It was sometime after midnight on Dec. 8, 2007, when Dr. Eric Goren told me my husband might not live till morning. The kidney cancer that had metastasized almost six years earlier was growing in his lungs. He was in intensive care at the Hospital of the University of Pennsylvania in Philadelphia and had begun to spit blood.

Terence Bryan Foley, 67 years old, my husband of 20 years, father of our two teenagers, a Chinese historian who earned his PhD in his sixties, a man who played more than 15 musical instruments and spoke six languages, a San Francisco cable car conductor and sports photographer, an expert on dairy cattle and swine nutrition, film noir, and Dixieland jazz, was confused. He knew his name, but not the year. He wanted a Coke.

Should Terence begin to hemorrhage, the doctor asked, what should he do?

This was our third end-of-life warning in seven years. We had fought off the others, so perhaps we could dodge this one, too. Terence’s oncologist and I both believed that a new medicine he had just begun taking, Pfizer’s (PFE) Sutent, would buy him more life.

Keep him alive if you can, I said.

Terence died six days later, on Friday, Dec. 14.

What I couldn’t know then was that the thinking behind my request—along with hundreds of decisions we made over the years—was a window on the impossible calculus at the core of today’s health-care dilemma. Terence and I were eager to beat his cancer. Backed by robust medical insurance provided by a succession of my corporate employers, we were able to wage a fierce battle. As we made our way through a series of expensive last chances, like the one I asked for that night, we didn’t have to think about money, allocation of medical resources, the struggles of roughly 46 million uninsured Americans, or the impact on corporate bottom lines.

Terence’s treatment was expensive. The bills for his seven years of medical care totaled $618,616, almost two-thirds of which was for his final 24 months. Still, no one can say for sure if the treatments helped extend his life.

Over the final four days before hospice—two in intensive care, two in a cancer ward—our insurance was billed $43,711 for doctors, medicines, monitors, X-rays, and scans. Two years later the only thing I can see that the money bought for certain was confirmation he was dying. Along with a colleague, Charles Babcock, I spent months poring over almost 5,000 pages of documents collected from six hospitals, four insurers, Medicare, three oncologists, and a surgeon. Those papers tell the story of a system filled with people doing their best. Stepping back and looking at that large stack through a different lens, a string of complex questions emerges.

31% for Paperwork

Health-care costs represent 17% of today’s U.S. gross domestic product. Medicare devotes about a quarter of its budget to care in the last year of life, according to the policy journal Health Affairs. Yet as I fought to buy my husband more time, it didn’t matter to me that the hospital charged more than 12 times what Medicare then reimbursed for a chest scan. It also didn’t matter that UnitedHealthcare (UNH) reimbursed the hospital for 80% of the $3,232 price of a scan, while a few months later our new insurer, Empire BlueCross & BlueShield, paid 24% for the same test. And I didn’t have time to be thankful that the insurers negotiated the rates with the hospital so neither my employers nor I actually paid the difference between the sticker and discounted prices.

Looking at that stack of documents, it is easy to see why 31% of the money spent on health care went to paperwork and administration, according to research published in 2003 in the New England Journal of Medicine. That number has stayed the same or grown since then, says Dr. Steffie Woolhandler, a professor at Harvard Medical School and a co-author of the study. Often Terence’s bills, with their blizzard of codes, took days to decipher. What did “opd patins t” or “bal xfr ded” mean? Was the dose charged the same as the dose prescribed?

The documents revealed an economic system in which the sellers don’t set the prices and the buyers don’t know what they are. Prices bear little relation to demand or how well goods and services work. “No other nation would allow a health system to be run the way we do it. It’s completely insane,” said Uwe E. Reinhardt, a political economy professor at Princeton University who has advised Congress, the Veteran’s Administration, and other federal agencies on health-care economics.

In reviewing Terence’s records, we found Presbyterian Medical Center in Philadelphia charged UnitedHealthcare $8,120 in 2006 for a 350 mg dose of the drug Avastin, which should have been free as part of a clinical trial. When my Bloomberg colleague inquired, the 80% insurance payment was refunded. A small mixup, but telling.

Some drugs Terence took probably did him no good. At least one helped fewer than 10% of patients. Today, pharmaceutical companies and government agencies are trying to sort out the economics of developing drugs that will help only a small subset of patients. These drugs are very expensive. Should every patient have the right to them?

Terence and I answered yes. Each drug potentially added life. Yet that, too, led me to a question I still can’t answer. When is it time to quit? Congress dodged the question last year as it tried to craft a health-care bill. The mere hint of limiting the ability to choose care created a whirlwind of accusations of “death panels.”

One thing I know is that I don’t envy the policymakers. As the health-care debate heated up, I remembered the fat sheaf of insurance statements that had piled up after Terence’s death. Our children, Terry, 21, and Georgia, 15, assented to my idea of gathering every record to examine what they would show about end-of-life care—its science, emotions, and costs. Terence would have approved.

Taking it all into account, the data showed we had made a bargain that hardly any economist looking solely at the numbers would say made sense.

Why did we do it? I was one big reason. Not me alone, of course. The system has a strong bias toward action. My husband, too, was unusual, said Keith Flaherty, his oncologist, in his passionate willingness to endure discomfort for a chance to see his daughter grow from a child to a young woman, and his son graduate from high school.

After Terence died, Flaherty drew me a picture of a bell curve, showing the range of survival times for people with kidney cancer. Terence was way off in the tail on the right-hand side, an indication he had beaten the odds. For many, an explosion of research and drug discoveries had made it possible to daisy-chain treatments and extend lives for years—enough time to keep our quest from having been total madness.

Terence used to tell a story, almost certainly apocryphal, about his Uncle Bob. Climbing aboard a landing craft before the invasion of Normandy, Bob’s sergeant was said to have told the men that by the end of the day, 9 out of 10 of them would be dead. Said Bob: “Each one of us looked around and felt so sorry for those other nine poor sonsabitches.”

For me, it was about pushing the bell curve. Knowing there was something to be done, we couldn’t not do it. Believing beyond logic that we were going to escape the fate of those other poor sonsabitches.

It is hard to put a price on that kind of hope.

A shadow but good odds

We found the cancer by accident, on Sunday, Nov. 5, 2000, in Portland, Ore. Terry had invited a dozen friends for a sleepover to celebrate his 12th birthday. I was making pancakes and shipping the boys home. Terence had been having stomach cramps for weeks. Suddenly he was lying on the bed, doubled over in pain. Our family doctor ordered him to the emergency room.

We were immediately triaged through. Not a good sign, I thought. The kids sat on the waiting-room floor, Barbies and X-Men around them, while Terence writhed in a curtained alcove. When he returned from a scan, the doctor said, almost as an aside: There’s a shadow on his kidney. When he’s feeling better, you should take a look at it. Both of us were annoyed. Why would we think about a shadow on his kidney? That wasn’t the problem. He was in such pain he could barely breathe.

The cause of the pain turned out to be violent ulcerative colitis. The damaged colon was removed on Dec. 13, in an operation that left Terence so weak that he spent three weeks, including Christmas morning, immobile in a chair. Colleagues delivered meals to the house. My sister wrapped presents. My boss sent over her husband to put up our lights. I felt so bad for Terence that I got him a cat, the pet he had long wanted. The orange kitten howled in a box under the tree.

And the shadow? We were so grateful he was out of pain that we would have ignored it had someone from the hospital not called to urge us to find out what it meant. Within a month, Terence was in surgery again. On Jan. 18, Dr. Craig Turner removed the diseased kidney. Emerging from the five-hour operation, Turner confirmed the worst: He believed the shadow was cancer. A week later, when Terence was well enough to walk into the doctor’s office, Turner was reassuring.

“We got it all,” he said.

Terence teared up. “Thank you for saving my life.”

The bills from Regence BlueCross BlueShield of Oregon show the operation was relatively inexpensive, just over $25,000, about 4% of the eventual total charged to keep Terence alive. Our share was $209.87. I never looked at or thought about the total cost, or the $14,084 that our insurance—in reality, my employer—paid. We never had to consider who was actually shouldering the bills.

Kidney cancer is uncommon, accounting for about 3% of all cancers, or about 50,000 new cases in the U.S. last year, according to the Kidney Cancer Assn. Terence was a typical patient: an older man, overweight, and an ex-smoker. Asymptomatic for a long time, most kidney cancers are discovered accidentally or too late. So we felt lucky. The first tool for fighting kidney cancer is usually the one used since medieval times: the knife, or its technological equivalent. If a tumor is removed early enough, before it flings microscopic cells into the bloodstream that can implant in other organs, surgery is close to a cure.

For Terence the odds looked good. His 7-centimeter tumor showed no signs of having spread. According to the traditional method of evaluating, or staging, the cancer, that meant he had an 85% chance of surviving five years. A lab report soon chilled our optimism. Tests on Terence’s tumor showed that he had so-called collecting duct cancer. Named for the part of the kidney where it is thought to originate, collecting duct is the rarest and most aggressive form of kidney cancer. In my online research, almost everyone who had it died within months, sometimes weeks, of diagnosis.

Most kidney cancers don’t respond well to chemotherapy. There was no accepted treatment after surgery. Almost nothing was known about collecting duct cancer. Only about 1% of kidney cancer patients receive that diagnosis. Dr. Turner and I could find just 50 cases documented in the medical literature worldwide, and nothing had proved effective in halting it. “Watchful waiting” was the recommended path.

Waiting for him to die was what we feared.

He didn’t die. He got better. We didn’t know why. We tried not to think about it.

By the spring of 2002, we had moved to Lexington, Ky., where I was the editor of the local newspaper and Terence was creating an Asia Center at the University of Kentucky. He seemed fine. He began moving Chinese and Japanese history books to his office. On Saturdays we drove through the bluegrass to take seven-year-old Georgia to riding lessons. We reluctantly let 13-year-old Terry crowd-surf at his first rock concert.

Then, on May 6, 2002, Terry called me at work, panic in his voice. “Mom, come home. Dad is very sick.”

His father was in bed, his face flaming with fever, shaking with chills under a pile of blankets. He could barely speak. “The cancer is in my lungs,” he said. “I’ve got six to nine months left.”

Fear, and internet plunge

He had been keeping that secret for months. In February, routine follow-up scans had spotted the cancer’s spread. “The first thing Terence said was, ‘Doc, do you have any female patients who have recently died? I need to find a widower so my wife can meet her next husband,’ ” his Lexington oncologist, Dr. Scott Pierce, later recalled. After more tests, Dr. Pierce prescribed Interleukin-2 because there were no other options. Injections of the protein, at $735 a dose, were intended to stimulate the immune response to help fight the cancer’s invasion. The overall response rate was only about 10%. For most patients, Interleukin-2 did absolutely nothing.

Terence hadn’t wanted to worry us. In his mind, if he recovered, we would never know how close he came; if he died, he would have spared us months of anguish. He started a diary and spent more time in the office so we would get used to his absence.

His secret was betrayed by his violent reaction to his first dose of IL-2. Suddenly his actions over the last several weeks made sense. He had been giving away musical instruments and pieces of art. “I have too much stuff,” he had told me, a bizarrely improbable statement coming from him. I was amused, exasperated, and touched by his desire to protect us. Even under the strain of his disease, he was so much himself. “Did you think I wouldn’t have noticed if you didn’t come home one day?” I asked.

I spent that night awake in our dark living room. For the first and only time, I felt pure terror. A few days later I visited a therapist.

“I can’t survive without him,” I said.

“What does he say when you feel this way?” she asked.

“He says I can handle anything.”

“You’ll need to say that to yourself.”

Terence stopped taking IL-2 after a few weeks of treatments, unable to stand the side effects.

I plunged into the Internet. If there were something out there that could save him, I was going to find it. Years before, one of my former colleagues, dying from AIDS, had suddenly come back to vigorous life because of a chance introduction to a doctor who prescribed what was then an experimental antiviral cocktail. Another had beaten leukemia with a cutting-edge bone marrow transplant. We could defeat this.

I downloaded papers, presentations to the Kidney Cancer Assn., abstracts from the National Library of Medicine. I called researchers and oncologists, pathologists and fellow journalists. When the research became overwhelming, I hired a retired nurse to help. My boss’s wife, a nurse herself, dug in too. After I messaged one couple about a clinical trial in Texas, they offered us their spare bedroom.

Throughout the spring and summer of 2002, Georgia, then 8, rode her bicycle up and down shady South Ashland Avenue. Thirteen-year-old Terry and his friends Shannon, Hughes, and Tanner came in last at their first battle of the bands. Terence sounded optimistic. “It’s my dream,” he said. “Some day we’re going to gig together.”

Awaiting scans, learning the violin

The truth was we were both shaken by the dire prognosis.

“What would you regret dying without having seen?” I asked. He answered without hesitation: “Pompeii.” We pulled Terry from his eighth-grade class, Georgia out of second, and flew to Italy to see the excavated remains of the city once buried under volcanic ash. We walked the cobbled streets, poked into frescoed houses, taverns, and baths, and took an eerie comfort from the 2,000-year-old shapes of families huddled together, trying to ward off disaster.

By then our research had led us to the Cleveland Clinic, where Dr. Ronald Bukowski had specialized in kidney cancer for over 20 years. At our first meeting, in August 2002, Terence explained that he had collecting duct cancer.

“No you don’t,” Bukowski said.

We were confused. How did he know?

“You’re sitting here,” he said. “If you had collecting duct, you would be dead.”

Bukowski argued that the disease was growing so slowly that we should simply watch and wait. We did, for three years. Then, in December 2005, a scan showed that the cancer in his lungs had begun to grow.

By this time, research had progressed. New drugs designed to attack a tumor’s blood supply were appearing to slow the growth of a wide range of cancers. Bukowski recommended we enter a clinical trial, pretty much the only way to get these targeted therapies. He referred us to Dr. Flaherty in Philadelphia, where we had moved in June 2003 when I changed jobs.

The drugs Flaherty was testing—Genentech’s Avastin and Bayer’s Nexavar—had showed promise individually. The trial would find out how they worked together. In March 2006, Terence took his first intravenous dose of Avastin, an hour-long process, and swallowed his first Nexavar. The side effects were hard. There were rashes, sometimes debilitating stomach pains. But he continued teaching, picking up the kids at school, studying and writing. He worked on his book, a grammar text based on classical Chinese poetry. He started to learn to play the violin and to read and write Arabic. Every two weeks he went for an Avastin drip. And every month we anxiously awaited the results of a chest scan.

At first the cancer didn’t budge. Then it began to retreat.

Because Terence was in a clinical trial, Genentech and Bayer provided their drugs free. I learned that over the years of Terence’s battle with cancer, some insurers drove harder bargains than others. In December 2006, for example, United Healthcare paid $2,586 to University of Pennsylvania Hospital for a chest scan; in March 2007, after I switched employers, Empire BlueCross paid $776 for the same $3,232 bill.

When it came to the insurance companies, the sticker price meant little since they had negotiated their own deals with the hospital. Neither the hospital nor the insurance companies would elaborate. The entire medical bill for seven years, in fact, was steeply discounted. The $618,616 was lowered to $254,176 when the insurers paid their share and imposed their discounts. The portion of the charges that were not covered for the most part vaporized. Terence and I were responsible for and paid $9,468—less than 4%.

During the trial, Terence packed boxes for the troops in Iraq and Afghanistan, loading them in our kitchen with deodorant, wet wipes, Mars bars, Kool-Aid, beef jerky, batteries, and magazines. A veteran of Naval Intelligence and the U.S. Air Force reserves, he walked almost every day to the post office with a box addressed to “Any Soldier.” Behind the counter, the smiling lady with the long red hair extensions became his friend, and every so often a soldier would drop him a thank-you note.

Life went on.

Then, in August 2007, from half a world away, I heard the cancer return.

I was on a business trip to China when Terence coughed during one of our phone calls. By the time I got home, scans had confirmed growth of one of the lung’s cancerous spots.

By now, more than six years had passed since we first saw the shadow, and I was used to the scares. Avastin’s side effects—fatigue, stomach ailments, rashes—had been getting him down, and the doctor had agreed back in May to let him stop treatments. So we’ll go back on the Avastin, I thought, or cut out or laser out the growth, add new treatments, and go on.

The records document our renewed fight. Terence resumed Avastin. Because he was no longer in a trial, our insurance company was billed $27,360 a dose, every two weeks, more than the cost of the kidney surgery in 2000. Empire BlueCross paid $6,566.40. We paid nothing. So who did the paying? The health insurance system depends on healthy people bearing the cost for sick ones like Terence. For all its incredible treatment benefits, the system is untenable. Should you have had a voice in Terence’s final days? Would I make the same decision with my money for your loved ones? These are things I think about now but can’t answer.

No consensus

He coughed almost continuously. His weight plunged. He needed help on the stairs. He began to use a cane. When his friend Woody came to visit, Terence couldn’t muster the breath to blow his cornet. He coughed and coughed and coughed. In the last week of October, he called me at work.

“I can’t pick Georgia up at school,” he said. “I can’t get out of the chair.” On Halloween, his Dracula costume stayed in the basement. We left the candy on the doorstep.

On Nov. 8 we saw Dr. Ali Musani, a pulmonologist specializing in cancer. We hoped that the growing tumor in Terence’s chest could be removed. Unable to stand or sit unassisted, he lay on the floor and refused to get up. Alarmed, Musani admitted him to the hospital. He said there was nothing he could do about the tumor. He gently mentioned that it might be time to consider hospice. We brushed off the suggestion.

Terence stayed in the hospital four days. Meanwhile a quiet tension was building. Flaherty and I believed this episode to be a temporary setback. Other doctors and nurses saw a patient near the end.

On Nov. 11, before discharging him, a doctor propped one of Terence’s scans on a light board so we could clearly see the blizzard of white spots, hundreds of tumors, covering his lungs.

Avastin wasn’t stopping them.

Flaherty was not fazed by the growth, and pointed out that many of the doctors looking at the scans didn’t understand the course of kidney cancer. He and I wanted to move on to the next link in the daisy chain of newly available drugs. Sutent, another targeted therapy, had been approved the year before. It worked as Avastin did, by stopping cancer’s ability to build extra blood vessels to feed its growth, but in a different way. One $200 pill a day. A shot at more life. Sutent might have more serious side effects—rashes, fatigue, stomach distress, strokes—but Terence was game. He began taking it on Nov. 15.

At home, he drew a line down the middle of a piece of paper. On one side he wrote things to throw away. On the other, things to keep.

“Stop that!” I snapped. “You aren’t going to die.”

I prepared for what I expected would be a new phase of our life. I found protein drinks online and protein bars in a bodybuilding shop. I got forms for a handicapped license plate, looked into outfitting our row house with a stair lift.

Terence was no longer able to get in and out of bed alone, so I hired a health aide. Whatever he craved, I bought. I wrote down everything he ate. Cold grapefruit slices. Chicken noodle soup. Clam chowder. I counted the calories he consumed one day: 210.

On Friday, Dec. 7, just as the aide was packing to leave for the day, Terence looked up, startled, as the corners of his mouth foamed bright red with blood. It was a struggle to get him down our narrow stairs to the ambulance. In the emergency room it was clear something was seriously wrong. “What’s your name?” asked the ER doctor. Terence responded correctly. “What’s the date?” Terence gave the doctor what the kids and I recognized as “Daddy’s ‘Just how dumb are you?’ ” look. But he couldn’t answer.

“Who’s the President of the United States?” That triggered something. “That moron, Bush,” he said.

Terence was admitted that night to a ward where Eric Goren was doing his last intensive-care overnight shift of a three-year residency. In a small break room, alongside vending machines selling soft drinks and chips, Goren told me that bleeding from the lungs might suddenly become uncontrollable. If that happened, what should he and his team do?

I wanted to see whether Flaherty still believed Sutent could make a difference, but I couldn’t reach him. Goren and I settled on what the hospital called Code-A. Do everything possible to prevent a major bleed or anything life-threatening. But don’t take heroic measures if death seems inevitable.

I called the children to the hospital.

My decision about Terence’s treatment, so hard on Saturday, was easy by Monday. The scans now were showing signs of cancer in his brain, surrounded by a cascade of hundreds of tiny strokes. I had Terence’s signed living will, but I didn’t need it. I knew what this man who lived for books, music, and ideas would want.

When Flaherty arrived, he looked shaken. “I didn’t expect this,” he said.

That afternoon I signed the papers transferring Terence to hospice. The next day the hospital staff took away the machines and the monitors. The oncologists and radiologists and lab technicians disappeared. Hospice nurses, social workers, chaplains, and counselors for me and the children—began to arrive and the focus shifted from treatment to easing our transition.

Over the next three days we were charged $14,022 for the same hospital bed. Included were the pain and anxiety medications Ativan and Dialaudid, his monitoring, and counseling for a different kind of pain management for me and the children. The bill was less than a third of the previous four days’ $43,711.

Terence drifted into a coma on Tuesday. I e-mailed his friends and read their goodbyes aloud, hoping he could hear and understand. I slept in a chair. At about 2:30 a.m. Friday, a noise in the hall startled me. I awoke just in time to hold his hand as he died.

They gave me back his wedding ring the next day.

Ten days later, the kids hung Daddy’s Christmas stocking alongside our three. I mailed the cards he had addressed months earlier, slipping in a black-bordered note. I threw away the protein bars, gave the energy drinks to a shelter, and flushed an opened bottle of Sutent down the drain.

Looking back, memories of my zeal to treat are tinged with sadness. Should I have given up earlier? Would earlier hospice care been kinder? I hadn’t believed Terence was going to die so I had never confronted any of those dilemmas. And I never let us have the chance to say goodbye.

I think had he known the costs, Terence would have objected to spending an amount equivalent to the cost of vaccine for nearly a quarter million children in developing countries. That’s how he would have thought about it.

But when I ask myself whether I would do it all again, the answer is—absolutely. I couldn’t not do it again.

Second-guessing

Late last year, I waded through a snowstorm to Keith Flaherty’s office in Boston, where he had moved to a new job. Did we help Terence or harm him? There’s a possibility, he said, that the treatment actually made the cancer worse, causing it to rage out of control at the end. Or, as another doctor suggested in passing at the time, the strokes were a side effect of the Sutent and not the cancer.

But neither Flaherty nor I believe that. The average patient on Flaherty’s trial got 14 months of extra life. Without any treatment at all, Flaherty estimates that for someone with Terence’s stage of the disease it was three months. Terence got 17 months—still within the realm of chance but on the far-right side of the bell curve.

There is another bell curve that Terence did not live to climb. It charts the survival times for patients treated not just with Sutent, Avastin, and Nexavar, but also Novartis’ (NVS) Afinitor and GlaxoSmithKline’s (GSK) Votrient—both made available since Terence’s death. Doctors and patients now are doing what we dreamed of, staggering one drug after another and buying years more of life.

Slides on the results of Flaherty’s clinical trial, presented at the 2008 meeting of the American Society of Clinical Oncology, showed that Avastin and Nexavar worked well on a wide variety of patients. Only Flaherty and I know that the solitary tick mark at 17 months was Terence.

Only I know that those months included an afternoon looking down at the Mediterranean with Georgia from a sunny balcony in southern Spain. Moving Terry into his college dorm. Celebrating our 20th anniversary with a carriage ride through Philadelphia’s cobbled streets. A final Thanksgiving game of charades with cousins Margo and Glenn.

And one last chance for Terence to pave the way for all those other poor sonsabitches.

Acupuncture not only cools hot flashes that occur as a result of breast cancer treatment but may offer a host of other benefits to boost women’s well-being.

A new study shows acupuncture was as good as drug therapy with Effexor (venlafaxine) at easing hot flashes in breast cancer patients, but it also improved sex drive, energy levels, and clarity of thought.

“Acupuncture offers patients a safe, effective and durable treatment option for hot flashes, something that affects the majority of breast cancer survivors. Compared to drug therapy, acupuncture actually has benefits, as opposed to more side effects,” researcher Eleanor Walker, MD, division director of breast services in the department of radiation oncology at Henry Ford Hospital in Detroit, says in a news release.

According to the National Cancer Institute, one in eight women will develop breast cancer in her lifetime. Typical treatment for breast cancer involves chemotherapy and five years of hormone therapy that often causes unpleasant side effects, such as hot flashes, night sweats, and decreased sex drive and energy levels.

Researchers say these side effects of breast cancer treatment significantly decrease a woman’s quality of life and may cause some women to discontinue treatment.

Acupuncture has already been shown to reduce hot flashes in menopausal women, but researchers say this is the first study to compare acupuncture to drug treatment in easing hot flashes in breast cancer patients. The results appear in the Journal of Clinical Oncology.

Fifty breast cancer patients were randomly assigned to receive either acupuncture or drug treatment for 12 weeks. The acupuncture group received acupuncture treatments twice per week for the first four weeks and then once a week for the remaining eight weeks; the drug group received 37.5 milligrams of Effexor each night for the first week and then 75 milligrams per night for the remaining 11 weeks.

All participants stopped their treatment after 12 weeks and kept a diary to record the number and severity of hot flashes; they were surveyed about their overall physical and mental health for one year.

Both groups experienced a 50% decline in hot flashes and symptoms of depression, but the acupuncture treatment appeared to have more lasting effects with fewer side effects.

For example, two weeks after the treatments stopped, the drug therapy group experienced an increase in hot flashes; the acupuncture group did not experience any increase in the frequency of their hot flashes until three months after treatment.

In addition, the Effexor group reported 18 instances of negative side effects, including nausea, dry mouth, dizziness, and anxiety, compared with no adverse side effects reported among the acupuncture group.

Most breast cancer patients treated with acupuncture also reported an improvement in their energy, clarity of thought, and sense of well-being. About 25% of women in the acupuncture group also reported an increase in their sex drive.

Heinz, 71, and her husband, Massachusetts Sen. John Kerry, the 2004 Democratic presidential nominee, own a house just north of Ketchum along the Big Wood River.

On Wednesday, Heinz—the widow of Sen. John Heinz, heir to the Heinz ketchup fortune—told that she found out in late September that she had cancer in her left breast after having her annual mammogram.

In early October, she underwent lumpectomies on both breasts at a Washington hospital after doctors also discovered what they thought was a benign growth on her right breast. That diagnosis was initially confirmed in post-operative pathology, but two other doctors later found it to be malignant. In November, Heinz had another pair of lumpectomies performed at Massachusetts General Hospital.

Doctors also inserted titanium clips in the tissue of both breasts during the operations, and next month she will receive five days of targeted radiation. Heinz contended that younger women should continue undergoing mammograms despite a federal panel’s recent recommendation to reduce their frequency.

“Chemotherapy is serious,” she said. “It also costs a lot of money. It’s very painful. And it’s very destructive of people’s—most people’s—lives, for a while anyway. So why put people through that instead of just having a test that’s done, and it’s done? So that’s why I was so upset about that decision of this panel.”

Heinz has been a significant contributor to nonprofit organizations within the valley, including a $325,000 donation in 1992 from the Heinz Family Foundation to purchase and preserve Galena Lodge, a popular Nordic skiing destination north of Ketchum. Heinz was also the keynote speaker at the 2006 Sun Valley Sustainability Conference.

We have been writing a series on “cancer and sexuality” for past few weeks and hopefully this series helped people with cancer to better understand how it affects the sexuality. In part 1 of this series we covered about the question what is sexuality and how cancer affects it.  In part 2 we covered what type of cancer treatments exist and how they bring changes in woman and man’s sexuality. Finally in the previous article part 3 we cover various remedies available for changes in sexuality due to cancer.

This will be the last article on the series cancer and sexuality in which we would discuss the following topcis:

• Cancer treatment and its effect on relationships
• Cancer treatment effect on fertility
• Additional Resources for questions and concerns

We start with the first topic on cancer treatment and its effect on personal relationship with the partner

Effect on relationships

At a time when your need for closeness and intimacy is greater than ever, you may feel as if you and your partner are being split apart. It’s important to remember that even though your life has changed, you have not lost the ability to love and be loved.

Cancer and its treatment may change your outward appearance, but they cannot change the essence of who you are as a person. If you have experienced love and affection before cancer treatment, there is every reason to think that your partner, family members, and friends will continue to love and value you now. In fact, most partners are supportive, and often patients are more concerned about loss of attractiveness than their partners are. When partners do hesitate to initiate sexual activity, it is usually out of fear of being pushy or accidentally causing pain. Thus, communication is essential.

If you are in a relationship with another person, then you may have discovered that being close to someone involves many different things. Your sexuality depends on your sexual organs, brain, and hormones. It involves communication, intimacy, and physical elements. Sitting with your partner and sharing your feelings, holding hands, hugging, cuddling, and kissing can provide the intimacy and social support you need.

This section contains more information to help you keep your relationship healthy and positive:

• Advice for Single Patients
• Advice for Patients in a Relationship
• Advice for Partners

Advice for Single Patients

If you are single, you may have concerns about dating during or after cancer treatment. Questions about what to tell someone, or when to tell someone, become a major issue. Your doctor, nurse, social worker, therapist, or chaplain is available to listen to your concerns and give you advice.

Single patients who begin dating after cancer treatment often say that they develop a powerful “radar” around new people. They are able to tell the difference between people who are interested in only a temporary, casual affair and those who enjoy their company because of who they are.

When you have established trust and friendship, go ahead and tell your new partner about your cancer and cancer treatment. This needs to happen early enough so that your relationship can be based upon honesty, confidence, and acceptance.

It is normal to fear being rejected. If a partner rejects you because of your cancer, however, she or he may not be the person you want in your life. Every person has flaws, and a healthy, quality relationship should be formed with someone who accepts yours—just as you would accept your partner’s.

Many people find that their love and commitment to a partner deepen when facing the challenge of cancer. Opportunities may arise for you to give and receive love in ways that will enrich all your new relationships.

Advice for Patients in a Relationship

As patients cope with their cancer, cancer treatment, and their own sexuality, they also need to consider how best to share feelings with their partners. This can be incredibly difficult for some people, especially those who didn’t communicate well about their relationships before cancer.

If there is too much pressure on you or your partner, it may make either or both of you reluctant to initiate or participate in sexual activities. You may feel uncomfortable or nervous about your “first time” during or after cancer treatment. Your partner may be afraid of hurting you or afraid that the sexual part of your relationship is over. This may lead to mixed signals, arguments, or avoiding one another physically.

The good news is that with solid communication and realistic expectations, patients and their partners can develop a relationship that is fulfilling, sometimes even more than what was experienced before cancer. Some men or women even find sex comforting during cancer treatment because they need to feel close to a partner.

The following advice for sharing your needs and worries with your partner may help you become closer:

• Sometimes it’s easier to face challenges when you know ahead of time what they are. Learn how the cancer and its treatment may affect your sexual relationship. Talk with your partner, and plan together how you will handle problems. This may help you both feel more in control at a time when many things seem to be out of your control.
• When discussing serious topics, pick a time and place that foster relaxation and privacy. Focus on one or two specific things you would like to change in your relationship, and ask for the changes in a positive way.
• Encourage your partner to share his or her feelings. He or she may need some of your encouragement to know that it’s OK to talk about concerns. Invite your partner to share in conversations with your doctor or nurse, or talk to your partner about what you have learned when you come home. This will help him or her feel involved, and you both will feel that you are working as a team.
• Often, when people don’t have sexual intercourse, they quit all forms of affection. It is important to continue with physical affection even if other sexual activity has stopped. Maintain your loving feelings together by kissing, hugging, cuddling, and caressing one another. Physical touch is extremely therapeutic and may even boost the healing process. If you want your partner to touch you in a certain way, show or tell him or her. Touch your partner when you feel tired, even if you aren’t ready to have sexual intercourse. This sets the stage for more physical intimacy later when you do have energy and feel better.
• Be patient with yourself and with each other. Give yourself time to heal, physically and emotionally. If you have a day when you feel bad, allow yourself to have some space, and see how you feel the next day.
• Consider counseling. You and your partner may have a history of difficult communication, or perhaps your partner also may be grieving about the changes in your body, which is normal. Your doctor can refer you to a social worker or psychologist to meet together for some “coaching.”

Advice for Partners

If you are a partner of a patient, you need to realize the importance of expressing tenderness and affection frequently. The best cancer treatment that you can provide is “hug treatment.” Love and affection will reduce the feelings of “aloneness” and fear that most cancer patients have while going through cancer treatment. Some research scientists believe that sharing physical touch and closeness boosts the immune system and may contribute to good health.

So that your partner understands your expectations, it is important for him or her to know that a hug may be “just a hug” and not a request for sex. Enjoy touch for its own sake, even though it may not be sexual or an invitation to engage in sexual activity.

Conversation starters:

• We haven’t been holding hands or cuddling lately. Let’s take a stroll or watch a movie and act like we used to when we were dating.
• I haven’t held your hand during a movie in a long time. How about if we go (or rent) a movie, so that I can hold your hand?
• I know you feel alone, but so do I. Can we talk?
• I don’t always know where to touch you to make you feel good, but if you show me, then I’ll feel less nervous.
• How about a hug?
• I feel a little unsure about our physical relationship because I’m worried about hurting you. Would it be OK if we talked to the doctor together at your next appointment? I think that would help me feel more comfortable.

• I know you don’t have much energy today. Is there anything I can do for you?

• This is a difficult time for both of us, but I love you just as much now as I ever have. What could we do together to help us feel better?
• You are just as sexy to me today as you ever have been.

Cancer treatment effect on fertility

Patients’ fertility can be affected both during cancer treatment—when an unplanned pregnancy could be a serious problem—and later, if the cancer treatment causes infertility. For patients who want to have children, this can be devastating.

First, it is important to know that you should prevent pregnancy during chemotherapy or radiation treatment and for at least six months after treatment. Although cancer treatment may lower a man’s sperm count or cause a woman’s menstrual period to stop, a pregnancy may still be possible. Talk to your doctor or nurse about the best method of birth control for you.

Chemotherapy drugs and radiation to the pelvis cause genetic changes in sperm and oocytes (eggs). Embryos with genetic damage often miscarry early in pregnancy. There is also a risk of having a baby with a birth defect, but so few babies have been conceived during a parent’s cancer treatment that no statistics exist on the risk of birth defects.

If a woman is pregnant and her husband is having chemotherapy, using a condom will keep the medicines from reaching the fetus through intercourse. Also, during the first few days after having radioactive seed implants for prostate cancer, men may ejaculate a radioactive seed in their semen. The doctor can advise when it is safe to resume intercourse and whether to use a condom.

By six to 12 months after cancer treatment, the sperm that were exposed to chemotherapy or radiation have all been ejaculated. Eggs that are healthy enough to be ovulated are also more likely to be undamaged. In fact, both the eggs and the stem cells that produce sperm have some ability to repair genetic damage during the first several years after cancer treatment. However, genetic damage is common in human embryos even when neither parent has had cancer treatment. A third of very early pregnancies miscarry because the embryo had genetic damage, often without a woman’s ever realizing she was pregnant.

If a woman already is pregnant at the time of cancer diagnosis, she may be able to continue the pregnancy and have a healthy baby even if she needs chemotherapy, particularly if the pregnancy is past the first three months, when most organs are formed. This situation occurs occasionally in young women with breast cancer.

The following pages provide information about fertility after cancer treatment:

• Causes of Infertility
• Preserving Fertility in Women
• Preserving Fertility in Men
• Recovery of Fertility After Cancer Treatment
• Questions to Ask Your Doctor

Causes of Infertility

Cancer treatment can interfere with fertility in many ways, as the medicines and treatments that work to kill cancer cells also affect other cells, organs, and hormones in the body. Since every patient is different, your doctor may not be able to predict whether your cancer treatment will make you infertile. The effects from cancer treatment may be temporary or permanent. If fertility does recover, it won’t necessarily happen right away.

Fertility after cancer treatment will be affected by age at the time of cancer treatment, especially for women; type of treatment; kind and dose of chemotherapy drugs used; amount and target area of radiation; type and extent of surgery; whether one or multiple cancer treatments are used; and how long treatment lasts.

This section contains more on:

• Causes of Infertility in Women
• Causes of Infertility in Men

Causes of Infertility: Women

Some cancer treatments, such as a hysterectomy, prevent pregnancy in women at any age.

Another cause of infertility in women is premature ovarian failure, which is when menopause occurs before a woman is 40. Premature ovarian failure happens when both ovaries are surgically removed, and it may also occur if the ovaries are damaged from chemotherapy or pelvic radiation therapy. Higher doses are more destructive than lower doses. Chemotherapy with alkylating agents, such as cyclophosphamide, is the most toxic and can directly damage the ovaries. Total body irradiation, typically used before a stem cell or bone marrow transplant, causes very high rates of infertility. However, a few young women have been able to have babies afterward.

Younger women and those who had lower doses of chemotherapy or radiation therapy are more likely to regain menstrual periods, though the periods may not occur regularly. Women over 35 are less likely to recover their fertility. This may be because a woman in her 30s has fewer eggs in reserve, so a larger percentage of eggs are destroyed. However, even young women are at risk for early infertility and menopause because the eggs in the ovaries may be damaged or killed by cancer treatment.

Causes of Infertility: Men

Cancer treatment can damage fertility, temporarily or permanently, in men, too. Men begin producing sperm cells at puberty and continue to be fertile for the rest of their lives. To produce permanent infertility, a cancer treatment must eliminate all of the stem cells in the testicles that produce new, mature sperm cells. This can happen if both testicles are removed, if the testicles get a high dose of radiation, or if very high doses of alkylating chemotherapy drugs are given. Men with testicular cancer, who are typically young, are likely to be infertile before they are diagnosed with cancer, but about half recover good fertility despite having a testicle removed and undergoing chemotherapy.

Preserving Fertility in Women

There are several ways to try to preserve fertility in women, but most remain experimental, with unknown success rates. Some options are not appropriate for certain patients, depending on the type of cancer.

• The most widely available and successful way of preserving fertility before cancer treatment is embryo freezing. This includes removing the eggs, fertilizing them in vitro (in a test tube) with the sperm of your partner or a donor, and then freezing and storing the embryos. It takes about two weeks from the start of a woman’s menstrual cycle to get eggs to use for in vitro fertilization; waiting may be a problem with a fast-growing cancer like acute leukemia. Also, the hormones given so that more than one of a woman’s eggs will ripen may stimulate breast cancer cells to grow, so researchers are trying to use different hormone combinations to make hormonal stimulation safer for these young women. Another option would be to simply harvest the one egg that ripens in a natural menstrual cycle, but the chance that the egg will fertilize, survive freezing, and later produce a live birth when transferred to the woman’s uterus is less than 10 percent. Insurance rarely covers these procedures, and they often cost $5,000 to $8,000.
• A woman who has lost her uterus but still has at least one ovary could go through in vitro fertilization (IVF) to use her eggs and sperm from a partner or donor to create embryos. Another woman could then carry the pregnancy (surrogate or gestational carrier).
• Some women opt to have the eggs frozen unfertilized, particularly if they are not in a committed relationship. Later, the eggs can be thawed and in vitro fertilization attempted. Egg-freezing remains experimental and has resulted in fewer than 500 live births around the world.
• Some women have parts of their ovaries removed surgically and frozen before cancer treatment. Although some centers are banking ovarian tissue before cancer treatment, this technique is still experimental and has resulted in only a few pregnancies around the world.
• For women receiving chemotherapy, one option may be to take a hormone that puts the ovaries into temporary menopause during the cancer treatment. However, many infertility specialists doubt that the hormones truly prevent the chemotherapy from damaging the ovaries. The hormone shots are expensive, and it is possible that they could have some impact on the success of chemotherapy.
• For women receiving radiation treatment, it may be possible to move the ovaries out of the radiation area surgically. Sometimes they can be relocated at the sides of the pelvis, out of the radiation target field. There is a 50 percent chance that women will resume menstruating after this procedure.
• Adoption is another option.

Preserving Fertility in Men

Fertility preservation is much easier, cheaper, and more effective for most men. It simply involves collecting a sample of semen and freezing it. Sperm must be banked before any chemotherapy or pelvic radiation therapy begins in order to avoid storing damaged sperm. The sperm can be thawed later and used for intrauterine insemination or in vitro fertilization.

Many young men diagnosed with cancer have poor sperm quality because of the illness, recent anesthesia, or stress. Even if a man has only a few live sperm in his semen, however, they can be used with in vitro fertilization to give a good chance of a pregnancy. In this situation, when the sample is thawed, the healthiest sperm are captured and injected into the woman’s harvested eggs using a robotic microscope in the laboratory.

Insurance generally does not cover the cost of the sperm banking, and storing one ejaculate for five years averages around $500. Some sperm banks have special payment plans for cancer patients. For men who no longer ejaculate semen but would like to bank sperm, a urologist may be able to collect sperm with outpatient surgery to retrieve them from the storage areas above the testicles or even from tissue inside the testicles.

Recovery of Fertility After Cancer Treatment

For some people, fertility does return after cancer treatment. However, it may take a long time.

For women, the return of menstruation may or may not signal fertility, but getting blood tests for hormones and other tests performed by an infertility specialist can give a better answer.

Women who have had chemotherapy or have had radiation treatment to the pelvic or abdominal area should consult an obstetrician before trying to get pregnant, to make sure that their heart, lungs, and uterus are healthy enough to avoid pregnancy complications. For example, when a girl or young woman has radiation that includes the uterus, it is important to know whether the uterus is normal in size and can expand enough during pregnancy.

Men often have low sperm counts or motility (the movement of the sperm) at the time their cancer is diagnosed, but this may improve after cancer treatment. Sperm quality may rise for several years following cancer treatment, depending on the drugs used, the doses, and each person’s individual recovery. Even though men may produce sperm, the number and their ability to move may not be enough to conceive without some medical help. A semen analysis, in which a man’s semen is examined under a microscope, can indicate whether a pregnancy is likely through intercourse or what type of infertility treatment will be needed. Because each person’s situation is different, it is important to talk to your doctor before trying to start a pregnancy.

Questions to Ask Your Doctor

If you wish to have children after your cancer treatment, discuss the issue with your doctor as soon as possible. Understandably, thinking about the future and having children can be incredibly difficult while coping with a cancer diagnosis. But most options to preserve fertility need to take place before you begin chemotherapy or radiation therapy. You also may want to talk to a counselor familiar with cancer and fertility to prepare yourself for challenges and decisions.

Here are some questions you may want to ask:

• Is there anything that can be done before starting my cancer treatment to increase the likelihood that I will be able to have children after cancer treatment?
• I am interested in freezing eggs or embryos. Is this an option for me? Could you please give me more information?
• I am interested in sperm banking. Is this an option for me? Could you please give me more information?
• I stopped having my period, but could I still get pregnant? Should I be using birth control?
• For how long will we need to prevent pregnancy during cancer treatment? Are condoms the best method for us?
• My partner is pregnant. Is there any special reason to avoid sex during my cancer treatment?
• Will my cancer treatment cause me to be infertile? Do you expect this to be temporary or permanent?
• Now that my cancer treatment has ended, I would like to have children. Is it OK for us to try to become pregnant?
• We have been trying to get pregnant without success. Should we talk to an infertility specialist?

Additional Resources

Often patients are not sure what to expect from their doctor or nurse when talking about sexual health or fertility during cancer treatment. Even healthcare providers in oncology sometimes do not know much about sex or fertility after cancer. If your doctor or nurse seems uncomfortable or dismisses your concerns, ask to see a specialist. This could be a mental health professional trained to treat sexual problems or a urologist or gynecologist with such training.

For more information about sexuality and cancer, you may call the National Cancer Institute’s Cancer Information Service toll free at (800) 422-6237. A trained cancer information specialist will answer your questions.

Classes to improve your appearance during cancer treatment are available to help you look good and feel better. Contact the American Cancer Society toll-free at (866)-228-4327 to find out about classes near you.

More information on sexuality and cancer is available on following websites:

American Cancer Society: Sexuality
The website covers side effects of different treatments that affect an individual’s sex life and ways to relieve some common problems. It also links to Web pages that address this issue and men and women separately.

National Cancer Institute: Sexuality and Reproductive Issues
The site addresses the effect cancer and cancer treatment can have on all aspects of an individual’s sexuality, including sexual desire and physical and psychological sexual dysfunction.

Lance Armstrong Foundation: Physical Effects of Cancer
Provides links to different physical effects, including sexual dysfunction in men and women and fertility.

Cancerbackup: Sexuality and Cancer
From the United Kingdom, an information and referral service for those who have been diagnosed with cancer. The following link provides information on aspects of sexuality and cancer.

Fertile Hope
Nonprofit organization dedicated to helping cancer patients who are faced with infertility. Provides links to resources, including financial assistance for treatment.

United Ostomy Associates of America
Organization offers guidebooks and fact sheets about having sex for those with an ostomy.

Women who took a commonly used class of osteoporosis drugs called bisphosphonates had significantly fewer invasive breast cancers than women not using the bone-strengthening pills, according to a new analysis of data from the Women’s Health Initiative.

The analysis from a segment of the more than 150,000 generally healthy post-menopausal women in the WHI study found that those taking Merck & Co’s Fosamax, or other bisphosphonates, had 32 percent fewer cases of invasive breast cancer than women who did not use the osteoporosis medicines, researchers found.

Fosamax is now available in generic form as alendronate. Other commonly used medicines from the class include Roche’s Boniva and Actonel, which is sold by Procter & Gamble Co.

“The idea that bisphosphonates could reduce breast cancer incidence is very exciting because there are about 30 million prescriptions for these agents written annually in the United States targeting bone health, and more could easily be used to counteract both osteoporosis and breast cancer,” Dr. Rowan Chlebowski, the study’s lead investigator and chief oncologist from the Los Angeles Biomedical Research Institute, said in a statement.

It was the landmark WHI research program that in 2002 found a link between long-term use of hormone replacement therapy by post-menopausal women and increased risk of breast cancer and heart attacks – findings that have been used as the basis for thousands of lawsuits against the makers of those drugs.

The latest findings from the observational study were presented at the San Antonio Breast Cancer Symposium on Thursday.

The impetus for looking at the connection between bisphosphonates and breast cancer came from data from a clinical trial in which breast cancer patients who were given Novartis’ bisphosphonate Zometa intravenously every six months had fewer contralateral breast cancers, Chlebowski explained.

“It appeared to make bone less hospitable to breast cancer,” Chlebowski said.

Contralateral breast cancer is typically a second new case of cancer in the other breast, rather than the spread of the originally detected breast cancer. Studying 2,816 participants who were using bisphosphonates when they entered the WHI program, researchers found that only 64 women developed breast cancer. That translates into 32 percent fewer breast cancers in women using bisphosphonates compared with women who did not use them, researchers said.

Researchers cautioned that this was an observational study that does not necessarily carry the same scientific weight as a blinded clinical trial.

However, they said, several ongoing breast cancer trials evaluating oral and intravenous bisphosphonates will be available in the near future to provide randomized clinical trial evidence regarding their influence on new contralateral breast cancer risk.

“This is not a definitive finding,” Chlebowski said in an interview. “But I think it could influence the decision making of women who are deciding whether to take a bisphosphonate or not.”

In part one of this series cancer and sexuality we briefly covered three topics:

We continue the series today covering the third question in detail on how can cancer and cancer treatment affect the sexuality. This section contains more information on sexual changes caused by:

• Cancer Treatment in Women
• Cancer Treatment in Men
• Cancer Treatment Side Effects
• Emotional Effects
• Anxiety and Depression

Cancer Treatment in Women

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in vaginal fluid. Ask your doctor how long your particular chemotherapy stays in the bloodstream. It can range from hours to days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have a type of radiation therapy that involves using a source of radiation that stays in your body over time, there may be a short period (a few days or less) when your doctors want you to avoid sexual activity until the strongest radiation has left the body.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is weak.

Cancer treatment can cause a variety of sexual changes. Even though the causes may be different—surgery, chemotherapy, hormone treatment, and radiation—the resulting changes are often similar.

• Surgery
• Chemotherapy
• Hormone Treatment
• Radiation

Cancer Treatment in Women: Surgery

• Some pelvic surgeries change the vagina. For example, radical hysterectomy shortens the vagina. When the bladder or colon is removed, parts of the vaginal wall may also be removed, making the vagina narrower. Loss of tissue around the vagina removes its “cushioning,” and scar tissue may form in the area. These changes can sometimes cause pain with deep thrusting and penetration or in certain intercourse positions.
• When both ovaries are removed in a younger woman, she will have an abrupt menopause. The most typical result is vaginal dryness and pain, but some women experience a loss of sexual desire, as well. Also, the loss of the hormone estrogen reduces the blood supply of the vagina and thins the vaginal walls. The result is that the vagina feels dry and tight, especially during penetration.  It is unclear why many women who have sudden menopause lose some desire for sex. It may be because of the loss of androgens, hormones produced by the ovaries. However, several studies have found that a woman’s androgen levels after cancer can not predict her desire for sex. Many women find that if sex hurts, they stop looking forward to it, which interferes with desire. Medications, fatigue, and nausea also can be part of the problem.
• If some or all of the vulva is removed, a woman may lose some important erotic zones, especially if the clitoris is included. The vaginal entrance also may be narrowed, making penetration painful or difficult.
• After surgery on the breasts to remove a tumor, or a mastectomy to remove one or both breasts, a woman may lose the ability to feel sexual pleasure from nipple caressing. The loss of pleasure may lessen sexual desire or arousal, or caressing an untreated breast may trigger distracting thoughts about breast cancer.

Cancer Treatment in Women: Chemotherapy

• In women who have not yet reached menopause, chemotherapy can damage the ovaries, causing sexual changes. Alkylating chemotherapy drugs, especially at high doses, can destroy the function of ovaries so that they no longer produce hormones. This will cause sudden menopause, which is usually permanent. Women who stop having menstrual periods may experience vaginal dryness, pain, and a loss of desire, just like women whose ovaries were removed in surgery or damaged by radiation therapy.
• Lower doses of chemotherapy may temporarily stop a woman’s periods. They may resume, along with hormone production, especially if a woman is under age 35 when she is treated.
• If chemotherapy causes mucositis (mouth soreness), it also may cause soreness in the vagina, making sexual intercourse extremely painful.
• If chemotherapy causes neuropathy (tingling or numbness) in the hands and feet, it also may cause numbness in the clitoris, though this has not been proved.

Cancer Treatment in Women: Hormone Treatment

• Some hormone treatments may cause sexual changes, but they are less likely to do so than chemotherapy.
• Most studies of women taking tamoxifen after breast cancer find that the hormone does not interfere with sexual desire. Since tamoxifen acts like a weak estrogen in the genital system, many women find it helps with vaginal dryness, although some women experience vaginal irritation.
• Raloxifene, which is also taken after breast cancer to prevent recurrence, also does not interfere with sexual desire in women, though it is less likely than tamoxifen to help with menopausal vaginal dryness.
• Aromatase inhibitor medicines, such as Arimidex, are increasingly taken to prevent breast cancer recurrence. Unfortunately, this class of medicines is likely to lead to vaginal dryness and pain with sex, but lubricants and moisturizers can help.

Cancer Treatment in Women: Radiation

• Radiation to the pelvis can damage the ovaries, leading to the same problems with vaginal dryness or pain as when both ovaries are removed in surgery or damaged by chemotherapy. A lower dose of radiation may cause less damage such that a young woman may recover menstrual periods. At higher doses, the menopause is permanent. (Post-menopausal women may experience a lack of desire because of the loss of androgens, hormones produced by the ovaries.)
• Radiation can do direct damage to the vagina. Inflammation in the vagina can cause the walls to stick together during healing, or it can result in narrow bands of scar tissue along the vaginal canal.
• Some women develop radiation ulcers, painful sores that take a long time to heal.

Cancer Treatment in Men

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in semen. You may want to ask your doctor how long your chemotherapy drugs will stay in your bloodstream, since it can range from hours to several days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have radiation therapy using implants in your body, such as seed implants for prostate cancer, there may be a brief period where your doctors want you to avoid sexual activity until the strongest radiation has left the body. After that you are not in danger of harming a partner or any other person who gets close to you.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is very weakened.

Erectile dysfunction, also known as impotence, is when a man cannot get or maintain a firm erection. Some men experience erectile dysfunction because of cancer treatment. Erectile dysfunction also is much more common with aging, especially for men who are smokers, are overweight, or have diabetes, high blood pressure, or heart disease. Men who are already having some mild erection problems may find these get worse with cancer treatment.

Cancer treatment can cause a variety of sexual changes:

• Surgery
• Hormone therapy
• Radiation
• Chemotherapy

Cancer Treatment in Men: Surgery

• The most common types of cancer surgeries that cause erectile dysfunction are those that remove the prostate, prostate and bladder, or the lower part of the colon and rectum. These operations often cut or bruise important nerves that direct blood flow into the penis. Even though surgeons try to spare the nerves, many men end up with erection problems. (Nerve-sparing techniques work best for younger, healthy men who are having firm, reliable erections before cancer diagnosis.).
• If the prostate and the seminal vesicles (the small glands behind the prostate) are surgically removed, a man will experience “dry” orgasms, meaning that he will not ejaculate semen. The muscles still pump at the base of the penis, and the feeling of orgasmic pleasure still occurs, but about half of men say their orgasm feels weaker. A man can reach orgasm without having an erection, but it may take practice to find the right kind of stimulation.
• Some men with testicular cancer have an operation to remove the lymph nodes in their abdomen (retroperitoneal lymphadenectomy) or to remove some nodes that remain enlarged after chemotherapy. These surgeries sometimes damage the nerves involved in ejaculation, also resulting in dry orgasm.
• Another surgery that may damage these nerves is sigmoidectomy, done to remove colon cancer in the sigmoid colon.
• If both of the testicles are removed, a man will experience loss of desire for sex since testosterone, the hormone that helps men feel desire, is made in the testicles. This hormone can stimulate prostate cancer cells, so the goal of the surgery is to stop its production. About 20 percent of men, especially those under age 60, can still get erections and have orgasms after removal of both testicles, although it takes more effort and stimulation.

Cancer Treatment in Men: Hormone Treatment

• Many men with advanced prostate cancer do not have their testicles removed but instead take hormone therapy designed to “turn off” the testicles so that they do not produce testosterone. The sexual side effects are very much the same as described above with surgery to remove the testicles.
• Some men take hormone therapy for only a few months around the time of surgery or radiation therapy for prostate cancer. Unfortunately, in some men, sexual side effects of the hormones persist, and things do not go back to normal. This is also a limitation of using “intermittent” hormone therapy, in which hormones are given until a man’s PSA blood test result (a test for prostate-specific antigen, a sign of prostate cancer) goes down to near zero. Then the man can stop the hormones for a few months. Some men recover sexually, but others continue to experience loss of desire and erection problems during the months off hormones.

Cancer Treatment in Men: Radiation

• Men who have radiation treatment in the pelvic area may develop erectile dysfunction because the radiation causes a gradual scarring in the tissue in the target area, which may include small blood vessels and nerves that are involved in erection. The changes after radiation therapy tend to be gradual, often not appearing until a few months after the treatment is over. The higher the dose of radiation near the base of the penis, the more likely it is that there will be a problem.
• Radiation treatment also can cause pain during ejaculation. Pain is most often temporary due to irritation of the urethra (tube that carries urine or semen) right after radiation therapy. Sometimes pain occurs later and is caused by a tight band of scar tissue in the urethra, called a stricture.  Radiation aimed near the prostate and seminal vesicles typically reduces semen to only a few drops.

Cancer Treatment in Men: Chemotherapy

After chemotherapy, only a few men experience new sexual changes. Sometimes high doses of drugs that can cause nerve damage result in erectile dysfunction or in dry orgasm, but this is much less common than after surgery or pelvic radiation therapy.

Men who get high doses of chemotherapy, especially if they are having a stem cell or bone marrow transplant, sometimes end up with low testosterone levels, even several years after treatment. They may notice loss of interest in sex and erection problems. A simple blood test can find this problem, and replacement hormones can be given.

Cancer Treatment Side Effects

Cancer treatment side effects, such as fatigue, nausea, vomiting, diarrhea, constipation, hair loss—including pubic hair—weight changes, scars, and sensitivity to tastes and smells may leave you feeling exhausted and uncomfortable. These side effects consume so much energy that sex may be the very last thing on your mind.

Fortunately, patients have options to help relieve their symptoms, and many patients take medicines to treat pain, nausea, anxiety, depression, or other symptoms. However, many of these medicines can decrease sexual desire, which combined with the effects of cancer treatment, may cause you to feel indifferent toward sex. Furthermore, many medicines taken for depression or anxiety may make it harder to reach orgasm.

Some of the medicines also may affect your mental state—how alert or sharp you feel, your mood, and how you interact with people—and so you may not be thinking or communicating clearly. This can negatively affect how you relate to your partner, making sexual contact difficult.

Therefore, if you are experiencing any symptoms or side effects—whatever the cause—ask your doctor or another member of your healthcare team to work with you to find other remedies or strategies to help you feel better.

Emotional Effects

Often during cancer treatment, patients’ needs for intimacy and affection increase. Unfortunately, this happens when relationships may be strained by worry and concern.

Your emotions have a big impact on your sexuality. The way you feel about your body and yourself can influence how you interact with others. You may feel inadequate, out of sync with your partner, and not sure about what to do to feel better

The following are examples of ways that your emotions may affect your sexuality:

• Changes in your appearance may be stressful and cause you to feel unattractive or self-conscious. These changes may make you unable to focus on sexual excitement and pleasure. Surgery that changes your appearance can be especially difficult.
• Feeling negative emotions like anger or guilt may keep you or your partner from wanting to have sex.
• Feeling afraid may distract you and cause you not to care about sex.
• Being fearful of “giving your partner cancer” may affect your ability to be close to your partner. (You cannot give anyone cancer, nor can people “catch” cancer from you. For more information about what causes cancer, talk to your doctor.)
• Often patients’ partners feel fearful of causing harm or pain, so you may feel confused or worried if your partner keeps you at a distance.
• Feeling “stressed out” may cause your sexual desire to decrease.
• Tension, anxiety, or trouble getting in the mood for sex can slow down the ability to reach orgasm.
• You may feel helpless and frustrated by changes beyond your control.
• You may be upset about or grieving changes in your fertility.
• You may fear rejection and decide to pull away before your partner can hurt you.
• You may feel embarrassed that your partner has had to act as your caretaker when you were ill and have trouble switching back to feeling like lovers.
• You may lose desire toward your partner because of a conflict between the two of you. Perhaps you feel desire when you see a sexy love scene in a movie but not when you get into bed with your partner.

Anxiety and Depression

Although most sexual changes after cancer are caused by physical changes, some result from anxiety or depression. Therefore, it is important to have depression and anxiety assessed before having any sexual changes evaluated or treated. This is also important since anxiety and depression share some common symptoms with treatment side effects.

Fortunately, the anxiety and depression many people feel during cancer treatment fades with time for most. But if the emotional reaction to cancer does not improve within a few months of treatment, patients may benefit from some counseling, which can be as effective as medication for depression and anxiety. Also, it’s important to know that some medicines prescribed to treat depression or anxiety can have sexual side effects.

Anxiety

Anxiety about cancer can preoccupy your thoughts, interfering with your ability to enjoy many activities, including sex. Worry and fear about the future may make it hard to share intimacy and affection. Anxiety is a treatable condition, however, responding to both counseling and medicine. Symptoms can be physical or emotional and include:

• Feeling apprehensive or fearful
• Feeling worried
• Feeling that things are “out of control” or endless
• Feeling irritable, restless or edgy
• Feeling stressed or tense, sometimes physically in the muscles with neck or backache
• Having fast or irregular heartbeats
• Sweating
• Having an unsettled stomach, possibly with diarrhea or nausea
• Shaking or trembling
• Having nightmares or vivid images during waking hours of a particularly traumatic part of your cancer treatment

Depression

Depression is also treatable. It affects 15 percent to 25 percent of cancer patients and about 25 percent of cancer survivors. Depression is more than just crying and feeling sad; it can affect your quality of life, including your sexuality. In fact, loss of desire is a classic symptom of depression. Other emotional and physical symptoms include:

• Feeling sad, drained, restless, irritable, or anxious
• Losing interest in activities that you used to enjoy
• Feeling hopeless, helpless, guilty, or worthless
• Losing emotional expression—as if your emotional reactions are inappropriate or nonexistent
• Withdrawing socially from family, friends, pets, and other loved ones
• Experiencing problems with thinking clearly, such as having trouble concentrating, remembering, or making decisions
• Losing your appetite with weight loss, or overeating and gaining weight
• Having disrupted sleep, such as insomnia (sleeplessness), oversleeping, or waking up early
• Abusing drugs or alcohol
• Having thoughts of death or suicide

It’s understandable that sexuality may not be the primary focus for many cancer patients, at least not right away. Sexuality is an incredibly personal topic, and each person’s experiences, feelings, and expectations are unique. But at some point, whether because of sexual changes, relationship issues, or difficulties with fertility, patients realize the impact of cancer on their sexuality.

Each patient’s cancer journey is unique, so it’s impossible to know what your experiences will be. You may undergo permanent changes in your body, physical discomforts, emotional struggles, and problems with fertility. But no matter the diagnosis or prognosis, you deserve the best quality of life, and this includes care of your sexual health. By learning about how your sexuality is likely to change and getting suggestions for healing, you become a partner and advocate in your own care.

In a series of articles we would explore this topic and try to answer some of the questions in your mind.This is the first article in this series and we would explore the following questions:

What is sexuality?

When you think of sexuality, your first thought may be the physical act of sexual intercourse. But sexuality goes beyond engaging in sexual activity.

As a human being, your sexuality is a part of your physical, emotional, intellectual, and social self. It affects how you think of yourself and how you relate to others, as well as how they relate to you, and it is a part of you throughout your entire life.

Since every person is different, it is difficult to define “normal” sexuality or sexual activity. Many factors may influence your sexuality, including your gender, sexual orientation, hormone levels, age, and personal perspectives, such as your views on sex and your religious beliefs and values.

You may have certain definitions of how you think a man or woman should look and behave, and these expectations play a part in your sexuality, too.

It’s important to recognize what is normal for you—what makes you feel comfortable and satisfied—and that it may be different from what is normal for someone else. And it’s equally important to remember that cancer and its treatment may cause changes in your sexual function, but they cannot take away the life experience and emotions that make you a sexual person.

What is a normal sexual response?

A “normal” sexual response involves a person experiencing one or more of the following phases:

• Desire
• Arousal
• Orgasm
• Resolution

Cancer and cancer treatment can cause changes in any phase of the sexual response. Understanding these phases may help you explain your experiences to your doctor or nurse. This may help them diagnose changes and prescribe remedies to help you.

Desire

Desire happens when you feel interested in someone sexually. For example, if a man or woman walked by, you may feel an attraction to that person or begin to imagine that person as a partner. Desire may also come from feelings of sexual pleasure and tension in your body, or from a sexual fantasy. The more you think about sex, the more frustrated you may feel if you do not have a chance to have sexual pleasure. All of these feelings can be called “desire.”

Lack of desire is the most common sexual problem for all cancer patients. You may think, “I used to think about sex, but now it doesn’t seem important to me,” or “I want to have a sexual relationship, but I don’t feel desirable or sexy,” or “I just don’t feel like having sex anymore.”

Arousal

Arousal is sexual excitement, which may be caused by touching, stroking, fantasizing, or seeing or hearing sexual sights and sounds. Your heartbeat, pulse, and blood pressure rise. Your breathing may become deeper and heavier. In both men and women, blood flows into the genitals as part of sexual arousal.

• For women, arousal includes both mental excitement and the physical response of vaginal lubrication and expansion. The vagina becomes moist and expands. The outer genitals, including the clitoris, swell and turn a deeper color.
• In men, the penis becomes erect, and arousal includes getting and maintaining an erection sufficient for intercourse.

Most often, loss of desire and trouble getting mentally aroused go together. Instead of feeling good, sexual touch may seem annoying or you may feel “numb.” You may find yourself thinking that your body isn’t responding the way it is “supposed to.” But sometimes you feel turned on in your mind, but your body does not respond physically. You may feel interested in sex, even excited, but also frustrated that you have vaginal dryness if you are a woman, or do not get a firm erection if you are a man. Problems with physical arousal are often caused by damage to the body from cancer treatment.

• After cancer treatment, or just with normal aging, women may respond more slowly to sexual stimulation, produce less or insufficient lubrication, and may feel that breast or genital caressing does not bring pleasure.
• Changes with arousal in men include not being able to get or sustain an erection, having an erection that is not firm or reliable, or not having erections as frequently as desired.

Orgasm

A person who reaches a sexual climax has an orgasm. For men and women, this means a rhythmic contraction of the genitals, which causes intense, pleasurable feelings throughout the body. Overall, you may feel satisfaction, pleasure, and gratification.When women have an orgasm, the vaginal walls contract, and often waves of pleasure are felt in the clitoris and outer vagina. Many women enjoy reaching more than one orgasm, while others prefer to have one intense climax.

• When men have an orgasm, they experience an ejaculation, when the penis releases semen.

When changes with orgasm occur, men and women may find that it takes a longer time to reach orgasm, more stimulation is needed, or that orgasms cannot be achieved at all.

• Women may find that the clitoris or vaginal opening feels less sensitive. Some women have pain with sex or distracting thoughts about cancer or feeling unattractive. It takes some mental focus on pleasure for a woman to reach orgasm.
• After cancer treatment, some men experience “dry orgasms” in which muscles contract and they feel pleasure, but no semen comes out of the penis. Some men also find that their orgasms are weaker and less pleasurable.

Resolution

Resolution is when the body calms down and is no longer excited. Your heartbeat, pulse, and blood pressure return to normal, and blood drains from the genital area. Resolution happens rapidly after an orgasm. If a person doesn’t have an orgasm, resolution happens eventually but just takes longer.

Women can have one orgasm right after another, known as multiple orgasms. Usually men have to wait a certain amount of time after an orgasm before becoming aroused again. This time, called the refractory period, can increase with age or medical conditions.

How can my cancer and cancer treatment affect my sexuality?

Cancer and its treatment may affect your sexuality, but every patient is different. Some patients experience sexual changes in all of the phases of sexual response, while others experience none.

The most common sexual change for cancer patients is an overall loss of desire. Most men and women are still able to have an orgasm even if cancer treatment interferes with erections or vaginal lubrication, or involves removing some parts of the pelvic organs. However, it is common for patients to need more time or stimulation to reach orgasm.

Unfortunately, when sexual changes do occur, they generally do not improve right away; indeed, they may persist until a good remedy is found. Finding the most helpful remedy may take time and patience because sexual changes can be caused by both psychological and physical factors.

Furthermore, the sexual changes caused by cancer treatment may be long term or permanent. Talk with your doctor, nurse, or another healthcare professional before treatment to learn about what to expect from your cancer or cancer treatment concerning your sexuality. By knowing what may happen, you may be better prepared and more knowledgeable about potential sexual changes.

In the next article we would explore this question in more details.

Cancer or the ‘Big C’, as it is fearfully referred to, is no longer considered a death sentence. The number of individuals who have survived cancer has considerably increased over the years. Certain adult cancers have a survival rate of 70% or more, while a few childhood cancers may boast of a greater cure rate.

Surviving cancer requires a great deal of strength, endurance and courage. While cancer can change lives for ever, it can also be viewed as an experience that may help an individual to grow in different ways. Appreciation of self and others is at the centre of this change and,in this context, cancer survivors learn to acknowledge their bodies and their health in a better way. It will be important for them to appreciate the new lease of life and to take better care of themselves, in all ways possible.

Most often treatments like radiation, chemotherapy and surgery are required to bring cancer under control; nevertheless, the root cause is never addressed. Besides, these treatments exhaust the patients and mar their quality of life. This is where naturopathy can help to bring relief from the ‘body–racking’ side effects and to restore the individual’s overall health.

Naturopathy is a complimentary branch of medicine that makes use of natural and safe therapies. It upholds detoxification as the first step towards recovery from cancer. Naturopathy recommends 5 natural steps, which are dealt with in the following sessions.

Stage 1 – Toxic Lifestyle

If fully / highly toxic, you need to get de- numbed,as toxicity often leaves people numb towards their reactions to the world.

• If you are smoking, work on stopping that habit.
• Avoid excessive alcohol /coffee consumption. These overload your liver
• Ensure enough sleep everyday
• Exercise regularly

Stage 2 – Healthy Eating

More attention must be paid to what you eat.

• Go for a fruit/ vegetable- rich diet. By adding more vegetables and fruits, you are giving your body fiber for detoxification and necessary nutrients for both detoxification and healing.
• Water is the medium that transports toxins out of the body and nutrients into the elimination organs.
• Most meat are full of antibiotics, hormones and pesticides, due to the manner in which they are bred and grown. Besides, the meat also contains stress chemicals secreted by the animals while being slaughtered.
• Allergens place the body in a constant fighting state; by definition, allergens are foreign substances that the body rejects. When your body constantly wastes energy fighting allergens, its energy stores will be depleted when time to heal or detoxify arrives.
• Avoid alcohol, coffee and regular tea; these will only help to over-load your liver (the major elimination organ).
• Avoid condiments sauces, mustard, ketchup, Worcester sauce, MSG, steak, BBQ, chili shrimp and soy sauce, pickled vegetables, relishes, salad dressings (unless homemade).

These will affect the liver and the kidneys, therefore slowly shutting down all your elimination apparatus.

Stage 3 – Organ Repair

This stage involves repair done to the 2 major detoxification organs which are affected by the medical procedures involved in treating cancer.

The liver, besides many other functions, is responsible for breaking down medications (anesthetics, chemotherapeutic, drugs, radiation effects, etc.). Once the liver gets clogged, it cannot continue detoxifying the body of all the remaining toxins.

The best way to balance and rejuvenate the liver is through 2 phases:

• By draining or cleaning up its toxins
• By strengthening and boosting its powers through Supportive Therapy.

The body’s ability to protect itself from toxic substances and the body’s ability to heal are both dependent on the integrity of the intestinal lining. Allopathic treatments often lead to intestinal damage, like increased intestinal permeability, thereby allowing increased absorption of pathogens, allergens and toxins. This process results in putting more stress on the immune system, decreasing its ability to focus on healing.

The intestinal damage is corrected in 2 stages:

• Eliminate/ clean up all pathogens (yeast, pesticides, pathogenic bacteria, etc.) and also all the damage caused by allopathic treatments.
• Restore the normal, friendly bowel flora

Once these stages are completed, you need to re- evaluate your medications for symptoms such as pain or depression.

Are they all necessary?

Remember: Drugs are chemicals that need to be metabolized by the liver; they cause side effects because the end products of their metabolism are toxins.

One example of over -prescribed medications are antibiotics.

Considering that most infections are viral, antibiotics are none other than toxins!, There are many natural alternatives(homeopathics, herbs, nutritional supplements), that work by addressing the cause of your problem.

Eliminating Toxins -Stage 4.

This stage of your natural recovery involves preparation of emunctories (=elimination organs). Before pouring toxins out of the cells into the blood, the patient must “open the gates “; so the toxins will leave the body completely.

If the toxins continue being circulated in the blood, they cause degeneration, or get deposited in fat tissues.

Restoring Detox Organs- Stage 5

Restoring the liver and the intestine may be done by re directing toxin elimination through the skin rather than through the usual route

In this stage, it must be ensured that the elimination organs are strong enough to handle all toxicity and that they continue keeping up with the body’s demands.

The best way to support the major detoxification organs is:

• By giving them a rest. This can be done by re- directing toxin elimination through the skin rather than the usual route.
• Saunas, sweat inducing exercises (aerobic) and niacin therapyare some methods by which this can be achieved.
• Another way of “resting” your digestive elimination organs is by mimicking a fast. Digestive enzymes will help you digest without the digestive organs actually working very hard.
• By using supportive supplementation – including fibre, vitamin C , chlorophyll, other anti-oxidants and different herbs such as garlic, red clover, cayenne.

Detoxification is your first step towards cancer recovery. As a cancer survivor, remember you are a winner already! Keep going and enjoy life!

The combination of the immunomodulatory drug lenalidomide and the proteasome inhibitor bortezomib appears to be both safe and potentially able to induce durable responses in patients with relapsed or relapsed/refractory multiple myeloma, U.S. researchers report online in the Journal of Clinical Oncology.

“Lenalidomide and bortezomib is a well tolerated and very active combination that can overcome resistance to either agent separately,” Dr. Paul G. Richardson of the Dana-Farber Cancer Institute, Boston. He called the median overall survival of 37 months for patients in the study “especially noteworthy in a phase 1 population.”

The report notes,

“The regimen showed efficacy even in heavily pretreated patients who were previously exposed to immunomodulatory agents and to bortezomib.”

The study — the first prospective trial to assess this combination of drugs in patients with relapsed and relapsed/refractory multiple myeloma — included 38 patients (median age, 59 years). Patients were grouped into threes, and each successive group received a higher dose of lenalidomide and/or bortezomib.

Lenalidomide was given orally on each of the first 14 days of a 21-day cycle, and bortezomib was given intravenously on days 1, 4, 8 and 11. Patients whose disease progressed following two cycles could also receive dexamethasone.

The study established the maximum tolerated dose as lenalidomide 15 mg/d plus bortezomib 1.0 mg/m2.

Patients received a median of 10.5 treatment cycles of lenalidomide and 10 of bortezomib. Thirteen patients received both drugs for more than a year, and one patient was still being treated when the study closed in November 2008, having received 74 cycles.

Sixty-one percent of patients achieved at least minimum response. Among patients who had been refractory to previous treatment with lenalidomide, bortezomib or thalidomide, 12 achieved at least minimal response and six achieved at least partial response.

Responses were noted as being durable, with median time to progression of 7.7 months.

Four patients discontinued treatment for toxicities considered to be related to lenalidomide. The most common adverse events were neutropenia, thrombocytopenia and fatigue.

Dr. Richardson told that lenalidomide-plus-bortezomib is also showing promise in two current myeloma studies, including one in patients with relapsed or relapsed/refractory disease.

The study was supported in part by Millennium Pharmaceuticals, Johnson & Johnson Pharmaceuticals Research and Development, and Celgene.

October is officially tagged “Breast Cancer Awareness Month”. Of recent, there have been a lot of medical breakthroughs in the detection and treatment of Breast Cancer. Scientists have identified more accurate tools for screening younger women who are more likely to get the most dangerous forms and new strategies have also been developed for the treatment of newly diagnosed pregnant women.  Advanced research has led to the development of better, less toxic drugs to guard against recurrences.

In the Western world, breast cancer deaths have plummeted and survival rates are soaring. Research has made more headway in the fight against breast cancer than any other form of cancer. These milestone achievements are as a result of the constant campaigns, awareness creation and fundraising activities directed toward the cause. Early detection and a study which showed that hormone replacement therapy in postmenopausal women strongly contributed to the development of breast cancer are greatly responsible for the lower incidence rates.

In breast cancer, some cells in the breast for reasons poorly understood start growing abnormally, dividing more rapidly than normal cells and may spread (metastatize) to adjascent tissue, lymph nodes or other parts of the body.The most common type begins in the milk producing ducts while otherforms occur in other breast tissue. It is known that 5 to 10% of breast cancer cases areinherited. There is usually a defect in one of two genes namely BRCA1 and BRCA2 (Breast Cancer Genes 1 and 2).

Most genetic mutations related to breast cancer are not inherited and develop during one’s lifetime such as exposure to polycyclic aromatic hydrocarbons found in tobacco and charred meats and radiation exposure.

Newer drugs such as Herceptin and Tamoxifen that are specifically targeted for the treatment of pathologically different cancer types has greatly reduced deaths as a result of breast cancer. In the past, one drug was used to treat all forms of breast cancer with less than satisfactory results.

Types of Breast Cancer:

The majority of tumours (about 60%) are hormone sensitive and are stimulated by the female sex hormones oestrogen and progesterone. About 25% of cases are the deadlier form associated with an excessive amount of the protein known as HER2.

Some cancers are both hormone sensitive and HER2 positive. There is a form of breast cancer more likely to occur in younger women known as Triple Negative Breast Cancer because it is neither oestrogen sensitive, progesterone sensitive nor HER2 positive. Fortunately, there have been developments in treatments to help all three forms.

Hormone Responsive Cancer is usually treated with Tamoxifen which is given after surgery to suppress hormones that stimulate tumour growth. Tamoxifen has serious side effects such as vaginal bleeding, hot flashes, an increased risk of uterine cancer and the development of blood clots. There are newer oestrogen-blocking aromatase inhibitors namely Femara, Arimidex and Aromasin which have been found to offer the same or even better results.

HER2 Cancer due the HER2 protein triggering the growth of cancer cells is an aggressive form of cancer.

The drug Herceptin is used to stop the action of this protein and is combined with chemotherapy. Tykerb, also a protein suppressor, will be on the market in 2007 and has shown excellent results when combined  with the chemotherapeutic agent, Xeloda.

Triple Negative Cancer is tackled with the use of a colon cancer drug known as Avastin and is combined with chemotherapy with promising results.

In the past, a pregnant woman found to have breast cancer had to make the difficult decision of having to save her own life or the life of the unborn child. New treatment guidelines allow women to have a mastectomy or a breast conserving lumpectomy and commence chemotherapy as early as the second trimester. Some studies have shown that there have been little or no adverse effects on the foetus while others have shown that the development of the foetus may be affected by chemotherapy. Radiation and oestrogen therapy may  harm the foetus and should be delayed until after the birth of the child.

More than 75% of cases of breast cancer occur in women aged over 50 years. Other risk factors include having a first degree relative (mother, daughter, sister) who has had breast cancer, having had breast cancer previously, an abnormal biopsy result, a mutation in the breast cancer genes, postmenopausal obesity, hormone replacement therapy and prolonged exposure to oestrogen such as reaching puberty before the age of 12 years, starting menopause after age 55 years and having children after the age of 30 or not having children at all.

Women are advised to have routine mammograms once they reach age 40. MRI’s are useful for locating difficult to identify tumours.The risk of developing breast cancer may be reduced by checking breasts monthly for lumps, getting regular exercise which boosts immune function and cuts the risk in half, watching your weight as obesity encourages further storage of oestrogen in fatty tissue. Women who are about 30kg overweight are up to 3 times more likely to develop advanced metastatic cancers than women who are not overweight. Exposure to oestrogen should be minimized thus hormone replacement therapy should be dicouraged.

It should be noted that men may also develop breast cancer. As a matter of fact, a male case was the first I was presented with as a medical student. In men, like women, the most common sign of breast cancer is a lump (often painless) or thickening of breast tissue. Other signs include change in the size or contour of the breast, clear or bloody nipple discharge, retraction or indentation of the nipple, flattening or retraction of the skin overlying the breast and redness or pitting of the skin overlying the breast.