On August 30, 2010, pursuant to the Hatch-Waxman Act, NATCO notified Celgene that its ANDA requesting approval from the FDA for a generic version of Revlimid® contained a paragraph IV certification asserting that various Revlimid® patents are invalid, unenforceable and/or not infringed. Lenalidomide, which is presently marketed as Revlimid by Celgene, is a derivative of thalidomide and is used in the treatment for multiple myeloma. Lenalidomide has also shown efficacy in the class of hematological disorders known as myelodysplastic syndromes (MDS).

NATCO believes it may be a “first applicant” to file an ANDA for the 25 mg generic version of Revlimid® and, should its ANDA be approved, may be entitled to 180 days of generic market exclusivity for that strength.

The market size of Revlimid in the USA is estimated to be around US $ 1.5 Billion, growing at 44% compared to last year.

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.

Eating pomegranates or drinking pomegranate juice may help prevent and slow the growth of some types of breast cancer. A new study shows a group of phytochemicals called ellagitannins found in abundance in pomegranates inhibited the growth of estrogen-responsive breast cancer in laboratory tests.

The abstract of the study says “Estrogen stimulates the proliferation of breast cancer cells and the growth of estrogen-responsive tumors. The aromatase enzyme, which converts androgen to estrogen, plays a key role in breast carcinogenesis. The pomegranate fruit, a rich source of ellagitannins (ET), has attracted recent attention due to its anticancer and antiatherosclerotic properties. On consumption, pomegranate ETs hydrolyze, releasing ellagic acid, which is then converted to 3,8-dihydroxy-6H-dibenzo[b,d]pyran-6-one (“urolithin”) derivatives by gut microflora. The purpose of this study was to investigate the antiaromatase activity and inhibition of testosterone-induced breast cancer cell proliferation by ET-derived compounds isolated from pomegranates. A panel of 10 ET-derived compounds including ellagic acid, gallagic acid, and urolithins A and B (and their acetylated, methylated, and sulfated analogues prepared in our laboratory) were examined for their ability to inhibit aromatase activity and testosterone-induced breast cancer cell proliferation. Using a microsomal aromatase assay, we screened the panel of ET-derived compounds and identified six with antiaromatase activity. Among these, urolithin B (UB) was shown to most effectively inhibit aromatase activity in a live cell assay. Kinetic analysis of UB showed mixed inhibition, suggesting more than one inhibitory mechanism. Proliferation assays also determined that UB significantly inhibited testosterone-induced MCF-7aro cell proliferation. The remaining test compounds also exhibited antiproliferative activity, but to a lesser degree than UB. These studies suggest that pomegranate ET–derived compounds have potential for the prevention of estrogen-responsive breast cancers.”

Researchers say the ellagitannins in pomegranates work by inhibiting aromatase, which is a key enzyme used by the body to make estrogen and plays a key role in breast cancer growth.

“We were surprised by our findings,” Chen says. “We previously found other fruits, such as grapes, to be capable of the inhibition of aromatase. But phytochemicals in pomegranates and in grapes are different.”

Researchers say pomegranates have recently been hailed for their potential anti-cancer and heart healthy benefits thanks to their high antioxidant content. But they say this is the first study to look at their effects on aromatase and breast cancer growth.

In the study, published in Cancer Prevention Research, researchers examined the impact of 10 ellagitannin-derived compounds from pomegranates on aromatase activity and breast cancer cell growth in laboratory tests.

The results showed that of those 10 compounds, urolithin B most significantly inhibited breast cancer cell growth.

Experts say further studies will be needed to determine whether eating or drinking pomegranate-derived products will have the same effect in humans, but these results are promising.

“More research on the individual components and the combination of chemicals is needed to understand the potential risks and benefits of using pomegranate juice or isolated compounds for a health benefit or for cancer prevention,” Powel Brown, MD, PhD, chairman of the clinical cancer prevention department at the University of Texas M.D. Anderson Cancer Center. Brown was not associated with the study.

Until then, researchers say people may consider eating more pomegranates to protect against cancer in the breast and perhaps other tissues and organs.

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.

The FDA today approved Cervarix, a new vaccine to prevent cervical cancer and precancerous lesions caused by human papillomavirus (HPV) types 16 and 18. The vaccine is approved for use in girls and women ages 10 years through 25 years.

Genital HPV infections are the most common sexually-transmitted diseases in the United States, and HPV types 16 and 18 are the cause of about 70 percent of cervical cancers worldwide. There will be an estimated 11,270 new cases and 4,070 deaths from cervical cancer in the United States during 2009, according to the National Cancer Institute at the National Institutes of Health.

“The licensure of Cervarix adds another option in the prevention of cervical cancer” said Karen Midthun, M.D., acting director of the FDA’s Center for Biologics Evaluation and Research. “It has the potential to save lives from cervical cancer as well as reduce the need for biopsies and invasive procedures associated with the necessary follow-up from abnormal Pap tests.”

The primary clinical study for Cervarix included more than 18,000 women ages 15 years through 25 years in the United States and 11 other countries. Of these women, about 9,000 received Cervarix and 9,000 received Havrix, a licensed hepatitis A virus vaccine, as a control.

The results showed that among women who had not already been infected by HPV types 16 and/or 18 before the start of the study, Cervarix was about 93 percent effective in preventing precancerous cervical lesions caused by these HPV types. Among all Cervarix vaccinees, which included those who tested negative for HPV 16 and/or 18, and those who tested positive at the start of the study, Cervarix was approximately 53 percent effective in preventing precancerous cervical lesions.

Studies also were performed to measure the immune response to Cervarix in girls ages 10 years through 14 years. Their immune response was similar to that of women ages 15 years through 25 years, indicating that the vaccine should have similar effectiveness in the 10 through 14 year age group.

The current data show that Cervarix provides protection for about 6.4 years, but additional information on the length of protection is forthcoming.

No vaccine is 100 percent effective, and Cervarix does not protect against HPV infections that an individual may already have at the time of vaccination, nor does Cervarix necessarily protect against those HPV types not in the vaccine. Therefore, regular Pap tests continue to be recommended for all women who receive Cervarix. Pap screening remains critically important to detect precancerous changes, which would allow treatment before cancer develops.

Cervarix contains the adjuvant ASO4. ASO4 is a combination of aluminum hydroxide and monophosphoryl lipid A (MPL) and is the first vaccine licensed by the FDA that includes MPL as an adjuvant. An adjuvant is a substance incorporated into a vaccine that enhances or directs the immune response of the vaccinated individual.

The safety of the vaccine was evaluated in about 24,000 girls and women, with about 13,000 of these receiving Cervarix. The most commonly reported adverse reactions in the Cervarix group included pain, redness, and swelling at the injection site, fatigue, headache, muscle and joint aches, and gastrointestinal distress.

Although Cervarix is not indicated for pregnant women, the FDA is requiring the manufacturer, GlaxoSmithKline Biologicals to conduct a postmarketing study to assess the safety of Cervarix in pregnant women following vaccination prior to identification of pregnancy. Women who are pregnant, or think that they may be pregnant, or plan to become pregnant during the vaccination course, should not use Cervarix.

Cervarix is administered in three separate shots, with the initial dose being followed by two additional shots at one and six months.

Cervarix is manufactured by GlaxoSmithKline Biologicals, based in the United Kingdom.

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.

A group of 3,020 people aged 65 and older were selected. Of this group, 164 people already had Alzheimer’s disease and 522 people already had a cancer diagnosis. Researchers tracked the group for an average of five years to see whether they developed dementia and an average of eight years to see whether they developed cancer.

The 164 people with Alzheimer’s were found to be 69 percent less likely to undergo hospitalization for cancer during the study period.

The 522 people who had cancer were 43 percent less likely to develop Alzheimer’s disease over the course of the study period.

While the reasons for these results are not clear the connection between the two may prove to be significant. Catherine Roe from Washington University School of Medicine in St Louis, had this to say about the results of the study: “Discovering the links between these two conditions may help us better understand both diseases and open up avenues for possible treatments.”

More in depth studies into the correlation are planned.

The initial data from a Phase III study using the Revlimid in multiple myeloma patients who had undergone stem cell transplant reported that the trial had met its primary endpoint of a statistically significant improvement in time to disease progression.

The investigational study evaluated Revlimid compared to placebo in multiple myeloma patients following autologous stem cell transplant, and the independent Data and Safety Monitoring Board reported that the trial had met its primary endpoint of a statistically significant improvement in time to disease progression.

The Phase III, randomized, double-blind, multi-center clinical study was led by the Cancer and Leukemia Group B, or CALGB, and the independent Data and Safety Monitoring Board reported that the trial had met its primary endpoint of a statistically significant improvement in time to disease progression. The study was sponsored by the National Cancer Institute under a Clinical Trials Agreement with Celgene.

Revlimid, in combination with dexamethasone, is already indicated for the treatment of multiple myeloma patients who have received at least one prior therapy.

The Revlimid pivotal MM-015 trial exceeded pre-specified interim efficacy endpoint in newly diagnosed Multiple Myeloma. Further results from the study will be presented in a peer-reviewed setting in 2010.

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.