What can you do if you are denied access to enough painkillers to give you continuing pain relief? First of all, I’ll remind you that the usual reason for doctors and nurses limiting supplies of painkillers is not cruelty or sadism, but sheer ignorance! So you may be able to overcome your problem by telling your doctors and nurses some of the things you have learned here. I’m sure I don’t have to warn you to try to be diplomatic about this— we all know how doctors hate to feel that their authority is being undermined in any way!

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Our bodies are made up of millions of cells that grow, divide, and die in an orderly, controlled manner. This dynamic balance allows us to grow hair and skin, maintain a healthy lining to our digestive tract and airway, respond to physical stresses, and repair injuries.

It is believed that most cancers start out as the loss of control of one single cell. A single cancer cell multiplies and becomes a group of cancer cells whose growth is not controlled by the body’s healthy cells, and the balance between cell division and cell death is lost. Over months to years, depending on the type of cancer cell, the cancer grows big enough to be detectable or cause problems.

What causes the first cancer cell to become cancerous is still uncertain. Most likely, a series of events has to occur for that to happen. For example, the cell may be genetically predisposed but will not become cancerous unless it is exposed to certain substances or radiation.

For some cancers that seem to arise in multiple spots at once, there may be many cells that lose control at the same time and give rise to many cancers. These cells “at risk” may be exposed to the final “hit,” such as radiation or cancer-causing substance, at the same time, so they all become cancerous at the same time.

Now That I Am Done with Treatment, Do I Need to Look for a Cause for My Cancer?

If you have no obvious risk factors for your type of cancer, discuss with your doctor whether it would be worthwhile to look for something in your environment or diet that may have contributed to your developing your type of cancer—for something like asbestos, which is often associated with cancer of the lung lining. The reasons for this inquiry would be

•to ensure that you are not still exposed to something that is continuing to put you at risk for developing this cancer again

• to make sure others are not being exposed

• to provide data for future research

Nothing will change the fact that you had your cancer. Any effort to look for a cause should be geared toward improving future for you and others.

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This is an area of intense interest and research. At this time the most important recommendations are to

•avoid sun exposure

•eat cruciferous (cabbage family) vegetables

•avoid obesity

•eat a low-fat diet

•include fiber in your diet

•avoid excessive alcohol

•minimize salt-cured, smoked, and nitrite-cured foods

•eat four to six helpings of fruits and vegetables daily

What Is the Difference between Something Causing Cancer and Something Being Associated with Cancer?

When something causes cancer, it is directly responsible for changes in normal cells that contribute to their becoming cancerous. For example, exposure to the sun causes skin cells to change in such a way that they can become cancerous.

Something is said to be associated with cancer where there exists a statistical relationship between the event being measured and cancer. This says nothing about whether the associated variable being measured is responsible in any way for the changes in the cell that cause it to become cancerous. For example, there may be an association between playing tennis and skin cancer. Playing tennis does not cause any changes in the body that lead to cancer. It is the high sun exposure common to tennis player is responsible for the increased risk of skin cancer.

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There are practical reasons why many people do not participate in clinical trials:

•People are unaware of the availability and benefits of trials.

•Trials have limited participation; there may be no space in ongoing trials for a person’s particular cancer situation.

•People may not qualify for trials applicable to their type of cancer, because of concurrent medical conditions, age, location family constraints.

•Certain kinds of clinical trials offer little or no therapeutic benefit.

What Are the Downsides of Clinical Trials?

There are some potential disadvantages to your participating in a clinical trial:

•By definition, not all of the risks and benefits are known ahead of time; there can be unexpected dangers and side effects.

• Doctors have less experience working with new treatments than with standard, established ones.

•You may lose an opportunity for a dependable response from standard therapy if you pursue a clinical trial of therapy that proves to be less successful than standard therapy.

•Clinical trials require an investment in terms of your time, energy, and testing to comply with the required follow-up during and after treatment.

• Hospitalization may be required for some treatments.

• Trials can add to the emotional stress of not knowing exact which treatment you are getting. As was discussed above, some patients receive a placebo (e.g., an inactive sugar pill) instead of the experimental treatment in placebo-controlled studies. In other studies, you randomly receive either standard treatment or the new treatment. Despite the reassurance that you are receiving treatment that has an anticancer effect, not knowing exactly what treatment you are getting can be stressful.

•Some people feel like “a number” instead of an individual human being.

Although clinical trials increase your potential options, they are not for everyone.

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No. There is a limit to what tests and scans show. A cancer can be too small to be detected with current techniques, or it can be in a place that escapes current methods of detection.

Your doctor will talk with you, examine you, and order appropriate tests to look for cancer. This approach allows doctors, with reasonable risk and cost to you, to pick up most detectable cancers.

What Is a Recurrence?

If you were in complete remission (no evidence of cancer) for any length of time and now there is evidence that the same cancer has come back, you have had a recurrence of your cancer. The returning cancer is called a recurrence.

Each cancer is defined by the organ in which it originated, the organ in which the first cell became cancerous. Your cancer can recur in a different place from where it appeared earlier or in the same place. It has to be the same kind of cancer to be a recurrence. If you had prostate cancer confined to the prostate gland years ago and now you have cancer in the bone that tests show to be prost cancer in the bone, you have had a recurrence of prostate cane Conversely, if you had prostate cancer years ago and now you have colon cancer, you have developed a new, unrelated cane called a “second primary.”

How Do Doctors Know Whether a New Cancer Is a Recurrence о a Past Cancer or an Unrelated Second Primary?

Evaluation of a piece of the new cancer under a microscope and with other sophisticated tests tells doctors what kind of cancer is. In most cases this evaluation can determine whether the ne cancer is a recurrence of a prior cancer or an unrelated second primary. When possible, doctors will compare slides of the ne cancer with slides of the prior cancer under the microscope resolve any question about the new cancer’s being a recurrence. Occasionally, some uncertainty persists whether a cancer is recurrence of a prior cancer or a new, second cancer.

Can a Cancer Ever Come Back as a Different Cancer?

Some types of cancer can transform or change into a different form of the same type of cancer when they recur. For example, low grade lymphoma can go into remission and then recur in a different, high-grade form. Even though the new lymphoma behave: very differently, it is felt to be a recurrence of the original lymphoma and not a second, unrelated primary.

Lymphomas always come back as lymphomas, even if the) come back as a different type of lymphoma. Breast cancer recurs only as breast cancer. Prostate cancer recurs as prostate cancer, and so on.

What Is a Local Recurrence?

A local recurrence is recurrent cancer at or near the place of the original cancer. If you had melanoma treated with surgery and you develop a recurrence near your scar, you are said to have a local recurrence.

If I Have a Recurrence in the Future, Can I Ever Be Cured of My Cancer?

Yes. Many people are cured of their cancer after being treated for recurrent cancer.

Recurrence is not a death sentence; it is an illness.

If your original cancer was treatable, there is a good chance that a recurrence will be treatable.

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When you go for a second opinion, the new doctor will perhaps inform you that he or she would have advised different treatment for your cancer when you were first diagnosed. Obviously, this does not help you in any way, since you can never go back where you were and make the decision again. Even though it just one doctor’s opinion, knowing that you might have bee treated differently can make you feel anxious about something that you cannot change.

A more common problem is that you will receive conflicting information or advice about your current situation. You will have to sort out which information to believe and which advice to follow. This process of deciding what to do with conflicting advice can be extremely stressful. In the long run, however, gathering information and sorting through the options will provide you the lifelong comfort of knowing that you made decisions on the basis of the best information available at the time.

Weigh and balance the answers to the following questions, and you will get an idea of the best option for you:

•What are all the treatment options available to me now, both conventional and investigational?

• What is the cure rate of each option?

• What is the response rate of each option?

•What are the short-term risks of each option?

•What are the long-term risks of each option?

•What are the risks of a second cancer?

• What are the risks of future medical problems?

•Will any current treatment options limit future treatment options?

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