are associated with a defined family history. Most cases of breast cancer occur in the absence of a family history. Breast cancer becomes more frequent with increasing age. Other factors that increase a woman's risk of developing breast cancer include: older age at first pregnancy or no pregnancies, progestin-containing hormone replacement therapy after menopause, and increased alcohol consumption.

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    What is meant by “high risk” breast cancer?

    The term "high risk" describes a breast cancer that has a greater chance of spreading to distant body organs such as the bones, liver, lungs, or brain (these are referred to as metastases). Factors that place a woman in the high risk category are: larger size of the primary breast cancer, the presence of cancer cells in the underarm lymph nodes, or certain characteristics of the cancer cells.

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    How does the physician decide between chemotherapy and radiation therapy after breast cancer surgery?

    Chemotherapy involves the use of medications to treat possible microscopic cancer cells that might still be present in tissues distant from the breast. It is most commonly used when the primary breast cancer is felt to be "high risk." Radiation therapy is used to prevent a recurrence of cancer in the remaining breast tissue after a lumpectomy. After a mastectomy (total removal of the breast), radiation is sometimes used if the cancer was large or if several underarm lymph nodes contain cancer.

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    What is the difference between chemotherapy and hormonal therapy?

    Chemotherapy refers to a group of anti-cancer medications that work by attacking the cell machinery that allows cells to divide, grow, and spread. Most chemotherapy medications, though not all, are given intravenously (in the vein). Chemotherapy is administered in cycles (over a certain number of weeks), and not every day. Hormonal therapies require the presence of specific receptors (binding sites) in the cancer cell for estrogen and/or progesterone in order for the treatment to work. Most hormonal therapies are medications taken daily in pill form. A breast cancer that has neither estrogen or progesterone receptors will not respond to hormonal therapy.

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    What is Herceptin® and when is it used in treatment?

    Herceptin® (Trastuzumab) is a monoclonal antibody treatment that can be used in approximately 20% of breast cancers that have increased numbers of a receptor called HER-2/NEU (also referred to as "over expression of HER-2/NEU"). Herceptin® is an intravenous treatment that can be given either by itself or in combination with chemotherapy to treat metastatic breast cancer. Research is taking place to see if Herceptin® is helpful in the treatment of early breast cancer before it has spread to distant sites.

    Authored By: Kathleen Grant, MD
    Reviewed By: Stephen Hufford, MD

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    Radiation Therapy

    What is Radiation Therapy?

    Radiation Therapy is the delivery of treatment using radiations from natural or artificial sources to treat disease, most often cancer. Natural sources include Cobalt-60, Iodine-131, Iodine-125, Gold-189, and isotopes or other variants of other elements as well. Radiations are produced or emitted by these elements and are used like x-rays. You may see them referred to as gamma rays when they are from naturally occurring sources as opposed to x-rays which are from artificial sources, or are particles like electrons, protons, and other subatomic particles.

    Artificial sources are linear accelerators or other machines which produce highly penetrating x-rays. These radiations are shaped and/or combined to provide the best treatment for the patient's disease in which they are used. In the treatment of cancer, radiation therapy is frequently coordinated with other treatments, such as chemotherapy and/or radiation and/or surgery. This is called combined-modality treatment.

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    What is Radiation Oncology?

    Radiation Oncology is the medical specialty in which physicians are trained to use radiation therapy in the treatment of diseases. Physicians, who are trained in this specialty, are called radiation oncologists.

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    What is a Department of Radiation Oncology?

    A Department of Radiation Oncology consists of radiation oncologists and staff members who are specially trained in the delivery of radiation treatment, including medical physicists, medical dosimetrists, and therapists. Other staff members who help care for patients undergoing radiation treatments include nurses, dietitians, social workers, and counselors. These staff provide specific assistance to patients, as needed, to help them successfully complete the course of treatment. Also, there are receptionists and administrative assistants who help patients make their way through the process of initial evaluation, treatments, if indicated, and the follow-up process after treatment.

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    What is the role of medical physicists in the Radiation Oncology Department?

    Medical physicists assure the safe and accurate delivery of radiation treatments. They maintain and calibrate treatment equipment and participate in the implementation of new treatment techniques and methods, including radiation treatments which may be given in other areas of the hospital, such as patient rooms, operating rooms, and the cardiac catheterization laboratories.

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    What is the role of medical dosimetrists in a Radiation Oncology Department?

    Medical dosimetrists do the calculations and computations that are needed to deliver the complex, precise, and accurate radiation treatments needed to achieve the best results with a minimum of side effects for the patient.

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    What is the role of radiation therapists in a Radiation Oncology Department?

    Radiation therapists document and deliver accurate, precise daily radiation treatments, implementing the treatment plan for each individual patient. They assess the patient at each treatment and refer the patient to a nurse or the radiation oncologist for further assessments, if needed. Also, they assist patients with daily treatment schedules, if needed.

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    What is the competence of the treatment staff in the Department of Radiation Oncology?

    All treatment planning and implementation procedures are performed and/or supervised by staff that are credentialed and/or licensed by national and/or state certifying organizations. Periodic inspections take place by groups that are independent of the Department and the hospital to assure that these certificates and licenses are kept current.

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    What happens to me if I come to the Department of Radiation Oncology to be considered for treatment?

    Patients who come to the Department of Radiation Oncology to be considered for treatment first have a consultation with a radiation oncologist. A radiation oncologist is a physician who is trained in the use of radiation therapy in the treatment of patients' diseases. During the consultation, the radiation oncologist will take the patient's medical history, examine the patient physically, and discuss the possible role of radiation treatment in the patient's case. If, after discussion, the radiation oncologist and the patient elect to proceed with radiation treatment, they will then next schedule a planning session or simulation.

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    What is simulation?

    Simulations, or planning sessions, are procedures that a radiation oncologist and patient schedule prior to beginning a course of radiation treatments. At this session, members of the radiation oncology team make devices which allow the patient to be treated in precisely the same position for each treatment. Images are made and measurements are taken which permit the calculation and delivery of precise, accurate, individualized treatments. Occasionally, dyes or contrast materials are used as part of this procedure.

    Authored By: Daniel Glaubiger, MD, PhD
    Reviewed By: Mark Rounsaville, MD & Roy Abendroth, MD

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    Ovarian Cancer

    What is ovarian cancer? Are there different types of ovarian cancer?

    The term, ovarian cancer, is used to refer to a malignancy of the outer lining or epithelium of the ovary. The most common subtype is called papillary serous carcinoma because of the frond-like appearance microscopically. The second most common subtype is endometrioid. Mucinous and clear cell carcinoma are less common subtypes and tend to have a poorer prognosis. The terms, "ovarian carcinoma of low malignant potential" or "borderline carcinoma," refer to a process that is much more slowly growing, poorly responsive to chemotherapy, is treated primarily surgically, and has a better survival rate.

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    How does ovarian cancer spread?

    Most commonly, ovarian cancer spreads through direct contact with other tissues in the pelvis or by spreading through the fluid in the abdominal cavity. Also, it can invade lymph channels to spread through lymph nodes. Travel through the blood vessels is much less common but does occur and can manifest itself as liver metastases or malignant cells in a pleural effusion which is fluid around the lungs.

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    What is the cause of ovarian cancer?

    The causes of ovarian cancer remain poorly understood. One hypothesis is that an increased number of ovulations increase the risk of ovarian cancer. A second theory is that high chronic levels of pituitary hormones that stimulate the ovary (pituitary gonadotropins) can somehow lead to cancer. Both theories could explain why use of oral contraceptives and multiple pregnancies reduce the risk of ovarian cancer and why the use of fertility drugs with increased ovulations is associated with an increased risk of ovarian cancer in some studies.

    There may be genetic factors, as well. Inherited gene mutations, especially BRCA-1 and BRCA-2, are associated with an increased risk of both breast and ovarian cancer. A woman with a family history of either or both malignancies, including both mother's and father's family history, may therefore be at increased risk. Also, there are other genetic syndromes that have been described. The mechanism by which a gene mutation can lead to development of a cancer is poorly understood.

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    What is the CA-125 tumor marker?

    This is a substance that is made by ovarian epithelial cancer cells and can be measured in the blood. Eighty percent of advanced ovarian cancers will have an elevated CA-125. Other conditions, including endometriosis, menstruation, pregnancy, and liver disease, can also elevate the CA-125. Also, it can be elevated in other non-ovarian cancers, such as breast, lung, and colon cancer. Measurements of the CA-125 are especially useful in monitoring the response of a known ovarian cancer to therapy. An ovarian cancer that is responding or shrinking due to chemotherapy will have a dropping CA-125. A cancer that is progressing or growing will have a rising CA-125.

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    Why don't we screen every woman for ovarian cancer?

    First, it is not a very common cancer. With 27,000 new cases in the United States yearly, one would have to screen 2,500 women to find one case. Only 50% of early-stage ovarian cancers will have an elevated CA-125. Also, many non-cancer conditions can cause an elevated CA-125 (false positive). This group may then undergo multiple other tests, including exploratory surgery which can have serious risks and side effects. A second issue is that of frequency of screening. Each CA-125 test only provides data for the specific point in time at which the test was performed: test results do not predict whether a woman will have or will not have ovarian cancer in the future.

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    What is meant by the 'the stage' of ovarian cancer?

    Stage refers to the extent of the cancer at the time of diagnosis. Different stages have different prognoses. Stage I refers to cancer limited to the ovaries but also includes the presence of cancer cells in fluid in the abdominal cavity. Stage II indicates cancer that has spread to other areas of the pelvis. Stage III refers to cancer that has spread to lymph nodes or to surface tissues in the upper abdomen. Stage IV refers to distant organ involvement, such as the liver or the pleura of the lung.

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    What is the usual treatment for ovarian cancer?

    Most commonly, surgery is the first step in treatment. When ovarian cancer is suspected because of the presence of an ovarian mass, tests including a CA-125 blood test and a CT scan or MRI of the abdomen and pelvis are done. Most cases of ovarian cancer require removal of both ovaries, both fallopian tubes, the uterus, and the omentum (a fatty apron overlying the intestines), with additional biopsies of various abdominal lining surfaces including the diaphragm and biopsies of lymph nodes. Also, any fluid in the abdomen is sent for examination by a pathologist. These tests determine the stage of the cancer.

    Stage III and Stage IV ovarian cancers are treated with chemotherapy; the drugs carboplatin or cisplatin and paclitaxel are the most commonly employed drugs, usually for five to six months. There are many research studies through the National Cancer Institute or pharmaceutical companies testing new drugs or new combinations of available drugs. Women with Stage I or Stage II disease that is aggressive or high grade are also usually treated with chemotherapy after surgery to decrease the risk of recurrence.

    At times, the cancer may be inoperable when it is diagnosed. In this situation, chemotherapy is given for a few months or more as the first treatment step and the patient then proceeds to surgery when the cancer has shrunk.

    Authored By: Kathleen Grant, MD
    Reviewed By: David Minor, MD




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