Cervical cancer, breast, ovarian cancer and lymphedema

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Cervical cancer, breast, ovarian cancer

High cervical cancer rates sign of larger problems

Our Home Page: Lymphedema People

http://www.lymphedemapeople.com

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High cervical cancer rates sign of larger problems

July 22, 2005 06:08:26 PM PST

Despite overall declines in cervical death rates in the U.S., certain groups of women are significantly more likely to die from the disease, which is likely due to underlying disparities access to health care, according to a new report from the National Cancer Institute.

The investigators found that women living in areas with high death rates from cervical cancer were less likely to have a usual source of health care or to use preventive services, such as cancer screening.

These women also tended to have low income and education levels, and experienced relatively high rates of other diseases such as breast cancer, colorectal cancer and heart disease.

High rates of cervical cancer "are markers for a lot of other events," according to study author Dr. Harold P. Freeman, director of the National Cancer Institute's Center to Reduce Cancer Health Disparities in Rockville, Maryland.

Freeman added that all of the above diseases, like cervical cancer, can be screened for and treated.

In the case of cervical cancer, annual Pap smears help diagnose cervical cancer in its very early stages, when it can be very effectively treated, he said. It's a "cancer from which, presumably, no woman should die."

However, 4,000 women still die every year from cervical cancer, Freeman said, probably because, in part, they have limited access to services to detect the cancer in its early stages.

But to help reduce cervical cancer rates, experts also need to educate women about why it's important to be screened, and how to do it. "We need to couple education to access," Freeman told Reuters Health.

In their analysis, Freeman and his team reviewed the available study findings on cervical cancer rates in the U.S. and the circumstances of women living in areas where death rates remain high.

They found that cervical cancer death rates are generally declining in the U.S., but remain high among African-American women in the south, women living along the Mexican border, white women in Appalachia, American Indians in the Northern Plains, Vietnamese-American women, and Alaska Natives.

"These women tend to have a fragmented health care system," Freeman noted.

Freeman and his team summarize their findings in the NCI report Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities.

Previous research, also out of the National Cancer Institute, has shown that cervical cancer rates trended downward between 1975 and 2000, but women in high poverty counties had at least a one-third higher incidence than women in low poverty counties.

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Cervical Cancer Resources and Information

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National Cervical Cancer Coalition

http://www.nccc-online.org/

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Cervical Cancer - MedlinePlus

Information and Links Page

http://www.nlm.nih.gov/medlineplus/cervicalcancer.html

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Cervical cancer information centre

CancerBacup - UK

http://www.cancerbacup.org.uk/Cancertype/Cervix

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What Is Cervical Cancer?

American Cancer Society

http://www.cancer.org/docroot/CRI/conte ... ncer_8.asp

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Cervical Cancer

eMedicine

http://www.emedicine.com/med/topic324.htm

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Leg Swelling After Cancer

With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen.

Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs.

This swelling occurs because of one of several factors.

First, the swelling begins after lymph nodes have been removed for cancer biopsies.

Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system.

Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling beings.

This swelling is called lymphedema. The swelling that occurs is permanent, and while it is not curable it is treatable.

Permanent Leg Swelling

****In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered****

There are several groups of people who experience leg swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by.

Group One

This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.

Group Two

Another extremely large group that experiences permanent leg swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid.

In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries.

This is also referred to as secondary lymphedema.

Group Three

Group three consists of people who have leg swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.

The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later.

This type of leg swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system.

This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.

What is Lymphedema?

Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.

A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.

What are the symptoms of Lymphedema?

If you are an at risk person for leg lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.

1.) Unexplained aching, hurting or pain in the leg.

2.) Experiencing "fleeting lymphedema." This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown leg lymphedema.

3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the foot, or between the ankle and knee. This is an indication of early lymphatic malfunction.

4.) Any arm inflammation, redness or infection.

5.) You may experience a feeling of tightness, heaviness or weakness of the leg.

How is Lymphedema Treated?

The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment.

It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.

With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.

What are some of the complications of lymphedema?

1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient.

2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

Can lymphedema be cured?

No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.

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Your Body After Cancer Treatment

Lymphedema: Arm or Leg Swelling

Lymphedema is a swelling of a part of the body, usually an arm or leg, that is caused by the buildup of lymph fluid. It can be caused by cancer or the treatment of cancer. There are many different types of lymphedema. Some types happen right after surgery, are mild, and don't last long. Other types can occur months or years after cancer treatment and can be quite painful. Lymphedema can also develop after an insect bite, minor injury, or burn.

People who are at risk for lymphedema are those who have had:

Breast cancer--if you had radiation therapy or had your underarm lymph nodes removed. Your risk is even higher if you had radiation in the underarm area after your lymph nodes were removed.
Melanoma of the arms or legs--if you had lymph nodes removed and/or had radiation therapy.

Prostate cancer--if you had surgery or radiation therapy to the whole pelvis.

Cancer of the female or male reproductive organs--if you were treated with surgery to remove lymph nodes or had radiation therapy.
Other cancers that have spread to the lower abdominal area. The pressure from the growing tumor can make it hard for your body to drain fluid.

Full article: http://www.nci.nih.gov/cancertopics/lif ... ment/page5

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Cancer Resources and Information:

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Your Body After Cancer Treatment

http://www.nci.nih.gov/cancertopics/lif ... ment/page5

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Cancer Information on the Internet

http://www.hackley.org/medical_services ... _links.htm

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Cancer Resource Center

http://patient.cancerconsultants.com/li ... x?id=32333

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Cancer Lynx

http://www.cancerlynx.com/

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Cancer Information & Support International

http://www.cancer-info.com/

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Lymphedema

WHAT IS IT?

Lymphedema is a buildup of a fluid called lymph and protein in the tissues under the skin. Lymph accumulates when there is an obstruction to normal flow causing swelling, usually in an arm or leg. The lymph system is similar to the blood system in its network of vessels that carry lymph fluid throughout the body.

Trauma to lymphatic tissue by surgery or radiotherapy is the main cause of lymphedema in the context of cancer. It can result from surgery and/or radiation therapy during treatment for cancers of the breast, abdomen, melanoma, connective tissues (sarcomas) and the pelvic area, as well as lymphomas, in both men and women. Lymphedema may also be the result of infection, such as dermatophytosis in the foot.

Cancer tumors also can block the lymph vessels, especially in people with prostate cancer or lymphoma.

IF I HAVE CANCER WILL I DEVELOP LYMPHEDEMA?

Not necessarily. The most frequent cases occur in women with breast cancer; 10% to 25% of breast cancer patients will develop lymphedema. While most cases are mild, approximately 400,000 women cope daily with some degree of disfigurement, discomfort, and sometimes disability because of arm and hand swelling.

Because of improvements in radiation and surgical techniques (such as removing smaller samples of lymph nodes), lymphedema is less common today than it use to be. Lymphedema develops in about one in four breast cancer patients who have a mastectomy with lymph-node dissection. The risk doubles for those who also receive radiation treatments to the underarm area.

Radical prostatectomy, a procedure that removes the prostate gland, seminal vesicles and sometimes the nearby pelvic lymph nodes, can lead to lymphedema .One type of Kaposi’s sarcoma is called the lymphadenopathic form that can spread throughout the body and may aggressively involve lymph nodes, viscera, and occasionally the GI tract – resulting in a kind of lymphedema.

SENTINEL LYMPH NODE BIOPSY

If breast cancer spreads, it first goes to the lymph nodes under the arm. That's why women with breast cancer have these nodes examined. Until recently, surgeons would remove as many lymph nodes as possible, but this greatly increased the risk of lymphedema. More recently, a growing number of physicians have begun focusing on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to show evidence of cancer’s spread. Experts believe that if a sentinel node is removed and found to be healthy, then the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares as many as 75% of women who have no evidence of tumor spread to the axillary nodes the risk of complications, especially lymphedema.

WHEN DOES IT DEVELOP?

Lymphedema can appear any time after surgery or radiation treatment including many years later.

When the condition develops very soon after surgery, it is usually mild, and goes away within one to two weeks. It can also develop six to eight weeks after surgery or radiation. Again, this type of lymphedema usually goes away in a few weeks.

Unfortunately, the more common form of lymphedema in cancer survivors develops slowly over time. It may show up many months or even years after treatment ends and swelling can range from mild to severe. In most cases however, lymphedema appears between six and 12 months after treatment. While people who have many lymph nodes removed and radiation therapy have the highest risk of developing lymphedema, some high-risk patients won’t develop the condition.

WHEN TO CALL A PROFESSIONAL

Patients should contact a physician if they had a mastectomy, lower abdominal surgery or radiation treatments in the past, and the affected limb becomes red, painful or hot, or if it develops open sores or areas of broken skin. Doctors should be consulted especially if there is a fever in addition to swelling.

Diagnostic Tests

Usually, no specific testing is necessary to diagnose lymphedema, but tests may be done such as a blood count that can identify signs of infection. Ultrasound may be ordered to look for blood clots, which can cause swelling. Computed tomography (CT) may be used to find a tumor that could be blocking lymph vessels. In addition, there are more specialized tests that can identify lymph flow and lymph vessel abnormalities.

Symptoms

The first signs of lymphedema can be a change in a patient’s arms or legs or other affected area such as the groin. Initially, skin will remain soft, but if the problem continues, the limb may become hot and red and the skin hard and stiff. The lymph fluid that collects in the tissues can be very uncomfortable, but pain is not always present. Early symptoms of lymphedema may include:

A feeling of tightness around the arm on the area that was treated for cancer,

Decreased flexibility in a hand, elbow, wrist, fingers, or leg,

Difficulty fitting into clothing,

Tight fit of a ring, wristwatch, bracelet, or shoe,

Weakness, pain, aching or heaviness in the arm, legs, or feet,

Skin that looks shiny, has fewer folds, and feels stiff or taut,

A dull ache in the affected limb,

A feeling of tightness in the skin of the affected limb,
Difficulty moving a limb or bending at a joint because of swelling and skin tightness,

Pitting (small indentations left on the skin after pressing on the swollen area)

In most cases, only one arm or leg is affected. If the leg is involved, swelling usually begins at the foot, then progresses upward toward the ankle, calf and knee.

Severity

The severity is directly related to the extent of surgery and radiation treatment to the lymph nodes. Severity and general risk of developing lymphedema seems to increase with obesity, weight gain and infection in the affected area.

TREATMENTS

Lymphedema has no cure so treatment focuses on reducing the symptoms. Treatment has varied from virtually no treatment to surgery, but there are various practical methods to deal with the condition, including elevation of the limb (in the first year only), compression garments (no greater than 20-30 mm Hg), certain types of massage and exercises, pneumatic compression devices (controversial), and other types of physical therapy. Experts also recommend keeping the affected limb clean, dry and lubricated.

The National Lymphedema Network (www. Lymphnet.org) encourages massage by an specially certified expert in lymphedema massage.. In many cases, patients can also be trained to massage themselves to improve the flow of lymph fluids.

Medications

There are no medications to treat lymphedema. Diuretics have been found to be ineffective and may actually exacerbate the condition. Other medicines have been tried, but there is no clear evidence of significant effectiveness with any particular drug.

MILD LYMPHEDEMA:

Elevating the arm or leg above the level of the heart(during the first year) and flexing it frequently are basic methods to manage the condition. Since elevation is impractical except for short periods, patients should be fitted with an elastic sleeve, covering the arm or leg.

A significant reduction in edema (swelling) has been reported after wearing elastic sleeves for 6 consecutive hours per day. Using these garments during exercise, physical activity, and especially air travel is recommended, since air travel seems to exacerbate the condition.

If the legs are affected, avoid periods of prolonged standing. If working or standing a lot, a doctor may prescribe special graduated compression stockings to wear throughout the day. A doctor may also suggest a protein-rich, low-salt diet for those who are over-weight or obese.

MODERATE TO SEVERE:

For people with moderate to severe lymphedema in the legs, doctors prescribe pneumatic compression devices to be used at home to help reduce limb swelling. The “pneumatic stockings” are worn every day for an hour or two to reduce the swelling. Once the swelling has been reduced, a person may still need to wear elastic stockings up to the knee every day from the moment of rising until bedtime.

For lymphedema in the arm, pneumatic sleeves--like pneumatic stockings--can be used every day to reduce the swelling; elastic sleeves may also be needed.

Others recommend a special type of massage therapy called manual lymph drainage. Antibiotics also may be prescribed to prevent or treat infection in the affected limb. Since skin infections can be more serious in people with lymphedema, a person may need to have antibiotics administered intravenously in the hospital during an infection.

Complex Decongestive Therapy

More serious cases of lymphedema can be treated with Complex Decongestive Therapy by a physical therapist or other health care professional, who has special training. Complex Decongestive Therapy consists of skin care, massage, special bandaging, exercise, and fitting for a compression sleeve. Seeking and getting treatment early should lead to a shorter course of treatment to get the lymphedema under control. While most insurance companies will pay for this treatment, some do not.

Someone certified in the procedure should perform Manual Lymph Drainage (MLD).

In the case of lymphedema of the arm, the procedure involves a type of massage that moves built up fluid around the blocked vessels and across the chest to the other side of the body where the lymphatic system is still in tact. Usually the healthy area will be “worked” first. After each treatment, the effected area is carefully bandaged with a special layered wrap that looks like an ace bandage but is made of a different fabric. The wrap is important for keeping the effected limb de-congested. An average course is 15 daily treatments of 60 to 90 minutes each. After a MLD course of treatments, the patients will wear a compression garment every day. The patient should be measured for a new compression sleeve every six months or so. Sometimes a yearly MLD treatment course is recommended as a kind of “tune up.”

PREVENTING COMPLICATIONS

Because lymphedema development may occur even after several decades, patients should monitor themselves for signs of lymphedema and report any changes to their physicians.

Prevention is important and can require daily attention to manage the symptoms of swelling in particular. Arm and hand precautions are based on two key ideas: (1) Do not increase lymph production, which is directly proportional to blood flow, and (2) do not increase blockage to lymph system. Therefore, patients should avoid excessive heat, infections, and overly-strenuous arm exercises which would increase blood flow in the arm and thereby increase lymph production.

MANAGING LYMPHEDEMA

Patients should follow these suggestions to manage their lymphedema:

Avoid puncturing or injuring the skin in any way. Use first aid care if there is a break in the skin.

Avoid vaccinations, injections, blood pressure monitoring, blood drawing, and intravenous administration in the arm affected.

Avoid tight-fitting clothing or jewelry.

Avoid heat, such as with sunburns or tanning, baths, and saunas.

Avoid strenuous exertion, but do exercise while wearing compression garments.

Exercise, But Avoid Muscle Strain
It is important to use your affected limb for normal everyday activities, yet overuse can cause lymphedema to occur in some people. Follow these suggestions whenever possible:

Use affected arm or leg as normally as possible until fully healed, about 4 to 6 weeks after surgery or radiation treatment.

Exercise regularly but do not strain the arm or leg. Before any strenuous exercise, such as weightlifting or tennis, talk with a doctor, nurse, or physical therapist about specific goals and limitations to decide what level of activity is right. Ask if a fitted sleeve or stocking should be worn during strenuous activities or while flying.

If an arm or leg starts to ache, lie down and elevate it.

Avoid vigorous, repeated activities, heavy lifting, or pulling.

Watch for early signs of infection: rash, red blotches, swelling, increased heat, tenderness, or fever. Call a doctor right away if there are signs of infection.

Experts also recommend that those with lymphedema avoid any trauma to the area affected.

Trauma includes extreme temperature changes, repetitive movements against resistance (pushing or pulling), heavy lifting, and excessive exercise.

For More Information

American Cancer Society

The American Cancer Society held an international conference on lymphedema in 1998 in New York City. It involved 60 of the world’s leading experts and included a forum of more than 250 breast cancer survivors, leaders of breast cancer advocacy groups, and others. The conference report plus a lymphedema resource guide are available as a book from the ACS at cancer.org. (See below for title.)

National Lymphedema Network

The National Lymphedema Network is a charitable organization with an international scope. Founded in 1988, the Network’s mission is to provide education and guidance to patients and health care professionals. The Network promotes standardizing quality treatment for lymphedema patients. In addition, the organization supports research into the causes and possible alternative treatments for this “often incapacitating, often-neglected condition.”

Sources:

Current Trends in Lymphedema Management, Esther Muscari Lin, RN, MSN, CS, ACNP, AOCN, November 7, 2002.
American Cancer Society, Cancer (Vol. 92, No. 4: 748-752). http://www.cancer.org/

Cancer Principles and Practices of Oncology, Lippincott Williams &
Wilkins, 6th Edition, 2001. http://www.lww.com/productdetailresults ... 60,00.html

Harvard Medical School, Intelihealth.com, http://www.intelihealth.com/IH/ihtIH?t= ... SIHW000|~b, |

Lymphatic Research Foundation, http://www.lymphaticresearch.org/

Lymphedema Online Support Group, http://www.acor.org/.

Lymphology Association of North America, offers professional certification. http://www.clt-lana.org/main.html

Merck Manual, 17th Edition, 1999. http://www.merck.com/pubs/mmanual_home/contents.htm

National Lymphedema Network,

http://www.lymphnet.org/

https://www.cancerpage.com/centers/Side ... hedema.asp

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Genetic risk models miss many BRCA mutation carriers from small families

Reuters Health
Last Modified: June 19, 2007

Last Updated: 2007-06-19 16:00:16 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Among women with early-onset breast cancer, those with few surviving female relatives are at greater risk of harboring deleterious BRCA gene mutations than those from larger families, according to a report in the Journal of the American Medical Association for June 20.

The research team has found that models used for cancer risk counseling tend to underestimate risk among single cases of early onset breast cancer.

Beginning in 1997, Dr. Jeffrey N. Weitzel and associates at the City of Hope in Duarte, California, set up a prospective hereditary cancer registry. Registrants' family history was sought for three to five previous generations.

Among 1,543 women who underwent genetic cancer risk assessment and BRCA gene testing, 306 (19.8%) had breast cancer before they were 50 years old and had no first- or second-degree relatives with breast or ovarian cancers. Thus, the ability to predict their risk was compromised.

The team also analyzed risk among those with "limited family structure," defined as fewer than two first- or second-degree female relatives surviving beyond age 45 years in either lineage. Half of all of the "single cases" had a limited family structure.

BRCA gene mutations were detected in 13.7% women with a limited family structure and in 5.2% of those with adequate family structure (odds ratio 2.8, p = 0.02).

"This practical observation is consistent with autosomal dominant inheritance of a trait with sex-limited expression," they write.

Three predictive models widely used in cancer risk counseling clinics overestimated the likelihood of a mutation among subjects with an adequate family structure and underestimated that of subjects with a limited family structure.

"Our findings support BRCA gene mutation testing for women with early onset breast cancer when the results will influence medical management, regardless of mutation estimates from existing models," the research team advises. They also recommend that family structure should be incorporated as an actual variable in probability models.

In light of these limitations, Dr. Noah D. Kauff and Dr. Kenneth Offit, from Memorial Sloan-Kettering Cancer Center in New York, caution that risk assessment models represent only one aspect of the process of determining a patient's risk for deleterious mutations.

They note that clinical factors, such as pathologic and immunohistochemical features of tumors, and "consideration that breast cancer risk may be conferred by an as yet unidentified cancer susceptibility gene," should be included in the risk assessment.

Moreover, the editorialists add, it may not be appropriate to use currently available models "to triage individuals for genetic testing or...to provide cancer risk prediction and guidance of care in the absence of genetic testing."

JAMA 2007;297:2637-2639,2587-2595.

http://www.oncolink.upenn.edu/resources ... &year=2007

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Low number of uninvolved lymph nodes predicts breast cancer recurrence

David Douglas
Reuters Health
Last Modified: June 6, 2007

Last Updated: 2007-06-06 15:27:29 -0400 (Reuters Health)

NEW YORK (Reuters Health) - A variety of factors, including the number of involved and uninvolved lymph nodes, may be predictive of risk of locoregional failure following mastectomy for breast cancer, and such patients might benefit from radiotherapy (RT), according to researchers.

"Postmastectomy RT is generally recommended in most guidelines if 4 or more nodes are involved," lead investigator Dr. Per Karlsson told Reuters Health. "RT in the 1-to-3 positive-node group is controversial."

In the May 20th issue of the Journal of Clinical Oncology, Dr. Karlsson of the University of Gothenburg, Sweden and colleagues note that they studied data on 6600 patients treated with chemotherapy and endocrine therapy and followed for a median of 14 years. All had had mastectomy without RT.

In the 2588 node-negative patients, there was no group with a 10-year locoregional failure risk exceeding 20%. Thus, say the investigators, there was no indication of worse prognosis based on few uninvolved nodes in node-negative disease identified through sentinel node biopsy, or through selective node sampling based on a few palpable nodes.

However, in the 4072 node-positive patients, even after adjustment, increasing numbers of uninvolved nodes were associated with decreased risk of locoregional failure.

Compared to those with the lowest number of uninvolved nodes, premenopausal women with the highest number had a 35% decreased risk of locoregional failure. For postmenopausal women, the corresponding risk was reduced by 46%.

The 10-year cumulative incidence of locoregional failure was 20% in patients with 1 to 3 involved lymph nodes and fewer than 10 uninvolved nodes. Being less than 40 years of age and vessel invasion were associated significantly with increased risk.

"Our results indicate that patients with 1 to 3 positive nodes and a low number of identified uninvolved nodes, vascular invasion or young age have a high rate of locoregional failure postmastectomy," concluded Dr. Karlsson, "and they should be considered for similar treatment as patients with 4 or more nodes."

J Clin Oncol 2007;25:2019-2026.

http://www.oncolink.upenn.edu/resources ... &year=2007

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Breast-conserving therapy safe for younger breast cancer patients

Will Boggs, MD
Reuters Health
Last Modified: May 24, 2007

Last Updated: 2007-05-24 12:22:30 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Breast-conserving treatment is safe for women younger than 40 with breast cancer, according to a report in the May 15th issue of Cancer.

"Young age (40 years or younger) should not be a contraindication for the use of breast conserving therapy," Dr. Adri C. Voogd from Maastricht University in the Netherlands told Reuters Health. "Acceptable local control rates (almost comparable to the rates observed among patients >40 years) can be obtained if high-quality surgery and radiotherapy are combined with chemotherapy."

Dr. Voogd and her associates evaluated the probability of achieving local control after breast-conserving treatment and the factors contributing to outcomes in 758 patients 40 years old or younger who underwent this course of treatment between 1988 and 2002.

Ninety-five women developed a local recurrence without evidence of metastatic disease during follow-up, the authors report, and an additional 17 women had recurrences diagnosed after or concurrent with distant metastatic disease.

Actuarial local recurrence rates were 9% at 5 years and 17.9% at 10 years, the results indicate.

In a multivariate Cox regression analysis of prognostic factors for local recurrence-free survival, the use of adjuvant systemic therapy reduced the likelihood of local recurrence by 53%, and microscopic evidence of incomplete tumor excision increased the likelihood 2.98-fold. Adjuvant therapy also reduced the risk of contralateral breast cancer by 54%, the investigators report.

"Of the local recurrences that were identified in our study, the large majority occurred at or near the site of the primary tumor, and only 7% developed elsewhere in the breast," the researchers explain. "This suggests that, at least in young women, most local recurrences are not new primary tumors, but are more likely to be true recurrences, originating from residual tumor tissue or from genetic alterations in apparently normal breast tissue at the margins of the surgically excised tumor."

"Based on the results of our study, I would recommend that chemotherapy should be considered for all patients after breast-conserving therapy," Dr. Voogd said.

"With our findings, we hope to have taken away some of the fears and make breast conservation a more acceptable treatment option for young women with breast cancer," Dr. Voogd said. "However, we are also aware that the side effects of chemotherapy should not be ignored and that there may be sound reasons not to consider chemotherapy, such as the wish to have a child."

Cancer 2007;109:1957-1964.

http://www.oncolink.upenn.edu/resources ... &year=2007

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Exercise program improves well-being in survivors of breast cancer

Reuters Health
Last Modified: May 22, 2007

Last Updated: 2007-05-22 12:38:14 -0400 (Reuters Health)

NEW YORK (Reuters Health) - A closely supervised aerobic exercise program improves quality of life (QOL) in women previously treated for localized breast cancer, according to results of a study conducted in the UK.

Previous trial results have supported improved physical and psychological health from exercise, but it has been unclear if the benefit was derived from increased attention or the exercise itself.

To isolate exercise effects from those due to attention, Dr. Amanda J. Daley, from the University of Birmingham, and her associates designed a study that included both a placebo exercise group and a usual-care group, along with the active exercise group. Their findings appear in the Journal of Clinical Oncology for May.

The subjects were 108 women who had been treated for breast cancer between 1 and 3 years before, and who were physically inactive.

The active exercise program involved one-to-one 50-minute sessions three times a week for 8 weeks. Treatment comprised moderate-intensity exercise, with a heart-rate goal of 65% to 85% of the age-adjusted maximum. The instructor also discussed with the subjects cognitive-behavioral techniques for promoting exercise behavior.

The placebo exercise group also met for 24 sessions, but limited the exercise to light-intensity body conditioning and stretching, and no counseling.

The primary outcome was the change in QOL, documented by the Functional Assessment of Cancer Therapy - General (FACT-G).

The QOL benefits of exercise therapy compared with usual care were reflected by a mean difference in scores on the FACT-G at 8 weeks of 9.8 units (p = 0.004). The magnitude of the change, Dr. Daley's team notes, is "far greater than those reported for other types of health-enhancing and QOL interventions (eg, psychological support in cancer patients)."

Significant improvements were also observed in subscale scores for functional and social/family well-being, and for breast cancer concerns.

"These findings cannot be attributable to attention effects, because the exercise-placebo group did not report significant benefit, compared with usual care," the researchers say.

The results for functional well-being "are particularly promising," they add, "given that physical functioning is considered one of the most important components of QOL in cancer patients."

They propose that exercise may "expedite the recovery process," but add, "We are mindful that this study only demonstrated short-term gains."

J Clin Oncol 2007;25:1713-1721.

http://www.oncolink.upenn.edu/resources ... &year=2007

[patoco]

Novel breast cancer susceptibility genes identified

Reuters Health
Last Modified: May 28, 2007

Last Updated: 2007-05-28 1:00:03 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Researchers have identified four new genes that seem to influence the risk of breast cancer. Their findings, along with two related reports, appear in the May 27th online issue of Nature Genetics.

The breast cancer susceptibility genes BRCA1 and BRCA2 only account for less than 25% of familial cases, note Dr. Douglas F. Easton, from the University of Cambridge in the UK, and colleagues. To identify other susceptibility loci, they performed a genetic analysis involving 21,860 patients and 22,578 controls.

After conducting a genome-wide association study in a smaller number of cases and controls, the researchers focused on 30 single nucleotide polymorphisms of interest. This led to the discovery of four breast cancer susceptibility genes: FGFR2, TNRC9, MAP3K1, and LSP1. The functions of the genes largely involved regulation of cell growth and cell signaling.

In another study, Dr. David J. Hunter, from Harvard School of Public Health in Boston, and colleagues looked at FGFR2 in more depth and found that it primarily affects the risk of sporadic postmenopausal breast cancer.

In the third study, a research team led by Dr. Simon Stacey, from deCODE Genetics in Reykjavik, Iceland, identified genetic variants on chromosomes 2 and 16 that appear to increase the risk of estrogen-receptor-positive breast cancer. One of the variants was found to lie in close proximity to the TNRC9 susceptibility gene identified by Dr. Easton's group.

Dr. Easton's team comments that "the detection of further susceptibility loci will require genome-wide studies with more complete coverage and using larger numbers of cases and controls, together with the combination of results across multiple studies."

Nat Genet 2007.

http://www.oncolink.upenn.edu/resources ... &year=2007

[patoco]

Lymphedema in gynecologic cancer survivors: an area for exploration?

Cancer Nurs. 2007 Jul-Aug

Lockwood-Rayermann S.
From Harris College of Nursing and Health Sciences, Texas Christian
University, Fort Worth, Tex.

There is a paucity of research on the incidence and impact of lower
body lymphedema in the gynecologic cancer population. The cornerstone
of management for gynecologic cancer is cytoreductive surgery.

Depending on the site of the cancer, surgery traditionally involves
removal of the ovaries, fallopian tubes, uterus and cervix,
accompanied with extensive node dissection throughout the pelvic
cavity, and, in the case of ovarian cancer, removal of the omentum.
Resection of pelvic lymph nodes and vessels, compounded by
gravitational influences on lymphatic flow, can lead to lymphatic
congestion that impairs mobility, raises intra-abdominal pressure,
and increases abdominal and extremity girth. Lymphedema can be an
indicator of recurrence and is frequently associated with toxicities
such as skin breakdown, pain, neuropathy, and myopathy.

Physical changes, role changes, and psychosocial issues are common symptoms reported by breast cancer survivors with lymphedema. Assessment and management strategies for upper extremity lymphedema following treatment of breast cancer cannot be directly transferred to lower extremity lymphedema affecting women with cancer of the ovary, cervix, uterus, and vulva because of limb size, volume, and location.

Clinicians have anecdotally reported the presence of lower body
lymphedema in many gynecologic cancer patients. Survivors have
described tightness, swelling, and heaviness. Despite these clinical
findings, no systematic study of lower body lymphedema in women with
gynecologic cancer has been conducted. Whether lower body lymphedema
is as debilitating and long-term as post-mastectomy lymphedema is not
empirically known.

PMID: 17666969 [PubMed - in process]

(No Related Articles yet for this citation.)

http://www.ncbi.nlm.nih.gov/sites/entrez?
Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666969&ordinalpos=4&itool=
EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Unmet needs of gynaecological cancer survivors: implications for
developing community support services.

Psychooncology. 2007 Aug 6

Vanessa Beesley 1 *, Elizabeth Eakin 2, Suzanne Steginga 3, Joanne
Aitken 3, Jeff Dunn 3, Diana Battistutta 1
1Institute of Health and Biomedical Innovation, School of Public
Health, Queensland University of Technology, Brisbane, Australia
2Cancer Prevention Research Centre, School of Population Health,
University of Queensland, Brisbane, Australia
3Viertel Centre for Research in Cancer Control, The Cancer Council
Queensland, Brisbane, Australia

email: Vanessa Beesley (vanessa.beesley@qimr.edu.au)

*Correspondence to Vanessa Beesley, Cancer and Population Studies
Group, Queensland Institute of Medical Research, PO Box Royal
Brisbane Hospital, Herston, Qld 4029, Australia

Funded by:
Cancer Council Queensland

Keywords
supportive care • cancer • perceived needs • continuity of patient
care • oncology

Abstract
After treatment completion, gynaecological cancer survivors may face
long-term challenges and late effects, specific to this disease.
Available research on supportive care needs of women with
gynaecological cancer is limited. This study aimed to determine the
prevalence and correlates of unmet needs within a population of
gynaecological cancer survivors. Eight hundred and two women
participated in a population-based mail survey in 2004 (56% response
rate).

The questionnaire included a validated instrument to assess 45 need
items across multiple supportive care domains, and a range of
measures to evaluate related correlates consistent with a social-
ecological perspective. Forty-three per cent of respondents reported
having at least one moderate- or high-level unmet need.

The five highest included needing help with fear about the cancer
spreading (17%), concerns about the worries of those close to them
(15%), uncertainty about the future (14%), lack of energy/tiredness
(14%), and not being able to do things they used to do (14%).
Subgroups of women with higher odds of reporting some unmet needs
across multiple supportive care domains include those who, are not in
remission, live with lymphoedema or are unable to work due to
illness. Odds were also higher for women who had undergone more
recent treatment, and who lived in rural or remote locations. Further
assistance with the top specific concerns of gynaecological cancer
survivors is recommended. Identified subgroups with higher needs are
important targets for support.

http://www3.interscience.wiley.com/cgi-
bin/abstract/114298371/ABSTRACT?CRETRY=1&SRETRY=0

[patoco]

Straight talk about ovarian cancer

VIRGINIA R. MARTIN RN, AOCN, MSN

Nursing2005 April 2005 Volume 35 Number 4 Pages 36 - 41

Abstract

Learn how to help patients recognize and defeat this insidious malignancy.

ACCORDING TO AMERICAN Cancer Society (ACS) estimates for 2005, 22,220 women will develop ovarian cancer and 16,210 will die of it. The leading cause of death from gynecologic cancer in the United States, ovarian cancer has historically had a poor prognosis, largely because over 70% of women affected have advanced disease at diagnosis.

But medical science is gaining ground. Thanks to improved diagnosis, staging, and treatments, 5-year survival improved from 37% in the 1970s to 53% in 1998. Let's review how this insidious disease progresses, how you can help someone who has it, and what you need to know about promising screening methods that could lead to earlier detection and treatment.

Deep, changing organs

The ovaries are solid, slightly nodular, almond-shaped organs lying deep in the pelvis. Their hidden location, plus the fact that their size, shape, position, and histology change over a woman's lifetime, help explain why ovarian cancer isn't readily detected in the early stages. According to the National Comprehensive Cancer Network (NCCN), the median age at diagnosis is 63. This malignancy is rare in women under age 30.

Three major theories about the causes of ovarian cancer prevail:

* The incessant-ovulation theory zeroes in on how the monthly ovulatory cycle affects the ovaries. This theory holds that the epithelium may be more apt to mutate with each ovulation, so failure to break the cycle, as with pregnancy, increases the chance of mutation.

* The pituitary/gonadotropin hypothesis implicates elevated gonadotropin levels. Normally, the ovarian epithelium invaginates and forms inclusion cysts and clefts, but overstimulation by gonadotropins might trigger proliferation with subsequent malignant transformation.

* The inflammation theory considers monthly ovulation a possible cause of chronic inflammation and mutation in the epithelial cells that lead to ovarian cancer.

The causes of ovarian cancer are unclear, but genetic and endocrine factors raise the risk. (See How the problem starts .) The most significant link is a positive family history, which is present in 10% of women with the disease. Three hereditary syndromes in which ovarian cancer occurs more commonly affect certain families with a history of early breast and ovarian malignancies and hereditary nonpolyposis colorectal cancer.

Other factors associated with ovarian cancer include nulliparity, giving birth for the first time when over age 35, exposure to talc or asbestos, endometriosis, pelvic inflammatory disease, and living in a western industrialized country. On the bright side, researchers have identified seemingly protective factors, including a history of oral contraceptive use, giving birth before age 25, tubal ligation, breast-feeding, and hysterectomy.

Most commonly, ovarian cancer spreads via the peritoneal fluid that continuously circulates through the abdomen. Other routes for metastases are through the lymphatic fluid or by direct tumor extension. Bloodborne metastasis is rare, and this cancer rarely spreads beyond the abdomen, even when advanced.

Early signs

Retrospective studies indicate that over 70% of women with ovarian cancer have symptoms for 3 months or longer before diagnosis. But the early signs and symptoms can be nonspecific, including increased abdominal size, bloating, early satiety, abdominal pain, indigestion, vaginal bleeding, and changes in bowel and bladder habits. Because these symptoms can be vague, a woman may not pay much attention to them.

Teach your female patients to always investigate any of these symptoms if they occur.

When a woman does seek treatment and an ovarian mass is discovered, the clinical approach depends on clinical findings. If she's premenopausal, the health care practitioner will probably monitor her for a few ovulatory cycles and investigate further if the mass doesn't disappear. In a postmenopausal woman, any ovarian mass must immediately be investigated for cancer.

Diagnostic imaging and tumor markers

Diagnostic tests to detect ovarian cancer include the following:

* transvaginal and abdominal ultrasound. A transvaginal approach provides better visualization of the ovaries than the transabdominal method, but the location of the ovaries varies in each woman, so a combination of both approaches is recommended.

* computed tomography (CT) scan of the abdomen and pelvis

* a blood test for the tumor marker cancer antigen 125 (CA-125), which can be elevated in ovarian cancer. Although an ovarian mass can cause an elevated CA-125 level, so can endometriosis, pregnancy, liver disease, or fibroids, so the marker isn't specific.

Additionally, a woman can have ovarian cancer and a normal CA-125 level; only 50% of women with stage I disease have an elevated level. For this reason, the CA-125 isn't recommended as a screening tool for healthy women, but it can be useful in women with diagnosed ovarian cancer.

Surgery: First and foremost

Surgery is the mainstay of treatment for ovarian cancer, and a gynecologic oncologist has the most training to perform the exploratory laparotomy. The goals of surgery are to determine a definitive diagnosis, to stage the disease if cancer is present, and to remove as much of the tumor as possible. (See Staging ovarian cancer .) The procedure includes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, scraping the abdominal surface of the diaphragm, peritoneal cytology, omentectomy, pelvic and para-aortic lymph node sampling, and peritoneal and random biopsies.

Although disease stage is the key prognostic factor for ovarian cancer, other factors influence outcome. They include the volume of cancerous tissue remaining after surgery, histologic type and grade, the woman's age, and her overall condition or performance status. (See Rating performance .) A woman whose performance status is 0 to 2 is more likely to respond to chemotherapy, experience less toxicity, and have better outcomes. Findings associated with a poorer prognosis include a clear cell, mucinous, or poorly differentiated (unclear cell type) tumor, and diagnosis after age 69.

Is additional treatment warranted?

If your patient has well-differentiated stage IA or IB ovarian cancer that's been surgically removed, she's considered low risk and needs no further treatment. The oncologist will determine a follow-up plan.

Stage IA or IB ovarian cancer with a poorly differentiated tumor and stages IC, II, III, and IV disease are classified as high risk, and the patient requires chemotherapy. Scientists are still seeking the optimal regimen, but early clinical trials have shown that combination therapy with a platinum compound such as cisplatin or carboplatin is superior to using a single agent. The NCCN states that paclitaxel/carboplatin is the preferred regimen. (See Exploring chemotherapy options for other choices.)

A complete remission from cancer means all signs and symptoms disappear; remission after initial therapy that lasts 5 years may be considered a cure. Although 75% to 80% of women with ovarian cancer achieve a complete remission after initial therapy, 80% of them have a recurrence. Unfortunately, recurrent disease isn't curable, so researchers are exploring strategies to prevent or delay recurrence, such as improved induction and maintenance regimens and the use of intraperitoneal chemotherapy.

Currently, intraperitoneal therapy is recommended only in the context of a clinical trial, but researchers have been studying it closely because ovarian cancer tends to stay in the abdomen. Study results show higher rates of progression-free survival and overall survival, but the challenges of administering therapy and managing toxicity are formidable.

Remission and monitoring

A typical woman with complete remission from ovarian cancer undergoes regular CA-125 monitoring and periodic abdominopelvic CT scans to check for recurrence. In most cases of recurrent disease, the CA-125 level rises above normal before the woman develops symptoms. Even when the CA-125 level is elevated, most oncologists don't start chemotherapy unless a pelvic examination or abdominopelvic CT scan indicates disease recurrence; treating measurable disease lets the practitioner identify a response.

If a woman's cancer recurs, her response to initial chemotherapy and the length of time until recurrence help determine subsequent therapy. If she achieved complete remission and didn't have a recurrence for more than 6 months after completing initial therapy, her disease is considered drug sensitive and she'll probably receive the same regimen.

Ovarian cancer that recurs less than 6 months after a woman achieves a complete remission is considered drug resistant . If the cancer doesn't respond to initial therapy at all, it's labeled drug refractory . Drug-resistant or drug-refractory disease is typically treated with a different agent, or the woman may be offered the option of participating in a clinical trial. If curing ovarian cancer isn't possible, the patient may receive salvage therapy , which is chemotherapy to help manage symptoms and possibly prolong survival.

When recommending a treatment approach for recurrent disease, the oncologist considers the woman's prior responses, quality of life, toxicity profile, current symptoms, disease volume, the ability of her gastrointestinal system to absorb drugs, her age, other illnesses, and social issues.

Radiation therapy may be included in the palliative treatment plan and may help if the patient has uncontrolled vaginal bleeding or pain. Radiation to the entire abdomen isn't often considered because it's toxic. For recurrent disease in a specific area, a radiation oncologist should outline a treatment plan. The goal of all palliative treatment is to balance the toxicities with quality of life.

Providing education and support

Research indicates that the more a patient feels threatened or harmed by cancer, the more education and support she needs. With ovarian cancer, her psychosocial and physical challenges might include advanced disease at diagnosis, repeated cycles of aggressive treatment, little respite from therapy, and a poor chance of survival. Your challenges are to address her psychosocial needs while preparing her for treatment and helping her manage adverse reactions to treatment and advanced disease.

Preoperatively, educate your patient and her family about the surgical procedure for ovarian cancer and what to expect afterward. Explain that after surgery, you'll monitor her for infection, circulatory complications, fluid and electrolyte imbalances, and pain, and that you'll work with the surgeon to manage any problems.

If your patient will receive chemotherapy, teach her and her family about the major adverse reactions. Explain how to prepare and respond if she develops fatigue, nausea, vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, or myelosuppression.
Problems such as depression and anxiety are common when a patient faces serious illness and possible death. She may need help coping with such issues as premature menopause; loss of fertility; altered body image, sexual function, and family relationships; impaired functional capacity; financial problems; and loss of spiritual well-being.

Assess her for mood changes, feelings of worthlessness, inability to concentrate, fatigue, insomnia, impaired functioning, agitation, restlessness, and apprehensiveness. Review her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history for factors that may contribute to depression.

Listen to her concerns and refer her to support services, such as the local chapter of the ACS. Managing her symptoms, participating in a support group, meeting with a mental health professional, and taking antidepressant or antianxiety medication all can help resolve depression and anxiety.

Finally, if cure isn't an option, you can give your patient and her family tremendous support when you help them cope with end-of-life decisions and involve the hospice team when the time is right.

Managing the effects of advancing disease

Complications of advancing ovarian cancer can pose significant nursing challenges. Here's a review of assessment findings and management strategies for common problems.

Ascites , accumulation of fluid in the peritoneal cavity, occurs when channels that normally remove fluid are blocked or when cancer cells prevent absorption of peritoneal fluid. Symptoms include early satiety, dyspnea, increased abdominal girth, constipation, and pain.

Suspect ascites if your patient has a protuberant abdomen with bulging flanks, an everted umbilicus, diminished bowel sounds, shiny or taut abdominal skin, and dullness to percussion in dependent areas of the abdomen. (For details, see “Assessing for Ascites” in the February issue of Nursing2005 .) An abdominal ultrasound usually confirms the diagnosis.
The treatment for ascites is removing the fluid. The oncologist may perform paracentesis in the office or in the radiology department with ultrasound guidance.

Intestinal obstruction involving the small or large intestine may plague a patient with progressing ovarian cancer. Tumor growth in the abdomen or adhesions can cause a partial or complete obstruction that interferes with peristalsis. An obstruction can be acute or chronic. Signs and symptoms of acute obstruction include acute abdominal distension and pain and projectile vomiting. Symptoms of chronic obstruction include abdominal distension and discomfort, constipation, and nausea and vomiting.

Hyperactive bowel sounds may be the first sign of acute intestinal obstruction as the bowel tries to move digestive contents past the blockage. Teach your patient to recognize problems and to immediately contact her health care provider if they occur.

A patient who develops an acute intestinal obstruction may need hospitalization and insertion of a nasogastric tube to decompress her bowel. Because a woman with advanced cancer may already be debilitated, surgery is considered only if conservative interventions fail or she's in acute distress.

Deep vein thrombosis (DVT) is a risk for all cancer patients because of prolonged immobility, tumors that decrease or obstruct blood flow, and hypercoagulability associated with cancer. Common signs and symptoms include unilateral leg edema or pain accompanied by tenderness, warmth, and erythema. The treatment for DVT includes anticoagulation therapy and possibly placement of a filter in the inferior vena cava.

Malnutrition is one of the greatest challenges for a woman with ovarian cancer. Treatments or advancing disease may take away her appetite, causing her to lose weight. This wasting syndrome is called cancer cachexia , an advanced state of protein-energy malnutrition. Besides weight loss, signs of cancer cachexia include decreased subcutaneous tissue, edema, abdominal distension, dry skin, and behavioral changes such as irritability. Cancer patients with weight loss generally have poor performance status, poor response to chemotherapy, poor median survival, and possibly a greater infection risk.

Measures to protect the patient from malnutrition include treating the underlying problem, delaying chemotherapy, getting a nutrition consult, and medications (such as corticosteroids, megestrol, hydrazine, dronabinol, nabilone, oxandrolone, growth hormones, and medroxyprogesterone). Advise her to eat frequent, small meals served at room temperature; eliminate disagreeable food odors; get help with food preparation; and use nutritional supplements.

Lymphedema , an accumulation of lymphatic fluid in the interstitial tissue, occurs when the tumor blocks the lymphatic system or when lymph nodes have been removed. Lymphedema associated with ovarian cancer affects the legs. The affected leg maintains full sensation, but with edema, range of motion decreases and the skin feels tight to the patient.

Your patient should be referred to a knowledgeable practitioner in lymphedema management. The severity and grade of lymphedema determine the interventions, which may include range-of-motion exercises, meticulous skin care to reduce the risk of skin breakdown, elevation, massage or physical therapy to manually aid drainage, compression bandaging, or sequential pump therapy.

Pleural effusion occurs when the rate of pleural fluid production exceeds its removal rate from the pleural space, such as when a tumor invades the thoracic duct, or when ascites fluid seeps through the diaphragm. Signs and symptoms may include dyspnea, decreased or absent breath sounds, decreased tactile fremitus, or dullness to percussion. An effusion is treated by draining the fluid via thoracentesis or insertion of a tunneled indwelling pleural catheter.

What about screening and prevention?

Current screening methods for ovarian cancer aren't sensitive or specific enough for routine use. A woman with a positive family history, however, should have a formal risk assessment with an extensive family history, education, risk estimation and counseling, optional genetic testing, and specific screening and prevention strategies. Screening strategies often include a rectovaginal pelvic exam, a CA-125 blood test, and transvaginal ultrasound.

Scientists are exploring the natural history of ovarian cancer to develop cost-effective, sensitive screening strategies. Researchers studying cell proteins are developing a test that tracks trends in multiple tumor markers specific for ovarian cancer. The first published study reported 18 of 18 stage I cancers and 63 of 66 healthy controls accurately identified, yielding 100% sensitivity and 95% specificity. A yet-unpublished study accurately identified 22 of 22 cases of early stage I disease, 81 of 81 cases of stage II to stage IV disease, and 68 of 68 cases of benign disease. The test must be validated and standardized before being used as a screening tool.

Prevention strategies for ovarian cancer may include a prophylactic bilateral oophorectomy in high-risk women who've finished childbearing. Other prevention strategies being used in clinical trials include the use of oral contraceptives and other drugs such as acetaminophen and the synthetic retinoid, fenretinide.

Finally, you have many opportunities to improve the outlook for ovarian cancer. Educate your female patients about the signs and symptoms and emphasize the importance of reporting “insignificant” symptoms that could be early warning signs. Early detection and treatment offer the best chance for survival.

Education, support, and hands-on care

Patient outcomes for ovarian cancer are getting better as detection and treatment methods improve. When you give a woman the education, support, and hands-on care she needs to combat this malignancy, you bolster her ability to successfully fight back.

How the problem starts

Three major categories of ovarian cancer have been identified:
Epithelial cancers , arising from the cells lining or covering the ovaries, account for 90% of ovarian malignancies. Epithelial cancers are further classified as serous (most common), endometrioid, clear cell, mucinous, and poorly differentiated.

Germ cell cancers start in cells destined to become ova.

Stromal cell cancers start in the connective tissue cells that hold the ovaries together and produce female hormones.

Staging ovarian cancer

Stage I: Tumor limited to the ovaries

IA , limited to one ovary, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsule intact

IB , limited to both ovaries, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsules intact

IC * , limited to one or both ovaries, tumor on ovarian surface, capsule ruptured, ascites or peritoneal washings containing malignant cells

Stage II: Tumor involving one or both ovaries with pelvic extension

IIA , extension or metastasis to the uterus or tubes, no malignant cells in ascites or peritoneal washings

IIB , extension to other pelvic tissues, no malignant cells in ascites or peritoneal washings

IIC * , pelvic extension, ascites fluid or peritoneal washings containing malignant cells

Stage III: Tumor involving one or both ovaries, peritoneal implants outside the pelvis or regional lymph node metastasis

IIIA , gross tumor limited to the true pelvis, negative nodes, microscopic peritoneal metastasis beyond the pelvis

IIIB , macroscopic peritoneal metastasis 2 cm or less in greatest dimension beyond the pelvis

IIIC , abdominal implants greater than 2 cm in greatest dimension or positive regional nodes

Stage IV: Tumor involving one or both ovaries, metastasis greater than 2 cm in greatest dimension beyond the pelvis. If pleural effusion is present, cytologic test results must be positive. Parenchymal liver metastases equals stage IV.

Rating performance

The Eastern Cooperative Oncology Group established the following scale to rate the effects of cancer and its treatments on the patient.

0 Normal activity, asymptomatic

1 Symptomatic, fully ambulatory

2 Symptomatic, in bed less than 50% of the time

3 Symptomatic, in bed more than 50% of the time but not bedridden

4 100% bedridden

SELECTED WEB SITES

National Ovarian Cancer Coalition http://www.ovarian.org

Ovarian Cancer National Alliance http://www.ovariancancer.org

SHARE: Self-help for Women with Breast or Ovarian Cancer
http://www.sharecancersupport.org

Women's Cancer Network and CancerSource http://www.wcn.org
Last accessed on March 3, 2005.

Virginia R. Martin is the clinical director of ambulatory care at Fox Chase Cancer Center in Philadelphia, Pa.

The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

Exploring chemotherapy options

The current standard regimen for advanced ovarian cancer is paclitaxel (Taxol) and the platinum compound carboplatin. Alternatives are docetaxel (Taxotere) with carboplatin or paclitaxel with cisplatin, another platinum compound.

Recent clinical trials found no difference in survival between patients receiving carboplatin with either docetaxel or paclitaxel, but the docetaxel/carboplatin group had a greater incidence of myelosuppression. Those receiving paclitaxel/carboplatin had more neuropathy. Newer drugs being combined with carboplatin and paclitaxel are topotecan, liposomal doxorubicin, and gemcitabine.

The Gynecologic Oncology Group (GOG), a research group funded by the National Cancer Institute, is currently conducting a clinical trial for high-risk early-stage disease comparing three cycles of paclitaxel/carboplatin followed by surveillance versus paclitaxel alone weekly for 24 weeks. The GOG is also proposing a clinical trial on the use of carboplatin and paclitaxel combined with bevacizumab to treat advanced ovarian cancer.

To take this test online, visit http://www.nursingcenter.com/ce/nursing .

SELECTED REFERENCES

Bookman MA, et al. Optimal therapy of advanced ovarian cancer: Carboplatin and paclitaxel vs. cisplatin and paclitaxel (GOG 158) and an update on GOG0 182-ICON5. International Journal of Gynecological Cancer . 13(6):735–740, November/December 2003.
Cunningham RS, Bell R. Nutrition in cancer: An overview. Seminars in Oncology Nursing . 16(2):90–98, May 2000.
Ferrell B, et al. Psychological well being and quality of life in ovarian cancer survivors. Cancer . 98(5):1061–1071, September 1, 2003.
Howell D, et al. Impact of ovarian cancer perceived by women. Cancer Nursing . 26(1):1–9, February 2003.
Howell D, et al. Women's experience with recurrent ovarian cancer. Cancer Nursing . 26(1):10–17, February 2003.
Jemal A, et al. Cancer Statistics 2005. CA: A Cancer Journal for Clinicians . 55(1):10–30, January/February 2005.
Martin VR. Ovarian cancer. Seminars in Oncology Nursing . 18(3):174–183, August 2002.
Ozols RF. Future directions in the treatment of ovarian cancer. Seminars in Oncology . 29(1: Suppl. 1):32–42, February 2002.
Ozols RF, et al. Focus on epithelial ovarian cancer. Cancer Cell . 5(1):19–24, January 2004.

Source
Federation Internationale de Gynecologie et d'Obstetrique (International Federation of Gynecology and Obstetrics).

* Knowing whether rupture of the capsule was spontaneous or caused by the surgeon and whether peritoneal washings or ascites was the source of malignant cells helps the clinician decide whether a case should be categorized as stage IC or IIC. [Context Link]

http://www.nursingcenter.com/prodev/cea ... _ID=578782