Health Tips

Six Tips for A New Intimate Relationship
Here are six tips to start rebuilding your intimate relationship:
Make Time to Talk: Set a time and a place (not in bed) where you can talk openly, and share your concerns and desires. Listen carefully, without formulating a response before your loved one has finished speaking. Reflect what your partner has said, using your own words to make sure you understood what he meant. Set some goals to help you reconnect to each other.
Restrain Your Inner Geek: Email is not a good way to discuss your intimate issues. But if talking is difficult, try writing a letter, using nonjudgmental language to express your concerns and desires.
Stay Open-Minded: Withhold your judgement about each other’s performance and don’t make demands about how attempts at intimacy work out. You may prefer to make requests of your partner, so as not to pressure them into pre-treatment sexual perfection. Both of you have changed, so adjust your expectations and look for new ways to surprise each other.
Set The Stage: Agree on a room that will be just for the two of you. Enforce your time of privacy for intimacy. Turn off your phones, pagers, televisions, and hire a babysitter if necessary. Dim the lights, put on romantic music, or do whatever helps both of you feel attractive and confident.
Get Reacquainted: Start slowly -- kiss, hug, and cuddle. Express requests instead of making demands, using verbal or non-verbal communication. Try new ways to touch each other, remembering how you both have changed.
Sources:


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NEW YORK - U.S. regulators have told Merck & Co they cannot yet approve Merck's application to expand marketing of its cervical cancer vaccine Gardasil to an older group of women, the drugmaker said on Wednesday.

Merck had applied for the use of Gardasil in women ages 27 through 45. The U.S. Food and Drug Administration said in a letter regarding the application that it has completed its review and there are "issues" that preclude approval within the expected review time frame, Merck said.

"It's hard to get a feel for if this is a dead issue or if this is delayed," said Linda Bannister, an analyst for Edward Jones. "At the minimum, it's going to be delayed."

Merck said it also failed to win FDA approval to expand Gardasil to protect against more strains of the Human Papillomavirus that causes cervical cancer. The company for now is dropping plans to pursue that expansion, a spokeswoman said.

Gardasil, approved in June 2006 for preventing cervical cancer and genital warts in females ages 9-26, has been one of Merck's most successful newer products and has helped the company recover after the 2004 withdrawal of its Vioxx arthritis treatment.

The Gardasil setbacks could raise concerns about the degree of growth that Merck can hope to achieve with the product, which is the world's first vaccine to prevent cervical cancer.

A Merck spokeswoman said the agency has specific questions regarding Gardasil's effectiveness in this older age group.

The company said it had already discussed the questions with the FDA and expects to respond to the agency in July.

"Once we go back to the FDA, we'll have a better sense of what the review timing looks like," spokeswoman Amy Rose said.

The agency's response on the application for the older group does not affect Gardasil's current approval for females ages 9 to 26, Merck said.

Plans to seek approval for use in men
Ryan said the most important new opportunity for the vaccine will be for its use in males. The vaccine could help prevent males from contracting Human Papillomavirus and spreading it to females through sexual contact. Merck is on track to seek approval for use in males by the end of the year, Rose said.

It's a space-opera scene we know by heart: The hero's tiny craft faces off against the vast enemy ship. Now scale down the set a billion times or so, and replace Luke Skywalker's X-wing and the Death Star with a clump of drug-bearing molecules and a misshapen cancer cell.

This scenario -- from a National Cancer Institute video -- is just one possibility offered by the burgeoning field of cancer nanotechnology, where miniscule molecules are designed with literally atomic precision to combat a disease that kills half a million Americans every year.

"It's 21st-century medicine," said Vicki Colvin of Rice University's Center for Nanoscale Science and Technology. "It sits at the intersection of some of the greatest achievements in many different areas of science, from material science to cell biology to physics and advances in imaging."

Indeed, the National Cancer Institute, which recently announced two waves of funding for nanotech training and research, sees nanotechnology as vital to its stated goal of "eliminating suffering and death from cancer by 2015."

To anyone familiar with the long, often fruitless search for cancer's cure, or the unfulfilled promise of nanotechnology, this may seem far-fetched. But in recent years, scientists have learned more about how cancer works at the cellular level. They have also learned to build molecules that could detect and destroy cancer cells, making today's painful and often-ineffective treatments a thing of the past.

Though the jump from lab to patient is long, scientists are confident that it can be made.

"Developing any drug or diagnostic is a long process, and that's still going to be the case," said Greg Downing, director of the Office of Technology and Industrial Relations at the National Cancer Institute. "But these technologies have the potential to overcome challenges we can't overcome now."

The technologies now being developed are not the complex miniature machines usually associated with nanotechnology, but particles a few nanometers wide. (As a point of reference, the average human hair is about 100,000 nanometers wide, and a red blood cell is 4,000 nanometers in diameter.)

The first cancer nanotech applications will likely involve detection. Nanoparticles could recognize cancer's molecular signatures, gathering the proteins produced by cancerous cells or signaling the presence of telltale genetic changes. Researchers have already used a protein called albumin -- considered a naturally occurring nanoparticle -- to detect proteins found in ovarian cancer tissue.

Other nanoparticles could adhere to cancerous cells and, when viewed under a magnetic resonance imager or fluorescent light, reveal cancers now hidden to our eyes.

"Nanotech gives us the opportunity to detect cancer tumors at 1,000 cells, whereas we're now seeing them at 1 million cells. By the time you detect some cancers today, there's no option of curing them, only of prolonging life," said Sri Sridhar, director of Northeastern University's Nanomedicine Science and Technology Program.

While diagnostic nanoparticles will first be used to analyze blood or tissue samples outside the body, they could eventually be injected into the bloodstream (making it possible to also design particles that will be flushed from the patient unless they stick to cancer cells). But nanoparticles can be made not only to find those cells, but to destroy them.

One such application involves metallic molecules that adhere to cancer cells and can then be heated with microwaves, a magnetic field or infrared light, destroying the tumor while leaving surrounding tissues unharmed. Researchers at Rice University have done just this with gold-coated particles and breast cancer tissue cultures.

It's unpredictable, it's uncanny. It may be lurking within a body and the body wouldn't know. Many a minor ache, quietly ignored and quickly discarded in the past, may be the begetter of that which is pernicious, lethal and detrimental to life. It shrouds itself in dubious obscurity till the time comes for it to reveal the first symptoms. All this while, the fatal cell stealthily multiplies and spreads. It disseminates its devastating influence till it aborts the very functional mechanism of the human body. Such is the effect of cancer.

But thanks to the advances made today by clinical research, cancer cures and alternative cancer treatment are available. The choice of a particular alternative cancer treatment depends on the stage of the cancerous tumor. Traditional or conventional treatment options may include surgery, radiation, chemotherapy, hormone therapy, and immunotherapy. These therapies have all been tested in clinical research trials and proven to be acceptable, safe and effective, although with often unpleasant side effects.

Depending on the type of the disease, these cancer cures are used alone or in combination, to either control cancer cell growth or to eliminate the disease entirely.

Cancer is not a single disease. It is a large and complex family of malignancies that can affect virtually every organ in the body. Cancer kills one out of every four Americans, surpassed only by heart disease as the leading cause of death in this country. Over 1.2 million new cases are diagnosed every year, with half of them occurring in the lung, prostate, breast, colon and rectum. Cancer can strike at any age, although it is most common in people over 50.

There are around 200 different types of cancer. Two in five people, at some point in their lives, are susceptible to it. Cancer is the term given to a large group of diseases that vary in type and location. It is the result of a continuous, abnormal and relatively autonomous cell proliferation, which is due to the permanent alteration of some cells that gets transmitted to the cell family. It is a disease caused by the loss of control over a cell's reproduction capacity. Rather than dividing in a controlled and programed manner, the cell continues to divide and multiply abnormally, until a detectable lump or tumor develops.

This new growth can be either benign or malignant. A benign tumor does not spread, or metastasize, to other parts of the body and so are not cancerous. They can often be removed and are rarely a threat to life. A malignant tumor, however, can spread and is cancerous. When this tumor spreads, its malignant cells break off and travel through the blood lymph system to other parts of the body, resulting in a secondary tumor, or metastasis. The name given to the cancer, however, is reflective of the origination of the cancer. For example, if lung cancer spreads to the brain, the disease is still called metastatic lung cancer, not brain cancer.

Both external and internal factors cause cancer. Factors such as chemicals, radiation, viruses, hormones and inherited mutations may act together to start or further cancer. Ten or more years may pass between exposure and detectable cancer.

Anyone, from children to senior citizens can get this disease. What causes cancer in the first place, and how quickly the cells grow and spread, varies from person to person. While a large number of people with cancer overcome the disease and live fulfilled lives for many years, some succumb within a few months.

The journey with cancer is a long, stressful and strenuous one. The treatment procedure itself may be detrimental to the emotional well-being of the patient. This is where complementary and alternative therapies have stepped in to offer holistic treatment. Complementary and alternative medicine (CAM)—also referred to as integrative medicine—includes a broad range of healing philosophies, approaches and therapies. These therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, and control or cure disease.

The terms "complementary" and "alternative" are often used interchangeably, when in fact they are two different therapies. Complementary therapies such as acupuncture, aromatherapy, art therapy, counseling, massage, meditation, etc. are therapies which are given alongside conventional cancer treatments. The former, however, does not replace the latter. They play a supportive role and are only used in addition to standard treatments. Some commonly used methods of complementary therapy include mind-body control interventions such as visualization or relaxation; manual healing, including acupressure and massage; homeopathy; vitamins or herbal products; and acupuncture. Alternative therapies, on the other hand, are used instead of conventional treatments. Electromagnetic therapy, essiac (a mixture of herbs), iscador (mistletoe extract) and gerson therapy are some examples of alternative treatments.

Conventional approaches to cancer treatment have generally been studied for safety and effectiveness through a rigorous scientific process. Less is known about the safety and effectiveness of complementary and alternative methods since many of them have not undergone rigorous evaluation. Some remedies, however, once considered unorthodox, are finding a place in cancer treatment—not as cures, but as complementary therapies that may help patients feel better and recover faster. Traditional therapies such as ayurveda have also been known to cure cancer.

Though many of these therapies are still under evaluation, most have supporters who believe that they have added a positive aspect to their treatment and care, cope better with the physical symptoms and side effects of standard treatment, as well as with the complex and often distressing emotions that cancer can bring.

Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). They are studying new and better ways to prevent, detect, and treat ovarian cancer.

Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective. Research already has led to advances, and researchers continue to search for more effective methods.

Women who join clinical trials may be among the first to benefit if a new approach is effective. And even if the women in a trial do not benefit directly, they may still make an important contribution by helping doctors learn more about ovarian cancer and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

Researchers are conducting studies with women across the country:

• Prevention studies: For women who have a family history of ovarian cancer, the risk of developing the disease may be reduced by removing the ovaries before cancer is detected. This surgery is called prophylactic oophorectomy. Women who are at high risk of ovarian cancer are taking part in trials to study the benefits and harms of this surgery. Other doctors are studying whether certain drugs can help prevent ovarian cancer in women at high risk.
  
  
• Screening studies: Researchers are studying ways to find ovarian cancer in women who do not have symptoms.
  
  
• Treatment studies: Doctors are testing novel drugs and new combinations. They are studying biological therapies, such as monoclonal antibodies. Monoclonal antibodies can bind to cancer cells. They interfere with cancer cell growth and the spread of cancer.
  

If you are interested in being part of a clinical trial, talk with your doctor. You may want to read the NCI booklets Taking Part in Clinical Trials: What Cancer Patients Need To Know and Taking Part in Clinical Trials: Cancer Prevention Studies. NCI also offers an easy-to-read brochure called If You Have Cancer…What You Should Know About Clinical Trials. These NCI publications describe how clinical trials are carried out and explain their possible benefits and risks.

NCI's Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. It has general information about clinical trials as well as detailed information about specific ongoing studies of ovarian cancer. NCI's Information Specialists at 1-800-4-CANCER or at LiveHelp at http://www.cancer.gov/help can answer questions and provide information about clinical trials.

Learning you have ovarian cancer can change your life and the lives of those close to you. These changes can be hard to handle. It is normal for you, your family, and your friends to have many different and sometimes confusing feelings.

You may worry about caring for your family, keeping your job, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of your health care team can answer questions about treatment, working, and other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful if you want to talk about your feelings or concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.

It is natural for you to be worried about the effects of ovarian cancer and its treatment on your sexuality. You may want to talk with your doctor about possible sexual side effects and whether these effects will be permanent. Whatever happens, it may be helpful for you and your partner to talk about your feelings and help one another find ways to share intimacy during and after treatment.

For tips on coping, you may want to read the NCI booklet Taking Time: Support for People With Cancer. NCI's Information Specialists at 1-800-4-CANCER and at LiveHelp (http://www.cancer.gov/help) can help you locate programs, services, and publications. For a list of organizations offering support, you may want to get the NCI fact sheet "National Organizations That Offer Services to People With Cancer and The

You will need regular checkups after treatment for ovarian cancer. Even when there are no longer any signs of cancer, the disease sometimes returns because undetected cancer cells remained somewhere in your body after treatment.

Checkups help ensure that any changes in your health are noted and treated if needed. Checkups may include a pelvic exam, a CA-125 test, other blood tests, and imaging exams.

If you have any health problems between checkups, you should contact your doctor.

You may wish to read the NCI booklet Facing Forward Series: Life After Cancer Treatment. It answers questions about follow-up care and other concerns. It also suggests ways to talk with your doctor about making a plan of action for recovery and future health.

Complementary medicine

It's natural to want to help yourself feel better. Some people with cancer say that complementary medicine helps them feel better. An approach is called complementary medicine when it is used along with standard cancer treatment. Acupuncture, massage therapy, herbal products, vitamins or special diets, and meditation are examples of such approaches.

Talk with your doctor if you are thinking about trying anything new. Things that seem safe, such as certain herbal teas, may change the way your cancer treatment works. These changes could be harmful. And certain complementary approaches could be harmful even if used alone.

You may find it helpful to read the NCI booklet Thinking About Complementary & Alternative Medicine: A Guide for People with Cancer.

You also may request materials from the National Center for Complementary and Alternative Medicine, which is part of the National Institutes of Health. You can reach their clearinghouse at 1-888-644-6226 (voice) and 1-866-464-3615 (TTY). Also, you can visit their Web site at http://www.nccam.nih.gov.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body.

Radiation therapy is rarely used in the initial treatment of ovarian cancer, but it may be used to relieve pain and other problems caused by the disease. The treatment is given at a hospital or clinic. Each treatment takes only a few minutes.

Side effects depend mainly on the amount of radiation given and the part of your body that is treated. Radiation therapy to your abdomen and pelvis may cause nausea, vomiting, diarrhea, or bloody stools. Also, your skin in the treated area may become red, dry, and tender. Although the side effects can be distressing, your doctor can usually treat or control them. Also, they gradually go away after treatment ends.

NCI provides a booklet called Radiation Therapy and You: A Guide to Self-Help During Cancer Treatment.

Supportive care

Ovarian cancer and its treatment can lead to other health problems. You may receive supportive care to prevent or control these problems and to improve your comfort and quality of life.

Your health care team can help you with the following problems:

• Pain: Your doctor or a specialist in pain control can suggest ways to relieve or reduce pain. More information about pain control can be found in the NCI booklets Pain Control: A Guide for People with Cancer and Their Families, Get Relief from Cancer Pain, and Understanding Cancer Pain.
  
  
• Swollen abdomen (from abnormal fluid buildup called ascites): The swelling can be uncomfortable. Your health care team can remove the fluid whenever it builds up.
  
  
• Blocked intestine: Cancer can block the intestine. Your doctor may be able to open the blockage with surgery.
  
  
• Swollen legs (from lymphedema): Swollen legs can be uncomfortable and hard to bend. You may find exercises, massages, or compression bandages helpful. Physical therapists trained to manage lymphedema can also help.
  
  
• Shortness of breath: Advanced cancer can cause fluid to collect around the lungs. The fluid can make it hard to breathe. Your health care team can remove the fluid whenever it builds up.
  
  
• Sadness: It is normal to feel sad after a diagnosis of a serious illness. Some people find it helpful to talk about their feelings. See the "Sources of Support" section for more information.
  

You can get information about supportive care on NCI's Web site at http://www.cancer.gov/cancertopics/coping and from NCI's Cancer Information Service at 1-800-4-CANCER or LiveHelp (http://www.cancer.gov/help).

Nutrition and physical activity

It's important for women with ovarian cancer to take care of themselves. Taking care of yourself includes eating well and staying as active as you can.

You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods do not taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to deal with these problems. Also, the NCI booklet Eating Hints for Cancer Patients has many useful ideas and recipes.

Many women find they feel better when they stay active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know about it.

Chemotherapy uses anticancer drugs to kill cancer cells. Most women have chemotherapy for ovarian cancer after surgery. Some women have chemotherapy before surgery.

Usually, more than one drug is given. Drugs for ovarian cancer can be given in different ways:

• By vein (IV): The drugs can be given through a thin tube inserted into a vein.
  
  
• By vein and directly into the abdomen: Some women get IV chemotherapy along with intraperitoneal (IP) chemotherapy. For IP chemotherapy, the drugs are given through a thin tube inserted into the abdomen.
  
  
• By mouth: Some drugs for ovarian cancer can be given by mouth.
  

Chemotherapy is given in cycles. Each treatment period is followed by a rest period. The length of the rest period and the number of cycles depend on the anticancer drugs used.

You may have your treatment in a clinic, at the doctor's office, or at home. Some women may need to stay in the hospital during treatment.

The side effects of chemotherapy depend mainly on which drugs are given and how much. The drugs can harm normal cells that divide rapidly:

• Blood cells: These cells fight infection, help blood to clot, and carry oxygen to all parts of your body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team checks you for low levels of blood cells. If blood tests show low levels, your health care team can suggest medicines that can help your body make new blood cells.
  
  
• Cells in hair roots: Some drugs can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
  
  
• Cells that line the digestive tract: Some drugs can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Ask your health care team about medicines that help with these problems.
  

Some drugs used to treat ovarian cancer can cause hearing loss, kidney damage, joint pain, and tingling or numbness in the hands or feet. Most of these side effects usually go away after treatment ends.

You may find it helpful to read NCI's booklet Chemotherapy and You: A Guide to Self-Help During Cancer Treatment.

The surgeon makes a long cut in the wall of the abdomen. This type of surgery is called a laparotomy. If ovarian cancer is found, the surgeon removes:

• both ovaries and fallopian tubes (salpingo-oophorectomy)
  
  
• the uterus (hysterectomy)
  
  
• the omentum (the thin, fatty pad of tissue that covers the intestines)
  
  
• nearby lymph nodes
  
  
• samples of tissue from the pelvis and abdomen
  

If the cancer has spread, the surgeon removes as much cancer as possible. This is called "debulking" surgery.

If you have early Stage I ovarian cancer, the extent of surgery may depend on whether you want to get pregnant and have children. Some women with very early ovarian cancer may decide with their doctor to have only one ovary, one fallopian tube, and the omentum removed.

You may be uncomfortable for the first few days after surgery. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

The time it takes to heal after surgery is different for each woman. You will spend several days in the hospital. It may be several weeks before you return to normal activities.

If you haven't gone through menopause yet, surgery may cause hot flashes, vaginal dryness, and night sweats. These symptoms are caused by the sudden loss of female hormones. Talk with your doctor or nurse about your symptoms so that you can develop a treatment plan together. There are drugs and lifestyle changes that can help, and most symptoms go away or lessen with time.

Your doctor can describe your treatment choices and the expected results. Most women have surgery and chemotherapy. Rarely, radiation therapy is used.

Cancer treatment can affect cancer cells in the pelvis, in the abdomen, or throughout the body:

• Local therapy: Surgery and radiation therapy are local therapies. They remove or destroy ovarian cancer in the pelvis. When ovarian cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
  
  
• Intraperitoneal chemotherapy: Chemotherapy can be given directly into the abdomen and pelvis through a thin tube. The drugs destroy or control cancer in the abdomen and pelvis.
  
  
• Systemic chemotherapy: When chemotherapy is taken by mouth or injected into a vein, the drugs enter the bloodstream and destroy or control cancer throughout the body.
  

You may want to know how treatment may change your normal activities. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for women with all stages of ovarian cancer. The section on "The Promise of Cancer Research" has more information about clinical trials.

Many women with ovarian cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and treatment choices. Knowing more about ovarian cancer helps many women cope.

Shock and stress after the diagnosis can make it hard to think of everything you want to ask your doctor. It often helps to make a list of questions before an appointment. To help remember what your doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to your doctor-to take part in the discussion, to take notes, or just to listen.

You do not need to ask all your questions at once. You will have other chances to ask your doctor or nurse to explain things that are not clear and to ask for more details.

Your doctor may refer you to a gynecologic oncologist, a surgeon who specializes in treating ovarian cancer. Or you may ask for a referral. Other types of doctors who help treat women with ovarian cancer include gynecologists, medical oncologists, and radiation oncologists. You may have a team of doctors and nurses.

Getting a second opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it.

It may take some time and effort to gather medical records and arrange to see another doctor. In most cases, a brief delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Sometimes women with ovarian cancer need treatment right away.

There are a number of ways to find a doctor for a second opinion:

• Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
  
  
• NCI's Cancer Information Service, at 1-800-4-CANCER, can tell you about nearby treatment centers. Information Specialists also can assist you online through LiveHelp at http://www.cancer.gov/help.
  
  
• A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
  
  
• The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and passed exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. The Directory is in most public libraries. Also, ABMS offers this information at http://www.abms.org. (Click on "Who's Certified.")
  

To plan the best treatment, your doctor needs to know the grade of the tumor (see Diagnosis) and the extent (stage) of the disease. The stage is based on whether the tumor has invaded nearby tissues, whether the cancer has spread, and if so, to what parts of the body.

Usually, surgery is needed before staging can be complete. The surgeon takes many samples of tissue from the pelvis and abdomen to look for cancer.

Your doctor may order tests to find out whether the cancer has spread:

• CT scan: Doctors often use CT scans to make pictures of organs and tissues in the pelvis or abdomen. An x-ray machine linked to a computer takes several pictures. You may receive contrast material by mouth and by injection into your arm or hand. The contrast material helps the organs or tissues show up more clearly. Abdominal fluid or a tumor may show up on the CT scan.
  
  
• Chest x-ray: X-rays of the chest can show tumors or fluid.
  
  
• Barium enema x-ray: Your doctor may order a series of x-rays of the lower intestine. You are given an enema with a barium solution. The barium outlines the intestine on the x-rays. Areas blocked by cancer may show up on the x-rays.
  
  
• Colonoscopy: Your doctor inserts a long, lighted tube into the rectum and colon. This exam can help tell if cancer has spread to the colon or rectum.
  

These are the stages of ovarian cancer:

• Stage I: Cancer cells are found in one or both ovaries. Cancer cells may be found on the surface of the ovaries or in fluid collected from the abdomen.
  
  
• Stage II: Cancer cells have spread from one or both ovaries to other tissues in the pelvis. Cancer cells are found on the fallopian tubes, the uterus, or other tissues in the pelvis. Cancer cells may be found in fluid collected from the abdomen.
  
  
• Stage III: Cancer cells have spread to tissues outside the pelvis or to the regional lymph nodes. Cancer cells may be found on the outside of the liver.
  
  
• Stage IV: Cancer cells have spread to tissues outside the abdomen and pelvis. Cancer cells may be found inside the liver, in the lungs, or in other organs.
  

Early ovarian cancer may not cause obvious symptoms. But, as the cancer grows, symptoms may include:

• Pressure or pain in the abdomen, pelvis, back, or legs
  
  
• A swollen or bloated abdomen
  
  
• Nausea, indigestion, gas, constipation, or diarrhea
  
  
• Feeling very tired all the time
  

Less common symptoms include:

• Shortness of breath
  
  
• Feeling the need to urinate often
  
  
• Unusual vaginal bleeding (heavy periods, or bleeding after menopause)
  

Most often these symptoms are not due to cancer, but only a doctor can tell for sure. Any woman with these symptoms should tell her doctor.

Diagnosis

If you have a symptom that suggests ovarian cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history.

You may have one or more of the following tests. Your doctor can explain more about each test:

• Physical exam: Your doctor checks general signs of health. Your doctor may press on your abdomen to check for tumors or an abnormal buildup of fluid (ascites). A sample of fluid can be taken to look for ovarian cancer cells.
  
  
• Pelvic exam: Your doctor feels the ovaries and nearby organs for lumps or other changes in their shape or size. A Pap test is part of a normal pelvic exam, but it is not used to collect ovarian cells. The Pap test detects cervical cancer. The Pap test is not used to diagnose ovarian cancer.
  
  
• Blood tests: Your doctor may order blood tests. The lab may check the level of several substances, including CA-125. CA-125 is a substance found on the surface of ovarian cancer cells and on some normal tissues. A high CA-125 level could be a sign of cancer or other conditions. The CA-125 test is not used alone to diagnose ovarian cancer. This test is approved by the Food and Drug Administration for monitoring a woman's response to ovarian cancer treatment and for detecting its return after treatment.
  
  
• Ultrasound: The ultrasound device uses sound waves that people cannot hear. The device aims sound waves at organs inside the pelvis. The waves bounce off the organs. A computer creates a picture from the echoes. The picture may show an ovarian tumor. For a better view of the ovaries, the device may be inserted into the vagina (transvaginal ultrasound).
  
  
• Biopsy: A biopsy is the removal of tissue or fluid to look for cancer cells. Based on the results of the blood tests and ultrasound, your doctor may suggest surgery (a laparotomy) to remove tissue and fluid from the pelvis and abdomen. Surgery is usually needed to diagnose ovarian cancer. To learn more about surgery, see the "Treatment" section.
  

Although most women have a laparotomy for diagnosis, some women have a procedure known as laparoscopy. The doctor inserts a thin, lighted tube (a laparoscope) through a small incision in the abdomen. Laparoscopy may be used to remove a small, benign cyst or an early ovarian cancer. It may also be used to learn whether cancer has spread.

A pathologist uses a microscope to look for cancer cells in the tissue or fluid. If ovarian cancer cells are found, the pathologist describes the grade of the cells. Grades 1, 2, and 3 describe how abnormal the cancer cells look. Grade 1 cancer cells are not as likely as to grow and spread as grade 3 cells.

Doctors cannot always explain why one woman develops ovarian cancer and another does not. However, we do know that women with certain risk factors may be more likely than others to develop ovarian cancer. A risk factor is something that may increase the chance of developing a disease.

Studies have found the following risk factors for ovarian cancer:

• Family history of cancer: Women who have a mother, daughter, or sister with ovarian cancer have an increased risk of the disease. Also, women with a family history of cancer of the breast, uterus, colon, or rectum may also have an increased risk of ovarian cancer.
  
  If several women in a family have ovarian or breast cancer, especially at a young age, this is considered a strong family history. If you have a strong family history of ovarian or breast cancer, you may wish to talk to a genetic counselor. The counselor may suggest genetic testing for you and the women in your family. Genetic tests can sometimes show the presence of specific gene changes that increase the risk of ovarian cancer.
  
  
• Personal history of cancer: Women who have had cancer of the breast, uterus, colon, or rectum have a higher risk of ovarian cancer.
  
  
• Age over 55: Most women are over age 55 when diagnosed with ovarian cancer.
  
  
• Never pregnant: Older women who have never been pregnant have an increased risk of ovarian cancer.
  
  
• Menopausal hormone therapy: Some studies have suggested that women who take estrogen by itself (estrogen without progesterone) for 10 or more years may have an increased risk of ovarian cancer.
  

Scientists have also studied whether taking certain fertility drugs, using talcum powder, or being obese are risk factors. It is not clear whether these are risk factors, but if they are, they are not strong risk factors.

Having a risk factor does not mean that a woman will get ovarian cancer. Most women who have risk factors do not get ovarian cancer. On the other hand, women who do get the disease often have no known risk factors, except for growing older. Women who think they may be at risk of ovarian cancer should talk with their doctor

The ovaries

The ovaries are part of a woman's reproductive system. They are in the pelvis. Each ovary is about the size of an almond.

The ovaries make the female hormones—estrogen and progesterone. They also release eggs. An egg travels from an ovary through a fallopian tube to the womb (uterus).

When a woman goes through her "change of life" (menopause), her ovaries stop releasing eggs and make far lower levels of hormones.

Understanding ovarian cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

Benign tumors are not cancer:

• Benign tumors are rarely life-threatening.
  
  
• Generally, benign tumors can be removed. They usually do not grow back.
  
  
• Benign tumors do not invade the tissues around them.
  
  
• Cells from benign tumors do not spread to other parts of the body.
  

Malignant tumors are cancer:

• Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
  
  
• Malignant tumors often can be removed. But sometimes they grow back.
  
  
• Malignant tumors can invade and damage nearby tissues and organs.
  
  
• Cells from malignant tumors can spread to other parts of the body. Cancer cells spread by breaking away from the original (primary) tumor and entering the lymphatic system or bloodstream. The cells invade other organs and form new tumors that damage these organs. The spread of cancer is called metastasis.
  

Benign and malignant cysts

An ovarian cyst may be found on the surface of an ovary or inside it. A cyst contains fluid. Sometimes it contains solid tissue too. Most ovarian cysts are benign (not cancer).

Most ovarian cysts go away with time. Sometimes, a doctor will find a cyst that does not go away or that gets larger. The doctor may order tests to make sure that the cyst is not cancer.

Ovarian cancer

Ovarian cancer can invade, shed, or spread to other organs:

• Invade: A malignant ovarian tumor can grow and invade organs next to the ovaries, such as the fallopian tubes and uterus.
  
  
• Shed: Cancer cells can shed (break off) from the main ovarian tumor. Shedding into the abdomen may lead to new tumors forming on the surface of nearby organs and tissues. The doctor may call these seeds or implants.
  
  
• Spread: Cancer cells can spread through the lymphatic system to lymph nodes in the pelvis, abdomen, and chest. Cancer cells may also spread through the bloodstream to organs such as the liver and lungs.
  

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the original tumor. For example, if ovarian cancer spreads to the liver, the cancer cells in the liver are actually ovarian cancer cells. The disease is metastatic ovarian cancer, not liver cancer. For that reason, it is treated as ovarian cancer, not liver cancer. Doctors call the new tumor "distant" or metastatic disease.

Smoking cessation is the most important measure that can prevent lung cancer. Many products, such as nicotine gum, nicotine sprays, or nicotine inhalers, may be helpful to people trying to quit smoking. Minimizing exposure to passive smoking is also an effective preventive measure. Using a home radon test kit can identify and allow correction of increased radon levels in the home, which can also cause lung cancers. Methods that allow early detection of cancers, such as the helical low-dose CT scan, may also be of value in the identification of small cancers that can be cured by surgical resection and prevention of widespread, incurable metastatic cancer.

Lung Cancer At A Glance

• Lung cancer is the number-one cause of cancer deaths in both men and women in the U.S. and worldwide.
• Cigarette smoking is the principal risk factor for development of lung cancer.
• Passive exposure to tobacco smoke can also cause cancer.
• The two types of lung cancer, which grow and spread differently, are the small cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC).
• The stage of lung cancer refers to the extent to which the cancer has spread in the body.
• Treatment of lung cancer can involve a combination of surgery, chemotherapy, and radiation therapy as well as newer experimental methods.
• The general prognosis of lung cancer is poor, with overall survival rates of about 16% at five years.
• Smoking cessation is the most important measure that can prevent the development of lung cancer.

The prognosis of lung cancer refers to the chance for recovery and is dependent upon the localization and size of the tumor, the presence of symptoms, the type of lung cancer, and the overall health status of the patient.

SCLC has the most aggressive growth of all lung cancers, with a median survival time of only two to four months after diagnosis when untreated. (That is, by two to four months, half of all patients have died.) However, SCLC is also the type of lung cancer most responsive to radiation therapy and chemotherapy. Because SCLC spreads rapidly and is usually disseminated at the time of diagnosis, methods such as surgical removal or localized radiation therapy are less effective in treating this tumor type. However, when chemotherapy is used alone or in combination with other methods, survival time can be prolonged four- to fivefold. Of all patients with SCLC, only 5%-10% are alive five years after diagnosis. Most of those who survive have limited stage (LS) SCLC.

In non-small cell lung cancer (NSCLC), results of standard treatment are generally poor in all but the most localized cancers that can be surgically removed. However, in stage I cancers that can be completely removed, the five-year survival rate can approach 75%. Radiation therapy can produce a cure in a small minority of patients with NSCLC and leads to relief of symptoms in most patients. In advanced-stage disease, chemotherapy offers modest improvements in survival time, although overall survival rates are poor.

The overall prognosis for lung cancer is poor when compared with some other cancers. Survival rates for lung cancer are generally lower than those for most cancers, with an overall five-year survival rate for lung cancer of about 16% compared to 65% for colon cancer, 89% for breast cancer, and over 99% for prostate cancer.

The stage of a tumor refers to the extent to which a cancer has spread in the body. Staging involves both evaluation of a tumor's size as well as the presence or absence of metastases in the lymph nodes or in other organs. Staging is important for determining how a particular tumor should be treated, since lung cancer therapies are geared toward specific tumor stages. Staging of a tumor is also critical in estimating the prognosis of a given patient, with higher-stage tumors generally having a worse prognosis than lower-stage tumors.

Doctors may use several tests to accurately stage a lung cancer, including laboratory (blood chemistry) tests, x-rays, CT scans, bone scans, and MRI scans. Abnormal blood chemistry tests may signal the presence of metastases in bone or liver, and radiological procedures can document the size of a tumor as well as possible spread to other organs.

NSCLC are assigned a stage from I to IV in order of severity:

• In stage I, the cancer is confined to the lung.
  
  
• In stages II and III, the cancer is confined to the chest (with larger and more invasive tumors classified as stage III).
  
  
• Stage IV cancer has spread away from the chest to other parts of the body.

SCLC are staged using a two-tiered system:

• Limited stage (LS) SCLC refers to cancer that is confined to its area of origin in the chest.
  
  
• In extensive-stage (ES) SCLC, the cancer has spread beyond the chest to other parts of the body.

How is lung cancer treated?

Treatment for lung cancer can involve surgical removal of tumor, chemotherapy, or radiation therapy, as well as combinations of these methods. The decision about which treatments will be appropriate for a given individual must take into account the localization and extent of the tumor as well as the overall health status of the patient.

As with other cancers, therapy may be prescribed that is intended to be curative (removal or eradication of a cancer) or palliative (measures that are unable to cure a cancer but can reduce pain and suffering). More than one type of therapy may be prescribed. In such cases, the therapy that is added to enhance the effects of the primary therapy is referred to as adjuvant therapy. An example of adjuvant therapy is chemotherapy or radiotherapy administered after surgical removal of a tumor in order to be certain that all tumor cells are killed.

Surgery: Surgical removal of the tumor is generally performed for limited-stage (stage I or sometimes stage II) NSCLC and is the treatment of choice for cancer that has not spread beyond the lung. About 10%-35% of lung cancers can be removed surgically, but removal does not always result in a cure, since the tumors may already have spread and can recur at a later time. Among people who have an isolated, slow-growing lung cancer removed, 25%-40% are alive five years after diagnosis. Surgery may not be possible if the cancer is too close to the trachea or if the person has other serious conditions (such as severe heart or lung disease) that would limit their ability to tolerate an operation. Surgery is less often performed with SCLC because these tumors are less likely to be localized to one area that can be removed.

The surgical procedure chosen depends upon the size and location of the tumor. Surgeons must open the chest wall and may perform a wedge resection of the lung (removal of a portion of one lobe), a lobectomy (removal of one lobe), or a pneumonectomy (removal of an entire lung). Sometimes lymph nodes in the region of the lungs are also removed (lymphadenectomy). Surgery for lung cancer is a major surgical procedure that requires general anesthesia, hospitalization and follow-up care for weeks to months. Following the surgical procedure, patients may experience difficulty breathing, shortness of breath, pain, and weakness. The risks of surgery include complications due to bleeding, infection, and complications of general anesthesia.

Radiation: Radiation therapy may be employed as a treatment for both NSCLC and SCLC. Radiation therapy uses high-energy x-rays or other types of radiation to kill dividing cancer cells. Radiation therapy may be given as curative therapy, palliative therapy (using lower doses of radiation than with curative regimens) or as adjuvant therapy to surgery or chemotherapy. The radiation is either delivered externally, by using a machine that directs radiation toward the cancer, or internally through placement of radioactive substances in sealed containers within the area of the body where the tumor is localized. Brachytherapy is a term used to describe the use of a small pellet of radioactive material placed directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope. A type of external radiation therapy called the "gamma knife" is sometimes used to treat single brain metastases. In this procedure, multiple beams of radiation are focused on the tumor over a few minutes to hours while the head is held in place by a rigid frame. Radiation therapy can be given if a person refuses surgery, if a tumor has spread to areas such as the lymph nodes or trachea making surgical removal impossible, or if a person has other conditions that make them too ill to undergo major surgery. Radiation therapy generally only shrinks a tumor or limits its growth when given as a sole therapy, yet in 10%-15% of people it leads to long-term remission and palliation of the cancer. Combining radiation therapy with chemotherapy can further increase the chances of survival when chemotherapy is administered. External radiation therapy can generally be carried out on an outpatient basis while internal radiation therapy requires a brief hospitalization. A person who has severe lung disease in addition to a lung cancer may not be able to receive radiotherapy to the lung.

For external radiation therapy, a process called simulation is necessary prior to treatment. Using CT scans, computers, and precise measurements, simulation maps out the exact location where the radiation will be delivered, called the treatment field or port. This process usually takes 30 minutes to two hours. The external radiation treatment itself generally is done over four or five days a week for several weeks.

Radiation therapy does not carry the risks of major surgery, but it can have unpleasant side effects including tiredness and lack of energy. A reduced white cell count (rendering a person more susceptible to infection) and low blood platelet levels (making blood clotting more difficult) can also occur with radiation therapy. If the digestive organs are in the field exposed to radiation, patients may experience nausea, vomiting, or diarrhea. Radiation therapy can irritate the skin in the area that is treated, but this irritation generally improves with time after treatment has ended.

Chemotherapy: Both NSCLC and SCLC may be treated with chemotherapy. Chemotherapy refers to the administration of drugs that stop the growth of cancer cells by killing them or preventing them from dividing. Chemotherapy may be given alone, as an adjuvant to surgical therapy, or in combination with radiotherapy. While a number of chemotherapeutic drugs have been developed, the platinum-based drugs have been the most effective in treatment of lung cancers.

Chemotherapy is the treatment of choice for most SCLC, since these tumors are generally widespread in the body when they are diagnosed. Only half of people who have SCLC survive for four months without chemotherapy. With chemotherapy, their survival time is increased up to four- to fivefold. Chemotherapy alone is not particularly effective in treating NSCLC, but when NSCLC have metastasized, it can prolong survival in many cases.

Chemotherapy may be given as pills, as an intravenous infusion, or as a combination of the two. Chemotherapy treatments are usually given in an outpatient setting. A combination of drugs is given in a series of treatments, called cycles, over a period of weeks to months, with breaks in between cycles. Unfortunately, the drugs used in chemotherapy also kill normally dividing cells in the body, resulting in unpleasant side effects. Damage to blood cells can result in increased susceptibility to infections and difficulties with blood clotting (bleeding or bruising easily). Other side effects include fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and mouth sores. The side effects of chemotherapy vary according to the dosage and combination of drugs used and may also vary from individual to individual. Medications have been developed that can treat or prevent many of the side effects of chemotherapy. The side effects generally disappear during the recovery phase of the treatment or after its completion.

Brain prophylactic radiation: SCLC often spreads to the brain. Sometimes people with SCLC that is responding well to treatment are treated with radiation therapy to the head to treat very early spread to the brain (called micrometastasis) that is not yet detectable with CT or MRI scans and has not yet produced symptoms. Brain radiation therapy can cause short-term memory problems, fatigue, nausea and other side effects.

Treatment of recurrence: Lung cancer that has returned following treatment with surgery, chemotherapy, and/or radiation therapy is called recurrent or relapsed. If a recurrent cancer is confined to one site in the lung, it may be treated with surgery. Relapsed tumors generally do not respond to the chemotherapeutic drugs that were previously administered. Since platinum-based drugs are generally used in initial chemotherapy of lung cancers, these agents are not useful in most cases of recurrence. A type of chemotherapy referred to as second-line chemotherapy is used to treat recurrent cancers that have previously been treated with chemotherapy, and a number of second-line chemotherapeutic regimens have been proved effective at prolonging survival. People with recurrent lung cancer who are well enough to tolerate therapy are also good candidates for experimental therapies (see below) including clinical trials.

Targeted therapy: One alternative to standard chemotherapy is the drug erlotinib (Tarceva) which may be used in patients with NSCLC who are no longer responding to chemotherapy. It is a so-called targeted drug, a drug that more specifically targets cancer cells, resulting in less damage to normal cells. Erlotinib targets a protein called the epidermal growth factor receptor (EGFR) which helps cells to divide. This protein is found at abnormally high levels on the surface of some types of cancer cells, including many cases of non-small cell lung cancer. Erlotinib is taken by mouth in pill form.

Other attempts at targeted therapy include drugs known as antiangiogenesis drugs, which block the development of new blood vessels within a tumor. The antiangiogenic drug bevacizumab (Avastin) has recently been found to prolong survival in advanced lung cancer when it is added to the standard chemotherapy regimen. Bevacizumab is given intravenously every two to three weeks. However, since this drug may cause bleeding, it is not appropriate for use in patients who are coughing up blood, if the lung cancer has spread to the brain, or in people who are receiving anticoagulation therapy ("blood thinner" medications). Bevacizumab is also not used in cases of squamous cell cancer, because it leads to bleeding from this type of lung cancer.

Photodynamic therapy (PDT): One newer therapy used for different types and stages of lung cancer (as well as some other cancers) is photodynamic therapy. In photodynamic treatment, a photosynthesizing agent (such as a porphyrin, a naturally occurring substance in the body) is injected into the bloodstream a few hours prior to surgery. During this time, the agent deposits itself selectively in rapidly growing cells such as cancer cells. A procedure then follows in which the physician applies a certain wavelength of light through a handheld wand directly to the site of the cancer and surrounding tissues. The energy from the light activates the photosensitizing agent, causing the production of a toxin that destroys the tumor cells. PDT has the advantages that it can precisely target the location of the cancer, is less invasive than surgery, and can be repeated at the same site if necessary. The drawbacks of PDT are that it is only useful in treating cancers that can be reached with a light source and is not suitable for treatment of extensive cancers. Research is ongoing to further determine the effectiveness of PDT in lung cancer.

Experimental therapies: Since no therapy is currently available that is absolutely effective in treating lung cancer, patients may be offered a number of new therapies that are still in the experimental stage, meaning that doctors do not yet have enough information to decide whether these therapies should become accepted forms of treatment for lung cancer. New drugs or new combinations of drugs are tested in so-called clinical trials, which are studies that evaluate the effectiveness of new medications in comparison with those treatments already in widespread use. Experimental treatments known as immunotherapies are being studied that involve the use of vaccine-related therapies or other therapies that attempt to utilize the body's immune system to fight cancer cells.

Doctors use a wide range of diagnostic procedures and tests to diagnose lung cancer. These include:

• The history and physical examination may reveal the presence of symptoms or signs that are suspicious for lung cancer. In addition to asking about symptoms and risk factors for cancer development, doctors may detect signs of breathing difficulties, airway obstruction, or infections in the lungs. Cyanosis, a bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood, suggests compromised function of the lung. Likewise, changes in the tissue of the nail beds, known as clubbing, may also indicate lung disease.
  
  
• The chest x-ray is the most common first diagnostic step when any new symptoms of lung cancer are present. The chest x-ray procedure often involves a view from the back to the front of the chest as well as a view from the side. Like any x-ray procedure, chest x-rays expose the patient briefly to a minimum amount of radiation. Chest x-rays may reveal suspicious areas in the lungs but are unable to determine if these areas are cancerous. In particular, calcified nodules in the lungs or benign tumors called hamartomas may be identified on a chest x-ray and simulate lung cancer.
  
  
• CT (computerized axial tomography scan, or CAT scan) scans may be performed on the chest, abdomen, and/or brain to examine for both metastatic and primary tumor. A CT scan of the chest may be ordered when x-rays are negative or do not yield sufficient information about the extent or location of a tumor. CT scans are x-ray procedures that combine multiple images with the aid of a computer to generate cross-sectional views of the body. The images are taken by a large donut-shaped x-ray machine at different angles around the body. One advantage of CT scans is that they are more sensitive than standard chest x-rays in the detection of lung nodules. Sometimes intravenous contrast material is given prior to the procedure to help delineate the organs and their positions. A CT scan exposes the patient to a minimal amount of radiation. The most common side effect is an adverse reaction to intravenous contrast material that may have been given prior to the procedure. There may be resulting itching, a rash, or hives that generally disappear rather quickly. Severe anaphylactic reactions (life-threatening allergic reactions with breathing difficulties) to contrast material are rare. CT scans of the abdomen may identify metastatic cancer in the liver or adrenal glands, and CT scans of the head may be ordered to reveal the presence and extent of metastatic cancer in the brain.
  
  
• A technique called a low-dose helical CT scan (or spiral CT scan) is sometimes used in screening for lung cancers. This procedure requires a special type of CAT scanner and has been shown to be an effective tool for the identification of small lung cancers in smokers and former smokers. However, it has not yet been proven whether the use of this technique actually saves lives or lowers the risk of death from lung cancer. The heightened sensitivity of this method is actually one of the sources of its drawbacks, since lung nodules requiring further evaluation will be seen in approximately 20% of people with this technique. Of the nodules identified by low-dose helical screening CTs, 90% are not cancerous but require up to two years of costly and often uncomfortable follow-up and testing. Trials are underway to further determine the utility of spiral CT scans in screening for lung cancer.
  
  
• Magnetic resonance imaging (MRI) scans may be indicated when precise detail about a tumor's location is required. The MRI technique uses magnetism, radio waves, and a computer to produce images of body structures. As with CT scanning, the patient is placed on a moveable bed which is inserted into the MRI scanner. There are no known side effects of MRI scanning, and there is no exposure to radiation. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. People with heart pacemakers, metal implants, artificial heart valves, and other surgically implanted structures cannot be scanned with an MRI because of the risk that the magnet may move the metal parts of these structures.
  
  
• Positron emission tomography (PET) scanning is a specialized imaging technique that uses short-lived radioactive substances to produce three-dimensional colored images of those substances functioning within the body. While CT scans and MRI scans look at anatomical structures, PET scans measure metabolic activity and functioning of tissue. PET scans can determine whether a tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor. In PET scanning, the patient receives a short half-lived radioactive drug and receives approximately the amount of radiation exposure as with two chest x-rays. The drug discharges positrons from wherever they are used in the body. As the positrons encounter electrons within the body, a reaction producing gamma rays occurs. A scanner records these gamma rays and maps the area where the drug is located. For example, combining glucose (a common energy source in the body) with a radioactive substance will show where glucose is being used in a growing tumor.
  
  
• Bone scans are used to create images of bones on a computer screen or on film. Doctors may order a bone scan to determine whether a lung cancer has metastasized to the bones. In a bone scan, a small amount of radioactive material is injected into the bloodstream and collects in the bones, especially in abnormal areas such as those involved by metastatic tumors. The radioactive material is detected by a scanner, and the image of the bones is recorded on a special film for permanent viewing.
  
  
• Sputum cytology: The diagnosis of lung cancer always requires confirmation of malignant cells by a pathologist, even when symptoms and x-ray studies are suspicious for lung cancer. The simplest method to establish the diagnosis is the examination of sputum under a microscope. If a tumor is centrally located and has invaded the airways, this procedure, known as a sputum cytology examination, may allow visualization of tumor cells for diagnosis. This is the most risk-free and inexpensive tissue diagnostic procedure, but its value is limited since tumor cells will not always be present in sputum even if a cancer is present. Also, noncancerous cells may occasionally undergo changes in reaction to inflammation or injury that makes them look like cancer cells.
  
  
• Bronchoscopy: Examination of the airways by bronchoscopy (visualizing the airways through a thin probe inserted in a tube through the nose or mouth) may reveal areas of tumor that can be sampled for pathologic diagnosis. A tumor in the central areas of the lung or arising from the larger airways is accessible to sampling using this technique. Bronchoscopy may be performed using a rigid or a flexible, fiberoptic bronchoscope and can be performed in a same-day outpatient bronchoscopy suite, an operating room, or on a hospital ward. The procedure can be uncomfortable and require sedation or anesthesia. While the procedure is relatively safe, the procedure must be carried out by a lung specialist (pulmonologist or surgeon) experienced in the procedure. When a tumor is visualized and adequately sampled, an accurate cancer diagnosis is generally possible. Some patients may cough up dark-brown blood for one to two days after the procedure. More serious, and rare, complications include a greater amount of bleeding, decreased levels of oxygen in the blood, and heart arrhythmias as well as complications from sedative medications and anesthesia.
  
  
• Needle biopsy: Fine needle aspiration (FNA) through the skin, most commonly performed with radiological imaging for guidance, may be useful in retrieving cells for diagnosis from tumor nodules in the lungs. Needle biopsies are particularly useful when the lung tumor is peripherally located in the lung and not accessible to sampling by bronchoscopy. A small amount of local anesthetic is given prior to insertion of a thin needle through the chest wall into the abnormal area in the lung. Cells are suctioned into the syringe and are examined under the microscope for tumor cells. This procedure is generally accurate when the tissue from the affected area is adequately sampled, but in some cases, adjacent or uninvolved areas of the lung may be mistakenly sampled. A small risk (3%-5%) of an air leak from the lungs (called a pneumothorax, which can easily be treated) accompanies the procedure.
  
  
• Thoracentesis: Sometimes lung cancers involve the lining tissue of the lungs (pleura) and lead to an accumulation of fluid in the space between the lungs and chest wall (called a pleural effusion). Aspiration of a sample of this fluid with a thin needle (thoracentesis) may reveal the cancer cells and establish the diagnosis. As with the needle biopsy, a small risk of a pneumothorax is associated with this procedure.
  
  
• Major surgical procedures: If none of the aforementioned methods yields a diagnosis, surgical methods must be employed to obtain tumor tissue for diagnosis. These can include mediastinoscopy (examining the chest cavity between the lungs through a surgically inserted probe with biopsy of tumor masses or lymph nodes) or thoracotomy (surgical opening of the chest wall with removal of as much tumor as possible). Thoracotomy is rarely able to completely remove a lung cancer, and both mediastinoscopy and thoracotomy carry the risks of major surgical procedures (complications such as bleeding, infection, and risks from anesthesia and medications). These procedures are performed in an operating room, and the patient must be hospitalized.
  
  
• Blood tests: While routine blood tests alone cannot diagnose lung cancer, they may reveal biochemical or metabolic abnormalities in the body that accompany cancer. For example, elevated levels of calcium or of the enzyme alkaline phosphatase may accompany cancer that is metastatic to the bones. Likewise, elevated levels of certain enzymes normally present within liver cells, including aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT), signal liver damage, possibly through the presence of metastatic tumor.

Schematic illustration of a lung cancer located in the right upper lobe of the lung.